Morning everyone! It’s not just me today, so I’m going to introduce the Barts team in a minute, but on the end we have Andrew Frost from MTS who actually really led the charge and did all the commissioning for the London Nightingale. So the presentation today is a small journey through the eyes of MTS and Barts Health who rapidly commissioned and handed over and operated the London Nightingale. This will demonstrate all the things that became possible in such a short period of time, and to review at the end of the presentation the lessons learned and the aspects of resilience planning - oh my computer’s gone! That’s the first resilience planning done - and also to showcase what is best and best about clinical engineering. Next slide.
So, a lot of us in capital equipping, who plan and build hospitals, came back from our Christmas break in 2019 and leading into January 2020, and saw on LinkedIn some pictures of some hospitals, this is the one in China, and raised an eyebrow to say how is it in the UK, it takes us between two and five years to commission and build a hospital, and yet something had been erected in 12 weeks, apparently. So no one realised really at the time, maybe the government, but we certainly didn’t that COVID had already hit and struck.
The NHS was coordinated by the COBRA team. And this was obviously an immediate call to arms for many of our colleagues who are in the room here today, and we were not unique. Many of you worked around the clock and responded in the same fashion as we did. For MTS though we were mobilising three teams simultaneously and we were asking our staff to stay away from home for up to seven weeks and isolating from their loved ones. We’ve heard from Joe Emmerson earlier that he was one of the clients that we handed over the Manchester Arena to, and Joe, having heard your presentation that’s probably the last thing you needed in your job at that moment. But today we’re going to hear a little bit from the London Barts team.
The journey started actually with the Royal Free NHS Trust, who had been asked to bring the ExCel Centre into commission, having recently completed and handed over the Chase Farm Hospital. The Barts health team were later asked to operate this, and obviously they’re based one mile up the road. Most people in this room know that the London Nightingale was a hospital with full ventilation at each bed, unlike the other surge centres which were on the stepdown care. So obviously the Nightingales were designed as surge centres to support the NHS capacity, and most hospitals as you know were converting operating theatres and additional ICUs at a rapid rate, and the numbers at that point were growing at an alarming rate.
We’d established when we arrived on site that there was potential for 4,000 beds, 2,000 beds in the north area and 2,000 beds in the south area, and the contractors and electrical teams were so advanced that within three days of being on site a marquee had to be erected to cope with the deliveries as there was no space in the north hall to store all the equipment. So we had to then start segregating the equipment. So we started with the new, those items that had been loaned, not for us, not even required for this type of facility, and many items were just randomly arriving without much planning.
So almost no one knew what was arriving in each delivery, and the quantity of donated equipment was arriving literally by the truckload. We had community beds, which you can see in the picture, which were just not suitable for ventilation, and this was a logistics exercise to work with the army to remove them from site having unpacked over a hundred on the day that we arrived. We also had deliveries of unfilled matrasses, and the amazing army team, along with MTS and our colleagues from events, so Susanne [Del Thea? 0:55:53], all set to work in showing these were ready for safety testing. The command centre had not issued any instructions on governance and safety, and so MTS implemented their own system, unloaded all the equipment into EQUIP, which Joe, you’ve just highlighted earlier, and is a well tried and tested system amongst your colleagues in this room. And we’ve set up an equipment workshop in a coffee shop in the central parade, which two weeks previously had probably had Coldplay visited in there. But it was testament to the clinical engineering profession that also the beds could be commissioned.
But in reality there were never 5,000 of everything. And thanks to Andrew and Steve, who’s in the room here, who’s an ex-USA army logistics corps, we were able to create a system here and at Manchester of getting all the items checked with matching consumables, which was crucial, as every and each bed bay was created. In the context most district general hospitals have between eight and 12 level 3 ITU beds, and we were working towards 500 fully ventilated beds - this was unprecedented. So this would have a profound impact, not just on equipment but also on the recruitment of specialist staff who could obviously manage and use this equipment.
Twice daily, there were bronze, silver and gold team briefings which were being given, and the result of these could be the total remobilisation of vast quantities of equipment to surrounding ICU teams; 79 Penlon anaesthetic machines were brought in, unpacked, tested, registered, put into EQUIP only within two hours to be ordered to be despatched back out again. There were days when this was very stressful, as the national shortage increased, and the requirement to have sufficient capacity at the London Nightingale became more acute. MTS had developed a standard list of equipment required for each bed space, and crucially also the surrounding area bed space, so the shared spaces. But equipment was arriving from private hospitals, amazing suppliers and manufacturers who are in this room probably, and then the national procurement team were coordinating this. So, there was a record breaking 38,000 steps done by Andrew probably a day being walked. And that was to and from the control centre to get the information to find out what equipment was coming in, how many beds could be commissioned and know then what patients they could take. So that was a difficult job. And we felt on occasions we became the Amazon warehouse of Central London. Governments had approached all the manufacturers to respond to the crisis, like Dyson and McLaren, and we’re going to hear from Farhang and Professor Paul White later this morning I think on some of their issues.
So governance, I mean one of the issues that we had was contrary to the advice that was being given that this was a field hospital and not worry about governance, MTS took the decision on day three to implement EQUIP, and to capture and put in all the safety aspects and governance needed to commission these hospitals, and this is the same for Manchester, London, Cardiff, which we set up and then handed over. But we knew also under the governance that at some point the responsibility for safe equipment would be questioned. No one wants Auntie Gladys to die because the ventilator was faulty for example. And also we could see that at some point the facility was going to need to be handed back and put into use again, so where was that equipment going to go and to whom?
So equipment was being delivered that was not appropriate - it was unsafe, a lot of it was broken, and there was goodwill and intent. So this is a picture of one of the storage areas at the Barts site that we captured, segregated and had the army ship that off. I mean there are other news, life did continue, and little pictures you’ve got here I thought were quite nice. One important aspect was there were stories, we believe them to be true, that patients were dying because the ventilators were not necessarily faulty, but the power surges had potentially killed people in Russia. So this was a really live and important issue for us, particularly as we’re dealing with anaesthetic machines. But in happier news Andrew, there’s a picture of you at the ambulance from 1983 I think. You were back on site in 2021, and even Caroline’s dog decided to participate in some social distancing.
But on a more serious note, piece by piece the whole project came together. And although there was only one bed for every six beds, the bear huggers, due to electrical surges, meant that not every bed had a bear hugger. So temperature control for patients became an issue. The tympanic thermometers couldn’t be read due to the ambient temperature in the room. It was too cold in the London ExCel, and so the Barts team needed to replace all the models and exchange those. There was one consultant for every 30 patients. And the team on site also realised very quickly that due to the clinical staff that were coming in to look after the patients who, some of them had come out of retirement or had changed jobs, that we needed the same equipment every six bays for standardisation for those members of staff.
So the final image and slide really is just showing you the final article. That was the small journey that we took to get to that place. In April, Dr Malcolm Birch, who’ll be well known to many of you, is the Director of Clinical Physics at Barts Health, who’s just recently retired, gave MTS the positive news that Barts Health were going to take on the Nightingale as their sixth legal operational hospital, not a field hospital, and here to talk about how MTS and Barts handed over, and how Barts implemented their robust processes are Nirmal Raj, Allan Wilkins and Mary Caddies. So I’m going to step away for about five minutes and let them speak, and then come back and finish on some resilience planning. Thanks Allan.
ALLAN WILKINS
Thanks Ruth and good morning everybody. So as Ruth has said Barts Health became the legal entity. As you know, or may know, NHS England are not able to operate and run a hospital, so Barts Health, our CEO took the decision to take it over as our sixth hospital in the group. And because we operate in Barts Health, a group model, we were able to do this in terms of operational governance as well as strategically. It sat quite well and, as Ruth has pointed out, it’s only about a mile down the road. So I think at this stage it’s important to say that we were there from the early days. So Barts Health and indeed clinical engineering weren’t parachuted in, we were part of the strategy from day one, as well as embedding our governance structures. So myself and the senior team, and Nirmal and Mary Caddies were instrumental in achieving this. So it was a field hospital in the sense it was a temporary hospital as you’re well aware, but I think it’s important to make the distinction, it was a proper hospital. To all intents and purposes it was a fully-fledged ITU hospital.
So the senior management team of clinical engineering came in, and we based ourselves there for several weeks, initially from the end of March so that we could embed the governance structures from Barts Health within in the Nightingale as our sixth operational hospital. And that was from a strategic level and all the way down to basic clinical engineering concepts. At this stage I’ll mention that we were also, we weren’t seconded there, we were actually still overseeing our other sites within the Barts Health Group, and in addition to doing that, Barts Health, the Royal London Hospital site, was also expanding our 15th floor and 14th floor to create a large capacity ITU footprint. So that increased the Royal London to 176 ITU beds. So we were also overseeing that whilst continuing to establish the Nightingale.
So we continued to engage MTS who were to be honest a godsend and ally in helping us commission and get this hospital ready to take patients. And we worked with the hospital senior leadership structure to embed our operational processes, right through from very early on. Because of course the core was patient safety. We had COVID patients, but the core was we had to get this to be a true hospital and concentrate on the safety. It was as you know potentially a 4,000 bed hospital, and I remember when I walked there on the first day and saw a vast expanse of ultimately am empty warehouse, it was just uncomprehendable, you just could not comprehend the scale of this. And as Ruth as said it was going to be 2,000 beds on each site, and then the central boulevard was the operational, the supplies, the procurement, etc. But within all of the plans it was still an unknown. This was wave one, we were talking about, so we had to incorporate scalable up to the 4,000 provision within our operational plan, but it became quite apparent quite early on that the 500-bed model was the reality.
So just a bit about how it opened. It was built in just nine days, and that seems quite remarkable really, and as Ruth said in China when we saw that hospital built, we thought the UK could never achieve such a feat. And we did. And it’s something to be really quite proud of as a team and as a country really. It was an excellent project, logistics ability from the British Army. They were there on site. It’s what they do best. There were many workstreams. There was an organisation command structure, Prince 2, set up to set this into place, and we hit the ground running. And as Joe alluded to earlier, you know, we in Barts Health Group have six hospitals, or five hospitals in our trust, and of course everybody wants to do things their own way. So we had teams from all over the country, all over different trusts, they’ve all got their own ways of working. But this was a real team spirit, and everybody came together for the common goal, and there wasn’t those challenges that you sometimes see within the NHS structures to overcome, believe or not, and it was quite a remarkable achievement.
So the Prince of Wales opened it on the 3rd April as the first operational Nightingale in the UK, and we took our first patient around Easter. We took the first patient on the 7th April. There was a fairly strict criteria to admit patients. And as Ruth said the whole operation was entirely dependent on the NHS in London and beyond, and loaned staff from other hospitals. And as you’re aware Sir Simon Stevens, the NHS Chief Executive, said it was a huge success if we ever needed to use them, and we did. The hospital treated around 60 patients in total, and around 30 of those at any one time. Unfortunately I think it was about 18 patients that passed away throughout that period.
Now 60 patients doesn’t sound that many, certainly in the vast expanse of the ExCel. But in conventional ICU terms that’s, as you can appreciate, quite significant. And of course these were challenging patients. These were complex critically ill patients. In phase one we were still learning how we were caring for these patients, so that presented challenge in terms of equipment, as well as clinical care, and of course in a strange environment. So to put it into context, 60 patients, the Royal London, our largest site, our baseline ITU is 44 beds. And many of the staff in that environment were working with equipment that was unfamiliar to the UK, let alone their own hospitals, and indeed they weren’t necessarily confident or used to working in a clinical environment or an ITU environment.
So why was it needed then for 60 patients, and many people have arguably rightly asked that question, this was the first wave. The NHS was not ready to accommodate something like this. Currently the UK has eight to 13 ITU beds, bed spaces for eight to 13, eight to 13 bed spaces per 100k of the population, and London is on the lower end of that. So you can see that we weren’t quite ready to keep up with this situation. So at the first wave the Nightingale was essential. It enabled NHS hospitals to expand their ITU footprint. It enabled hospitals to repurpose their estate and their services. It gave us the breathing space to accommodate what was coming.
So operationally clinical engineering set up a 24/7 service. It gave us the opportunity we dream of, we got to run things differently. We got to move away from the NHS politics, the NHS things that hold us back sometimes. We got to do this very differently, and indeed take the learning forward back into our own organisation. So we quickly embedded the service across all levels, and we used volunteer healthcare scientists, led by experienced engineers, who were there on the ground in the clinical area. And we built on their clinical, they built on their clinical experience and scientific training to learn necessary new skills, and quickly became invaluable when integrating on the ground. We had great support from Ruth Thompson and the Healthcare Science Networks around the country who helped us to find and train these healthcare scientists. Integration with clinicians was crucial. As you’re probably well aware clinical engineering perhaps sits in the basement or on the sidelines as a support service, and we’re not embedded within clinical care as much as we should be and we would like to be, and this really gave an opportunity to break down those barriers and that integration with clinicians was key. They were in and out of our office several times a day, and we really worked together, and it made a difference to patient care, which is why we were there.
So the whole experience underlines the importance of clinical engineering to frontline care and the value that scientists bring to the wider healthcare system. It was a challenging clinical environment and we had several patient safety issues to overcome. And as I say we were learning to manage COVID patients in a very different environment. We were using equipment perhaps arguably slightly off label, or veering towards off label use. So we used anaesthetic machines as ventilators, was one crucial concept, in an environment that was quite vast, and therefore we had different consumables as well as different equipment. So there was various ET circuits which presented a challenge with humidification which we had to overcome, and taping things together and, you know, equipment is not necessarily designed to be used in this way to ventilate this level of patient. Patient safety and the associated governance was therefore crucial so that we could learn from any issues that did happen. The reporting, the infrastructure was there to report and instantly learn from what was an ever changing landscape was crucial, and we had the IT infrastructure eventually to use IT to the best of our capability.
We had a flat hierarchy, and as Ruth has said there were daily command and silver, gold and bronze level meetings. And a four o’clock clinical meeting was a good meeting to summarise. It was a room like this, where clinicians and everybody came together, operational or otherwise, procurement, to work out the challenges that presented. This was a 24-hour operation, decisions were made, decisions were changed quite literally within half an hour. The night shift came on shift, the decisions were already in place. The learning was fantastic. The facility was therefore very dynamic, things were changing quite literally as I say by the half hour. As Joe has alluded to inter-NHS and other third parties is crucial in an organisation like this, where everybody has come from their own ways of doing things, it was crucial, and procurement and supplies in particular, because that was such an unknown challenge, we had to have that communication. The communication was key to making this work.
In terms of the medical equipment, we had the medical devices policy from Barts Health, which was embedded as the central thread throughout the Nightingale structure. But there were slight derogations, because of the field hospital element that we were working to, there were slight derogations. For example sample testing that was done. You might test every piece of equipment in normal circumstances, the vast scale of this, and indeed then the turning around and sending equipment back out. We had to have slight derogations on what we deemed, so we had to rely on 9001 processes, we had to rely on CE mark, and the assurance that that should give us to be assured that we could perhaps sample test five items rather than every single item. It was the only way. We had to get something of this at scale. Now we were looking at the things in a UK response, but of course globally manufacturers were looking at things globally, and therefore we had, we were seventh in the worst case of criticality at some points, and therefore we weren’t able to get the equipment we required until the UK became escalated to a higher severity.
I want to touch on the training elements now. Mary was instrumental in adapting the training for the Nightingale staff, who quickly became needing to adapt to equipment without the PPE on, and that we had 56 beds, there was one critical care registered nurse for every four beds, and a registered nurse for every two beds. If we can have the next slide please, thanks. Yes, that’s it. So the day before, we called it day zero, we had the staff who were going to be on come on day zero, and this is where they go to set up on Emerson ward, which was basically an area within the ExCel where they could actually use the medical equipment. It was set up as a four-bed space, and they could really learn and get to grips with the equipment without the PPE on etc. And then there was a manual created so that this was something they could refer to. There were people, bedside specialists on site, if we move to two slides on, and the next one sorry, one more. Sorry, I think I’ve gone past it, but there was the potential, there were bedside experts who were able to support within the environment, the clinical scientists and the healthcare staff who were on the floor to use the skills that they had learned on the equipment within the Emerson ward on day zero. So they had that experience and that familiarity with the equipment before they were able to go in there.
If I hand over to Ruth now, and she can discuss the resilience as we move forward.
RUTH STICKLAND
Thanks Allan. So I think we’re going to do some speed slides now, as John’s given me the nod, which is always good. So just bear with me as I get back to my slot. OK so some resilience planning. We’ve given you a little bit of a walk and talk through the London Nightingale, but there’s talk of a third wave; however, most hospitals are still in catch-up mode for business as usual, and the impact of the first and second wave. So this has demonstrated the need for national resilience planning. How has COVID equipment impacted your own standardisation, so donated equipment has had impacts for all of you for things like maintenance and lifecycle costs that you’ve inherited. We heard a bit from Joe about one trust had had over 10,000 items donated. What is its condition, where is the location of it, is it even required? What major rehearsals and MAJAX might come next, and what profiling and types of equipment, and the accompanying consumables which is crucial, and is there a national and regional stockpile of what type of equipment, and I’m going to skip on a little bit just for time’s sake.
However, there is a new directorate going to focus on potentially selling British technology on an international stage, or and we hope focus that we have the right investment and trained people, equipment and the supply of this is planned. Talk has been of stock piles, but of what and where is it, who can access it, and can this flow through the system and be transparent to trusts and the ICSs? And indeed some resilience planning I believe in terms of ICSs is the potential to share equipment in collaborative hubs, and also to look at equipment libraries.
Now this slide may not look like it goes with this presentation, but really we’re talking about resilience planning. We’ve seen one form of resilience planning, but there are many levels. One of the other aspects is that the government has a pathfinder list of eight hospitals which it plans to build with a further 40, and they intend to do this by 2030. And this ambitious plan has come with an NHS ex-blueprint for digital hospitals. So the internet of things and connectively we heard John talk about earlier about medical devices has shown to be the case, and other presentations we’ve heard in this meeting. But the 2016 report by MarketsAndMarkets predicted that the market would be valued at about £1.34bn with over six billion things being requested. So these things are medical devices, and soon we’re going to hear about patient devices and staff wearables.
So the digital planning calls for investment in RFID and RTLS, which we’ll probably hear about later on today. So as this requirement increases of individual trust or hospital, the investment in infrastructure and connected medical devices is very well documented. But that has an impact on the capabilities and skill bases for clinical engineers. We’re going to call them healthcare technologists. But what is clear is that the clinical engineering industry has stepped into the spotlight, and with other NHS colleagues and the vital support in the management and the availability of equipment, the demands on the industry are going to increase and change with it, and this focus and spotlight should continue providing essential resilience to the NHS. So, by the way of a small thanks, we commissioned a small video, initially to just give some posterity for our staff to remember their journey by, but I think really the part at the end will reflect hopefully how you all feel.
VIDEO
We will see many thousands of people infected by coronavirus, that’s what we’re seeing in other countries.
From blank sheet to fully operational hospital in less than a fortnight. A 21st century global pandemic requires an unprecedented response, and the NHS Nightingale is just that. Throughout the day-to-day we’ve seen trucks like that arriving, delivering the oxygen which will be crucial for treatment.
I want to thank everyone on the NHS frontline and those carrying out essential roles.
APPLAUSE
RUTH STICKLAND
And that’s me done, so my clap is actually to all of you, so thank you.
Ruth Strickland's presentation at the EBME Expo : Resilience Planning in an Emergency – Life Saving Equipment
