Last week, HTN covered the nationwide release of the free-to-use Acute COVID app, which supports NHS staff that have been redeployed from their regular roles to work with COVID-19 patients.
Co-designed and developed by Imagineear Health and a team from Chelsea and Westminster Hospital NHS Foundation Trust (which includes both Chelsea and Westminster and West Middlesex University Hospitals), the app is part of the CW Innovation programme, a joint venture with the trust’s charity CW+. As well as detailing the different stages of COVID-19, the digital tool provides an instructional video on how to perform a non-invasive ventilation procedure on patients, and points staff towards personal health and wellbeing resources.
To find out more about how and why the educational app evolved, and to discuss how clinicians can co-create tech, we got in touch with Dr Ryan Dhunnookchand, Senior Respiratory Registrar and Medical Education Fellow at the trust and a member of the Acute COVID app team.
“Chelsea has a very good structure that allows for innovation”
“I’ve been working with the respiratory team at Chelsea and Westminster since October 2019. The pandemic arrived and quite early on we were already hearing [about a] ‘life-changing pandemic event unravelling’,” Dr Dhunnookchand explained, providing background on how the app came into existence.
“As a unit, the respiratory team is very evidence-based in its approach – we’re always talking about the latest journal articles. We were seeing this pandemic unfold back in January  and thinking that may well be a problem. [I was] then rapidly redeployed, as most people were,” he said.
However, the trust’s wider appetite for encouraging staff innovation, stood the team in good stead. “Chelsea has a very good structure that allows for innovation. Early on it was consulting a wide range of staff in terms of ‘here’s the impending problem, how are we best going to cope and manage with it?’
“We then set about as two teams of 10 doctors managing a COVID ward, pretty much 24/7 for five days on, five days off. That was how we managed the first wave, from March until September. That was a pretty intense time and during that there was quite a good concentration of respiratory specialists who were well supported to provide [treatment] to patients who weren’t yet needing intensive care, to try to absorb some of that pressure to allow bed space but still provide a good standard of care. So, we started using non-invasive ventilation,” he added.
For non-intensive care personnel and non-specialist respiratory care, Dr Dhunnookchand explained, those doctors and nurses may have heard about NIV (non-invasive ventilation) or CPAP (continuous positive airway pressure) but they “don’t necessarily understand the pros and cons of using it or trying to use it.”
“Certainly,” he added, “we were using it for conditions that we wouldn’t normally use it for but, actually, we found that certain subtypes of patients coming through didn’t need to be sedated and paralysed and ventilated on a mechanical ventilator – because their disease severity was not at a point where they needed that level of support. What they needed was oxygenation and to be kept awake to interact with doctors and nurses, and to speak to their family or take part in physiotherapy. It’s all really crucial and you miss out on all of that when someone is so unwell that you have to paralyse them and put them to sleep.”
This, Dr Dhunnookchand said, represented “a unique opportunity to use it for patients that were very hypoxic – not getting enough oxygen on board.”
As guidance was “very varied” across the nation, as well as across the world, with no consensus on how to “manage acute COVID respiratory distress syndrome in patients who didn’t need to be ventilated in an intensive care setting” but who did still need support, staff at Chelsea and Westminster used their experience to develop a strategy for placing them on a NIV circuit.
“We had some success – we reduced the need for intensive care in a number of our patients, which was great for the patient, for the trust and the unit. We had excellent outcomes for many of our patients and if you look at how they flowed through the hospital, it worked really well.”
The emphasis on this type of procedure contributed to the hospital being able to facilitate around 26 non-invasive ventilated patients at a time, which he added was “fantastic for what is essentially a very busy hospital.”
“The release of emergency funding was unlikely to happen again”
In the Autumn of 2020, however, with the second wave expected and government funding available, the team turned their thoughts to innovation and how embracing digital could help both patients and staff prepare for potential future waves.
“The wave had settled but we were so well aware that the release of additional emergency funding to the NHS was unlikely to happen again. We had arrived at a point where we’d amassed this large amount of expertise [but weren’t] going to be able to replicate that for the next wave,” Dr Dhunnookchand said.
“It’s intensely sapping [work] doing five long-days on, five days off. I must give praise to all of our partners; the only reason the majority of us medics, nurses and allied healthcare professionals were able to work on an emergency pandemic basis was because we had the support of our amazing partners at home.”
When considering how his own juniors would feel about using non-invasive ventilation on COVID patients, it became clear that more support was needed for the wide range of staff supporting the pandemic effort.
The team tried to find information across the internet and different journals, but there was a wide range of ideas, nothing formalised and no consensus statement yet from the British Thoracic Society, which then arrived in October-time, a good six or seven months post the first wave.
“Clearly,” he continued, “it was a bit of a challenge for non-specialists to start using this equipment. We realised we didn’t have the ability to put all of the same specialists back in the same arena to go through the second wave – and most other hospitals had the same problem. Up-skilling staff became a huge area of interest.”
The timing worked well for Dr Dhunnookchand, who had taken time out of his training to become a consultant to work closely with Chelsea and Westminster’s Dr Orhan Orhan, the Director of Medical Education. “A new fellow role – COVID-19 Medical Education Fellow – was created to support the medical education team to deliver the task of up-skilling members of staff with a clinician who could train, demonstrate and discuss NIV with front-line experiences and help troubleshoot,” he added.
This involved regular out-of-hours training events, sometimes for three hours at a time, and the creation of the video that features in the app.
“The origins of that video are that it was done on our acute respiratory unit/COVID ward, it was as real as it could get, without having a COVID patient next to you while filming,” commented Dr Dhunnookchand. “I’d love to re-do parts of the video [now] as we’ve learnt a little bit more information and have newer ventilators available. I think that will be part of the longevity of the app, bringing it up to date. We created the video to supplement the teaching we were doing and feedback [from a Test Bed and the teaching sessions] allowed that programme to evolve.”
“My juniors are very app-orientated”
The team ran the training programme while also developing the app, which was a collaboration between the department of medical education, the respiratory department, the director of nursing and the nursing department.
Dr Sadia Khan, who Dr Dhunnookchand calls an “excellent cardiologist and a pioneer of innovation at Chelsea,” first offered the idea of the app, which had funding from Pfizer for development but required content about how to use CPAP, which is where the training programme slotted in.
“I thought that our teaching sessions were developed and mature,” Dr Dhunnookchand explained, “so why not incorporate that as the structure and backbone of the app? My colleagues and juniors were feeding back that two- or three-hour sessions are great when we can – but sometimes that’s not manageable and they just need to troubleshoot or refer to some guidelines, quickly.”
Apps and smartphone technology, he adds, were the obvious choice as a platform. “Sometimes for a snapshot, you need to look at your phone to find the information, rather than log onto a computer to find the internal guidelines, as it can be cumbersome. A lot of us use apps on our phone for various medical care. My juniors are very app-orientated, it’s a vital learning aid and it helps,” he said.
The team took their NIV curriculum, partnered with the tech company Imagineear Health and saw the app begin to take shape in around three months.
“It took about 10 weeks to structure the app in a way that was conducive to an easy user interface,” he continued, adding that they “didn’t want to write a book on this, we just wanted to provide the information in the most helpful way. There is a lot to be said about the app content being written by doctors and nurses, because I think we’ve got a reasonable grasp of what we want to find out for ourselves – and how and where and what’s acceptable in terms of time taken.”
After creating a framework and a storyboard, the production team “brushed up the video” and added chapters, which Dr Dhunnookchand said, “was a great idea because it allows that quick access to certain bits of information”.
“We were able to marry that up with the guidelines and being able to put them into a position on the app where you can access them extremely quickly and zoom in and out.” This format allows for quick updates and swift uploading of new guidelines as they come out, which is important due to the fact that “the COVID care world changes frequently.”
So far, Dr Dhunnookchand adds, the app has been a success. “The video is getting a lot of hits. People’s feedback is that it is very useful to see how to set up a circuit in a patient room. Even demonstrating it on myself shows pitfalls such as wearing glasses [and] is a journey of learning,” he said.
“I hope we’ve developed something that is useful on an intellectual basis and a practical basis – how to get the best out of the resources we’ve got at a time when [we have] limited resources , as well as maintaining a standard of care that means the patient is getting the best out of us and that we are striving to provide the relevant drugs, the relevant technology and comfortable, competent care to the patients, so that they have the best chance of survival.
As to what this means for the near future, he added: “Chelsea and Westminster and West Middlesex University Hospitals have shown they’re ready to innovate, so it’s great to see this finally come to fruition just in time for the third wave. It means that I can scale down the out-of-hours teaching sessions. And, hopefully, it allows a wider range of professionals to take part in the learning. It is a learning tool and I hope it can be used by our physiotherapists, pharmacologists and dieticians – they see patients on the wards, they support [us] and might have questions they don’t want to ask, but they can go and find the app.
“It’s another skill in our repertoire, to [help us] deal with what are unprecedented times and what may become an ongoing endemic issue. It’s another tool people can be proud to learn about and information that they can apply in a supervised setting. It’s been fantastic to work on.”
Staff wellbeing is also another area of the app that the team hope to add to: “In every piece of work that we’re doing, including the app, signposting about mental wellbeing is so important. It deserves its own piece in a way. The app doesn’t go nearly as far as we’d like to address wellbeing. That’s certainly one area that will be improved and developed, so that we’re giving the people that we work with the best access.”
The decision to make the able available outside the walls of the trust was also based on a desire to share learnings from that “unprecedented” year. Dr Dhunnookchand said: “It’s a good resource that’s had excellent feedback so it feels appropriate to share it. That’s something, as a healthcare service, we’ve realised is more and more important – sharing good resources, without the complications of licensing and fees. This is a learning tool at a time when a lot of people need something that is compact and concise and shows you what you want to see. When I’m trawling the internet there’s so much other fake news or out-of-date things that it becomes difficult.”
However, he was keen to emphasise that, although the app was now freely available to those working in other trusts, “we’re not saying that our guidelines are the only way to do it”.
He explained, “that’s how we have managed. They’re not things we have just decided we want to do. They have gone through a tried and trusted process, which includes a review date. Once the teaching was transferred to the app, it was rolled out on a pilot basis. We scrutinised it, changed bits and then we got it to the wider team”.
“In the same way that you can go onto YouTube and look at videos on how to apply it, ours at least comes from a centre where we’ve used it extensively. We’ve tied it towards consensus statements and guidelines, nationally, as best we can. That’s the idea of continuing to adapt the app and keep it current. But you have to take it with your trust or institution’s resources in mind,” he concluded, as “we might use different ventilators to other hospitals that are five minutes down the road.”
However, overall Dr Dhunnookchand hopes that the app, “gives people a thirst for more information” because “it’s a really useful skill, even if you’re a non-specialist. I think will be seeing this kind of NIV device being used more and more.”
The Acute COVID app is currently available to download on App Store and Google Play.