Critical care for the mind and body

University Hospitals of North Midlands Trust's Dr Sobia Khan is a clinical psychologist based on Royal Stoke University Hospital's busy critical care unit. She explains how living with Covid-19 affects the mental health of patients and staff and what is being done to help them.

Dr Khan works with a multidisciplinary team to assess and investigate the level and cause of anxiety in Covid patients.

Dr Khan said: "Being admitted to critical care can be frightening for any patient and people often feel scared of the environment because of the lines, tubes and ventilators. But to come in because you are very ill with Covid adds a whole new level of worry. We know that critical care admission can be associated with depression, anxiety and post-traumatic stress disorder and patients can frequently experience hallucinations and nightmares because of the medication they are on. For patients with Covid, these issues are made even worse. They are often anxious because of what they have heard about the virus in the media. They are also scared that they might have passed the virus on to loved ones or be grieving for someone they have lost to Covid. All of these factors can take a severe toll on someone emotionally as well as physically. It can also make it difficult for them to engage in rehabilitation. But whilst it is normal to experience a certain level of anxiety and low mood in critical care, we do not accept this as an unavoidable side effect of the experience. Our job is to try and make things as easy as we can for people.

"Thankfully we have a clinical team who understand the relevance of psychological care. They are very good at helping to provide some of this support themselves but they are also good at making referrals if more specialist help is needed. The worst thing for a patient is to be left with their thoughts and fears and have no one to share them with and we find that communication is key. Information and education can also go a long way for patients. It can settle a lot of anxiety if people receive tailored information about their journey so that they understand what has happened to them but also what they can expect from various procedures. For example, being taken off a ventilator can be a gruelling process. People assume that once they're off, that's that. But they have to gradually get used to breathing by themselves again and relying less and less on the oxygen support from the ventilator. Initially the patient can feel that their breathing is becoming more difficult each day and often they misinterpret this as a sign that they are deteriorating. We reassure patients and help them to understand that their discomfort is normal and that it is actually caused by their beginning to breathe independently again. That they are getting better, not worse."

A strong emphasis is put on rehabilitation and early mobilisation to improve patient outcomes.

Dr Khan said: "The misconception about patients in critical care is that they have to be lying down, but actually they're kept as active as they possibly can be. Many of the people we care for have to learn all the basics again – breathing, eating, drinking, walking, talking, everything that we take for granted on a daily basis. Just getting to the bathroom unassisted can be a major achievement for those who have been seriously unwell. All of this requires energy and strength and this means significant effort on the part of both the team and the person being cared for to get their fitness back. They have to commit to and engage with rehabilitation, which can be extremely tiring and challenging. But it's important to note that patients are not passive participants in their care - we need their hope, perseverance, motivation, trust and spirit."

The team in critical care try to take a personalised approach with every patient.

Dr Khan said: "We use something called behaviour plans, which are placed at the bedside for all staff to see and provide guidance about how best to work with each patient. Sometimes we care for people with specialist needs such as mental health or learning disabilities and these plans are especially helpful for us being  able to work consistently as a team. We also always ask family or carers to tell us what would be most helpful for a particular person and we have had a lot of positive feedback about this approach from colleagues.

"When patients are in hospital for a long time they can start to feel disconnected to the outside world, so sometimes I even spend time talking to them about current affairs. This helps them to feel a part of things and a little bit more normal. Ultimately, we have to remember that a patient is a person. We are caring for someone's loved one and we have to treat them as the individual they are. We need to take care of their mind as well as their body. After all, this what makes them unique."

The critical care psychology team was established in 2017 and psychological services are delivered as part of the multidisciplinary rehabilitation service. Dr Sobia Khan leads the team and is supported by an assistant psychologist. Both are based on the critical care unit and care for staff as well as patients.

Sobia also provides psychological support to staff on the critical care unit.

She said: "We have a robust staff wellbeing initiative in critical care which is led by the senior nursing team and involves the whole multidisciplinary team. I have worked closely with them and the clinical director during the pandemic to provide psychological advice and guidance about how best to support staff. During the first wave I increased my hours to provide drop-in sessions for staff in critical care and I also made sure they had a space to process their feelings and to give them advice and strategies about what they could do to help them cope. I have really enjoyed doing this. I have experience working in the human rights sector and I was able to use my knowledge to design the needed support. I could see parallels with what NHS staff were experiencing and others groups I have worked with such as veterans and those working in the context of humanitarian relief. NHS staff are wonderful, caring people and they give so much of themselves. Staff often tell me that the hardest part of the pandemic is to not to see relatives at patient bedsides. So they go out of their way to compensate for this as much as possible. Of course, they are human too and need to experience some of the care they give out to others. We have to remember to care for the carers."