14th April 2020 At Citywest Self Isolation and Step Down Facility: Paul Reid, CEO HSE, Dr Siobhan NiBhriain National Integrated Lead, HSE, Helen Stokes, GM, Dublin Midlands Hospital Group, Taoiseach Leo Varadkar, Site Manager Mary Walshe and Siobhan McArdle, AND Primary Care, HS
“I was always going to help.”
Mary Walshe was in Thailand in January when she first heard of Coronavirus. She never anticipated that within three months she would be back in Ireland, setting up the country’s first self-isolation facility in Citywest – the well known Dublin hotel and conference facility
Having retired early (from a position of Chief Officer Dublin North) on April 1st last year, Mary did so “in order to spend some quality time with family and to travel because that’s one of my loves. I hadn’t been in a position to do it for a while so when I set off, I ended up spending most of last year travelling.
“I went on a big trip after Christmas - going to Vietnam, Cambodia, Thailand, Australia to see family and New Zealand and then returning to Ireland March 2nd. I was ahead of the virus the whole way – the day that I left Christchurch the first case was after being announced in Auckland. To be honest, I was glad to be home.
“I had another trip planned to go away at the end of March but obviously that was never going to happen. So I continued in my normal retirement activities – reading, walking and meeting up with family but even at that stage my movements were restricted as with everyone else’s and then on March 18th I got a call from Yvonne O’Neill AND on behalf of David Walsh who asked me would I come back to lead on the self-isolation at Citywest.
“Obviously at that stage, I had no knowledge of what was planned but very quickly it became obvious that negotiations were well underway with the hotel owners – led by Jim Curran from HSE Estates. The aim was to take over control of the hotel by licence. Those negotiations continued right up to late on Wednesday, March 25th when the agreement was reached and the appropriate legal documentation signed.
Essentially Mary was project managing a service that had never before existed: a self-isolation facility in a non-acute setting.
"Our aim was to create a safe environment for residents to self-isolate to allow for us to minimise the risk of community transmission of COVID-19. It’s an isolation facility for those who are unable to self-isolate in their own community. We provide health care assessment and monitoring for residents during the period of self-isolation in the facility in line with HPSC Guidelines and further provide access to a 24/7 GP service."
In the intervening period, however, Mary was already working with her main team, the core group who were brought together to deliver on the self-isolation facility (with HSE Acute Hospitals Division lead on the acute facility to be housed at the venue). That core group consisted of Dr Deirdre Mulholland, Director of Public Health, Aileen O Brien, Infection Control Lead, Helen Stokes, GM, Dublin Midlands Hospital Group, Paul Braham, Mental Health Services and Marie Caroll Brown, Business Manager CHO7.
“While this was the core group, we obviously had many key people from various specialist areas to provide significant support and expertise. Everyone had the right attitude and everyone worked really hard – you can do so much when you have a positive attitude. We are very much at the heart of Community Operations and our key support there was from Siobhan McArdle, Asst National Director Primary Care.”
With around 150 hotel staff to be trained, Mary and her team were focused on the key areas of cleaning, security and catering. “The hotel was amazing – they did everything they could to help us. Obviously we were repurposing the facility and in some instances that meant changing to a clinical setting where for example, on a practical basis, some areas we would need carpet removed and lino put down. We have to have areas for example where staff have to put on PPE.
“One of the most critical people involved with us was Dr Jane Care, Asst Director - Public Health who led out on the healthcare recruitment process for us. It was really important to get the appropriate skillmix. We now have a mix of nurses inclusive of PHNs, nurses who came over from Tusla and Agency Staff as well. That now means we have a 24-hour nursing presence here.
“We have a Clinical Nurse Manager here, an Assistant Director of Public Health and during the day we have up to three nurses. Clearly our staffing levels will be reviewed as the service accepts more referrals. We take referrals on a seven day a week basis.”
Medical support came from “two very dynamic GPs – Dr Brian Blake and Dr Aisling Ni Shuilleabhan who worked very closely with us.” This support is vital to the service and Mary explained how the GPs and nurses collectively make all the key decisions: “Everything is based on operational criteria agreed from the start. Clearly, while our clients are COVID 19 positive, they may also have other issues and the GPs are in a position to lead out on that.”
The involvement of HSE IT personnel in the development of a clinical management system was praised by Mary: “We needed access to an integrated digital system to manage the service in accordance with an agreed process. The system was to include the ability to manage bed capacity, allow for remote and site-based monitoring and further linkages to appropriate systems. We also needed a dedicated email address for referral.
“That referral and subsequent triage process is an integral and important function for us and for our clients. ICT needed to be the enabler to allow GPs to do their job. This is a large facility; they want to be able to access the relevant clinical information when needed – whether at 3pm or seven in the evening if necessary. It took a lot of work but it was turned around in a matter of days. I cannot thank and praise HSE IT personnel Fergus Murray and Alan Price enough for their incredible work and commitment, along with Procurement’s Vincent McCarthy, to get this system operational in such a short timeframe.”
Further support came from the staff of the Central Remedial Clinic: “I already knew CEO Stephanie Manahan and the swiftness of her response to the overall situation meant that we were able to access administrative and healthcare staff immediately. As a result, most of the administrative support to this service is now being provided by CRC staff along with a number of their healthcare assistants who work in partnership with our staff nurses.
“They have come from Disability Services to this service which of course is totally different. But they have absolutely embraced it; they have a great attitude. I would sincerely thank Stephanie and their supervisors who came with them too of course.
Significant emphasis was placed on education of all staff: “Dr Deirdre Mulholland and Aileen O Brien led on this area. We did a lot of training with the Citywest staff – dispelling the myths and clearly presenting all the facts and leading with accurate information. We had training and education sessions with groups –management, nursing, administration, healthcare assistants, medical, catering and security. We were honest with people as well in terms of risk – all within the context of everyone across the community being at risk but obviously in this instance, they are in an environment where people are positive.”
The first clients were transferred from hospitals around the city on Wednesday, April 1st. “We were delighted to be able to facilitate that and to be able to ease the pressure on our acute hospital colleagues”
“We are running a seven-day week service here where the decisions regarding the referral, admissions, care and discharge of clients are made jointly by our GP and nursing staff. Obviously some of our clients will have other medical issues and it is vital that we have access to GP care.”
The triage process in accepting referrals is extremely important: “It’s vitally important that we only accept individuals for who we know we can care for here. It’s also important for us to ensure that those people coming here understand what’s involved. Although they will be staying in their own room, they do have a little bit more here facilities wise – there are dedicated walks for certain types of clients, but they do have to understand that when they are transferred here, there still are restrictions – the self-isolation principles remain.”
Having started with around 12 patients being referred daily, that figure is expected to increase. “There are plans for more self-isolation facilities across the country but until those are up and running we will accept referrals from any part of the country. We accept both GP and Hospital referrals but obviously there is a triage process and it is done on an agreed criteria-based approach.
One of the successes of the core team has been the development of their Guidance Document: “We were designing and establishing something that hadn’t been done before. We were cognizant that there was an expectation that we weren’t just designing this for ourselves but that in the principle, purpose and scope of the project we were developing guidance and template for how this could be done elsewhere across the country.
“Particularly in the area of infection control – for us here in Citywest, we were in a hotel environment and the nature of the cleaning regime required is different to a healthcare setting. So in our document it was outlined clearly to hotel management what was required. We were in a 750-bed hotel, but it could be done in a 50-bed hotel/facility with the sample best practice and principles applied. “
As anticipated Mary pointed to the learning ultimately behind enhanced once the facility opened its doors to its first clients: “We can plan a patient’s pathway from when they arrive through to when they get to their room but it is really only when we initiate the service that we can gauge it properly and even after 48 hours we made some minor adjustments - that’s the learning – what process work and what needs to be amended.”
The co-operation and tireless work ethic that Mary has experienced over the past three weeks in those who have supported the establishment of this new service have meant that they could achieve their aim within a breathlessly short timeframe: “I cannot thank everyone involved enough for what they did and how they did it. From the outset, we were cognisant of ensuring clear communication and involvement within our own organisation – working with the National Ambulance Service, providing dietary and social work support, counselling services and EHO support – but also that we met and worked closely with outside agencies including the local gardai, and local pharmacists for example. That is critical.
For patients who are admitted, the environment as Mary explains is welcoming and supportive: “We know it is an uncertain time for everyone and for any person who is admitted to any of our facilities, we want to do everything we can to support them. We developed an information pack for each person and while we outline the clear guidelines to be followed, we also are aware of their health and wellbeing. This is a vast facility and we have designated paths and walkways in a specific and secure way to allow for walks and our dietary and catering functions are evolving to ensure we look after all their needs. We have access to counseling and social work support so we are clearly patient-focused.”
While Mary is continuing to oversee the running of the Self Isolation Facility, she is also working with the Acute Hospitals Division in the development of the acute hospital step down facility underway at Citywest. It's not what she ever thought she would be doing April 2020, but like many others, she is enthusiastic about doing what she can in tackling the challenge that is Covid 19.