Experiences of Infection control measures

Hygiene and sterility are always important on an ICU (Intensive Care Unit) to keep patients, staff and visitors safe. Staff routinely work with rigorous infection control measures; in particular to prevent hospital-related transmissions such as MRSA or Norovirus. With Covid-19 (Covid), an airborne viral infection, the implementation of additional infection control practices was key.

On this page patients talk about their experiences of infection control measures.

  • Staff in personal protective equipment (PPE) added to patients’ confusion
  • The visitor ban and absence of loved ones left patients lonely and isolated
  • Both is likely to have made delirium worse.

Covid patients were admitted to separate wards to minimise the risk of infection for others, ensuring that care for non-Covid patients could continue. However, for Covid patients this meant that all the patients around them were fighting the same viral infection. When people we spoke to saw other people decline, they sometimes related this to how they themselves were doing; they were deeply affected by seeing others deteriorate (read more on this under Uncertain survival).

Experiences of staff wearing personal protective equipment (PPE)

Covid-19 infection control measures changed the environment in which patients were cared in as well as what staff were wearing.

In the first wave in the spring of 2020 it was unknown how infectious Covid was or exactly how it spread. Clinical staff put up all sorts of makeshift barriers between patients and between patients and staff. Paul was in a ward surrounded by plastic sheeting, like a tent, with sealed zips to reduce the spread of infection. He remembered the sounds of the zips being undone hundreds of times a day.

Paul vividly remembered the sound of the zips of the makeshift tunnel to prevent the spreading of the virus.

Hospital staff and visitors in contact with Covid patients are required to wear appropriate personal protective equipment (PPE), including gowns, masks, gloves, goggles, hats and visors. This can be disorientating for patients; some people we spoke to described the masks and suits staff wore as “space suits” and “Hazmat suit type things”.

Laurence would frequently see nurses change in and out of PPE, and appreciated how difficult this made their work.

For Moazzam the amount of PPE that staff was wearing signified how ill he was.

Moazzam remembered that staff was wearing less PPE as he got better.

Whilst PPE is essential for the protection of staff and patients, it is a barrier to communication and the provision of care: when staff are in full PPE only their eyes are visible and the masks make it hard to communicate. This limits their ability to express compassion and empathy.

PPE could also make it hard to recognise staff, which amplified patients’ feelings of confusion and isolation. Their voices became an important way to differentiate between staff members. Chris recalled that staff “all wrote their names across their aprons so you always knew the nurse’s name as well, which was very helpful.”

Paul noted with sadness that PPE meant he would be unable to recognise the people who had saved his life if they were to see them on the street. He felt that he “could walk past every one of them in the street and not recognise them because they had their masks and their face masks and the visors. But they would introduce themselves every day, and they had their name on their PPE. I’d maybe recognise voices.”

Feelings of isolation and anxiety

Seeing staff in full PPE could be disorientating and scary for patients, especially when they were not fully awake or conscious.

In the early days of the pandemic, when little was known about how transmissible or lethal Covid was, there was often a fearful atmosphere around patients. Carl and Emma who were admitted to ICU early on in the pandemic described having a sense that staff did not want to be close to them. The experiences of isolation and disorientation, that are common for ICU patients, were amplified by the absence of loved ones and of physical touch. With no family members or friends by their side to hold their hand or comfort them, it was very reassuring when staff touched patients, regardless of the gloves they wore.

Waking up at night with staff in PPE by his bedside made Brian jump.

Feelings of confusion and disorientation

Patients in intensive care will often have bad dreams, hallucinations or delirium (see also ‘Sleep, dreams and hallucinations in ICU/ICU patient experience module’). Between 50% and 80% of patients on ventilation are believed to suffer from delusions caused by critical illness, the medications prescribed to help them tolerate particular treatments or being attached to equipment*.

It is possible that these experiences of delirium were more common and intense for Covid ICU patients than they are for ICU patients more generally *2. Admissions were on average longer than for other ICU patients, and were mechanically ventilated for longer periods. Covid patients required medications for deeper sedation to enable proning and ‘ventilator synchrony’ (a better match between their breathing pattern and the ventilator) and were also on these medications for longer periods. The restriction on hospital visits for infection control meant that no familiar voices could reorient patients back from their hallucinations.

In her role as an intensive care nurse, Melanie advocated for more family visits wherever possible within the circumstances.

People like Paul, Nahied, Carl and Victor described their dreams as “weird”, “surreal” and “terrifying”; they dreamed of being restrained, hurt, or even tortured. For some, time was distorted so that when they woke up, it felt as if they had been in ICU for several years.

Staff wearing PPE contributed to their confusion and disorientation. Paul recalled “a lot of doctors and nurses and consultants round the [ICU] bed with the masks on and the visors on and all the PPE, and I was very confused, because I had these delirium dreams”. Caroline vaguely remembered “disembodied heads” that were probably nurses wearing PPE.

Caroline has a vague memory of “disembodied heads” which she now knows were the nurses wearing PPE.

For Carl, these dreams continued after they had left the ICU. Pete, continued to be haunted by their memory: “I haven’t had them since [I was discharged from hospital], but the thing is, because they were so realistic, the memory of them is with me all the time, which I don’t like.”

Patients who have had hallucinations are often given the opportunity to visit the unit (see also ‘Coming to terms with what happened’) to see for themselves what the ICU environment is like. They can talk to staff about what happened in more detail. The hope is that this helps people differentiate between what was a dream and what actually happened, and to understand why they had particular delusions. Unfortunately, these visits often had to be suspended due to infection control. Between the peaks of Covid infections some people we spoke to were able to visit the ward and to meet some staff members who had taken care of them.

Laurence’s doctors and nurses wanted him to come back to ICU to see the ward, but this practice was temporarily suspended.

Mike and Veronica went to the ICU to meet doctors and nurses who had taken care of Veronica when she was critically ill.

Neil had “funny hilarious, sometimes scary hallucinations”. He wanted to visit the ICU to put faces to the voices he remembers.

Experiences of the visitor ban

In UK hospitals visits were suspended for most of the Covid-19 pandemic. Some hospitals made an exception for family members of end-of-life patients. The restriction on visits to the hospital had a profound effect on patients’ and family members’ experiences of the hospital stay.

From the early days of the pandemic, staff began facilitating contact between patients and family members through video calls. Whether it was available to patients and family members depended on each hospital’s staffing resources. Video calls required equipment as well as nurses to free up time for this important but additional task.

Carl and Emma stressed how isolated and lonely they had been in ICU and on the ward without family members or friends there, especially before staff started video calling family members. Emma said that she had felt really “anxiousy” in ICU: “I just felt really scared and very lonely. I was too scared to be scared.

Using their phone could be too complicated for patients who were weakened from the illness and just woken up from sedation. Carl felt that calling his family sooner after waking up from ventilation could have reduced his confusion.

When staff began making video calls to facilitate contact between family members and patients, this made a real difference. Laurence, who did have immediate access to videocalling after regaining consciousness, said: “That digital connection was a stroke of genius, really. So, I think that would be a brilliant idea if we have to live with Covid again, that every patient has a way of being digitally connected without relying on trying to use their phone.”

Carl was admitted to ICU in late March 2020, before videoconferencing was used. He felt that videoconferencing could have decreased this feeling of being isolated and confused.

After waking up from being ventilated, Laurence could FaceTime his family, which was a real morale booster for him and his family.

Video calling was not always easy emotionally for patients and family members.

When Emma could not use her phone, the nurse helped her make the calls until she could do so herself.

Many people like Caroline and Nahied described how the staff made a positive impact on their ICU experience. Although the high patient numbers meant that there were less nurses for each patient, staff on ICU tried to spend time talking with patients.

Nahied felt less lonely on ICU because a nurse would talk to her. She missed this on the general ward.

In Staying in touch despite the visitor ban you can hear family members speak about how they experienced not being able to visit their loved ones in ICU.

*Girard TD, Pandharipande PP, Ely EW. Delirium in the intensive care unit. Crit Care. 2008;12 Suppl 3(Suppl 3):S3. doi:10.1186/cc6149

*2 Prevalence and risk factors for delirium in critically ill patients with Covid-19 (Covid-D): a multi-centre cohort study, The Lancet

Uncertain survival

The Intensive Care Unit (ICU) is a place of uncertainty, where life-saving treatment is provided to those who are critically ill. The lives of ICU...