St. Bernard’s Hospital has seen a series of improvements over the last few years that have changed the face of healthcare in Gibraltar for the better, and under the recently launched formal constitution, the Gibraltar Health Authority (GHA) has set out its principles, values, and pledges to the community regarding the rights and obligations of patients, describing the constitution as: “Our commitment to your health, care and wellbeing.”
Sandra Gracia was appointed as the Director of Nursing and Ambulance Services for the GHA at St. Bernard’s Hospital in September 2018, having previously covered the post for two and a half years in an acting capacity.
“It is a very busy and challenging role, but I like challenges, but it is also an interesting one because of the fact that I feel empowered enough to make the changes that need to be implemented, not only for the patient which is the ultimate reason why we are all here, but also because there are so many exciting developments occurring,” Sandie says. “One of the greatest things happening at the moment is how we are changing nursing practice and at the same time taking pre-hospital care forward with the help of our Acting Chief Ambulance officer and seeing the difference and the impact that makes to patient outcomes.”
Sigurd Haveland is a paramedic and the Acting Chief Ambulance officer that Sandie is referring to and fortuitously he came into his role at the same time that Sandie became Director of Nursing. “This has enabled us to have discussions about the strategic direction of the Ambulance Service and I think that we have been successful in cementing that,” Sigurd tells me. “It is going to be a paramedic led ambulance service where technicians are the backbone of the pre-hospital care clinician.”
Calling the Ambulance Service ‘embryonic’ because it was only in 2000 when the service became professional and only 2013 when paramedics came in to fruition, Sigurd explains that it is a combination of technicians and paramedics delivering pre-hospital patient centered care.
Currently there are three operational ambulances supported at times with a paramedic vehicle. “We have two skill sets in the frontline ambulance clinicians; the technician and the paramedic who is a health care professional,” Sigurd states. “We also support pre-hospital operations with transport drivers which help us keep three ambulances operational all the time and our objective is to have three paramedics in every shift by 2023/5.” Sigurd goes on to say that there should be a paramedic available for every call, not necessarily in an ambulance, but every call will have either a paramedic present or will be supported by a paramedic.
Sandie comments that it is about changing the concept of the emergency ambulance service from what it was in Gibraltar and where it is getting to going forward. “It is about providing the best clinical outcome from a pre-hospital setting because obviously that impacts on the community at large and the survival of anybody that is going to come in as an acute emergency.”
Sigurd points out that it is important for the public to recognise that the Gibraltar Ambulance Service is totally integrated with the health care system and with the GHA, but that when it comes to the emergency service they are a stand-alone operation.
The Ambulance Service in Gibraltar has a multi-faceted role and raising public awareness about what they do is an ongoing initiative. Maritime Attendance and Retrieval is one such speciality, where clinicians attend seamen or people out at sea and if necessary use their specialised skills to package, extricate and disembark patients before ferrying them to hospital. “Gibraltar Port is very important for maritime rescue and this is a service that the Port Authority and the Gibraltar Government provide to shipping,” Sigurd says.
They also work closely alongside the Gibraltar Fire & Rescue Service in the event of road traffic accidents, collisions, in fires and rescues. Sigurd adds: “There is now an appetite for paramedics to be trained in rock rescue as well and we have to look forward as to how we are going to manage any incidents up the Rock.”
Sandie and Sigurd are keen to highlight a campaign directed at educating the public on how to best use the emergency ambulance services. “The public should be aware that there are other routes to go down before an ambulance will come out to them,” Sandie comments. In that respect Sigurd has been active in integrating a telephone CPR assistance service and working alongside the Department of Education to launch CPR training in all the schools in Gibraltar, hopefully by October this year. “We want to increase and enhance bystander CPR in Gibraltar and we thought that the best way to do this was to go to the roots – the children.”
“We also have the Public Access Defibrillators Campaign – where we are looking at not only increasing but enhancing public defibrillation in pre-hospital care,” Sigurd confirms. “There are 14 operational defibrillators at the moment around Gibraltar, but we want to engage with companies who have defibrillators in their premises and are hoping that they can sign up with the GHA so their staff can be trained in defibrillator use, so that if there is an out-of-hospital cardiac arrest close to these business premises, the public will know where to access a defibrillator.”
Both Sandie and Sigurd want to thank the Gibraltar Cardiac Association who has been working alongside them to raise public awareness. “They have been bending over backwards to help with this,” Sigurd states. Sandie adds that the Gibraltar Government has given their commitment to expand the extra services and the clinical expertise within the ambulance service in the future.
Simple things could save a life and Gibraltar Insight is happy to publish a map of where the 14 defibrillators in Gibraltar can be found.
Behind the Scenes at the Day Surgery Unit
Amongst others, one of the success stories at St. Bernard’s Hospital has been the Day Surgery Unit which has become one of the flagship projects of the GHA. “One of the things that surprised us was how we changed public perception from what was the norm before to what could be delivered,” Sandie says, continuing, “the other thing that we were quite astounded by was getting the public on-board and you can see that on social media where there is always somebody thanking Day Surgery and saying how wonderful it is, and that is a huge achievement and a drive for the staff themselves to keep delivering that little bit extra back to their patients.”
The unit was designed with the patient in mind by a team headed up by Day Surgery Sister Angela Morgan and Sandie. “It was eight years in the making and we designed it the way we wanted it to be, and it works, so we are reaping the rewards now of what Day Surgery could have been and what has eventually been done,” Angie says. “We work on the floor, we know what we need and we know what we need for our patients.”
Sandie adds that they were lucky that there was an appetite from the Gibraltar Government to empower the clinicians to say “look this is what we need, this is what the patients want and we were able to deliver that.”
The Day Surgery unit is nurse-led so once patients come into the Main Reception, welcoming and well-lit and furnished with comfy chairs, they are admitted by a nurse who takes a brief medical and case history and that same nurse is assigned to the patient all the way through their surgery procedure. Specialised day surgery trolleys designed to minimise patient manual handling provide all the functions of a bed, trolley and operating table together and accompany the day surgery patient throughout the entire patient journey through to first stage recovery. Happy healthcare employees can lead to happier patients and the nursing staff that I met were all incredibly friendly, happy in their work, extremely knowledgeable and able to put their patients at ease.
The suite has been in operation for six years but looks brand spanking new, rather like a VIP unit, and Sandie is quick to praise Angie and her staff for keeping it that way. There are fifteen beds at the moment with a complement of eight staff nurses and two Enrolled Nurses.
Ward Manager Caron Fennelly explains that they can facilitate a turnover of up to 30 patients a day – depending on the number of surgeons operating on the same day, which can be up to four. “They have their surgery, maybe in the main hospital theatres or in our own theatre, so it is like a big circle, in, out and recover.”
Because of the geography of Gibraltar Sandie states that they have managed to extend the boundaries of day surgery. “When we have gone back to conferences in the UK they have been quite surprised at that not only is it the boundaries of day surgery that we have expanded beyond, it is the techniques that we have developed with our clinicians, our anaesthetists and our surgeons to be able to get the patients home within the same day,” Sandie confirms. This is due to a special type of analgesia and the take home medication that is prescribed, along with a follow-up call and somebody who they can call during the night for advice. The patient gets another follow-up call the next day and they can either come in or they can go straight to A & E if there is a problem. “We have been able to expand on the ‘basket of day surgery cases’ to include more complex, more invasive surgery,” she states.
This then takes the pressure off the reason for an in-patient stay and the patients actually now prefer to go home and rest, with research showing that they make a quicker recovery within their own home environment.
Angie comments that they have now outgrown the unit. “This was the foundation and we opened up with our vision in mind,” Sandie says, “but that vision has now expanded to include a wider range of surgical activity, and making the unit bigger is something that we will be looking forward to doing in the next couple of years.”