On the Front Line: Lessons in Critical Care Nursing from the Covid Pandemic
BIDMC nurse researchers share strategies to increase capacity and staff to manage influx of critically ill patients in first wave of COVID-19
BOSTON – Since March 2020, the COVID-19 pandemic has put unprecedented strain on the U.S. healthcare system as large increases in intensive care unit patients overwhelmed hospitals. Faced with this challenge, Beth Israel Deaconess Medical Center (BIDMC) increased intensive care capacity by 93% and maintained peak conditions during the nine weeks of spring 2020.
In a pair of papers and a guest editorial published in Dimensions of Critical Care Nursing, a team of nurse scientists from Beth Israel Deaconess Medical Center (BIDMC) share their experiences near double the capacity of the hospital’s intensive care unit; identification, training and redeployment of staff; and develop and set up a proning team to manage patients with acute respiratory distress syndrome during the first outbreak of COVID-19.
“As COVID-19 swept across the country, we at BIDMC prepared for the expected influx of highly infectious and critically ill patients,” said lead author Sharon C. O’Donoghue, DNP, RN, specialist nurse in the intensive medical field. care units at BIDMC. “It quickly became evident that a plan for the arrival of critically ill, highly infectious patients as well as an adequate staffing strategy protecting employees and assuring the public that it could be managed successfully was needed.”
After establishing a hospital incident command structure to clearly define roles, open lines of communication and develop contingency plans, BIDMC leadership began planning for the impending influx of COVID-19 patients in February. 2020.
BIDMC – a 673-bed accredited teaching hospital affiliated with Harvard Medical School – has nine specialized intensive care units located on two campuses for a total of 77 intensive care beds. Informed by an epidemic push exercise conducted at BIDMC in 2012, executives determined that the trigger to open additional intensive care space would be when 70 intensive care beds were occupied. When this milestone was taken on March 31, 2020, department staff had a 12-hour window to convert two 36-bed medico-surgical units into an additional intensive care space, providing 72 additional beds.
“Because the medico-surgical environment is not designed to provide an intensive care level of care, many changes had to be made and the need for distance only added to the difficulties,” said the lead author Susan DeSanto-Madeya, PhD, RN, FAAN, a staff scientist with the Beth Israel Hospital Nurses Alumna Association. “Many of these rooms were originally designed for patient privacy and calm, but patient visibility is a key component of ICU safety. So we changed the spaces to accommodate the ICU workflow. “
The changes included installing windows in all patient room doors and repositioning beds and monitors so patients and screens could be easily seen without entering the room. Sight lines have been increased with mirrors and baby monitors if needed. To further minimize staff exposure to the virus, healthcare providers were given two-way radios to reduce the number of staff required to enter a room when convenient patient care was required. Mobile supply carts and workstations have helped improve overall workflow efficiency.
In addition to the storage and management of medical equipment, including personal protective equipment (PPE), ventilators and oxygen, increasing intensive care capacity has also required the redeployment of 150 staff trained in intensive care. . The hospital has developed a recall list for former intensive care nurses. In addition, medical and surgical nurses who could bring their skills to care for critically ill patients within teams of nurses experienced in intensive care were also identified.
The redeployment of staff required training and support. In-person and social distance workshops were developed for each group, after which nurses were assigned to observe an intensive care nurse to reduce anxiety, practice new skills, and gain confidence.
“Staff identified the shadow experience as being the most beneficial in preparing them for deployment during the COVID-19 outbreak,” O’Donoghue said. “Historically, BIDMC has enjoyed strong collaborative relationships with staff in different areas and these relationships have proven to be critical to the success of all care teams. The social service played a major role in leading the teams, especially in difficult situations.
One of the redeployment teams was the Intensive Care Supine Position Team, assembled to support clinicians at the bedside by facilitating safe and rapid prone positioning. Proning is a procedure known to improve oxygenation in patients with acute respiratory distress syndrome – a key feature of severe COVID-19 – which is complex, time consuming, and not without potential dangers to the patient and the staff. The coalition maximized resources and facilitated over 160 interventions between March and May 2020.
“Although the pandemic was an unprecedented event, it prepared us for potential future crises requiring the collaboration of multidisciplinary teams to ensure optimal results in too large an environment,” said O’Donoghue. “BIDMC staff rose to the challenge and many positive lessons were learned from this difficult experience.
“We must continue to be vigilant in our assessment of what worked and what did not work and look for ways to improve the delivery of health care in all of our systems,” said DeSanto-Madeya, who is also an associate professor in the College of Nursing at the University of Rhode Island. “The memories of the past year and a half cannot be forgotten, and we can move forward with confidence knowing that we provided the best possible care despite all challenges. “
Co-authors included Jacqueline Hardman, BSN, RN; Joanna Anderson, BSN, IA, CCRN, CNRN; Jane Foley, DNP, IA; Jean Gillis, MSN, IA; Kimberly Maloof, MSN, IA; Andrea Milano, MSN, IA, CCRN, CMC; John Whitlock, MS, IA; Meghan Church, DPT; Kristin Russell, BSN, IA; Kelly A. Gamboa, DNP, IA, CNOR; Jennifer Sarge, BSN, IA, Ari Moskowitz, MD; Margaret M. Hayes, MD, ATSF; and Michael N. Cocchi, MD, of BIDMC.
The authors revealed that they had no significant relationship or financial interest in any commercial companies relating to this article.