Patient Safety Learning interviews a critical care outreach nurse from America to find out the challenges frontline teams are facing during the coronavirus pandemic.
About the Author
Critical Care Outreach Nurse.
Questions & Answers
Thank you for taking the time out to speak to Patient Safety Learning. With all countries across the world facing very similar challenges currently, what tips can you share with us?
I’m not sure we're doing anything differently to you; we continue not to use much CPAP or BiPAP. We currently have 62 patients ventilated and 6 on ECMO. Daily admissions and discharges are about equal, so while we are able to keep up it seems hard to see an end in sight.
Do you have somewhere to put personal protective equipment (PPE) on and off?
Our rooms all have a little alcove outside with a cupboard that has PPE in it. Some other units have PPE carts outside of the room.
Do you have a buddy for getting PPE on and off?
No. However, there has been a roving PPE superuser team who did one-on-one training for each team member on the COVID units. This team has been made up of nursing educators that usually do annual competency days, nursing orientation, CPR training, etc. They have also redeployed some outpatient nursing staff to help with this role. We changed brands of N95s during this time and many nurses had to be re-fit to the new brand style, so this team helped with that as well. For the critical care outreach team, we have made a point to instruct our team to take a “time out” to evaluate our PPE prior to entering a room.
Has your role changed since COVID-19?
Not formally, but the volume of patients has gone up significantly to the COVID wards as we have re-purposed our ortho, ENT and neurosurgery floors for primary covid units, and the staff are not particularly comfortable with respiratory decline as they are used to looking after the generally well, surgery patients.
How is your hospital coping?
Overall, we remain happy to be at the institution we are in. The hospital has made adjustments that the staff and community believe in to meet this need. The newest building (completed in 2012) was built to accommodate a massive influx of patients in a mass causality event, so it has been interesting to see some of these capabilities utilised.
What are your triggers/escalation for sending a patient to ICU now?
At the beginning of COVID-19, which for us was in the middle of March, with our first inpatient presenting on 6 March, anyone requiring more than 4L NC was transferred to the intensive care unit (ICU). As a reminder, we have at baseline 111 adult ICU beds and around 300 adult medical-surgical beds, 20 adult observation beds and 40 adult rehab beds. As we have worked through the past 6 weeks, we have opened an additional 45 adult ICU beds (two units, utilising the paediatric intensive care unit space and endoscopy recovery space when necessary) and additional medical-surgical capacity due to cancelled elective procedures. Now, we are using two units for immediate care unit (IMCU) care, keeping patients on high-flow cannulas and high-flow highihumidity cannulas on those units. Patients are staying on medical-surgical until they need more than 6 L NC.
Are you wearing your own uniforms still?
We are, but the hospital has brought in a scrub vendor that is available to pick up and drop off scrubs for anyone that wants to. We have told our nurses that they are welcome to use them as they need.
How are you washing them?
I am stripping at the door and putting my scrubs from the day directly into the washer where they stay until I have loaded it up with dirty scrubs then wash on hot. I shower immediately. I leave my shoes in the car. We have been wearing hair coverings.
Do you have a shortage of scrubs?
No. There are plenty for anyone that doesn’t wish to wear their own. This took a couple weeks to work out.
How are you looking after yourselves while at work?
We are taking time to relax when not on a call. Usually we are constantly looking for problems, or looking for work, or looking for more things to do, projects, etc, but we are now taking advantage of downtime to just be with each other and do some semblance of socialisation with our masks on in our office.
Do you have a well-being hub?
We have a wellness officer, a physician and a wellness pager, which we can call anytime. I have not needed to call, so I’m not sure what they are offering. They have set up a wellness room and are planning a Webex type group “therapy”.
Has your work provided anything else for their staff?
There have been a lot of free meals, but the critical care outreach team seems to have been overlooked from them, so we partake when we happen to be with the unit receiving the meal for the day.
Are you doing more simulation?
Less. Our simulation centre is closed until further notice. The physicians we work with for mock codes are pulmonary critical care MDs so they are too busy to plan for mock codes right now. We did plan for a bit of hands on time on a mock crash cart, planning for emergent intubations on the COVID units. The nurses appreciated the time to talk through the supplies and considerations for a COVID intubation outside of the critical care areas.
Is there time for teaching?
Some, I’m just not that confident that that there is an ability for the nurses to retain information we give them at this challenging time.
Have you got nurses and doctors redeployed in other areas?
Yes. A lot. Outpatient nurses working in a variety of settings, an urgent care clinic, a drive-through testing clinic for staff and local first responders, EMS, police, etc to come and get tested for free. We have extra medical surgical nurses (because of the closed units due to cancelled surgeries) working on the ICUs as a resource, a runner or on a team with an ICU nurse lead.
Do you have non ICU nurses working in ICU?
Yes. We have worked on a team nursing model.
Finally, what would you say have been the key learning points over the past few weeks?
As a team we have learned that things can get done quickly when needed to. In general, everyone works quite well together for the common good. Spirits remain high overall where I work!