Frontline Nurses See Opportunities for Change during COVID-19 Outbreak (Duke University, 3/16)

Mary Rochelle Phillips, MSN, RN, CCRN, Duke Regional Hospital- ICU Clinical Nurse II [i]

[i] The views and opinions expressed in this article are mine alone, and do not represent the opinions of my employer.

On the Front Lines in the ICU

Last week was one of the most frightening of my career as a frontline nurse in the ICU: after caring for a patient during one of my shifts, we were testing for COVID-19 the following night, after which the patient was placed in isolation. My heart raced and had many “what-ifs” going through my head. But then I realized I was giving in to the hysteria and needed to start thinking critically.

Luckily, I am a member of one of the top hospitals in the country that has extensive infection protocols and guidelines in place. My facility established real-time data and action plans that are easily accessible to staff, patients, and the surrounding community. I appreciate our leadership’s transparency and how our organization has been successful in coordination and constant communication in response to COVID-19.

It is reassuring to know that I have the full support of my organization throughout this time of uncertainty so I can continue to serve and care for our patients and our community. Yet, our health system needs to improve if we hope to address this challenge and the others that will inevitably follow.

As a world society, we have driven through past challenges such as SARS, MERS, and Ebola. But, despite extensive health advancements following these outbreaks, the world is still highly vulnerable to the spread of infectious diseases. In response to the most recent Ebola outbreak, Bill Gates said in a TED talk “the world needs to prepare for pandemics in the same serious way it prepares for war”. At the same time, he also predicted that “we are not ready” for the next outbreak. This was five years ago. He was correct then and, unfortunately, is still correct now.

As history is our great teacher, now is the time both to react to think strategically about the long-term implications of our reactive approaches. Unfortunate as it is, the coronavirus outbreak is forcing us to adapt and innovate in real time.

A Nurse’s Perspective on Proactive Opportunities for Change

My experience on the front lines suggests three actions involving crisis planning, telemedicine, and flexible use of skills that can build on existing expertise in the healthcare system in order to make a big difference.

Crisis Planning Teams: As former U.S. President Dwight D. Eisenhower once said, “Plans are useless – but planning is indispensable”. The simple act of proactive planning helps us to become better prepared and more successful at responding to chaos. All healthcare systems need to maintain Crisis Planning Teams. The mandate of a crisis planning team is to identify policies, practices, tools, and technologies that, when implemented, will enable frontline healthcare staff to better respond to future outbreaks. As part of this activity, the team needs to simulate mock codes to hospital staff. We need both planning and practice in implementing the plans – and in knowing how to adapt when the world works in ways that the plans do not expect.

As we think about planning for crisis management, let’s take to heart a recent internet meme: “Remember how it feels like working as a health care professional during the COVID-19 pandemic? Remember the band playing on the Titanic while the ship was sinking, and they just decided to continue to play? Yes, that’s us!”

This is the inconvenient truth: the healthcare system is being overwhelmed by the influx of new COVID-19 sufferers, but we are still playing the same tunes — operating at the same capacity and using the same mindsets — as before the outbreak. We need to reduce the need to bail out the ship so rapidly by flattening the curve.

Epidemiologists use “flatten the curve” as a strategy to reduce the number of people who are simultaneously getting sick and overwhelming the hospital system, so that the number of patients stays below capacity. Tactics such as social distancing and limiting the frequency and size of public gatherings, including schools and sporting events, are some recent examples of effective ways of flattening the curve.

We cannot simply try to flatten the curve by forcing frontline staff to work harder. Instead, we need planning for surges that allow us to respond more effectively. If not, then mandatory on-calls, overtime, and nursing shortages — all of which I have experienced — will result and compromise both patient and staff safety. Therefore, flattening the curve by getting ahead of the game is a must.

Telemedicine beyond and within the walls: Telemedicine has huge potential to increase both the scope and safety of our responses. Reaching patients in the community maintains the safety of the hospital and staff while increasing access to care. This practice allows the patient to receive care remotely while simultaneously limiting everyone’s exposure to their underlying illness. It also allows the hospital staff to make referrals as needed.

In addition, with increased patient needs and staffing issues, telemedicine within the walls of the hospital will be beneficial in the ICU, as Margaret Rouse recently discussed.[i] For instance, having a remote critical care nurse from the telemedicine side can be an extra set of eyes for the primary care nurse at the bedside. Additionally, if the bedside nurse needed help inside the isolation room, he/she needs the ability to communicate with the other primary team aside from the use of portable phones or call bell. Nurses are natural innovators, and temporary solutions we came up with at my current facility include walkie-talkies and baby monitors inside COVID-19 isolation rooms. There are many opportunities to add more ways of communicating, both in real time and asynchronously.

Flexible use of skills: To be most effective, we need to use all the skills of all the people in the health care system. This means having flexible licensures among MDs, APRNs, and RNs so they can serve patients in multiple states. For instance, travel nurses should be redeployed to the hardest hit areas of the country.

Unfortunately, under current regulations, many of the hardest-hit states in the U.S. are non-compact states (e.g., Washington, New York, Massachusetts), meaning that doctors and nurses will have to reapply for licensure in the state before they can begin their practice. As a result, states with low numbers of COVID-19 cases and staff surpluses cannot reinforce the hardest-hit, non-compact states. We need to relax this requirement now to set up the ability for people to adapt more flexibly in the future.

Looking Forward

Effective solutions to the COVID-19 pandemic and similar challenges in the future will require both technical and organizational responses. Leveraging technology and analytics to drive proactive change helps mitigate the risks of uncertainties. We have more resources than ever to stay connected, make informed decisions, and support each other. At the same time, we need to rethink regulations and organizational norms that get in the way of our ability to use our technical and personal skills.

Let’s use our resources in the way that they can have the most impact. And most importantly, don’t forget to wash your hands.

[1] The views and opinions expressed in this article are mine alone, and do not represent the opinions of my employer.

[2] https://searchhealthit.techtarget.com/definition/Electronic-Intensive-Care-Unit-eICU