Lessons learned after six months at war with COVID-19

Safe environment

Robust systems acted quickly to create negative pressure units for isolation of COVID-19 patients. These patients were separated from the general patient population with specialized staff caring for them. Normally, negative pressure isolation is offered in only a handful of hospital rooms. Creation of negative pressure units, where staff are in respiratory airborne PPE at all times while on the unit, ensured isolation would not be breached. Each staff member was provided hospital-issued scrubs and adequate airborne PPE. Staff had a choice between a PAPR, N-95 mask or a Draeger. Each type of protection has its strengths and weaknesses. I personally don’t like PAPRs because the motor makes it difficult to hear and I don’t like the cold air blowing on the back of my head. Many prefer PAPRs to N95s because the N95 leaves the user with abrasions on the face after a 12-hour shift. Staff in robust systems were offered adequate PPE and choices of how they were protected, taking into account variables like face shape, facial hair, and personal preference. In this system, I always had access to a new N95 on every shift. In other hospitals, I was told that only physicians had access to PAPRs, despite the fact that nurses spend exponentially more time at the patient bedside. In these hospitals, I was expected to wear a N95 for 2–3 weeks, and to switch to a surgical mask in the hallway outside of patient rooms. This requirement, especially when coupled with inadequate staffing ratios, led to staff touching their faces often and many breaches in PPE which led to infection of the staff.

PPE in robust systems were managed by PPE safety officers (PSO). Each COVID-19 unit has at least one PSO who is based in the donning/doffing area just outside the unit. They are responsible for checking PPE, cleaning and charging PAPR’s, ensuring adequate supplies of PPE, as well as managing supplies and medication that enter and leave the unit. Pharmacy techs drop off medications to the PSO who then deliver it to nursing. The PSO runs specimens to labs as appropriate, depending on the type of test and its final location.

Reasonable workload and resources

Robust systems saw the writing on the wall early in the pandemic. They immediately began training nurses to work in the ICU, recruiting and hiring experienced ICU nurses, and seeking experienced ICU nurses through staffing agencies. COVID-19 ICU units were purposefully overstaffed to allow staff adequate breaks, to take into account the higher acuity and increased task load with COVID-19. Resourceful units maintained adequate staffing ratios: 2 patients to 1 nurse, except in cases requiring continuous renal replacement therapy or prone positioning which created a 1:1 assignment. Charge nurses were not assigned patients, making them available to troubleshoot unit needs and act as a resource for patient care. There were also extra nurses who did not have a specific patient assignment and acted as a respite or resource nurse. It was their responsibility to circulate around the unit and help with patient care. They checked in on staff, helped manage emergencies, and ensured everyone received adequate breaks.

The workload in a COVID-19 ICU is very different than typical ICU care. First of all, every patient is seriously and unpredictably sick. Emergencies happen quickly and often. As an experienced ICU nurse, I can manage heart attacks and strokes and post-operative care because I’ve seen them countless times. I know what to expect. No one knew what to expect with COVID-19. Some patients have arrhythmias. Some patients require dialysis. Some patients bleed out. Patient condition changes quickly and often. You’re always on your toes. You are working in full PPE: A mask or PAPR, face shield, heavy plastic gown, multiple pair of gloves, and the loud motor creating negative pressure. This makes it difficult to see, hear, communicate, and perform manual tasks. It’s hot and exhausting.

Understanding that even the simplest tasks will be more challenging and take longer, robust systems adjusted policies and workflows to support nursing care. Cosigning policies were adjusted to require cosigning for only heparin and propofol. This limits the amount of times nurses enter different COVID-19 rooms, and simplifies the task of giving the medication. Robust hospitals also reprioritized documentation practices and relaxed standards on extraneous documentation, like Epic care plans. In another hospital, I was running between two rooms, assisting with intubation of one patient and titrating vasoactive medication in another. The charge nurse stopped me to tell me I hadn’t edited my care plan appropriately.

Staff support

Understanding that staff are their greatest resource, robust systems have gone above and beyond to support staff caring for COVID-19 patients. Adequate staffing and support staff ensure nurses are supported in emergencies. Respite or resource nurses rounding ensure staff take adequate breaks. The hospital recommends nurses leave the unit, remove their PPE and drink water at least every 2–3 hours. To support this recommendation, the hospital provided adequate staff to cover breaks, to ensure staff care for themselves as well as their patients. Respite rooms were created with music, donated food, and ample water and coffee, with tables set up for social distancing.

Nurses during this pandemic are experiencing stress, role strain and compassion fatigue. They are coming to work to go toe to toe with the world’s enemy, concerned about becoming infected themselves or infecting their family. Many leave long, exhausting shifts and go home to take care of vulnerable parents, family members and children. They are showing up to work, picking up extra shifts, and navigating the current deplorable state and political climate of the United States, including racial injustice and worrying about how their children will be schooled and cared for. The weight of the world is on our frontline workers, and we must protect them. Robust systems have seized control over the variables they do have control over. They offer counseling services, maintain appropriate workloads during shifts, and ensure staff experience smooth workflows and engage in self-care. Other hospitals are refusing to utilize staffing agencies, firing experienced staff for advocating for reasonable work environments, and maintaining unsafe staffing ratios. A good friend, a single mother, received an email informing her that her employment was terminated while she was home recovering from COVID-19 which she acquired at work.

Nurse burnout has long been an issue in the profession. Burnout leads to increased illness, decreased job satisfaction, increased turnover and, in some cases, a nurses’ decision to leave the profession altogether. This problem is more evident than ever during the pandemic. Healthcare workers are falling ill, mental health crises are on the rise, and units are experiencing increased call outs and resignations. Nurses want to work where they feel safe. The first wave of COVID-19 has stretched until the end of summer 2020 and we suspect an exponentially more catastrophic second wave is coming soon. We can consider this the eye of the storm. We are at war with COVID-19. The pandemic is wearing down our culture by dismantling our vulnerable communities, attacking our economy and disrupting our political landscape. In the hospital setting, COVID-19 is attacking our greatest asset: Our front-line staff. Attrition in warfare is a military strategy where one wears down the enemy to the point of collapse by causing losses in personnel and material. This is a weakness in many systems in the war against COVID-19. While we have a temporary reprieve, it would be wise for systems to act quickly to put structure and policy in place to recruit, maintain and support their front-line staff.