With the influx of patients, the critical care division quickly tripled in size, caring for over 150 patients at the peak of the surge. Approximately 120 patients required ventilatory support on a daily basis. This was greater than six times the normal volume. Given that there were no proven treatments for COVID-19, the team focused on supportive care including oxygen therapy, multiple medications, extracorporeal membrane oxygenation (ECMO), continuous veno-venous hemofiltration (CVVH), and prone positioning (Khan et al., 2020). All of these treatments were intricate and clinically challenging, which required an enhanced nursing skillset. It quickly became evident that we needed an effective nursing plan to manage the surge and complex needs of the COVID-19 patients.
Background: According to the Association for Professionals in Infection Control and Epidemiology (APIC), a pandemic is a global disease crisis or outbreak that affects a wide geographical area and a large number of people (APIC, 2014). In a global pandemic, there are a large number of deaths as well as social and economic disruption (APIC, 2014). In a systemic review by Pasquini-Descomps, Brender, and Maradan (2017), the last noted global health concern was the influenza pandemic of 2009 known as the H1N1 crisis. It was noted during this pandemic that there were significant impacts on health care including the need for increased hospitalizations, isolation of patients in hospitals, and increased vaccine and antiviral stockpiling. There were considerable social impacts such as airport screening, school closures, social distancing, masking, and shelter-in-place orders (Pasquini-Descomps et al., 2017). The COVID-19 pandemic shares similarities with the H1N1 crisis in terms of the social, financial, and global health impact.
Significance: The acuity and volume of patients that were admitted to critical care units at such a rapid pace during the COVID-19 pandemic posed many issues. The increasing patient volume coupled with an expansion of the division from four to ten units made staffing very difficult. The critical care division typically required 24 nurses on average per shift. At the peak of the pandemic, staffing requirements exceeded 50 nurses per shift. The units were staffed with a combination of seasoned and novice ICU registered nurses (RNs), contracted agency nurses, and redeployed RNs and ancillary staff with and without ICU experience.
Interventions: Developed during World War II, team nursing was a care model where a team of nurses and aides cared for a group of patients together (Duffield et al., 2010). The lead RN supervises the lesser-skilled staff in order to have a more effective and efficient use of staff (Duffield et al., 2010). According to Dickerson and Latina (2017), team nursing led to an increase in staff satisfaction, morale, and patient safety. Over a 90-day period of implementing a team nursing care model that involved having two RNs per patient, one novice and one experienced, staff satisfaction increased by 11%. Under the team nursing model, novice nurses reported feeling more supported and felt they had better opportunities to learn efficient strategies. The study also reported having zero patient falls over a three-month period, which supported the claim of increased safety (Dickerson and Latina, 2017). Although Duffield et al. (2010) suggested that team nursing is an older care model, the team nursing approach allowed the critical care division to tackle the large influx of patients with varying acuity levels. The team nursing care model helped with the reality that staffing was stretched beyond capacity and the traditional nursing care model would not have accommodated the heavy workload and complexity of care. A team nursing approach was adopted to manage the volume and patient acuity at LIJMC. Nurses from different specialties such as pediatric ICU, the operating room, and the emergency department served as functional or task RNs in the units. They worked alongside lead critical care nurses and assisted with tasks like finger sticks, documentation, and tube feedings. Team nursing allowed the primary nurse to spend less time away from the patients or performing lower-priority tasks, and more time performing complex interventions like patient monitoring, initiating and titrating medications, obtaining emergent blood specimens, and communicating with the interdisciplinary team about the rapidly changing plan of care. Patient care assistants served as integral parts of the nursing team. They were utilized for stocking supplies, performing activities of daily living with patients, equipment and patient transport, and assisting with FaceTime communication with families, as no visitors were allowed in the building.
Evaluation: Ma, Park, and Shang (2018) posited that employees work best in an environment with good interdisciplinary collaboration where each member of the nursing team feels that their contributions are valued and respected. Surgical ICU nurse Kaitlin Hendricks recalls how helpful the team nursing approach proved to be during the COVID-19 pandemic. According to Kaitlin, the team nursing approach was helpful especially on days where she was the primary nurse assigned to care for four critically ill patients. According to Kaitlin, without implementing the team nursing care model, this seemingly impossible situation would have actually been impossible. Jamie Roggio, cardiothoracic ICU nurse, noted that she saw that power of teamwork in one of the many pop-up ICUs. With the help of nurse managers, hospital directors, and environmental and engineering services, this newly renovated space became a fully functioning critical care unit. Jamie echoed Kaitlin’s feedback that functional nurses in a team nursing model helped to alleviate the workload and her stress level. Having a functional RN to perform what seemed like minor tasks like readjusting pillows, changing a patient’s gown, and hanging a new bottle of a medication allowed her to focus more on the patient’s clinical course. Dhalia Puri, pediatric ICU RN, served as a functional nurse during the height of pandemic. In her role she performed patient baths, postmortem care, and finger sticks, and changed bags on continuous infusions of lifesaving medications. As a functional nurse, Dhalia felt that the team nursing approach and collaboration was key.
Conclusion: With the patient volume surging to three times the norm in critical care, the division leaders were forced to come up with a plan to provide safe and quality care. What was old became new again; the team nursing care model helped to safely care for patients and staff. Through a team nursing approach, the teams were able to successfully divide and conquer. During several debriefs held following the peak of the crisis, the team overwhelmingly stated that the team nursing approach assisted with staff engagement, team building, stress reduction and burnout, improved patient care, and improved overall staff well-being.
References: Dickerson, J., & Latina, A. (2017). Team nursing. Nursing, 47(10), 16–17. doi:10.1097/01.nurse.0000524769.41591.fc Duffield, C., Roche, M., Diers, D., Catling-Paull, C., & Blay, N. (2010). Staffing, skill mix and the model of care. Journal of Clinical Nursing, 19(15–16), 2242-2251. https://doi:10.1111/j.1365-2702.2010.03225.x Kaufman, M. (2020, July 15). LIJ Ranks 2nd Citywide For Number Of Coronavirus Patients. Patch.com Khan, I., Zahra, S., Zaim, S., & Harky, A. (2020, May 05). At the heart of COVID‐19. https://onlinelibrary.wiley.com/doi/10.1111/jocs.14596 Ma, C., Park, S. H., & Shang, J. (2018). Inter- and intra-disciplinary collaboration and patient safety outcomes in U.S. acute care hospital units: a cross-sectional study. International Journal of Nursing Studies, 85(1–6). https://doi.org/10.1016/j.ijnurstu.2018.05.001 Association for Professionals in Infection Control and Epidemiology. (2014). Outbreaks, epidemics and pandemics—what you need to know. https://apic.org/Resource_/TinyMceFileManager/for_consumers/IPandYou_Bulletin_Outbreaks_Epidemics_Pandemics.pdf Pasquini-Descomps, H., Brender, N., & Maradan, D. (2017). Value for money in H1N1 influenza: a systematic review of the cost-effectiveness of pandemic interventions. Value in Health, 20(6), 819–827. https://doi:10.1016/j.jval.2016.05.005