It was late March 2020. Covid-19 had landed in the US, had washed through Seattle and ventured into the Big Apple, though as yet had only killed a few hundred New Yorkers. As the month drew to a close, Covid also made its debut in Philadelphia. Scientists around the world were playing catch-up with the little data that was available. And Temple University Hospital now opened its Boyer Building as a dedicated ICU for Covid-19 patients.
When Nurse of the Week Marissa Pietrolungo, BSN, MSN, CCRN, a 29-year-old cardiac care ICU nurse at Temple, arrived for her shift, she could see that her manager was troubled. More was awry than the usual headache of a shift being short one nurse. Much more. With the Boyer Building opening their doors for SARS-CoV-2 patients, the nursing staff was suddenly in need of 14 additional qualified nurses.
Pietrolungo automatically volunteered, and that same shift, she embarked on her first-hand experience with the soon-to-be-called “unprecedented event.”
During those initial Covid patient encounters, she knew enough—in the abstract, at least—to be well frightened. Pietrolungo told Temple’s Narrative Medicine Program (NMP), “The first time I went in the room, I was like `Oh my gosh, trying not to breathe.’ But there’s no way you can do that. And I’m in that room so much that I just honestly hope that my protective gear is protecting me.”
At first, things could be a bit surreal, but it wasn’t overwhelming. Pietrolungo says she started with an essay at preventive dentistry: “The first day, I did something simple like help my patient brush her teeth. She’d been in there for three days, but we were all so worried about transferring the disease that I don’t think anyone had thought about brushing her teeth. I brought in a toothbrush and toothpaste and mouthwash, and I set her up on the end of the bed. She was a Spanish speaker and we couldn’t really communicate, but she kept blowing me kisses.”
The lull was over quickly. As the Temple NMP’s writer described it, “Things in Boyer changed fast. The hospital filled with extremely sick COVID patients, many on ventilators. Normally, a cardiac intensive care nurse at Temple will care for one patient, sometimes two. Pietrolungo was soon caring for three ICU patients at a time – and quite often three to a room.”
But as things got worse, something seemed to compel her to fight harder to care for each of her patients and do whatever had to be done to help everyone through the long ordeal. Pietrolungo took initiative in devising ways to optimize the ward to function in worsening crisis conditions. She recalled for one interviewer that “We transitioned the rooms from holding one patient per room to holding two to three patients per room with makeshift curtains. We also turned the operating rooms into suites that would hold up to four patients on ventilators.”
When she was not strategizing or tending to a patient, Pietrolungo did whatever else had to be done. She emptied trash, mopped floors, recruited fellow nurses to take shifts in Boyer, held terrified patients as they struggled to breathe, and tended to the care and final comforts of the dying. In fact, she was the bedside nurse for 15 different Covid patients as they drew their last breaths, holding a mobile phone screen up so they could see their families one last time.
Looking back, she’s still not sure whether she contracted Covid herself during that insane spring, but there is no uncertainty in her description of her experience. The masks hurt. Wearing PPE for 12 hours is stifling. You have to confront fear before and during every shift, and every time you go home. You lose an unbearable number of patients, and it’s hard each time. What kept her going?
Pietrolungo says, “I go back to our responsibility to the patients… [who] are very sick and can take a turn for the worse in an instant.” And you have to marshal your fears; it’s the only way to get the job done. “Each time you enter the room, you are coming into direct contact with the disease, and you have to be okay with that risk to perform your job. If all I focused on was contracting the virus, I would not have been able to be the best nurse for my patients … I took care of my COVID patients like I would have taken care of anyone else.”
Congratulations, Marissa, for setting such an outstanding example of nurse leadership—and for the exceptional patient care, of course!
For a list of all ANN Covid Courage Award winners, click here.
As a nurse, you care not only for the patient in the bed, but for the family of the hospitalized patient. Caring for families whose loved ones are in intensive care carries special challenges as the family members deal with the stress of having their acutely ill loved one occupy a terribly unfamiliar setting filled with complex, off-putting medical devices.
To reduce the stress those families experience, nurses should focus their interventions on valuing the role of family members in patient care, improving communication and providing accurate information, according to the results of research published in the February 2021 issue of Critical Care Nurse.
A change in parental role or family dynamics: nurses should allow family members to be present at any time at the patient’s bedside and on the unit.
The appearance and behavior of the patient: nurses should provide information about specific changes observed and encourage asking questions about them.
The care setting: nurses should explain the specific features of the setting, providing reassurance that it is normal for family members to require clarification and repetition of information.
Communication and counseling with the healthcare staff: nurses should establish a communication channel with family members and adapt information to their level of stress and ability to understand the situation.
Unlike other research, this paper groups findings together from neonatal, pediatric, and adult ICUs, instead of looking at each setting separately, notes coauthor Valérie Lebel, Ph.D., RN, professor, Department of Nursing, Université du Québec en Outaouais, Quebec, Canada, herself a neonatal intensive care nurse.
What’s more, previous research typically doesn’t define the concept of “family,” she notes in an interview. “As nurses, you have to adapt your intervention to the type of family,” she says. For instance, a nurse can ensure that a family who might be socioeconomically disadvantaged could have free hospital parking or tickets for a meal. “If you don’t adapt your intervention to your family, it’s really hard to make sure that you really have a partnership with them,” Lebel says.
With COVID, the interventions discovered by the paper, which was done before the pandemic, might be difficult to execute, Lebel notes. “It’s really hard right now to make sure to apply all those interventions,” she says. Still, the nurse needs to find a way to team with the family “no matter what.” If the family cannot be with the patient because of COVID restrictions, the nurse “should find a way to team up with them anyway, to give them information, and to make sure they understand what’s going on.”
Fall prevention and mitigation of patient injury if a fall does occur is a critical part of a hospitalized patient’s plan of care. Having a comprehensive strategy in place to prevent in-hospital falls has grown challenging in recent years. Patients are getting older and sicker, the nursing workforce is aging, and of course, hospitals and caregivers are wrestling with the enormous pressures and limitations created by the pandemic. To work around these obstacles, the healthcare industry must become more aggressive in its approach to fall prevention and improving patient outcomes.
Not only is the cost of these falls to the healthcare system enormous—$20 billion annually—but the Centers for Medicare and Medicaid Services (CMS) is no longer reimbursing providers for treating patient injuries resulting from falls in a hospital.
For patients, the long-term effects of falls can be debilitating. Caregivers are also equally impacted. From a personal perspective, during my time working at the bedside on a MedSurg unit, I have personally experienced two patients falling during my watch. It is something I will never forget from an emotional perspective, and how draining it was on both the individual and team morale on the unit. My current clinical work today is in the hope that no other nurses or patients have to endure another patient fall.
Today, the criticality of patients is increasing. Nurses are seeing sicker patients than ever before. Patients are also living longer, with those 65 years and older representing nearly 40 percent of hospitalized adults. Nurse-to-patient ratios have also gotten out of balance, which can lead to fatigue, burn-out, and mistakes. In my experience, on any given night, a Med/Surg nurse could have up to eight patients at one time in his or her care. When you couple this with the fact that the nursing workforce is aging, a potential shortage could also pose big problems. The onset of COVID-19 has also presented its set of challenges.
For nurses, the restrictions that caring for a patient in the COVID “bubble” has placed on them–from donning and taking off PPE to the limited interaction they can have with patients–is something very new and hard to navigate. These protocols can leave patients susceptible to falls. Additionally, there are concerning reports that many COVID patients experience delirium, which also elevates the risk level for falls.
There are a number of ways hospitals can address these challenges to help improve patient outcomes.
One of the most important is improving bed technology—including standardization and interoperability. One studyshowed that 79% percent of falls were unassisted. In addition, 85% of falls occurred in the patient’s room. The problem is many hospitals today use multiple generations of beds, all with varying degrees of technology and options. This makes training on beds much more challenging. Hospitals should consider standardizing their beds to one specific kind, as this helps support a nurse’s interaction with the bed becoming a hardwired process and promotes easier decision-making. Thankfully, technology has arrived to help achieve these ends.
Stryker, for example, just came out with a new bed, the first of its kind, that can connect wirelessly to any nurse call system and can be used for all acuity levels. Called ProCuity™, this “intelligent” hospital bed not only helps alert nurses if a patient is out of position or has left the bed, it also eliminates difficult tasks like ensuring a nurse call cable is properly plugged in. By streamlining usability, training, and maintenance, technological advancements like this help hospitals make their beds work better for patients and staff.
Another important fall prevention strategy is data analysis. Numbers don’t lie and so one of the best ways to ensure a hospital’s fall prevention strategy is on track is to routinely monitor and analyze data around fall rates. By determining the cause and type of falls that occur, hospital administrators have a 360-degree view of the issue and can take forward-thinking action to prevent reoccurrence.
Communication is also paramount. When a fall occurs, all appropriate stakeholders in charge of a patient’s care should conduct post-fall huddles to assess all the factors that contributed to the accident and plan an appropriate mitigation strategy. Effective after-action review may also improve team performance by 20-25%. Likewise, nurses should communicate with their patients—what I call teach-back education. By asking open-ended questions about their well-being and state, nurses can help identify potential fall risk problems beyond just finding a shaky grab bar in the bathroom.
When it comes to fall prevention, there is no one size-fits-all-plan. But as the pandemic and other healthcare challenges have shown us, we can no longer be reactive in our planning. With better technology, more data, and increased education and communication, we can more quickly reach our desired outcomes—improving the safety of our patients and caregivers.
A slumber party to celebrate Delaney DePue’s 15th birthday last summer marked a new chapter — one defined by illness and uncertainty.
The teen from Fort Walton Beach, Florida, tested positive for covid-19 about a week later, said her mother, Sara, leaving her bedridden with flu-like symptoms. However, her expected recovery never came.
“There’s just no research there. Kids are not supposed to have this kind of condition.”
Delaney — who used to train 20 hours a week for competitive dance and had no diagnosed underlying conditions — now struggles to get through two classes in a row, she said. If she overexerts herself, she becomes bedridden with extreme fatigue. And shortness of breath overcomes her in random places like the grocery store.
Doctors ultimately diagnosed Delaney with COPD — a chronic lung inflammation that affects a person’s ability to breathe — said Sara, 47. No one has been able to pinpoint the cause of her daughter’s decline.
“There’s just no research there,” she said. “Kids are not supposed to have this kind of condition.”
While statistics indicate that children have largely been spared from the worst effects of covid, little is known about what causes a small percentage of them to develop serious illness. Doctors are now reporting the emergence of downstream complications that mimic what’s seen in adult “long haulers.”
In response, pediatric hospitals are creating clinics to provide a one-stop shop for care and to catch any anomalies that could otherwise go unnoticed. However, the treatment offered by these centers could come at a steep price tag to patients, health finance experts warned, especially given that so much about the condition is unknown.
Nonetheless, the increasing number of patients like Delaney is leading to a more structured follow-up plan for kids recovering from covid, said Dr. Uzma Hasan, division chief of pediatric infectious diseases at St. Barnabas Medical Center in New Jersey.
“The cost of missing these children means a horrible event,” she said.
Over the course of the pandemic, though, it has become apparent that some children develop serious and potentially long-term problems.
The most well-known of these complications is called “multisystem inflammatory syndrome in children,” or MIS-C. Symptoms — which include high fever, a skin rash and stomach pain — can appear up to a month after getting covid. Around 2,000 cases have been identified in the United States. Black and Hispanic children make up a disproportionate share: 69%.
More than 3 million children and young adults had tested positive for covid in the United States as of Feb. 18, the American Academy of Pediatrics and the Children’s Hospital Association report. Most of these kids experience mild, if any, symptoms.
But clinicians also said they’re increasingly hearing of children seeking help for different complications, such as fatigue, shortness of breath and loss of smell, that don’t go away.
Clinics for Child Long Haulers
At Norton Children’s Hospital in Louisville, Kentucky, clinicians set up a clinic in October after receiving calls from area pediatricians who had patients with long-haul symptoms.
No one knows how often children develop these symptoms, how many already have the illness or even what to name it, said Dr. Kris Bryant, president of the Pediatric Infectious Diseases Society, who works at the hospital.
The children see an infectious diseases doctor who then refers them or orders tests as necessary.
So far, the clinic has seen about 25 patients with a wide range of symptoms, said Dr. Daniel Blatt, a pediatric infectious diseases specialist involved with the clinic. Because covid mimics symptoms associated with a variety of other illnesses, he said, part of his job is to rule out any other possible causes.
“Because the virus is so new,” Blatt said, “there’s a presumption that everything is covid.”
Similarly, an ad hoc clinic for other young patients has been set up within the cardiology department at the Children’s Hospital & Medical Center in Omaha, Nebraska. Patients are screened to assess the heart’s structure and how it functions. She said they’ve been seeing six to eight patients per week.
“The question I can never answer for the parents,” said Dr. Jean Ballweg, a pediatric cardiologist at the hospital who also works at the clinic, “is why one child and not another?”
So far, Ballweg said, she’s seen no published literature on the heart health of children who develop these symptoms after recovering from covid. By standardizing how doctors in the clinic collect data and treat patients, Ballweg said, she hopes the information will provide some clues as to how the virus affects a child’s heart. “Hopefully, we can look at the collective experience and recognize patterns and provide better care.”
University Hospitals Rainbow Babies & Children’s Hospital in Cleveland is involved in creating a multidisciplinary clinic that will consolidate care by giving patients access to specialists and integrative medicine like acupuncture.
Clinicians saw a need for the unit after teenagers with post-covid symptoms began arriving at the hospital system’s clinic for adults with long-haul symptoms, said Dr. Amy Edwards, a pediatric infectious diseases specialist at the hospital involved with the project. So far, she said, she’s heard of about eight to 10 children who could need care.
The clinic, yet to open, intends to recruit more children through announcements, said Edwards. Identifying the right patient for the clinic will be complicated, she added. There’s no test to check for post-covid symptoms and there’s no agreed-on definition for the condition. Doctors also don’t know whether some symptoms can be cured, she said, or last a lifetime.
“The question is if we’re going to be able to do anything about it,” Edwards said.
‘I Don’t Know’ Is a Difficult Answer
Even Dr. Abby Siegel, a 51-year-old pediatrician who works in Stamford, Connecticut, couldn’t find answers for her daughter. Siegel tested positive for the virus last March after being exposed at work. She believes she passed on the virus to her husband and their then-17-year-old daughter, Lauren.
The family recovered by early April, but then both Siegel’s daughter and husband took a turn for the worse. Lauren — who played rugby — started feeling fatigued, shortness of breath and a racing heart rate. Siegel took her to multiple specialists — including a friend who is a cardiologist — all of whom doubted her.
Lauren, now 18, receives care at Mount Sinai Hospital’s adult covid care center and is improving. Siegel said the clinic has affirmed her daughter’s experience and helped her get more information about this condition. She wishes the doctors they had visited earlier had been more honest about the unknowns surrounding post-covid health problems.
“It’s amazing how we’re met with the denial rather than the ‘I don’t know,’” she said.
There’s another wrinkle that often comes with the I-don’t-know response.
The uncertainty swirling around these symptoms in children will likely require clinicians to run a battery of tests — procedures that could potentially cost their families a lot of money, said Glenn Melnick, a health economist and professor at USC Sol Price School of Public Policy. Pediatric hospitals usually have little regional competition, he said, allowing them to charge more for their specialized services.
For families without comprehensive health insurance or who face high deductibles, many tests could mean big bills.
Gerard Anderson, a professor of health policy and management at Johns Hopkins University, said these clinics’ potential profitability hinges on several factors. If a clinic serves a large enough area, it could attract enough patients to earn substantial dollars for the affiliated pediatric hospital. A child’s health care coverage plays a role as well — those who are privately insured are more lucrative patients than those covered by public programs like Medicaid, but only as long as the family can shoulder the financial burden.
“If I had a kid who had this problem,” said Anderson, “I’d be very concerned about my out-of-pocket liability.”
Published courtesy of KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
In the best of times, patients with mental health issues face challenges in finding support. Cuts in community services and limits on long-term care facilities can mean difficulty in accessing mental health services. As a consequence, those patients may find themselves being cared for in acute-care psychiatric hospitals or units.
Add a pandemic to the mix, and the dilemma for patients needing inpatient psychiatric care gets far worse. “It’s getting to somewhat of a crisis point,” says Judy L. Sheehan MSN, RN-BC, Director, Nursing Education at Butler Hospital in Providence, Rhode Island. Sheehan, a nurse since 1977, is primary editor of the forthcoming Inpatient Psychiatric Nursing, second edition.
Inpatient psych hospitals are under significant strain from COVID. For example, the governor of Virginia stopped admissions to psychiatric hospitals to lessen the spread of COVID, according to an article in STAT. In Kingston and Brooklyn, NY, psych units were closed to increase capacity for COVID patients, the story notes.
At Butler, a nonprofit, free-standing psychiatric hospital, the patient census was frequently at or above capacity. A patient who develops or begins to show COVID symptoms has to be quarantined, meaning that two patients cannot be in the same room, notes Sheehan. Similarly, if an admitted patient initially tests negative for COVID but then tests positive in two or three days, the patient would need to be isolated to a single room and no other patients would likely be admitted to that unit.
What’s more, while COVID patients who do not need psychiatric care can go to a field hospital, “there are no field hospitals set up for psychiatric patients who have COVID or are recovering from COVID,” Sheehan says. “When someone is a psych patient, it’s challenging for the medical environment to care for them in a way that deals with the psychiatric symptoms in the same way that it might be done in the psychiatric hospital.”
The length of the pandemic has also taken its toll, with patients suffering from mental health sequelae from COVID, notes Sheehan. “We’re starting to see more people with anxiety disorders who may never have come into the psych facility before.”
Add to this the impact on healthcare staff. As the virus spread through the community, Butler staff found themselves unable to work due to exposure to the virus or because of their becoming infected. That has since improved, but now Butler is dealing with staff out of work due to the side effects of the COVID vaccine.
Telemedicine and outpatient programs can help relieve the burden, says Sheehan. “I think that telemedicine is going to continue,” she says. “I hope that people begin to replace some of the discharge options for people out in the community. It’s hard for people who need sustained help,” she says.
Strengthening the concept of integrated multidisciplinary care can help mental health institutions deal with patients with medical diseases, notes an article in Translational Psychiatry, which offers recommendations learned in China.
Fortifying community-based mental health services, full use of information technology, and strengthening the coordinating role of government are other recommendations the Translational Psychiatry paper makes.
“Psychiatric patients do in fact have medical issues, and medical patients do in fact get psychiatric issues. So we’ve got to be more integrated in our approach. We have to be able to become well-versed in both behavioral health and medical care,” Sheehan says.
The health care system has been significantly impacted by the volume of patients in need of critical care services. Hospitals in geographic areas with large spikes in cases have experienced bed shortages and supply chain issues, specifically with needed PPE, staffing shortages and even a loss of staff due to COVID-related deaths.
Vaccine distribution and inoculation has launched in many geographic areas and scientists are studying treatments that are most effective for those receiving care for complications, but there is still a dire need to treat incoming patients. At the time of this article, the World Health Organization (WHO) reports more than 100 million confirmed cases of COVID-19 and more than two million deaths worldwide. The U.S. represents more than 25 million of those cases and more than 400,000 deaths. There have been three known variant strains identified in the U.K., South Africa and Brazil which seem to spread easily, leading to additional spikes in cases and a dire need for treatment worldwide.
Hospital executives are working quickly to mobilize all available resources to meet patient care demands, impacting the entire continuum of care. With widespread systemic nursing shortages and burnout already a severe issue, health care systems face a significant challenge in responding to the pandemic and extreme staffing needs. Executives are expediting resource planning and mobilization strategies to combat the strain put on nursing resources, implementing multi-modal strategies to manage these shortages. Examples include:
Surge Planning for Critical Care Units
Many organizations are conducting evaluations of all available nurses with previous experience in critical care, specifically within the last three years, and mobilizing them into critical care units. Hospitals are also recruiting from adjacent areas such as the operating room or the emergency department, where nurses experienced in urgent care can be mobilized into critical care environments.
Use of Traveler Nurses
Traveler nurses represent a growing trend in healthcare however due to COVID-19, the need to mobilize nurses is even more crucial. Traveling nurses often relocate where they can make the most salary, leading health care systems to compete to obtain travelers for their staffing needs. Traveler nurses also relocate to the greatest areas of need (generally large urban area hospitals), leaving smaller community hospitals with even greater staffing challenges.
Developing New Care Models
Nursing leaders are utilizing telemedicine approaches, remote electronic ICU monitoring and virtual nursing services, which support staffing models and leverage the most experienced nurses for ICU monitoring. Interprofessional team-based care models can support staffing by aligning scope of licensure to patient care needs, counteracting spikes in COVID-19 patients across the care delivery system.
To be successful at meeting this important call of duty, nurses require support from leadership to meet their obligations. Nursing leaders are called on to manage workforce preparedness and meet staff competency needs and staffing demands. We are seeing various workforce preparedness initiatives implemented across the health care system, including:
Evidence-based Knowledge Dissemination
Research continues to emerge related to the novel coronavirus. Recommendations for testing, treatment options and prevention interventions such as vaccinations are coming in at a rapid rate. This new knowledge needs quick dissemination using the right tools to distribute at a fast, accurate pace to help keep nurses informed on evidence that impacts patient outcomes.
Skills training programs are being implemented to re-teach and reinforce basic nursing competencies and skills. These programs help mobilize nurses who have not been at the bedside recently and need a quick refresher to effectively assist with patient care staffing needs.
These types of programs help facilitate rapid validation of clinical competency. Evidence-based competency skill checklists and courseware is a great approach to meet the needs of upskilling and prepare a broader workforce for staffing availability during high census. In my work with nursing education leaders, the following competency topics were the most requested in 2020:
SARS Cov2 Coronavirus (COVID-19) Overview
Mechanical Ventilation Care
Donning and Doffing PPE
Nasopharyngeal Specimen Collection
IV Medication Administration
Blood Product Administration
IM Vaccine Administration
In 2020, we celebrated the “Year of the Nurse & Nurse Midwife.” The pandemic shines a positive light on the nursing profession and reinforces the importance of clinical practice and leadership. Nurses in all roles have leaned into their roles, sacrificing their own safety and well-being for the cause. Nursing is truly a calling.
Nurses have a very important and impactful role during the coronavirus pandemic. They are resilient and service-minded, putting the needs of others above their own. The pandemic has reinforced the importance of workforce preparation, mobilization of resources, and support for continuous learning and competency. We know what works and how to move quickly should we experience another pandemic. The lessons we have learned as a profession during this crisis will not be wasted and should propel quicker response and further preparedness expectations for the next call to action.