April 1, 2020

'Do your planning now': EvergreenHealth CNO's stark warning to American hospitals

Daily Briefing

    EvergreenHealth, located in Kirkland, Washington, was unexpectedly the first U.S. acute care hospital with COVID-19 patients and has been at the forefront of early learnings ever since. Mary Shepler, CNO at EvergreenHealth, spoke with Carol Boston-Fleischhauer, Chief Nursing Officer at the Advisory Board, about the hospital’s early experiences and key advice she would give to health care executives that are bracing for a COVID-19 surge.

    Slide deck: How to support your workforce and shore up resiliency during an emergency

    Question: Mary, thank you so much for the opportunity to talk about EvergreenHealth's early response to COVID-19 and what you have learned. In many ways your health system is leading the country on this, and leaders would appreciate hearing your story. Could you review what steps you initially took when you realized you had the first U.S. hospital cases of COVID-19? 

    Mary Shepler: As you know, EvergreenHealth was the first hospital to care for inpatients who tested positive for COVID-19. While those first two cases of COVID-19 hit us very quickly—in fact, almost overnight—we had been planning for and anticipating its arrival, just like all other hospitals and health systems across the country.  

    So when we received the positive results for COVID- 19 on the evening of Friday, February 28. We immediately activated a full-scale incident command center, which I believe was one of our early success points.

    To support the needs of these critically ill patients, we rapidly converted a number of our inpatient units to negative airflow; and we designated half of our ICU unit for ICU patients and the other half for progressive care patients. We quickly updated our employees involved in caring for these patients on guidelines being released by the CDC. Subsequently, we also closed off half of the 48 treatment rooms in the ED that also provided negative airflow for the care of COVID-19 patient.

    We also launched a multi-tiered communication strategy. We began immediately with communication to patients who had tested positive and their families; other patients hospitalized in our organization in the ED or other areas of care; our staff who had cared for the positive patients; and all staff and providers. We also prepared for the immediate and ongoing communications to the community at large. 

    Beyond daily updates to our employees and physicians, we needed to work with local and national media in order to support and ensure accurate and transparent information was being shared at both local and national levels. We welcomed the CDC and the health department within days after the first diagnoses. So, another lesson: As you prepare for the surge, be sure you have a communication strategy, for both internal and external audiences. Be prepared to advance a plan and messaging that creates understanding and builds trust though an active and engaged dialogue.

    Q:  It sounds like your incident command center was critical to early decisions.  But, were there any challenges that presented themselves in the first two weeks?

    Shepler: Given that we had two undiagnosed COVID-19 patients in our organization without initial knowledge, one of our trials was determining how to support all of the employees who had been inadvertently exposed.

    Using the EMR as a tracer, we confirmed that approximately 200 employees had been exposed prior to the diagnosis being confirmed, including several physicians. As you can imagine, the consequences of furloughing all employees who had come in contact would significantly impact those staff members and the organization. So, working with the CDC we were counseled that as long as the employees were asymptomatic and wearing appropriate PPE, including a mask, they were safe to come to work.

    As guidelines changed regarding safety practices for employees, our policies changed also—about three times in the first 10 days—resulting in frequent and ongoing communications and, most importantly, adjustments in practice for the staff involved.

    We quickly decided to do active monitoring of all employees, including all those at the bedside. Anyone who touched a patient was having their temperature taken twice a day and their symptoms documented. For testing criteria, we stuck to a temperature of 99.5 or asymptomatic. We have since moved to screening all employees in the organization, and guests and visitors, as well.

    Hindsight being 20/20, we struggled over that first weekend to figure out testing criteria and the process for quickly getting symptomatic employees tested. It was at this point when we also looked into purchasing an in-house analyzer that allowed us to do COVID-19 testing in our own lab—and we were able to get that up and running in a matter of 7 days.

    We also set up two drive-thru testing station processes: one for area first responders and a second for our staff and patients.

    Q: That's a lot of exposed staff. Did you have to augment the workforce with other employees?

    Shepler: Beyond extending traveller contracts, we brought in crisis RNs, which to no surprise, increased the operating expense of COVID—as we've learned about every aspect of our care and operations related to the virus. We also changed the nursing ratios in our progressive care unit, adjusting for patients' acuity and support needed—obviously some patients needing more support than others. 

    Following CDC guidelines, we were early to suspend elective surgeries, and consequently, we've included nurses in the ICU schedule who typically work in the OR or PACU, and we provided educational resources to support their clinical skills to work in acute care areas.

    Q: How are you managing PPE?

    In the first three days we noticed, as expected, our supply was dwindling, so we started even more purposeful conservation methods early and immediately began ordering and purchasing new PPE and other supplies, including ventilators.  We launched a centralized PPE committee that manages the distribution of PPE across departments to mirror patients’ needs. We also provide refreshed training to ensure that everyone knows the importance of appropriately using PPE and is accurately donning and doffing their equipment.

    I’m especially proud of the creativity my team has applied in anticipating our staff’s needs as our patient volume increases. Clinicians use Capris, which safely allow them to share hoods with colleagues and sanitize them as required. Clinicians also now store our N95s in Tupperware containers to ensure they can be safely reused. Additionally, in some cases, we transitioned from exclusively using disposable gowns to using reusable gowns, which allows us to launder them and get them back within 12 hours.

    Q: Now I'd like to shift the focus a bit to discharging COVID-19 patients. Given you're so far ahead of the rest of the country, you're likely one of the first health systems to actively face this question. What have you done to coordinate patient care and transfers to post-acute organizations?

    Shepler: Yes, we have discharged people from our hospital and I think that's one of the stories that’s underreported. Patients get better and go to a post-acute care setting, if not home. So, we standardized a process to carefully manage our discharges, whether from the ED or an inpatient unit, to the correct next level of care.

    Most nursing facilities require two negative COVID-19 tests for a patient to be admitted. While this has presented a challenge, we have found a solution to meet their requirements. So, we work very closely with the receiving post-acute care organization, and we assess each transfer to ensure the care they will be receiving is acceptable for the level of care that they require. To support our patients’ needs, we ensure the post-acute provider has adequate PPE, and if necessary, we help them find the appropriate resources. We can’t afford the post-acute care providers to not be ready, that will only create another surge for us down the line.

    For inpatients discharged to home, our homecare nurses and staff follow up with consistent standard protocols to ensure continued healing. Families of our patients need additional support in the home setting, as well. Emotional support is especially critical as they learn how to take care of their family member as well as themselves, and our home care team is trained to help them learn new protocols for their own safety as well as their loved one’s safety.

    Q:  How are your employees holding up?

    Our employees, physicians, volunteers have been incredible in terms of stepping up over and over to the meet the needs of our patients—and each other—in this community health crisis.

    But they all feel painfully the fear of coronavirus. They fear for the safety of their family and friends, their own personal safety, their financial survival and of course uncertainty about the future we have yet to see, and grief for the loss of a life that is forever changed. Together we are defining a new norm and supporting each other along the way.

    We have continued to put in place support for our employees and physicians. For example, our social work department and behavioral health staff are doing regular debriefs and counseling on the units. We continue to have solid communication channels with all leaders and employees regarding this ever-changing situation.

    What we’ve learned most is that this is a marathon; and every day we look forward to taking on the next two miles. So, you have to focus early and stay with it, learning to pivot and make changes, often working under the pressure of having very little time to act. Managers, as always, bear much of the weight of the changes in routine operations and no less so during a pandemic. Anything that can be done to support their emotional needs and their workloads, beyond operational support, needs to be put in place as well.

    Q: Given that you are one or two weeks ahead of a lot of other hospitals as far as a COVID-19 response, what advice would you offer your peers in other locations?

    Shepler: If I have to pick one point of wisdom for my colleagues, it’s this: if YOU have time, do your planning now. Again, we were a hospital that literally had no warning that we had COVID-19 in our community—and, that COVID-19 was already present in our patients. So, we needed to redesign our entire clinical and support operations within 48 hours, and continue to redesign given the changing guidelines and changing circumstances. There was no map for this marathon we were running in and within an hour of receiving those first two test results. Every hospital in the country is now at various stages of a potential surge, some in dire circumstances; but in many cases, you have some lead time. Use it.

    Monitor the modeling for your community and consider resources—human and material, not just PPE. Be sure your disaster planning structure is in place and that it can be quickly implemented. You've got to think about supplies and not just PPE, but other supplies such as ventilators and EKG pads, medications and the like; supply chain planning is critical. Model the surge and the staff and supplies needed to reflect the needs, and know you are already in the marathon, and have miles ahead.

    Workforce planning, clarity about employee testing criteria, and mechanisms to support employees and physicians getting to work is all important to plan for. Ensuring employees and physicians are safe at work is critical in your initial planning. Think carefully about your staffing model; these patients are extremely ill and require greater staffing than the typical vent patient; so, consider how you will support patient care at the bedside. Who will you redeploy to help with basic physical care and support, and how will your care model change?

    One final point of learning: Plan early with your ethics committee to be prepared should any ethical decisions be necessary that are not routine in nature.  

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