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COVID-19 and Nurse-Sensitive Indicators

Using Performance Improvement Teams to Address Quality Indicators During a Pandemic

Stifter, Janet PhD, RN, CPHQ; Sermersheim, Emily DNP, MPH, RN, NPD-BC; Ellsworth, Mary MSN, RN-BC; Dowding, Erin MSN, APN, ACNS-BC, OCN; Day, Elizabeth MSN, APRN, CCNS, CCRN; Silvestri, Karen MSN, RN; Margwarth, Jessica MSN, APRN, AGCNS-BC; Korkmaz, Kerem MSN, RN, PCCN; Walkowiak, Nicole BSN, RN, CRRN, CWOCN; Boudreau, Lisa MSN, RN, CWOCN; Hernandez, Laura BA, BSN, RN, CWON; Harbert, Bryce MSN, RN; Ambutas, Shirley DNP, APN, CCRN-K, CCNS; Abraham, Aney DNP, RN, NE-BC; Shaw, Phil MEM, ASQLSSBB

Author Information
Journal of Nursing Care Quality: January/March 2021 - Volume 36 - Issue 1 - p 1-6
doi: 10.1097/NCQ.0000000000000523


The COVID-19 pandemic has had a profound impact on many aspects of health care delivery. As of this writing, the SARS-CoV-2 virus has infected more than 24 million people with more than 556 000 deaths worldwide.1 Health care providers are setting precedent by performing interventions that have not been part of our prior practice. From March through June 2020, our academic medical center in a large Midwestern city in the United States cared for more than 6000 COVID-positive patients ranging in age from 21 to 80+ years. We successfully extubated more than 100 ventilator-dependent patients and maintained a mortality rate of less than 11%. Registered nurses (RNs) at the medical center were leaders in convening telehealth ambulatory visits, using prone positioning of our ventilated patients in the intensive care units (ICUs), managing intravenous (IV) pumps in the hallways outside of ICU isolation rooms, and using iPads to create virtual communication opportunities with families during this time of visitor restriction. These innovative approaches to care delivery during the COVID-19 pandemic were our efforts to ensure an ongoing commitment to providing high-quality, safe nursing care.

At our medical center, we have a long history of nursing-shared governance or staff nurse involvement in our performance improvement (PI) efforts. With the discovery of increased health care–associated infections in our COVID-19 ICU patients, we turned to our nursing-led PI teams (eg, wound and skin care, central line–associated bloodstream infection [CLABSI], and catheter-associated urinary tract infection [CAUTI]) comprising frontline practitioners as well as specialty nurses, infection control nurses, clinical nurse specialists, unit leadership, and PI staff to identify redesigned processes to address these patients and their quality issues.

The purpose of this article is to share our first-round experience in caring for critically ill COVID-19 patients. We will describe the work and outcomes of our staff-driven PI teams utilizing the Plan-Do-Study-Act approach to quality improvement. We implemented alternative strategies with small tests of change to care for these vulnerable patients.


Central line–associated bloodstream infection is a significant health care–associated infection impacting patient outcomes. Central line–associated bloodstream infections result in increased lengths of stay, greater health care costs, and higher mortality rates.2 Evidence reveals that most central line infections are preventable, driving health care organizations to implement bundled, evidence-based prevention practices to eliminate these infections. In March 2020, our institution experienced a rise in patients diagnosed with COVID-19. This proved to be a complex patient population that necessitated alterations to our standard approach to central line maintenance and delivery of nursing care. Many of the ICU patients required prone positioning (placing the patient lying flat on their abdomen). This atypical position inhibited the ability to accurately assess central lines and provide the daily chlorhexidine gluconate treatment, required at our organization for central line care. Our CLABSI rates were better than the national benchmark for the first 3 quarters of FY20. This rate increased in the final quarter of FY20 as our patient population changed.

IV pumps outside of patient rooms

To minimize staff exposure and conserve personal protective equipment (PPE), IV pumps were externalized to the hallway for critically ill patients. This allowed for frequent titration of vasopressors and sedatives without entering the room and the ability to hear pump alarms with a closed door. Use of extension tubing and stopcocks was necessary to facilitate this practice change, which increased the number of connections and required the tubing to go under the door and thus lay on the floor. To mitigate the infection risk for this situation, nursing staff innovatively used stat-locks to secure the tubing to the wall and placed the tubing on top of blue disposable underpads on the ground. Patients with COVID-19 in the ICU setting had extended lengths of stay and ultimately, an increased number of central line days.

CLABSI case reviews

The rise in COVID-19 patients turned our ICU standard of care upside down. To decrease staff exposure and conserve PPE supplies, the weekly central line bundle compliance surveillance program, Eyes on Lines, was suspended. This had been initiated at our medical center in 2017 in response to an increase in the number of CLABSI cases. We achieved great success with this program, noting a sharp decline in CLABSIs. Because of the change in our standard of practice, however, we nearly doubled continence CLABSI incidence rate for the previous 9 months of the fiscal year.

With the rise in infections during the pandemic, our CLABSI Committee of staff nurses, PI specialists, and clinical nurse specialists performed extensive reviews of each CLABSI case to identify trends and opportunities to mitigate the CLABSI risk for this patient population. We identified that most of the COVID-19 patients had central lines placed for the urgent administration of vasopressors and sedatives. Because of the natural course of the disease process, these lines were clinically indicated for a duration of 2 to 3 weeks in many cases. Central lines placed in the neck were difficult to assess and manage because of prone positioning and secretions.

Central line maintenance resource

In response to these findings, we developed a central line maintenance resource to assist with navigating practice changes due to COVID-19 (see Supplemental Digital Content Figure 1, available at: To mitigate the risk of infection, this resource instructed staff to consult our vascular access team to transition the central line from the internal jugular vein to the basilic vein with a peripherally inserted central catheter line. If we were unable to move the line, we recommended the use of an adhesive moisture barrier such as AquaGuard (Cenorin LLC; Kent, Washington) over the dressing to protect from oral secretions. For propofol infusions, the frequency (every 12 hours) of necessary tubing changes posed challenges with drug waste and extension tubing supply. Based on feedback from staff, we determined that propofol should remain on an infusion pump in the room in closer proximity to the patients. These tips were shared in the resource that was developed in conjunction with the staff nurses and leadership teams of our adult ICUs. Outcomes are continually evaluated by the CLABSI Steering Committee via unannounced prevalence days as we incorporate these practice changes into a new COVID-19-based standard of care. In the first quarter of FY21, our CLABSI rate is decreasing with the presence of fewer COVID patients as well as the work of these enhanced interventions.


Hospital-acquired pressure injuries (HAPIs) increase mortality rates, hospital length of stay, health care costs, and hospital readmission rates.3 Historically, our HAPI rates have consistently exceeded our institutional goal and been below the national benchmark mean. In the first 3 quarters of FY20, our HAPI rate was well below the national benchmark. With COVID, this rate increased in the final quarter of FY20.

Quarterly prevalence surveys are conducted by the unit-based nurse-driven Skin, Wound, and Treatment (SWAT) teams. Monthly HAPI incidence is tracked to further decrease our prevalence. The incidence data are recorded by the wound, ostomy, and continence nurses (WOCNs) when a consult is placed by the RN and the HAPI is verified by the WOCN. The unit-based SWAT teams are then directed to conduct a clinical quality case review for all HAPIs to identify gaps in practice and implement a corrective action plan. The case is presented by the SWAT team members at the monthly Skin Oversight Committee meeting with a 30-day follow-up. As a result of this timely response to individual HAPI cases, we have seen a sustained reduction in hospital HAPI rates in our medical center with our typical rates falling below the national benchmark.

Prone-positioning team

Admissions for COVID-19 patients began in early March of 2020. By mid-March, the volume of COVID-19 patients in the ICU began to rise, requiring the opening of 2 additional ICUs. These patients were in acute respiratory failure, difficult to ventilate, hemodynamically unstable, and on multiple vasopressors. All these critical illness factors decreased the perfusion to the skin, thereby increasing the risk of developing pressure injuries.4 Prone positioning had been historically and successfully used at our medical center to improve lung function for patients with acute respiratory distress syndrome. To increase survival of the critically ill COVID-19 patients, a prone-positioning team was quickly created, with the first patient manually proned on March 18. The prone-positioning team made attempts to incorporate skin protection into the prone-positioning process; however, due to the severity of their condition, many patients remained in the prone position for up to 16 hours at a time, sometimes more. Some patients were proned several times for extensive periods. In addition, due to concerns about conserving PPE and decreasing unnecessary staff exposure to COVID-19, RNs began clustering their patient care. This led to a decrease in every 2-hour position changes.

Wound ostomy continence care nurse rounds

With the critical and highly unpredictable nature of these COVID-19 patients, wound consults were not being placed, deviating from the standard process. As this was realized, on April 1, the WOCNs identified potential HAPIs on a report that reflected nursing documentation of pressure injuries. Subsequently, the WOCNs began rounding on these patients and continued to record HAPI incidence data. In addition to the information previously tracked, the WOCNs also recorded whether the patient was COVID-19 positive or negative. Hospital-acquired pressure injuries were occurring most frequently in the COVID-19 patients in the ICU, with the majority of pressure injuries on the anterior surfaces of the body (lips, cheeks, chin, anterior arms, and legs) from lying in the prone position. The WOCNs collaborated with the interprofessional team (respiratory therapists, physical therapists, and critical care clinical nurse specialists), the unit-based SWAT teams, industry partners (regarding use of offloading positioners and prophylactic dressings), and experts at the National Pressure Injury Advisory Panel5 to identify resources for HAPI prevention for patients with COVID-19.

A new prevention plan

In May 2020, the HAPI incidence report and a new HAPI prevention plan developed by the WOCNs were sent out to nursing leadership and the unit SWAT team members to disseminate on their units. For prone positioning, interventions included application of prophylactic foam dressings to the anterior boney prominences, use of a soft endotracheal tube securement device, and a fluidized positioner to offload or reduce pressure on the face. These items are now contained in a new prone-positioning kit. Prone-positioning kits are created by SWAT team members in the ICU to ensure that staff has all necessary supplies and application instructions to facilitate consistent use in the prone patient. Education materials were developed on patient positioning that included providing offloading and “micro” or small turns for unstable patients. Finally, a patient-positioning system with wedges for offloading and glide sheets for friction reduction, which had demonstrated substantial HAPI reduction in the surgical ICU pre-COVID-19, was implemented in the other adult ICU units. In the first quarter of FY21, with our more aggressive measures, we were able to decrease our rate.


Catheter-associated urinary tract infection impacts patient outcomes by increasing morbidity, mortality, length of stay, and costs.2 Evidence suggests that the longer an indwelling urinary catheter remains in place, the greater the chances of developing a CAUTI.2 In the first 3 quarters of FY21, our CAUTI rates were well below the national benchmark. With COVID, this rate increased in the final quarter of the fiscal year. Catheter-associated urinary tract infections that occurred in April and May 2020 were all noted in COVID-19 patients, specifically the ICU patients who required manual prone positioning for acute respiratory distress syndrome. Of note, one of these adult ICUs had been without a CAUTI for more than 4 years.

Catheter care challenges with the proned patient

The rise in COVID-19 ICU patients resulted in a major increase in catheter usage and because of the unstable nature of these patients, the amount of time the catheter remained in place was increased. Catheter care was difficult to perform while the patient was in the proned position. Prior to the COVID-19 pandemic, all indwelling urinary catheters required use of a securement device to prevent pulling of the tube to prevent trauma and urethral erosion. A decision was made to not use securement devices with these catheters in the hopes of preventing a device-related pressure injury. In retrospect, in our attempt to avert one form of health care–acquired injury, we may have contributed to the increase in our CAUTI rates.

Usual workflows changed for the COVID patients. As noted, to conserve PPE and prevent exposure, patients were assessed through the window versus entering the room if hands-on care activities were not required. This resulted in fewer face-to-face interactions with the patient, posing a challenge for the assessment of the catheter.

A new standard for catheter care

Lessons learned during this pandemic have resulted in our CAUTI Committee developing a new standard of care for the COVID-19 population. Based on our new standard, the nurse must empty the indwelling urinary catheter drainage bag prior to any position changes to prevent backflow of urine into the bladder. Catheter care is now performed during the full-body chlorhexidine gluconate treatment by the primary nurse when the patient is moved to the supine position once daily. While the patient is supine, a catheter securement device is then applied. Prior to placement in the prone position, the securement device is removed from the anterior thigh and then placed on the posterior aspect of the thigh once in prone position. In prone position, the primary nurse completes the catheter care and the chlorhexidine gluconate treatment on the posterior aspect of the body.

Prior to the COVID-19 pandemic, providers at our medical center were very intentional as to why they would order a urine culture; the patient's symptoms had to meet specific criteria. During the pandemic, providers increased the number of cultures collected to identify the variable comorbid diagnoses as COVID-19 was so new and unfamiliar. We have since returned to our standard practices for urine culturing.


In contrast to our CLABSI, HAPI, and CAUTI rates, fall and fall with injury data at our medical center did not worsen because of COVID-19. We recently implemented the “Move to Morse Fall Prevention Campaign,” an initiative to improve accuracy of fall risk assessment and better predict fall risk, with the goal of fall prevention.6 Falls were a great concern for the COVID population as many patients were intubated, sedated, and in the prone position for extensive periods. They demonstrated weakness with both fine and gross motor skills and were unable to perform basic activities of daily living. Their stability during ambulation was greatly impacted. Many patients presented with cognitive impairment and demonstrated unpredictable, impulsive movement, such as attempting to get out of bed unassisted. The interprofessional rehabilitation team was challenged with getting these patients ambulating and sufficiently rehabilitated to return home.

Extensive physical and occupational therapy was necessary to recover mobility and activities of daily living skills. The patients were quite tremulous resulting in dropped items and difficulty opening juice and milk cartons. To aid this, staff pierced the packaging with a straw to facilitate less spillage. Patient room doors were kept open for enhanced visibility and better ability to hear bed/chair alarms. Low beds were used, and phones were placed within close proximity to prevent falls. Per the “Move to Morse Fall Prevention Campaign,” staff members remained with the high fall risk patients during ambulation, transfers, and, when appropriate, toileting. Handoff reports between therapists and nursing were a key strategy to preventing falls. As a result of the teamwork demonstrated on the acute rehabilitation COVID-19 unit and the other fall prevention measures required for the Morse campaign, we did not observe an uptick, echoing the success seen throughout the medical center with fall prevention.


The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey7 data for our medical center during the COVID-19 pandemic demonstrated a remarkable level of stability despite marked changes to our visitor policies and accessibility to our campus. This included a strict no visitor policy for all patients in the inpatient setting for the safety of our patients and staff. Our performance on the Global HCAHPS question, Rate the Hospital, remained unchanged at the 86th national percentile while our Nursing Communication performance remained strong at the 79th national percentile. Several of the HCAHPS domains demonstrated heightened performance during the COVID-19 pandemic including Doctor Communication, Staff Responsiveness, and Communication About Medication. Overall, the patient satisfaction performance of our medical center did not decrease in any domain as a result of COVID-19.

Interventions implemented to support our patients and families during this time of restricted visitation included the deployment of iPads to all inpatient units to facilitate visual and auditory communication between patients, families, and caregivers. The deployment of iPads included real-time training on the video workflow for clinicians, with nursing staff promoting and coordinating patient and family video visits. In addition, a new patient ambassador role was created and staffed by nursing and medical student volunteers. This virtual role was responsible for ensuring regular contact with patients and families, serving as liaisons for questions and concerns that they then shared with providers and RNs. This role also helped coordinate the virtual visits between patients, families, and care providers.


The high volume of COVID-19 patients coming to our organization led us down care pathways we had never trod before. Within 3 months, we saw more than 6000 patients and opened 2 additional ICUs to accommodate as many as 100 ventilated patients at a time. In response to the influx of critical care patients and to optimize our resources, we implemented a number of innovative plans including prone positioning, placement of IV pumps outside of the patient rooms, iPads to facilitate virtual communication, use of redeployed pediatric RNs as respiratory therapy extenders to assist with nonventilated patients, and a new model of team nursing in which acute care nurses were redeployed to work in the ICU environment in a dyad model led by an ICU RN (see Supplemental Digital Content Figure 2, available at: The extent to which several of these interventions may have impacted our nurse-sensitive quality indicators has been shared, but the full implications may never be fully known.

The goal of our team was to provide each of our patients an excellent care experience even as we went to extreme lengths at times for their survival. When we were challenged with this change to our standard of care, we turned to our existing shared governance teams for CLABSI, CAUTI, and wound and skin care, frontline clinical teams that are our PI teams at this institution, to create a new standard of care. We continue to care for COVID-19 patients. With the decreasing volume, our teams continue to modify these new care standards, reflecting on what we learned about this novel virus while planning for a potential resurgence.


Our organization has a long history of high-quality care as evidenced by 4 Magnet designations from the American Nurses Credentialing Center8 and a recent number 1 ranking for quality in academic medical centers by Vizient, Inc (Irving, Texas), a health care PI company.9 Throughout this pandemic, we learned that current evidence-based initiatives do not necessarily translate to the care of a novel disease process. We relied on our nurse-led PI teams to develop strategies to prevent health care–associated infections in this new population. In March 2020, our medical center began a journey into the new world of caring for patients afflicted with COVID-19. It is our hope that by sharing the experiences and work of our CLABSI, CAUTI, and wound and skin care PI teams, who implemented innovative strategies to care for these vulnerable patients, we can contribute to the nursing science and help other RNs to provide high-quality and safe care for these unique COVID-19 patients.


1. World Health Organization. WHO coronavirus disease (COVID-19) dashboard. World Health Organization Web site. Updated August 29, 2020. Accessed August 29, 2020.
2. Rodgers K. 2018 National and state healthcare associated infections progress report. Centers for Disease Control and Prevention Web site. Updated November 6, 2019. Accessed June 28, 2020.
3. Agency for Healthcare Research and Quality. AHRQ analysis finds hospital-acquired conditions declined by nearly 1 million from 2014-2017. Agency for Healthcare Research and Quality Web site. Published January 29, 2019. Accessed June 19, 2020.
4. National Pressure Injury Advisory Panel. Pressure injury prevention—PIP tips for prone positioning. National Pressure Injury Advisory Panel. Nestle Medical Hub Web site. Published 2020. Accessed June 19, 2020.
5. Alderden J, Rondinelli J, Pepper G, Cummins M, Whitney J. Risk factors for pressure injuries among critical care patients: a systematic review. Int J Nurs Stud. 2017;71:97–114. doi:10.1016/j.ijnurstu.2017.03.012.
6. Morse JM. Preventing Patient Falls: Establishing a Fall Intervention Program. 2nd ed. Springer; 2009.
7. Association for Healthcare Quality and Safety. CAHPS patient experience surveys and guidance. Department of Health & Human Services Web site. Updated August 2019. Accessed June 28, 2020.
8. American Nurses Credentialing Center. ANCC magnet recognition program. Nursing World Web site. Accessed August 29, 2020.
9. Hospital & Healthcare Management. Vizient, Inc. Hospital & Healthcare Management Web site. Published 2015. Accessed August 29, 2020.

COVID-19; health care–acquired infections; nurse-sensitive quality indicators; nursing; prone positioning; quality care

Supplemental Digital Content

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