HOW WERE YOU DIAGNOSED WITH COVID?
It all began rather innocuously the second week of March. I started the week as I normally would, free from symptoms of illness, but over the following 8 to 12 hours began feeling ill. At first, I experienced a fever which, for me, is atypical unless I am very ill. The fever prompted me to leave work and return home to rest. The following day I awoke to the same fever, which unbeknownst to me, would intermittently persist for weeks to come. In an abundance of caution and growing concern for my health, I went to the local walk-in clinic for evaluation. I was tested for flu and the result—negative. I began thinking, what could this be? At that time, the thought of being infected with COVID-19 did not really cross my mind. Based on the absence of any other symptoms, the physician did not feel that COVID testing was warranted. The Monday following my visit to the walk-in clinic, I began to feel better, my fever had broken, and I made the decision to return to work. By Wednesday of that same week, I began to feel like I had the week prior; this time, however, I experienced a strange chemical smell. At that time, the loss of or change in smell was not yet clearly identified as a symptom of a COVID-19 infection. That day I remember leaving work early and was subsequently prompted by our employee health department to be tested for COVID-19. The result was positive, a fear-laden reality that everyone working in health care at this time never wants to experience.
WHAT DID YOU DO WHILE YOU WERE OUT OF WORK FOR THE 4 WEEKS? WHAT DID YOU DO TO PREVENT SPREAD TO YOUR FAMILY? HOW MUCH COVID WAS ALREADY BEING SEEN IN YOUR HOSPITAL?
I remained at home, in isolation, for a total of 4 weeks before I could return to work. As the director of nursing for the medical division at Rhode Island Hospital, a 719-bed academic medical center in Providence, Rhode Island, staying home and maintaining my work was not easy. At the beginning of the isolation period, I made every attempt to remain connected to my work, providing support to my team and colleagues remotely. At that time, practices at the hospital began to change, and rapidly, in response to emerging knowledge about the virus. The numbers of identified COVID-19 cases grew, and the growing knowledge about the COVID-19 virus dictated a change to practices that made it impossible for me to keep up.
During my 4 weeks of quarantine, I also needed to remain cognizant about the potential of infecting my loved ones. At that time, the recommendations were simple—good hand hygiene, masking, and appropriate distancing. Given the “novel” status, little was known about the virus, how it was spread, and how to protect others. That said, my family and I remained hypervigilant about cleaning and respecting safe distancing. The impact, unfortunately, was not exclusive to me. Given the lack of availability of testing agents, universal testing was not available at the time. As a result, my husband was required to quarantine at home for 14 days, despite being symptom-free.
Just prior to my leave, I remember visiting the unit where the first COVID-19–infected patient had been admitted. COVID-19 was beginning to emerge as a sinister epidemic at that point. The numbers were rising, but effective control was not well understood. The hospital began to create “warm units.” These “warm zones” provided private rooms to those patients identified as having a confirmed COVID infection.
All practices were carefully monitored by our infectious disease and infection control departments. Leadership kept a close watch on patient and staff safety and began to identify an emergent need for reeducation on our infection control practices that were being revised as COVID knowledge emerged. The teach-back method ensured a firm understanding of practices. Staff were encouraged to participate in the buddy system, confirming that each appropriately and safely donned and doffed personal protective equipment.
Following 4 weeks of quarantine, I went back to work, but I still did not feel like myself. Fatigue consumed me; for approximately 6 to 8 weeks, it felt like a never-ending battle with my own body. Upon my return to work, there was mention of being at the peak of COVID-19 in the state; this, however, was not the case. Eventually, 14 additional COVID “warm units” were established, which included 5 intensive care units to accommodate an influx of more than 180 COVID-positive patients a day. The logistics of establishing those units was no easy task and the protocols and procedures changed almost daily at a precipitous rate. Infection control leaders worked tirelessly to ensure that our practices were aligned with the most current regulations and recommendations set forth by the Centers for Disease Control and Prevention and the World Health Organization.
WHAT WERE SOME OF THE OTHER CHALLENGES?
As the volume of COVID-positive patients increased beginning in early March, the need for staff also increased. At that point, staffing became the most intense logistical focus. Many patients on the “warm units” were very ill but did not necessarily meet the level of intensive care services. Other departments, such as perioperative services, were interrupted as a result of the growing concern for spreading infection. Elective surgery was no longer being performed, and our outpatient services had come to an abrupt halt. These department closures allowed for reallocation of staffing resources. This reallocation helped us provide necessary supports to the growing number of COVID-positive patients.
Along with my nursing colleagues, we worked feverishly to provide adequate staffing to our floors. Flexibility became a common theme, and with help from our labor union colleagues, we were able to establish agreements, which allowed for not-so-ordinary things to occur. Not unexpectedly, the changes to our staffing practices also elicited significant feeling of anxiety and fear among our staff. The rapid changes around us were affecting staff at a rate we could not have anticipated. Some were sick or quarantined because of a sick family member, creating a staffing conundrum. Schools and daycare facilities were abruptly closed and many staff shifted from being nurses, doctors, housekeepers, and so forth, to becoming the primary caretakers and teachers for their children. Many staff were living with or were in close contact with immune-compromised family members. These unforeseen obstacles forced staff to take leaves of absence, many with an unpredictable return-to-work date.
Supplies became limited. As the global impact of the virus grew, the ability to procure needed supplies became more difficult. We were all charged with the responsibility of conservation; using only what was absolutely needed became our focus. Supply chain worked closely with the nursing leadership team and infection control team to provide direction and regular updates about the availability of pertinent resources.
A large conference room was converted to the hospital “command center” where I, and a number of my colleagues, provided centralized operational leadership. The command center was staffed 24 hours per day, 7 days per week, and remains open to date to help navigate the uncertain rates of infection and evolving changes to hospital operations.
The Lifespan health system, for which Rhode Island Hospital is the flagship hospital, partnered with the state to develop a large alternative hospital at the Rhode Island Convention Center. To date, the alternative hospital has not been needed but remains available through December in anticipation of potential future surges. Community residents and local businesses generously brought donations of personal protective equipment, food, and other items to the hospital. These items were distributed throughout the hospital to all departments, with focused efforts for those working on the frontline.
Fortunately, the peak has subsided—at least for now. No more than 15 COVID-positive patients have required inpatient care on a given day since the beginning of July. With guidance from the state, visitation to the hospital has been gradually reinstated; though visitation is strictly limited, the process is extremely proscribed and requires an entirely separate workforce to execute it safely. We continue to hire people to work as health screeners, and support volume control during the allotted visiting hours, as we anticipate that the current limitations will continue into the foreseeable future.
WHAT WENT WELL?
These were exceptionally difficult times—patients were very sick, people were afraid, and those of us working in health care were inadvertently isolated. However, there were many silver linings, one of which was incredible interdepartmental collaboration. Many departments formed alliances and joined forces to fight against the virus. Physicians and nurses worked closely as a united team operationalizing decisions, all aimed at ensuring safe practices. Frontline staff in all areas rose to the occasion and worked tirelessly to provide exceptional care despite their personal fears and challenges. The prompt response by the organization at large, including the systemwide command center activation and the daily systemwide COVID discussions, helped us remain ahead of the virus and be prepared to fight an invisible enemy. Each day the entire leadership team focused on communicating vital information about virulence, protection, personal protective equipment availability, and COVID-19 testing. Today, we have been able to reduce our systemwide discussions to twice weekly. These continued ongoing discussions, although less frequent, allow us to stay connected to our affiliate hospitals and remain updated and prepared for potential future surges. In addition, we have identified COVID champions, members of our core frontline staff. This champion initiative has helped pioneer efficient diffusion of rapidly changing information about the COVID-19 virus.
IN RETROSPECT, WERE THERE OPPORTUNITIES TO IMPROVE?
An ongoing challenge is the ever-changing practices. The evolution of knowledge about the virus is happening at a rapid rate. It has been very difficult to remain informed and ensure that all staff are practicing to the most current standards. In retrospect, we have learned that a comprehensive staffing plan at all levels of care is paramount. We have learned that we need to be ready to educate, reeducate, and reallocate staff at a moment's notice. Luckily, we were able to prevent furloughs by job reassignment; however, we later recognized that these staff became unavailable as we shifted back to a more normalized operation and staff returned to their home departments. In addition, we became increasingly aware of the importance of caring for the caregiver. We have begun to focus more on improving our practices aimed at supporting the leadership and frontline staff, including initiatives aimed at stress reduction, and combating burnout, fear, and so forth.
The hospital has begun to identify a new “normal.” Vacations have resumed. The “warm units” have returned to their pre-COVID populations. There is a new sense of pride, which is guided by humble practice. We continue to provide the best care to our complex patients. The multifaceted logistics that support the care provided are well coordinated and managed, including the conversion of our learned lessons into practice. We continue to explore opportunities to be better prepared should the pandemic erupt once again—or some other equally serious situation. Our strength, adaptability, and perseverance are what makes us who we are, nurses—leaders of the silent battle.