The COVID-19 pandemic has resulted in significant challenges for university campuses across the country. Planning and initiating processes for coordinating student's return to campus, COVID-19 testing, and contact tracing have proven to be a significant public health task for many universities and colleges.1,2 While evolving literature is beginning to report on the experiences of some universities,3–5 limited information on key considerations is available for nurse leaders charged with implementing pandemic responses. This article reports on the experiences of a southeastern university's experience with managing the COVID-19 testing and contact tracing that were led by school of nursing faculty and nursing leadership.
NURSING LEADERSHIP STRUCTURE AND ROLES ON THE UNIVERSITY STEERING COMMITTEE
At Vanderbilt University (VU), located in Nashville, Tennessee, nursing leaders at the Vanderbilt University School of Nursing (VUSN) designed, implemented, and managed a robust in-house contact tracing program for all students in association with the offices of the Vanderbilt University Provost, Vice Chancellor for Administration, Director of the Sustainability and Environmental Management Office, Senior Director of Residential Experience, Assistant Provost, and Deputy Dean of Students. VUSN leaders worked in collaboration with experts at Vanderbilt University Medical Center (VUMC), VUSN, and Metro Public Health to coordinate timely contact tracing between campus and the Nashville community. Advanced practice registered nurses (APRNs) and registered nurses (RNs) from VUSN and Faculty Practices performed contact tracing for COVID-19–positive cases within 24 hours of a report of positive test results, with the majority of contact tracing being completed within just a few hours of the positive test result report.
Leadership for central contact tracing response team
From the start of the pandemic in March 2020, the school of nursing was active in the university's planning for student return to campus in the fall. Early on, the Interim Chancellor and the Provost appointed the Dean of VUSN to lead the university's public health taskforce. The taskforce gave input into the protocols and processes that would need to be in place in order to have in-person classes and students return to residential living. Considerations that led the initial planning included the complexity of reopening, the need for prevention measures, ensuring the ongoing health and well-being of the university community, and the potential for resurging cases.
Regular testing and contact tracing were found to be key elements for the reopening the campus. The school of nursing was designated as the unit that would be responsible for contact tracing and follow-up for students who tested positive for COVID-19. In conjunction with the Senior Associate Dean for Clinical and Community Partnerships who led the contact tracing initiative, the Dean helped coordinate the nursing school engagement in the university's activities in the area of community health planning and response. Both helped oversee and develop plans in consultation with experts at VUMC as well as national, state, and local public health officials to coordinating VUSN's key role in the return of nearly 20 000 students, faculty, and staff to campus.
As a core component of the preventive measures, leaders of the school of nursing were involved in guiding the development and implementation of protocols for COVID-19 testing, as well as rigorous contact tracing and symptom management, working with the Director of Environmental Health, Safety, and Sustainability for the university on the protocols for the return to campus.
Many groups were involved in the decision to return to campus, and university leadership took into account a variety of scenarios and best practices. The university identified the importance of having students be able to experience in-person learning and interaction with faculty, staff, and fellow students as well as planning for those who would opt for remote-only learning.
The process for planning and implementing a return to campus involved a number of steps (Table). Prior to students arriving on campus, the university established a Public Health Central Command Center (PHCCC) with the Director of Environmental Health, Safety, and Sustainability and the Senior Associate Dean for Clinical and Community Partnerships serving as incident co-commanders (Figure 1). The PHCCC managed all data and workflow associated with testing and contact tracing for students, faculty, and staff. This included setting up policies and procedures for COVID-19 testing, contact tracing, and student outreach. As outlined in Figure 2, a case management and contact tracing workflow was developed to identify the processes to be used once a student tested positive for COVID-19, including how student contact would be made, how contact tracing would be done, the steps to be taken if a student required isolation and quarantine, and how follow-up would be carried out. The knowledge and expertise of the Director of Environmental Health, Safety, and Sustainability were a crucial support for the contact tracing team and the extensive data management that was required.
Key Considerations in Developing and Leading a University Student COVID-19 Testing and Contact Tracing Program
|Open and ongoing communication with all key stakeholders
|Partner with robust data management capabilities and the Environmental Health, Safety, and Sustainability Director for comprehensive management of notification and trend analysis
|Reinforce the intentional effort by all faculty, staff, and students to exercise both personal and community responsibility of adhering to campus guidelines
|Keep updated on local orders and ordinances of the city, county, state, and national (eg Centers for Disease Control and Prevention) guidelines and recommendations
|Maintain student confidentiality
|Provide updates on process changes or new components to students and their family members to ensure transparency
|Align guidelines with the university's strategic framework to support the mission objectives of the institution with respect to research, teaching and instruction, and campus residential living and learning
|Highlight the importance of having flexibility and adaptability to respond to the constantly evolving nature of the pandemic
|Use a robust data tracking and monitoring system such as the REDCap database to ensure security of personal health information data collection
|Outline a case management and contact tracing workflow beneficial in ensuring continuity in the contact tracing and follow-up processes
|Ensure a robust plan for disseminating updates on the COVID-19 testing and contact tracing program via Web site updates, e-mail, campus newsletters, and university app
Abbreviation: REDCap, Research Electronic Data Capture.
VUSN nursing leaders utilized the organization of the VUSN faculty members of the Nurse Faculty Practice Division to construct the contact tracing process and subsequent testing. A separate service line was created within the VUSN Nurse Faculty Practice Division to provide the contact tracing and symptom assessment for students who would test COVID-19 positive or were identified as close contacts. This division worked in concert with the university's Student Health and Counseling Centers to provide comprehensive care to symptomatic students. Key components included outlining required manpower needs and the process of recruiting and training contact tracers. A Research Electronic Data Capture (REDCap)6 database was developed to track any student contact data including COVID-19 testing dates and results, as well as associated contact tracing. Scripts were developed for contact tracers to ensure continuity and consistency in messaging provided to students. The involvement and expertise of nursing leaders provided a great opportunity to help the university and provide quality, holistic care to students at a time when they were under significant physical and mental stress. The nursing leadership team was a key member of the university team in giving guidance concerning processes for isolation and quarantine for students, both on and off campus.
SHOWCASING SCHOOL OF NURSING'S CONTRIBUTIONS TO THE PUBLIC HEALTH RESPONSE
The role of nursing was key to coordinating and implementing the university's COVID-19 testing and contact tracing process. A testing center for high volume was established with testing of the protocol using VUSN's simulation laboratory. VUSN nursing leaders worked with key university partners to outline the use of new FDA-approved testing systems that could be self-administered, and all students received testing prior to return to campus and again within the first week of being on campus. The VUSN Nurse Faculty Practice Division structure allowed for the engagement of APRNs and RNs to participate in the contact tracing and symptom assessment. The VUSN Nurse Faculty Practice Division includes APRNs, who provide patient care at more than 10 clinics and on-call services in cooperation with VUMC, and RNs, As the project progressed in development, it became clear that a separate service line within the Nurse Faculty Practice Division needed to be developed in order for APRNs and RNs from VUSN to adequately perform contact tracing for COVID-19–positive cases, provide symptom assessment on a consistent basis while a student would be in isolation or quarantine, and act as an interface between the university, Student Health Center, and VUMC. The contact tracing team provided periodic wellness checks for all students in quarantine and isolation. This included providing information on resources available on campus as well as online. Each contact was documented in the REDCap database to enable ongoing data tracking.
COMPONENTS OF FACULTY PRACTICE CONTACT TRACING
The contact tracing team consists of the Senior Associate Dean for Clinical Practice and Community Partnerships, a lead Project Coordinator, and full- and part-time APRNs and RNs. The contact tracing team is notified by the PHCCC of positive COVID-19 test results through the university's asymptomatic testing program, the symptomatic student health testing program, and from individuals self-reporting through the university's Webform. For initial contact tracing, phone interviews of index cases are conducted after confirming the individual's identity, information is gathered on additional contact information, symptoms and medical status, COVID-19 testing, potential COVID-19 exposures, individuals who meet close contact criteria, and places visited during the infectious period. The contact tracers also calculate the infectious period and estimated isolation release dates. This information was also entered into the REDCap database. Students who are symptomatic are jointly managed with Student Health Services with documentation of ongoing monitoring documented in the REDCap database.
The contact tracing team identifies close contacts of individuals with COVID-19 through index case interviews and by individuals self-reporting through the university's Webform. During an initial close contact phone interview, after identity and close contact confirmations have been established, information is gathered on the living situation, symptoms, and COVID-19 testing. The contact tracers also calculate the quarantine period dates and enter these data in the REDCap database.
KEY LEADERSHIP PROCESSES, FUNCTIONS, AND ACTIONS THAT WERE USED TO INFLUENCE THE UNIVERSITY-WIDE CONTACT TRACING PROCESS
The contact tracing team has a program director and an assistant director, and the contact tracers work remotely through scheduled shifts, with a team lead on duty at all times who is also responsible for assigning cases. During the fall 2020 semester, the contact tracing team was available 7 days a week for approximately 12 hours. Communication among contact tracers is primarily done through Microsoft Teams via chat features and files. The contact tracing team can be contacted with questions or concerns through a shared e-mail address and phone number. Documentation from contact tracing calls is done within established templates (inclusive of thorough scripts) in REDCap, with key information recorded on secure Excel files (ie, cases and follow-up call scheduling can be seen at a glance). The contact tracing team reports findings to the PHCCC and collaborates with others as indicated such as VUMC (eg, employee close contacts), occupational or student health (eg, medical needs), and Metro Public Health (eg, close contacts and places external to VU and VUMC).
The contact tracing program follows guidelines from the Centers for Disease Control and Prevention, the World Health Organization, and the Tennessee Department of Health.7,8 During source and close contact calls, in addition to explaining COVID-19 and its transmission and giving instructions on isolation and quarantine, the contact tracers can provide education on university processes and resources such as COVID-19 testing and housing for isolation and quarantine. The contact tracers are also trained to provide clinical recommendations for medical and behavioral health services, including in emergency situations. The contact tracing team is suited to assess the physical and mental health of individuals in isolation and quarantine during their conversations.
DESCRIPTION OF KEY NURSING LEADERSHIP CONTRIBUTIONS
In addition to the contact tracing program, VUSN nurse leaders helped design and implement an asymptomatic testing program in collaboration with other VU leaders; acted as an interface between the university, Student Health Center, and VUMC; provided counseling for any students who are in quarantine and isolation; and provided periodic well checks for all students. In the first 3.5 months, the program managed more than 1130 index cases and 1341 close contacts. As a result of nursing leadership, students who tested positive with COVID-19 during the fall semester and students who required contact tracing were successfully managed. In addition, the university experienced a low positivity rate, less than the county or the state.
Managing the return to campus for students during the COVID-19 pandemic and coordinating contact tracing would be a feat for just a school of nursing alone. In participating in the entire university's return-to-campus response, VUSN nursing leaders helped ensure that effective processes were built to promote and enhance student safety and the university's public health response. The PHCCC and contract tracing processes demonstrated to be an efficient and effective way to track and trace COVID-19 cases on campus.
Unlike other major universities that have faced an increase in COVID-19–positive cases, the university has been able to resume classes on campus as scheduled, maintaining social distancing, the use of masks, the creation of outdoor dining tents, outside lawn areas for gathering, enhanced resources for student health, and wellness for more than 6800 undergraduate students and more than 12000 total student body.
Nursing leadership was instrumental in coordinating the COVID-19 contact tracing process and follow-up for the university's students on campus. Similar to the findings of the AONL (American Organization for Nursing Leadership) nursing leadership in COVID-19 survey,9 and reports of other school of nursing's efforts during the pandemic,10 the role of nursing leadership helped promote interdisciplinary collaboration and wider recognition of nurses' contributions.
Lessons learned included the importance of communication with other university and medical center stakeholders; coordination among health care personnel, student health, campus dining, security, and other entities; and collaboration with local and state public health entities. Attention to staffing considerations was required on an ongoing basis. Clinical staffing was adjusted on the basis of case volume and complexity of cases and contact tracing. For example, the original staffing plan was 3 APRNs or RNs per day covering 12 hours, 7 days a week. That staffing was increased to approximately 6 per day in the fall of 2020 in order to manage the undergraduate student population of more than 6800 students. Ensuring confidentiality in the contact tracing efforts and balancing health and privacy required ongoing education and training of contact tracers and staff having access to the tracking database.11 Learned in the face of evolving evidence, a flexible approach with iterative changes needed to be undertaken. For example, new information was evolving on a continual basis and protocols needed to be adjusted accordingly. It also emphasized the importance of frequent and effective communication within the team and other university stakeholders including students and their parents.
The process and lessons learned can help inform other nurse executive leaders who find themselves involved or charged with in leading pandemic response processes.
The ongoing pandemic offers the opportunity for nurse leaders to demonstrate their knowledge and expertise. Nurse leaders should embrace their knowledge and ability to influence the direction of an organization in a time of public health emergency. This article has highlighted how showcasing the role of nursing has helped position a school of nursing as a leader among the 10 campus schools within the university. The process enabled nursing leaders to help the university and provide quality, holistic care to mitigate not just student medical challenges related to COVID-19 but also mental and emotional challenges. The close partnership and collaboration VUSN formed throughout this challenging time with university administration, student support services, and health and safety services not only supported our students in an unparalleled way but also strengthened our ties to the university as a whole and will continue to impact future initiatives.
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8. World Health Organization. Contact tracing in the context of COVID-19. https://www.who.int/publications/i/item/contact-tracing-in-the-context-of-covid-19
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9. American Organization for Nursing Leadership. Nursing Leadership COVID-19 Study. https://www.aonl.org/resources/nursing-leadership-covid-19-survey
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