All nurses are facing new challenges in the ways that they care for patients. Nursing practices are changing to become more efficient and protect healthcare workers from contracting coronavirus. I’ve come up with a few tips to try and help travel nurses and staff nurses safely and efficiently care for their coronavirus patients.
Always Wear PPE
The PPE shortage is a hot topic. Travel nurses and other providers are rightfully demanding to be protected. The states and hospitals are working overtime to try and ensure that their healthcare workers have adequate PPE supply. There have been a few reports of healthcare workers becoming ill and dying in the US, and far more in Italy.
Remember: THERE IS NO EMERGENCY IN A PANDEMIC.
Yes, we travel to work every day to knowingly take care of these extremely sick, very contagious patients. But, providers NEED to be protected. This is a challenge for a lot of nurses and other providers, as it is in our nature to save a dying person. This goes against everything that’s been ingrained in our psyches. But, nurses are not martyrs. And, if healthcare workers start to come ill, the whole nation will feel the effects of this. There is no logical or compassionate reason for a nurse to lose their life because they ran into a dying patient’s room without PPE.
Keep up to date with the hospital’s most current recommendations for taking care of coronavirus positive and rule out patients. If you do not have any PPE to protect yourself, do NOT go in the room.
Nurses should be aware of where the proper PPE is located and stored for quick access. Travel nurses are especially susceptible to a frantic PPE search in an emergency because they are often asked to float between multiple units that all store their equipment in different locations. At the beginning of a shift, locate the surgical masks, N95 masks, isolation gowns, gloves, and eye protection supplies.
IF your patient does code or need to be intubated- double, triple check your PPE and ensure you have donned it properly. Ill-fitting PPE is as good as no PPE.
Cluster Your Nursing Care
Nurses should avoid entering and exiting a COVID-19 patient’s room unnecessarily. If possible, at the start of your shift, plan your day. This will be a bit difficult for nurses who traditionally just, ‘take the day as it comes’. Make a list of tasks you need to complete for the day and figure out the best timing and how to coordinate with your co-workers if you have tasks that require 2 or more nurses (for example: turning a heavy patient).
Review your medication admin times and organize your basic nursing care tasks around the times you will have to be in the room. If your med times are all spread out, chat with pharmacy and see if it’s possible to group any of them together to avoid the nurse having to go into the room more frequently.
Meds like saline flushes, GI prophylaxis, eye drops, creams, DVT prophylaxis, and vitamins can be clustered with time sensitive medications like antibiotics and anti-hypertensives. The goal is to enter the room as few times as possible.
As an ICU nurse, I know this is not always feasible. Sometimes a pump is beeping (make sure to have the alarms volume turned up so you can hear it outside the room!) or a patient is desaturating and you have no choice to enter the room. But, before you do (if it’s not an urgent issue) check and see if you have any upcoming medications or interventions due, and plan to complete that task while you are in the room.
These patients require a fluid care system, but nurses can reduce fatigue and use of PPE by planning out their care for the day.
Make a Checklist of Supplies for COVID-19 Rooms
Nurses should come up with checklists of supplies needed in rooms. Most facilities are trying to keep as little in the rooms as possible, since most of the surplus will be thrown away when the patient is moved out of that room.
Unit nurses should get together and make a ‘par’ checklist of what is absolutely necessary in each room for each shift, as well as admissions. The off-going nurses will be responsible for stocking their rooms for the next shift. That being, said, due to the nature of this disease, sometimes a very busy nurse may not have time to stock for the next shift. This should be communicated to the ongoing nurse so that they don’t go in the room and find that they have no supplies. And, we need to be understanding of this situation. We are all stressed and a little support and understanding of one another will go a long way.
Travel nurses and staff nurses are coming together to care for the overwhelming amount of coronavirus patients, and sometimes the communication lines breakdown. There are several reasons for this including stress, fatigue, and mechanical factors, like being in a PPE suit trying to communicate through a thick glass window.
Stress and fatigue are common issue for nurses caring for COVID-19 patients. Try and understand that each nurse is going through their own struggle, and we all need to take a little extra time to have empathy for each other.
Travel nurses- learn the names of your coworkers!! It is extremely difficult to communicate what you need in a code situation if you don’t know anyone’s names. A good idea is to have providers write their names on their masks so it’s easy to identify who’s who in the rooms.
Nurses have come up with some interesting ways to communicate needs while inside a COVID room. These include lots of sign language moves that no one can understand, trying to shout through a respirator or PAPR through a glass door, or writing ‘backwards’ on the glass doors and windows. Some better options include purchasing white boards (or using the current patient’s white board if it can be seen from the door), using dedicated clipboards with pens/paper inside the rooms, or using walkie-talkies to ask staff to grab supplies or come in the room to help.
Delegation and Teamwork
Across the nation, many facilities are employing non-critical care care staff like telemetry RNs, OR RNs, and procedural care area (PACU, Cath Lab, IR, Endo) RNs to help the ICU staff care for the coronavirus patients. Taking a team nursing approach, the non ICU RNs are able to complete non-critical care tasks and help with manual labor. Non- ICU tasks often include administration of medications within scope of practice, turns, tube feeds, foley care, oral care, priming IV tubing, skin care, and acting as a runner for equipment.
Critical care RNs need to familiarize themselves with the tasks that are within the scope for the non-ICU RNs and delegate appropriately. ICU nurses need to understand that these nurses are often super overwhelmed working in the ICU and far out of their comfort zones. Double check that they are comfortable and confident with the task assigned to them and provide support as needed. Empower the non-critical care nurses to provide care, and assure them that you will be there as back-up and are open to answering any questions.
And, to those non-critical care nurses who are coming to help out- THANK YOU! Please know that as an ICU nurse, I cannot express how much I appreciate you being there. I know this is probably terrifying for you, but thanks for stepping up and coming to give the us a hand. Our gratitude is endless.
BONUS TIP: Some hospitals are utilizing their OR teams to help prone patients. OR and procedural healthcare workers specialize in positioning and reduction of trauma associated with proning. Plus, many of these nurses and providers are not working due to the cancellation of elective surgeries and procedures. Encourage your facilities to use these resources wisely. I can guarantee that not all ICU RNs have ever proned a patient. Ask unit management about this option to help reduce stress on the ICU team and promote patient safety while proning.
Reducing Use of PPE
Some hospitals have implemented policies and procedures aimed at reducing the use of PPE. Administrations are trying their best to keep our providers protected but also conserve PPE. This thought process goes along with clustering nursing care- the more times a provider has to go in and out of the room- the more PPE is used. Inquire with management about some of the practices below to reduce PPE use in your facility.
Many units have adopted policies for multiple use of PPE in between COVID patients. This means that nurses can go from room to room in their mask, face shield, and gowns, if all of the patients they are seeing have coronavirus. Providers must take off their gloves and practice hand hygiene between rooms, but the other PPE can stay on. If a nurse has a rule out and a positive patient, they must see the rule out first, but can then go on into the positive patient’s room without changing PPE.
Some facilities have started putting equipment outside of the room to avoid entering the room for non-essential reasons. How many times have you had to go into a room to relieve an invisible ‘air bubble’ in a patient’s line? Nurses have put extension tubing on drips and threaded them through doors or constructed portals to be able to have access to the IV pumps outside the rooms. This allows titration of meds, replacement of bags, and troubleshooting of pumps all to be done without exposure to the patient. Other items that have been moved outside of the rooms include ventilators and monitors. Be aware- if the patient is in a negative pressure room, the staff must find the right logistics to place equipment outside the room and still maintain a good seal.
WASH YOUR HANDS ALL THE TIME
Above all else, like everything we’ve ever learned in nursing, hand hygiene is of utmost importance. Hand sanitizer is okay between patients, but after you have doffed your PPE, wash your hands in warm, soapy water for at least 20 seconds. Scrub any areas that were exposed.
Stay Safe and Stay Well. Remember: We are all in this together and we WILL prevail!