July 13, 2020/COVID-19

How Indian River Hospital Managed Its First COVID-19 Patients

Nurses’ critical thinking leads to surveillance success

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When the first COVID-19 positive patients presented at Cleveland Clinic Indian River Hospital, a 332-bed hospital in Vero Beach, Florida, it immediately became an all-hands-on-deck situation.

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Through the combination of multidisciplinary teamwork, nursing leadership and the quick and critical thinking of several nursing caregivers, Indian River Hospital soon had a process in place that would transform how caregivers identified and cared for COVID-19 patients.

The first COVID-19 cases

When the virus first hit the U.S., it took several days – sometimes as many as 10 to 14 – to receive COVID-19 testing results. Thus, patients who were presenting signs and symptoms of COVID-19 were presumed positive, but often began deteriorating well before test results were in.

At Indian River Hospital, these presumptive COVID-19 patients were triaged from the emergency department to the hospital’s 5th floor, where roughly 20 beds were set up and an isolated air system was in place.

Within a few days from the time the first presumptive patients were admitted, Indian River’s intensive care unit (ICU) began getting patients from the new COVID unit who were deteriorating quickly. In just one day, two back-to-back critically ill patients were sent to the ICU, requiring rapid intubation and mechanical ventilation.

“Emergent intubations can be stressful on a team – let alone two occurrences back-to-back,” recalls ICU Nurse Manager Sharon Welch, BSN, RN. “In the ICU, we heard that patients were being admitted to the COVID unit, but we weren’t sure what to expect. As soon as the back-to-back intubations happened, our nursing team knew we needed to become proactive with this patient population.”

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Implementing a surveillance process

Welch and several of her colleagues went to the COVID unit and conducted a surveillance of the unit’s patients. They focused on declining trends in patient respiratory status and spoke with each nurse on the unit to obtain information they felt would be beneficial to assess for respiratory decompensation – specifically increased respiratory rates and oxygen needs.

The surveillance idea was modeled from the SWAT surveillance process often used in large medical center ICUs. In the model, a SWAT nurse is assigned to communicate with the entire ‘house,’ talking to every nurse about every patient. The goal is to identify patients that may be decompensating or showing signs of decompensation. If a patient is identified, the SWAT nurse places the patient on a ‘SWAT Watch List’ and partners with the patient’s care team to review the plan of care, determine how to optimize care, or get the patient to a higher level of care before rapid deterioration occurs.

From the COVID unit surveillance, Welch and her team created their own SWAT Watch List. They brought their findings to the attention of their ICU physician colleagues, George Mitchell, DO, and Diego Maldonado, MD. In that one analysis, Welch and the ICU nurses identified four patients with the potential for rapid deterioration and a possible need to quickly transfer to the ICU.

Following their new motto: ‘get them down sooner rather than later,’ the ICU nurse leaders partnered with the COVID unit nurse leaders to address the need for accurate patient respiratory rates and noted increases in oxygen demand. Initially, they determined the COVID unit charge nurses would provide ICU nurses with daily ongoing patient status updates. Their goal was to proactively identify decompensation early and transition patients to the ICU for controlled, planned intubation versus rapid intubation.

Developing a comprehensive plan of action

For the next three days, the full multidisciplinary team – including ICU and COVID unit nurse leaders, nurses, respiratory therapists and physicians, Indian River’s hospitalist group, specifically Richard Rothman, MD, and Gene Posca, MD, and Director of Anesthesiology Paul Skaff, MD – worked to create a comprehensive plan of action surrounding surveillance and care of COVID-19 patients.

“Collectively, our multidisciplinary team met to establish a rapid plan of action for these cases,” says Dr. Maldonado. “We developed a protocol for patient management, including intubation, mechanical ventilation and ICU care.”

When the team was in agreement, Indian River’s resulting presumptive/COVID-19 positive patient surveillance process was as follows:

  • Hospitalists partnered with the COVID unit nursing team to identify patients in need of a pulmonary consult.
  • COVID unit nurses identified early indications of decompensation, flagging increased respiratory rates and oxygen needs.
  • Critical care intensivists and pulmonologists communicated with ICU charge nurses to keep ICU staff aware of potential COVID ICU transfers (prior to emergent need for intubation).

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Additionally, Dr. Skaff and the anesthesiology team had previously established 24/7 coverage for rapid sequence induction (RSI) intubation of all COVID-19 presumptive/positive patients.

“What started as a nursing surveillance process became a true partnership of a ‘team of teams’ in caring for our COVID patient population,” Welch says. “This is a great example of the collective efforts that can be accomplished with effective communication of a need and identified opportunity with caregivers that share a common goal.”

Dr. Maldonado adds that the established protocols were applied to all COVID-19 cases successfully, noting top priorities as saving lives and preventing staff contamination. He also says the protocols used at Indian River were applied within other Cleveland Clinic Florida region locations.

“I am very proud and thankful for my Cleveland Clinic Indian River team,” Dr. Maldonado says. “After these experiences, we feel not just like co-workers and colleagues, but also like family. We take care of each other and support each other in every sense.”

Welch couldn’t agree more: “In 26 years of being a nurse, this was something I’ve never experienced. It made us all stronger and brought our entire Indian River team together – from the PACU to the ED, pre-admission, everyone. We formed friendships and relationships we wouldn’t have formed otherwise.”

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