Lessons Learned: Leading Perioperative Nursing Through COVID-19

As the COVID-19 pandemic began to unfold across the United States, Cleveland Clinic immediately moved into action, planning and preparing for the unknown.

The health system utilized its resources, working with infectious disease teams, seeking recommendations from local, national and global health experts including those in China and other areas already impacted by the virus, and more. Discussions focused on how to best meet the needs of Cleveland Clinic communities, covering everything from how to structure Cleveland Clinic’s organization to how quickly the health system would be able to respond as the pandemic spread.

Among the planning and preparation, a top priority was determining the future strategy for patients in need of Cleveland Clinic’s surgical services. With more than 255,000 surgeries performed at Cleveland Clinic annually, leaders began to outline what surgical care would look like during the pandemic, with the anticipation that surgical services would likely be scaled back – and surgical nursing played a vital role in the process.

Meeting government mandated orders

On March 17, the Ohio Governor’s office, in collaboration with the Ohio Hospital Association, announced the postponing of nonessential surgeries and related procedures for adult and pediatric patients. The order declared that surgeries or procedures should only move forward if there was a:

• Threat to the patient’s life.
• Threat of permanent dysfunction of an extremity or organ system.
• Risk of metastasis or progression of staging.
• Risk of rapidly worsening to severe symptoms.

Additionally, there was significant emphasis on minimizing the number of individuals in perioperative settings to only those who were essential to conducting the surgery or procedure, as well as other patient care areas like post-anesthesia care units (PACUs).

Per the order, Cleveland Clinic fully shut down its ambulatory surgery centers (ASCs) and reduced hospital surgical teams and services at all locations. Most Ohio-based hospitals were reduced to one surgical team per day to provide care for emergency cases only, and others including main campus, Akron General, Fairview Hospital and Hillcrest Hospital were designated to offer limited services.

Considering scenarios and outlining plans of action

Cleveland Clinic’s leadership team, including perioperative nursing leaders from across the organization developed operational plans for Government-permitted surgical cases, such as surgeries that were urgent or emergent, those with concern for worsening symptoms over a 4-week period, cancer surgery or cancer evaluation and infected joint surgeries.

Additionally, with the safety of patients and caregivers in mind, Cleveland Clinic’s perioperative nurse leaders collaborated with their anesthesia and surgical physician colleagues to devise plans for various scenarios and situations, such as:

• How to proceed with patients who are scheduled to have surgery, but don’t yet have a confirmed COVID-19 status.
• How to prepare for surgeries on patients who are COVID-19 positive or are showing COVID-19 positive signs or symptoms.
• How to ensure patients with life-threatening conditions still receive the care they need.
• How to conserve personal protective equipment (PPE) in perioperative environments.

And, the team outlined and created comprehensive COVID-19 surgical/perioperative statements. The statements included detailed information for surgical procedural areas, such as guidelines for:

• Proper PPE usage, like when to use N-95 masks.
• Treating patients who are awaiting COVID-19 testing results.
• Treating high-risk patients who have tested positive for COVID-19.
• Treating patients who need emergent surgery, but haven’t yet received COVID-19 testing results and how to proceed with surgery for these patients; i.e. taking COVID-19 positive precautions.
• Number of caregivers per case and perioperative environment.

Helping in other care areas

With the reduction in perioperative staffing needs, extensive plans were also made to temporarily transition perioperative nursing caregivers to other care settings.

Specifically, an effort was made to cross-train ambulatory and perioperative nurses to care for patients in medical-surgical and critical-care settings. With the help of Northeast Ohio nursing school faculty members, Cleveland Clinic’s Office of Nursing Education and Professional Development cross-trained more than 6,000 nurses over the course of just a few weeks (by April 19).

The cross-training program was built to meet the needs of any nurse, providing all the tools and resources needed to care for patients – from getting actual floor experience to charting classes – so nurses were comfortable and confident in the care they would be providing.

In addition, many of the organization’s PACUs were designated as ‘overflow’ intensive care units (ICUs) in the event ICU beds for COVID-19 positive patients exceeded each hospital’s current ICU bed capacity. Perioperative nurse leaders worked closely with their ICU counterparts to understand caregiver training needs, proper staffing ratios, and the equipment and medications required to ensure the same level of care was provided, regardless of geography.

Getting back to the ‘new normal’

As government mandates lifted and healthcare organizations began re-opening surgical services, Cleveland Clinic’s executive leadership team appointed an interprofessional committee to lead surgical reactivation. This interprofessional team, led by Beri Ridgeway, MD, Institute Chair for Cleveland Clinic’s Obstetrics/Gynecology and Women’s Health Institute, was assembled to ensure a safe and thoughtful approach to surgery and procedure reactivation. Surgeons, anesthesia providers, continuous improvement specialists, and perioperative nursing leaders were assembled and mobilized by the ‘reactivation task force.’ This task force created a reactivation toolkit, and as part of the toolkit, a group of perioperative nurses led the development of a reactivation checklist.

Nurses provided significant input on how re-opening should look. They offered insight on compliance, social distancing, PPE, plans for re-stocking operating rooms and PACUs, how to reunite redeployed teams, requirements and resources needed to ensure 100-percent patient advocacy, changes to visitation and discharge, cleaning protocols, and more.

Following a phased approach to allow for proper time planning and preparing, Cleveland Clinic re-opened its first group of ASCs the first week in May, its second group in mid-May and the remaining re-openings will occur in June. Each hospital gradually expanded its perioperative footprint as well, also embracing the reactivation process to ensure patient and caregiver safety.

Interprofessional teams either converged in meetings the days prior to re-opening or early on re-opening day. They reviewed the checklist and met with a reactivation task force to discuss reactivation processes and protocols. Following, the task force held scheduled touchpoints to address issues, barriers, questions, successes, best practices, lessons learned and changes since initial reactivation – all of which were reviewed with Cleveland Clinic’s larger governance group and used as guidance for ongoing facility/services re-activation.

Lessons learned

Throughout the height of the pandemic in March and April, Cleveland Clinic’s perioperative nurse leaders noted several takeaways and lessons learned in preparing for and recovering from a health crisis of this magnitude.

1. Work closely with all perioperative leaders.

At Cleveland Clinic, nursing had an important seat at the table as perioperative leaders worked side-by-side to determine essential versus nonessential surgeries, analyze potential scenarios and outcomes, discuss how to best articulate changes to staff as well as how to instill caregiver confidence and ease anxiety. Collaborative leadership is vital to all aspects of planning – from the ability to make swift decisions to acknowledging and addressing caregiver concerns.

1. Transparent communication is key.

Throughout every phase of planning and preparation, perioperative nurse leaders worked closely with their teams conducting extensive leadership rounding and transparently communicating and educating. They appropriately considered caregiver suggestions and concerns to ensure Cleveland Clinic was taking all the right steps for both patients and caregivers. Roughly 50 perioperative nurse leaders, including the ACNO, directors and managers, held daily meetings to discuss challenges, issues and concerns. When reactivation resumed, meetings were held twice a week and, currently, they are held weekly. The best way for leaders to enhance relationships and further build trust during a time of crisis is through consistent, transparent communication.

1. The gift of time is invaluable.

As soon as COVID-19 hit the U.S., Cleveland Clinic began planning and preparing. Thankfully, Cleveland Clinic’s Ohio and Florida regions had a small gift of time to make necessary preparations that, unfortunately, places like Italy, New York and Detroit didn’t have. Leaders need to think about the gift of time: do you have it and how do you take advantage of it? Movements need to be made immediately to use every minute of available time.

1. Lead by example.

As soon as cross-training began, many perioperative leaders at Cleveland Clinic attended training classes along with caregivers. Leading by example is extremely important – especially in a crisis. If nurses are temporarily transitioning from a PACU to an ICU, perioperative nurse leaders need to have the knowledge to help their nurses. Leaders should sit down with their teams and inquire about comfort and confidence levels to determine how each caregiver can be the most helpful and most responsible.

1. Provide flexibility and support.

When situations evolve rapidly, caregivers look to their leaders to gauge their ‘emotional barometer.’ Cleveland Clinic perioperative leaders had to be flexible – and portray that flexibility to their teams – as they worked through how to continue to provide an appropriate level of perioperative nursing support, while also providing caregivers with critical training. The unprecedented changes also required much caregiver reassurance. Physically and emotionally, in a pandemic, leaders need to be flexible and provide support – however it’s needed.

1. Remain connected.

As the COVID-19 situation evolved, perioperative caregivers began taking on new assignments. For example, the manager of an ambulatory surgery center on Cleveland’s east side (Twinsburg ASC) became the point person for one of the regional testing centers. Perioperative nurses started assisting with temperature screenings and in the COVID-19 call center. Nurses embraced these opportunities, showcasing their talents and skills in other ways. However, leaders needed to stay connected to their teams – even though they were now widely spread and working in a multitude of different settings. Through daily text messages, phone calls, and emails, leaders must do everything possible to remain connected to their teams during a crisis.