Lauren Esposito is a critical care nurse in the cardiac ICU at Christiana Hospital in Delaware. When COVID-19 began to spread across the East Coast earlier this summer, her team transitioned to become an overflow unit for patients who had been infected with COVID-19. She shares insights on how her unit managed staffing during the crisis and what they’re doing to prepare for another surge.
Your unit responded to the COVID-19 pandemic. Can you tell us about what that was like and how it was different from your usual patient population?
We normally take care of cardiac surgery patients and cardiology patients. When COVID-19 started, we transitioned into an overflow unit. The first unit that COVID-19 patients went to was the medical ICU and then geographically, our ICU was right below them. It made the most sense for us to serve as the overflow unit so that we didn’t have to expose the entire hospital.
At first it was a little uneasy, but the support was amazing. Everyone was helping you if you needed anything in the room, just trying to be there for each other and provide resources that we needed. Everyone was very supportive as we made this change and took on more and more COVID patients.
What happened with staffing when you were responding to the pandemic?
Staffing became a challenge, but by implementing a tiered staffing model, we were able to flex and take care of more COVID-19 patients. It was stressful, but I think we did a very, very good job with the resources that we had.
The way it worked it was, two nurses could take care of anywhere from two to four patients, and we had the capacity to take care of four patients with an ICU level of care. We also utilized our step-down units, so they had nurses who were available to help offload us as well. Our unit had guidelines that outlined the ICU nurses’ roles, and then the step-down nurses’ roles as well.
It sounds like the guidelines were critical for this staffing model.
At the beginning of every day, the nurses would huddle and identify what the patients were going to require that day – whether it was testing or procedures. The ICU nurse was responsible for anything that would qualify the patient to be in an ICU. Then we determined the step-down nurses’ responsibilities. They were capable of assessing the patient and passing medication.
During the shift, if a patient was crashing, we were able to flex and have the ICU nurse go to that patient and provide care.
What other strategies made this model work for you?
Our cardiac step-down nurses – the nurses who take care of our cardiac surgery patients – took care of a lot of different tasks because of their unique skills. They were a huge asset, because they were able to take care of things like pacemakers, which not all nurses know how to do. I think the communication so that everyone knew what was expected of them each day helped to ensure that the patient got the best care.
Teamwork was also important. Our medical ICU would call us and prepare us for how they were going to transport the patient and explain what our role was as the receiving team. They also gave us tips and tricks – what to have in the room, what to not bring in the room.
I remember the first time I walked into a patient’s room, it really hits you that you are the primary caregiver and no one else can come in. I felt very alone. But then you look over and see other members of your team through the window, and they are ready to help if you need anything. You didn't actually feel alone. I felt the teamwork even though they weren't physically in the room with me.
What challenges did you encounter as the ICU nurse in this tiered model?
The hardest part was if you needed to be in two different places at once. So many times I couldn't leave the floor, but another nurse would step in and take one of my patients if they needed to go to a test or something.
Luckily, there was a lot of leadership support which created another layer of teamwork. Just knowing you could grab someone and say, "This is what I'm thinking," when you're caring for a new patient population. I think that's especially important.
If you were talking to another critical care nurse who was going to be switching to a tiered model for a COVID-19 surge, what advice would you have for them?
The biggest piece of advice I can offer is just communication. It rings true throughout the entire nursing profession. I felt like I talked so much more than I ever have – checking in to make sure tasks were getting done or that my team members were comfortable with what they needed to do. My advice is to take the time in the morning, or at any other point during the day, and check in with the person that you're tiered with to see how they’re doing and if they have any questions.
It’s especially important to check in with nurses who are put in situations that are not normal for them. For example, taking care of an intubated patient is something new for a step-down nurse. It can be very uncomfortable just because it's different than what they're used to. We were able to identify a lot of issues or potential issues with that morning huddle. It was a chance for people to ask questions if they had any uncertainty.
We also addressed emergency procedures. For example, if a patient was intubated, I would show the other nurse how to hit the 100% oxygen button. It’s good to give them extra information so they don't feel like they're absolutely alone and not supported.
Is your unit prepared if there is another COVID-19 surge?
Yes, we are ready. When we were transitioning back to our cardiac surgery patient population, it was always with the stipulation: “We have to be prepared if we need to do this again.”
Next time, at least it's not going to be as new, and we know what we have to do.