Bidirectional Communication and Education

The PCSS role was integral in supporting HICS and frontline staff communication and education needs. Early in the COVID-19 pandemic, the PCSS worked closely with HICS leadership and infection control to develop protocols for COVID-19 isolation, testing, and patient management. The PCSS role then became fundamental in providing education and improving adherence to policies at a time when staff were overwhelmed with information overload in the form of multiple daily emails; rapidly changing information and evidence; and information from outside sources, such as the media, social media, and family and friends. The PCSS worked daily to address frontline staff concerns regarding PPE, testing, high-risk exposure, and quarantine/isolation policies for exposed staff. The unique 1-on-1 capability of the PCSS to field questions, review updated hospital guidelines, and attend daily HICS meetings to learn about potential upcoming changes proved invaluable to frontline staff. The PCSS was also available to facilitate conversations and mediate conflict when debate ensued about COVID-19 testing or type of isolation for any given patient.

Development of Efficient Processes of Care

By identifying concerns and inefficiencies from the frontlines (Table 1), the PCSS role was able to proactively communicate these issues to hospital leadership and rapidly develop new processes to streamline care, making it easier for frontline staff to care for their patients. Some examples of this include: (1) creating a specific home oxygen pathway for COVID-19 patients due to their high oxygen needs with exertion; (2) COVID-19 testing pathways for patients discharging to off-site facilities; and (3) testing pathways for transplant recipients and immunocompromised patients.

TABLE 1 Role of the PCSS in Identifying Issues and Solutions

Probably the most effective example of the PCSS role was contributing to the creation and standardization of the discharge process for COVID-19 patients. This included the development of new standardized phrases in the electronic medical record (EMR) to standardize communication to patients, discharge and follow-up pathways, and discharge planning for complex patients with new tracheostomies. Many patients required home oxygen and that process was made more efficient by linking the home oxygen order and home oxygen evaluation orders in the EMR, creating a system of backup respiratory therapists (RTs) so that RT staffing could be flexed up as needed, and offloading RTs by relieving them of other duties such as albuterol administration.

Bolstering a Culture of Safety

Frontline staff safety in caring for patients with COVID-19 was paramount and a major area of focus for HICS and the PCSS role. Many practical considerations raised by frontline staff were addressed by the PCSS in real time. For example, as more patients were tested for COVID-19 and became people under investigation (PUIs), the PPE process required streamlining to prevent unnecessary exposures and conservation of PPE. Examples included regular staff and processes to build and maintain isolation carts in dedicated locations on COVID-19 units and in the emergency department (ED). Furthermore, many patient rooms did not have disposable stethoscopes requiring staff to leave the room to obtain a stethoscope thereby using more PPE and wasting provider time rather than focusing on patient care. Protocols were established to ensure a standard location for hanging the stethoscopes in patient rooms and to ensure stethoscopes would travel with patients from the emergency room to their hospital room or between units once admitted to the hospital. Finally, protocols were established for provider and staff safety, especially when transitioning home to minimize any exposure to their family. This included shower access at the on-campus exercise facility 7 d per wk from the hours of 6:00 am to 12:00 am so staff could shower after their shift. Scrub deposit was made available at the showers so staff could easily return soiled scrubs. Additional call rooms were also opened for the added staff working in the intensive care unit (ICU) at night.

Advance Care Planning

It was clear in discussions with the teams caring for COVID-19 patients that frontline providers had significant concerns about the high mortality and end of life care COVID-19 patients might require when hospitalized. As an institution, we made it a priority to determine patients’ wishes at the time of admission. Hospital medicine physicians on the COVID units suggested creating advance care planning packets that included a Medical Durable Power of Attorney (MDPOA) form as well as a Medical Orders for Scope of Treatment (MOST) form. Mandatory completion of the advance care planning packet at the time of admission facilitated minimizing the use of PPE, optimizing the use of interpreters, and ensuring patients’ wishes were identified and documented accurately. Standardized phrases and EMR reminders were also created to facilitate addressing code status and providing links to both English and Spanish MDPOA forms. In addition, a process was developed to upload the signed MDPOA forms into the EMR without transferring potentially contaminated paperwork outside of the patients’ rooms. Finally, we built a new care management process to increase completion of MDPOA paperwork from 25.8% (pre-COVID-19) to 40.2% (during COVID-19).

The PCSS also collaborated with multiple care teams to develop prompts and criteria for early palliative care consults for all hospitalized patients with COVID-19. In addition, the palliative care teams were physically located in the ICU and the ED conducting daily outreach to the Hospital Medicine teams to try to see high-risk patients early during their hospitalization. The chief medical officer (CMO) frequently advised on discussions where providers determined that a patient was receiving nonbeneficial interventions, eventually having the PCSS participate in ensuring backup for the frontline providers in enacting often challenging discussions and decision-making. This created a streamlined process for providers to receive assistance in these challenging scenarios.

We also changed our CODE blue process to ensure staff had adequate PPE, to minimize the number of people in the room, and to preserve PPE. The size of the CODE blue teams was decreased from 16 members to 12 members with only 8 team members entered patient rooms during cardiac arrests. Each member of the CODE blue teams received a fanny pack for their individual PPE. PPE Crash Packs were created and included 2 N95 masks (1 medium, 1 large), 1 gown, 4 pairs of gloves (2 medium, 2 large), and 2 face goggles. Rapid sequence intubation medications were added to COVID-19 units and a process was developed for instances where more than 1 CODE was called simultaneously.

Unmet Patient Needs

Expanding isolation precautions, preserving PPE for patients, and protecting staff from exposure to COVID-19 created unique challenges to providing the usual efficient and effective standards of care. There was a disproportionate volume of non-English speaking patients admitted during the initial surge of inpatient COVID-19 patients. To improve communication, we provided translation devices in rooms for non-English speaking patients to facilitate communication while preserving PPE. We also provided patients with iPads to interact with family members with those devices dedicated to a specific patient room to reduce cleaning and PPE use. In addition, we preferentially placed patients with COVID-19 in rooms with windows to the hallway, thereby allowing providers to call into the room to talk to the patient, but still maintain interpersonal distance. Patient care carts were created to provide patients with activities as they had less face-to-face interactions.

Many of the challenges identified by the PCSS revolved around building safe, effective transitions of care processes, such as arranging home oxygen, ensuring safe follow-up after discharge, and addressing delays in placing patients who required a rehabilitation or nursing facility after discharge. Two home oxygen coordinators facilitated discharging patients on oxygen, performing a pilot study using the Masimo™ device to monitor oxygenation after discharge for high-risk patients; postdischarge phone calls ensured patients received adequate follow-up. Leveraging the electronic patient portal (MyHealthConnection™), an app allowing individuals to access their own medical record, while they were in the hospital facilitated the use of virtual health visits after discharge. For uninsured patients or underinsured patients without a primary care provider, we built a process where a nurse would call the patient on discharge to ensure the transition home was safe if we were unable to establish follow-up care with a clinic. Many discharge delays were secondary to lack of placement options for COVID-19 patients; therefore, physical therapy began triaging all COVID-19 patients and appropriately deploying resources to provide more intensive services for patients similar to the services they would receive if they were discharged to a nursing or rehab facility. Furthermore, physiatrists opened a rehabilitation unit within the hospital to transition COVID-19 patients to a service who required ongoing but few other medical needs to offload medical services so they could care for patients who required hospitalization.

Family and Visitors

Another challenge for patients, as well as family and visitors, included the hospital-wide no visitor policy. This lack of family support placed undue burden on patients, but was necessary to protect families, patients, staff, and physicians. As previously noted, we were able to provide patients with iPads so they could video chat with friends and family daily. There was also a process for exceptions to the no-visitor policy in cases such as labor and delivery, patients who were minors, and end of life. These exceptions were posted on the hospital intranet, all exceptions were approved by HICS, and exceptions were communicated to hospital security by HICS.

Communication with families also proved challenging with the visitor policy. Through discussions between providers and the PCSS, we identified that multiple family members and friends were calling the nursing stations daily for updates, and it became a struggle for nurses and physicians to keep up with the many requests for information. To address this challenge, a communication nurse was enlisted on each unit and was responsible for fielding family member calls and updating families daily. Expectations were also added to the communication provided to patients and families at the time of admission, outlining the importance of identifying 1 family member to communicate with the medical team who could relay information to other family and friends.