Best Practice, Dartmouth Hitchcock Health

Dartmouth Hitchcock shared governance empowered frontline nurses to rapidly create COVID-19 workflows, simulation training, and PPE protocols during the pandemic.

Nursing Practice Governance Steps Up to the COVID-19 Pandemic, Dartmouth Hitchcock Health, Lebanon, New Hampshire

Katherine McFaun Williams BSN, ACM-RN, President, D-H Nursing Practice Governance, Dartmouth Hitchcock Center for Nursing Excellence, relates how her organization responded to the COVID-19 pandemic (Katherine.M.Williams@hitchcock.org):

Leadership and Culture

Dartmouth-Hitchcock Nursing Practice Governance, our shared governance model, would not be successful without the trust and expert Leadership of the D-H Nursing Leadership Team: Chief Nursing Officer Karen Clements, BSN, MSB, RN, FACHE; Vice President of Ambulatory Nursing; Joni Menard, PhD, RN; and Vice President of Inpatient Nursing Michelle Buck, MSN, RN. Together, they have fostered a culture at D-H that enables nurses at the patient’s side to be leaders and decision makers in daily practice and the profession through D-H’s Nursing Practice Governance structure (NPG).

Emergency Department Response

A great example of how D-H’s NPG was utilized during this recent crisis is best demonstrated by the exceptional work of the D-H Emergency Department. The following is a response from Deb Goodrum, BSN, RN, CEN, Manager of the D-H ED. Her Director, Moriah Tidwell, MSN, RN, supports their Clinical Practice Committee to be interprofessional, with the roles of RN, LNA, ED Technician, EMT, and Unit Assistant all participating in decisions about how to care for patients and their team in the ED.

The D-H ED truly demonstrates Nursing Practice Governance at its best.

We responded to the COVID crisis with our collaborative shared governance model. Our ED nursing staff are frontline workers who were immediately impacted by the anticipated incoming COVID patients. As a result, they set in motion several plans.

1. Education and training updates — every day at 7pm, an ED unit staff huddle captured all staff (nurses, techs, physicians, residents, local police officers, housekeeping) to share local and federal updates. These updates covered PPE needs, screening processes, testing options, and reflected DH processes on a daily basis. Staff recorded thoughts and comments on how they could change, implement, and adjust their work. Everyone eagerly engaged to take on this crisis.

2. The team identified an immediate need to change workflows. ED leadership posted a large “sticky” note on the door to capture two things from staff with two simple questions:

  • What do you need?
  • What are your ideas/suggestions?

3. Every day these post-it notes (serving as an improvised CPC council) were reviewed and aligned with DH policies. The team then immediately updated practices with ICS through the Emergency Department director for implementation.

4. Staff recognized an immediate need to perform simulation training for incoming patients requiring intubation. ED nurses quickly worked with ED Attendings to change respiratory arrest and code blue protocols.

  • ED Nurses initiated and held simulation codes on each shift twice daily. They led COVID codes from “outside” the COVID rooms with large Code Index Cards pre-printed with ACLS/PALS algorithms, which the nurse would hold up on the glass for the team inside the resuscitation room to view during codes.
  • In addition, ED nurses created new workflows to reduce staff in the COVID resuscitation room.
  • They also trained ED residents to manage vents and IV pumps, further decreasing staff in rooms.
  • These simulations, led by nursing staff, benefitted the entire team.
  • Furthermore, ED nurses utilized windows in COVID rooms to write with dry erase markers, communicating with outside staff about what was needed along with vital sign updates.

Technology and Communication Innovations

5. ED nurses recognized the need to increase Tele Emergency Medicine capacity in the ED to decrease staff in rooms. ED techs would scribe codes and traumas from a mobile tele unit, where they could “view and hear” the staff in COVID rooms and capture documentation.

6. Similarly, ED nurses used telemedicine to assess patients with consultant services.

Supply Conservation and Workflow Solutions

7. ED Nurses created “Polizzi” packs, which nurses taped to the outside of contact gowns (IV supplies, lab draw supplies, and to-go bags). These packs were placed outside rooms for nurses to grab quickly when caring for patients in COVID rooms, thereby decreasing supply waste. The packs were named after Kelly Polizzi, who suggested the idea.

8. ED nurses created workflows for transporting patients to CT and MRI. These workflows were subsequently adopted by the entire DH system, including sister hospitals.

9. ED nurses also created workflows to perform x-rays through the “window” doors, reducing staff exposure and PPE use. These protocols were adopted house-wide and by sister hospitals as well.

10. Additionally, ED nurses created a process to manage IV pumps outside the rooms for COVID critical care patients, reducing PPE use and staff exposure.

Patient Flow and Facility Adaptations

11. ED nurses created resuscitation workflows with Emergency services for patients arriving at the ED, decreasing exposure to ED staff and the hospital. They changed the entry route and created a resuscitation “room,” working with EMS to modify the workflow.

12. ED nurses also created trauma patient workflows to protect the trauma team caring for COVID patients while reducing PPE use.

13. Moreover, they created workflows to escort patients throughout the facility for direct admission and critical care patients.

14. ED nursing staff created workflows to stand up a COVID screening trailer outside the facility to test patients and healthcare workers. Staff continue to operate this trailer, which will become part of the community public health support in the year ahead.

15. ED nursing staff retrofitted and created donning and doffing stations within the departments immediately when the crisis hit. These rooms and workflows continue today and will remain functional for the year ahead.

16. ED nursing staff also supported Housekeeping staff in creating workflows for linen and waste disposal.

Summary

The ED has a Clinical Practice Council, open to all nurses and ED techs, to create workflows and processes. The above items demonstrate how quickly staff identified problems and created workflows daily to adjust, train, and prepare for caring for COVID patients.

Our ED staff quickly became the facility “experts” on PPE, screening, and testing. They continue to serve in that role, rapidly adapting to CDC recommendations and Dartmouth Hitchcock Incident Command Operation team guidance. Emergency medicine is public health, and our team rose to the occasion with enthusiasm, kindness, and grace.