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):
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 have fostered a culture at D-H that enables nurses at the patient’s side to be leaders and decision makers in our daily practice and profession through D-H’s Nursing Practice Governance structure. (NPG).
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. This is a response from Deb Goodrum, BSN, RN, CEN, Manager of the D-H ED below. 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 the decisions of 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 and they set in motion several plans.
1. Education and training updates – every day at 7pm, an ED unit staff huddle was held to capture all staff (nurses, techs, physicians, residents, local police officers, housekeeping) to share local and federal updates. (PPE needs, screening processes, testing options, and reflected DH processes on a daily basis). Thoughts and comments were recorded on how we could change, implement and adjust our work. Staff eagerly engaged to take on this crisis.
2. Immediate need to change workflows was identified – ED leadership posted a large “sticky” note on the door to capture 2 things from staff with 2 simple questions:
- What do you need?
- What are your ideas/suggestions?
3. Every day these post it notes (improvised CPC council) were reviewed and aligned with DH policies and we immediately updated practices with ICS through our Emergency Department director for implementation
4. Recognized immediate need to perform simulation training for incoming patients with need to intubate COVID patients. ED nurses quickly worked with ED Attendings to change respiratory arrests, code blues
- ED Nurses initiated and held simulation codes on each shift twice daily. The ED nurses led COVID codes from “outside” the COVID rooms with large Code Index Cards pre-printed with ACLS/PALS algorithms cards which the nurse would hold up on the glass for the team inside the resuscitation room to view during codes
- ED nurses created new workflows to reduce staff in the COVID resuscitation room
- ED nurses trained ED residents to manage vents and IV pumps to decrease staff in rooms
- Simulations led by nursing staff benefitted
- ED nurses utilized windows in COVID rooms to write with dry erase markers to communicate with outside staff what was needed and vital sign updates
5. ED nurses recognized need to increase Tele Emergency Medicine capacity in ED to decrease staff in room. ED techs would scribe codes and traumas from a mobile tele unit in the ED , the Techs could “view and hear” the staff in COVID rooms and capture documentation
6. ED nurses used tele medicine to assess patients with consultant services
7. ED Nurses created “Polizzi” packs which nurses taped to the outside of contact gowns (IV supplies, lab draw supplies, and to go bags) placed outside of rooms for nurses to take quickly to care for patients in COVID room – this decreased supply waste (Named after Kelly Polizzi who suggested it).
8. ED nurses created work flows for transporting patient to CT and MRI (these were adopted by the entire DH system, including our sister hospitals)
9. ED nurses created workflows to perform x-rays through the “window” doors, reducing staff exposed and reducing the use of PPE (these were adopted house wide and by our sister hospitals)
10. ED nurses created process to manage IV pumps outside the rooms for COVID critical care patients to reduce PPE and staff exposure
11. ED nurses created resuscitation workflows with Emergency services bringing patients to the ED decreasing exposure to ED staff and hospital (changed entry route and created a resuscitation “room”). Worked with EMS to change workflow
12. ED nurses created trauma patient workflows to protect trauma team caring for COVID patients reducing PPE use
13. ED nurses created workflows to escort patients throughout the facility for direct admission patients 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 for COVID. ED staff continue to operate and man 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 continue to be functional for the year ahead
16.ED nursing staff supported Housekeeping staff to create workflows for linen and waste disposals
The ED has a Clinical Practice Council, open to all nurses and ED techs, to create workflows and processes. The above items are examples of how quickly problems were identified and workflows were created daily in order to adjust, train and be prepared to care for COVID patients.
Our ED staff quickly became the “experts” on PPE, screening, testing for the facility and continue to be the experts changing rapidly with the CDC recommendations and Dartmouth Hitchcock Incident Command Operation team. Emergency medicine is public health and our team rose to the occasion with enthusiasm, kindness, and grace.