Christin Gordanier
Mid-summer 2021 Seattle was enjoying a hopeful reprieve from the previous winter and spring’s COVID surges. There was a brief period in July when masking was not required for vaccinated people in King County and case counts were low. In August of 2021, we started to hear more about the Delta variant that had wreaked havoc in India and the UK. By September, we saw a return to required masking for all and a steadily increasing case count in King County. By late fall everyone was dismayed to see surgical cases canceled yet again in the face of rising hospitalizations and deaths. Here is an interview with two Nurse Mangers from the NW campus about what it was like to lead through this Delta surge.
Amy Ungerleider, Manager of the Med Tele Unit, UWMC NW
Med Tele had the acute care hot zone unit during all COVID surges, including Delta.
What was most challenging leading trough this time?
It was disheartening to realize that the vaccine would not be the definitive end of the pandemic. In this surge we saw many immunocompromised and even previously healthy patients who had been fully vaccinated still getting hospitalized with COVID. Additionally, there was anger and frustration shared by caregivers toward the unvaccinated sick who were straining the healthcare system. Suddenly, the pandemic felt political, and the spirit of healthcare heroes seemed to have faded.
In this surge, there was a significant shift in the support required, from addressing fear to addressing anger, and helping nurses find their compassion and willingness to connect with patients and their families despite their vaccination status. Overall, staff at this point were tired and it was clear that we were in for a much longer haul than any of us had hoped for.
What went well?
It was surprising how easy it was to set up the hot zone again. During this surge there was not the constant daily (or hourly!) policy and procedure changes. The teams knew what to do and there was not the same element of fear or the unknown this time. We also did not see so many staff getting sick themselves. Staff knew how to care for COVID patients and had all the supplies needed. That relief was palpable. On the Med Tele unit here were quite a few new grad nurses who brought fresh energy and enthusiasm during this time.
Cristine Beal, Manager, ICU, SCU, UWMC NW
What was most challenging leading through this time?
“Here we go again.” That was the thought on everyone’s mind in the fall of 2022.
This was a challenging time for our team members working with our patients’ families and other visitors. Visitor restriction policies were in flux during this time. When patients with COVID who had not been vaccinated were admitted to the ICU, the staff would feel concerned that the visitors at the bedside were also not vaccinated. This caused some fear and frustration for staff when they worked closely with these visitors in the room. As a manager, it was important to be a sounding board for staff frustrations, and to be a support when visitors refused to follow masking requirements, etc. In the ICU, issues with visitation were especially challenging as we worked to balance the very critical nature of the patient’s status and the need for caregivers at the bedside. Some of these fears were alleviated with the vaccination/testing requirement that went into place in the very late fall.
What went well?
This time the ICU felt ready. They knew what to do, how to set up a hot zone, we had supplies, and the staff felt safer because they were vaccinated. The ICU was also in a better position from a staffing perspective. This was in part to having quite a few travelers which the ICU had historically not had before. The travelers also brought fresh perspectives and much-needed relief. An unexpected benefit of having travelers who had worked in other hospitals throughout the country is we heard time and again how lucky we are here at UW.
2021 brought challenges that we hope we might not see again in our careers, even still, there is no other place we would rather weather the storm.
Kellie Garth Green, MN, RN, CCRN
As we think back to 2021, some of the most challenging things all inpatient staff needed to navigate were the changes to our visitor policies. At the forefront of this incredibly difficult work were our frontline nursing managers. They were called day and night, 7 days a week, to address requests for exceptions to our visitor policies. Most days they started their shifts addressing new requests for visitors, many of them begging for additional family members to be present during end of life.
This work was grueling, heart breaking and constant. There were times when saying no one more time felt like a burden too heavy to carry. Calling person after person to share the reason for the visitor policy and how we were tasked with keeping all our patients and staff safe during the pandemic, and that their hearts went out to the families who were sacrificing so much in those moments, was difficult. They led with grace, compassion and steadfast strength, bearing the weight as only those who have had to say no to hundreds of sad, broken and angry family members can. For this we want to say thank you. Thank you for your kindness in the midst of tragedy. Thank you for your compassion and understanding for those who were angry at the situation and thank you for being human and showing those you support what it means to be a leader in the most difficult of times.
Sherri Del Bene RN, MN, NEA-BC
Assistant Administrator, Patient Care Services
The Nurse Managers played a central role in the COVID-19 pandemic. This group of committed and talented individuals led their staff through unknown territory while needing to change course almost daily. Throughout the pandemic, the Nurse Manager team prepared for caring for high numbers of patients with COVID-19. The medical center initially and intermittently experienced significant shortages in PPE and other supplies, space to care for patients and staff to provide care to patients. Each Nurse Manager worked closely with their teams to implement new processes related to PPE and supply shortages and staffing shortages. PAPR hoods were recycled and types of available masks changed frequently.
The Nurse Manager group prepared for implementing crisis standards of care should the census peak predicted by IHME arrive. In collaboration with the Clinical Nurse Specialists and Nurse Educators, the Nurse Managers developed a model for team nursing. Surgical Services nurses would serve as extenders for ICU nurses and ambulatory nurses would serve as extenders for acute care nurses in a patient care team. Individual units tested a team nursing model with nurses from the PACU in ICU and a nurse from the dermatology clinic on 6SE. Hot zones were set up and maintained on 5 East and 6SE respectively while other nurse managers prepared to set up hot zones on their units.
Many nurses and other staff expressed fear, and each Nurse Manager was present with their staff to educate, support, and solve problems. The visitor policy presented significant challenges for all staff, especially the Nurse Manager group. Nurse Managers communicated with often angry and frightened patients and families who were no longer able to visit their loved ones. Visitor restrictions proved to be a significant point of moral distress for all clinicians and leaders and the Nurse Managers navigated visitors' requests and clinician concerns on a daily basis.
During the first phase of the pandemic, Nurse Managers took turns rotating through the Medical Branch director role in the HEICs disaster chart. In addition to managing their own unit, the Nurse Manager in the Medical Branch Director role assumed responsibility for ensuring adequate supplies of PPE, communicating with the patient care leadership team and coordinating general operations.
Crisis preparations
As data sites such as IHME predicted extremely high census peaks, the leadership team prepared for extreme shortages in staffing, space, and supplies. Personal protective equipment supplies were spotty and availability changed daily. Teams made plans to care for patients in nontraditional areas such as the PACU, ICRU and OR. The nursing leadership team developed a model for Team Nursing to implement in the event of several nursing shortages in critical care and acute care. Nurses from PACU would play an “extender” role in Critical Care and nurses from Ambulatory Care would serve on the team as acute care nurse extenders. Our nurse educators and clinical nurse specialist collaborated with Nurse Manager to train PACU nurses in their Critical Care Role. The 6SE team simulated a team nursing model with acute care nurses partnered with a nurse from Ambulatory Care. Hot zones were set up to improve efficiency and preserve PPE in caring for patients with COVID-19. The teams evaluated documentation requirements and developed guidelines for contingency and crisis documentation.
Lindsay Boyd
Sepsis and Infection Prevention Clinical Nurse Specialist
COVID-19 vaccine clinic manager
“Embrace change” certainly took on a new meaning for the COVID-19 vaccination clinics. The teams across the campuses met the challenge of creating a new clinic space where no clinic previously existed, administering over 150,000 doses to patients and employees aged 5-105. Staff from all over the medical centers came together to quickly adapt and administer vaccines to new eligibility waves safely and efficiently. This was highlighted when, after a six-week hiatus, the clinics reopened to address the additional booster need. Staff reported immense satisfaction and even some burnout reduction while working for the clinics since “people are just so happy and grateful,” remarking that “this is something tangible I can do to help protect our staff and community." The amount of change, sometimes on a daily basis, was incredible, but staff worked to incorporate new workflows and to make sure every last drop of vaccine made it into eligible arms. The teams spread the community reach even further through supporting several pop-up clinics across the region.
Caron McMahon, MSN, RN
Director of Ambulatory Care Nursing, UW Medicine and Northwest
2021 will be remembered in the Ambulatory world as the year of “Hope”. The Covid 19 clinics sprang into action, clinic doors opened to healthcare staff and employees. I remember the overwhelming feeling of hope experienced, on Jan 2nd, 2021, when I received my first Covid 19 vaccine. This was it, this was the future, immunity for all healthcare workers and a chance of normality and potentially an opportunity to see and visit loved ones in person later in the year. What an incredible start to the year!
The Information Technology teams continued working hard, maintaining telemedicine visits with an active Zoom Protected Health Information link for these visits, ensuring quick access for the patient within the electronic health record. Their assistance in the process was invaluable and telemedicine continued to provide excellent access for patients across all Ambulatory services, reducing cancellation and no-show rates, reducing appointment duration, and increased opportunities for alternative services such as infusion areas to increase capacity as clinic in person volumes dropped, opening access to exam rooms.
Ambulatory technology advancements were evident throughout the year as we introduced the OBIX NST live data management system, facilitating live, real time interpretation and visibility across all obstetric services. The Destination one(D1) go live April 1st, 2021, and the out of hours nurse triage service change from the Community Care Line (aka the UW Medicine Nurse Line) to the contracted vendor, Carenet. The original contract for Ambulatory Care out of office call management switched from the Community Care line (CCL) to CareNet in phases:
Covid vaccine roll out: To maximize opportunities for community adherence and Covid vaccination compliance, the ambulatory services came together to obtain department of health Covid clinic administration accreditation for multiple Ambulatory Clinics with GIMC, WHCC and Pediatric clinic leading the way in July 2021.
The Pediatric clinic like all other ambulatory clinic’s continued to face challenges from a visitor policy perspective. Covid 19 social distance state mandated rules restricted the clinic ability to accommodate more than 1 visitor with a patient. This had a significant public facing impact as each clinic struggled to balance the safety regulations required of them to protect staff while also meeting the needs of the patients and families attending our services. At an early stage, the importance of childhood vaccination compliance let to a complete review of the pediatric clinic appointment template as it became apparent the children would continue to come and we had to find a way to protect the babies and immunocompromised children. This was achieved by accommodating well baby and newborn baby checks in the am and older children prioritize urgent care and higher risk infection control patients in the pm. The long-term effects of social distancing, home schooling and social disconnect for children became more evident in 2021 as we recognized increased mental health presentations and requests for access to counseling services. This presented the pediatric clinic with a unique opportunity to launch the Integrated Behavioral Health Program for children and their families. GIMC and the peds clinic partnered to recruit a fulltime Behavioral health social worker, facilitating both clinics ability to offer scheduled appointments for this vulnerable population.
The Diabetes Institute in SLU, in May 2021, recognized an opportunity to review and change their RN care delivery model. Based on provider feedback and a request from Dr. DeSantis, conversations and planning started and the team in its entirety selected the Care Team Model. The MD teams were divided into four groups, based on MD time in clinic, complexity of patient panels and appointment lengths. Care team evolved, consisting of MD’s, APP’s and RNs supported by medical assistants and nutrition staff. Provider staffing levels was reviewed, and additional APP and MD positions were identified, FTEs were approved, and the recruited process commenced as part of this project. RN team roles and goals were approved, and the revised workflows led to RN schedule changes and the implementation of a new RN 2 week / 80 hours self-scheduling process. The project commenced Oct 1st, 2021, team assignments workload was monitored from day one and the evident has demonstrated, an increased workload for the RN and does not facilitate remote work, but has proven better continuity of care with patients, better, improved working relationships with providers, clear delineation of workflow and increased RN learning from providers.
Aug 2021 also saw the introduction of Caron McMahon as Director for Ambulatory Care Nursing with responsibility for Professional practice standards across Montlake and Northwest and the launch of the AACN Healthy Work Environment standards as a retention initiative.