COVID-19: Mobilizing Quickly for a Rapid Response.

Abstract

As patients, hospitals, and the scientific community deal with the rapidly evolving effects of the coronavirus disease 2019 (COVID-19) pandemic, nurses have been called on to respond quickly and in many roles. Direct patient care is undeniably an international, national, and local priority. Yet as we deliver that care, many clinical questions arise about how we, as frontline caregivers in a time of crisis, might “do it better.” For example, evidence regarding COVID-19 indicates the importance of frequent handwashing, maintaining a safe distance from others, and avoiding touching our faces, but how are we modeling these evidence-based behaviors for patients and their families? What is the best way to provide care in accordance with the new worldwide rules and regulations regarding personal protective equipment? How are we compassionately communicating with the loved ones of patients who are hospitalized while enforcing enhanced visitation restrictions for the safety of all?Many new approaches are emerging, from both the lay press and the scientific literature, for achieving high-quality care and communication in the context of restricted visitation. We, as nurses—some of the most trusted members of the health care team1—are called on to deliver care that reflects the best scientific evidence. Doing so involves not only living out the daily rigor of providing care but also using our skills, creativity, and ingenuity to develop ideas for clinical inquiry, to study what we are doing and how we are doing it, and to determine in the midst of a crisis how to measure the care we provide in order to make it even better.The purpose of this column is to describe the planning and implementation of one such initiative and to share how thinking quickly and accessing critical resources can together produce strong clinical inquiry, even in times of duress. Our team identified the clinical problem of how to deliver high-quality, effective communication with families in the context of visitation restrictions. Here we describe, as a case in point, the project “Use of Video Chat to Facilitate Communication between the Healthcare Team and Loved Ones in the Intensive Care Unit” to emphasize the process of developing a clinical inquiry during a short time frame.For patients’ families and loved ones, and often patients themselves, the experience of the intensive care unit (ICU) can be isolating.2 The inability of significant others to be physically present in the ICU can cause isolation, which can contribute to worse patient outcomes, including depression, anxiety, and delirium,3, 4 and is often exacerbated by sporadic communication from the health care team.5 Because of the isolation imposed by COVID-19, health care organizations have quickly transitioned from open visitation policies, which improve patient outcomes and communication between the health care team and patients’ loved ones,6–8 to fully restricted visitation. The drastic change in visitation policies was imposed with little forewarning, thereby limiting transparency, contributing to anxiety among patients and families, and compounding stress for patients, their loved ones, and clinicians on the health care team. The ICU team at our institution was challenged to identify innovative methods that would promote effective communication and patient- and family-centered care while maintaining a consistent workflow.Evidence was lacking in the literature for optimal communication strategies in the context of restricted visitation.4 Although electronic tablets and smartphones have been used for more than a decade to educate patients9 and plan the discharge process,10, 11 and although their use has been studied in educational initiatives implemented before and after procedures and after discharge,12 most clinical inquiry related to these devices was limited to education. The acute care literature contains few studies of the ability of smartphones or texting interventions to improve communication or provide a virtual sense of presence between a family, their loved one in the ICU, and the team of health care providers entrusted with the patient’s care. Scientists in Denmark reported that the use of technological devices for communication demonstrated benefits for patients but had deleterious consequences on clinicians’ workflow processes.13Communication-focused studies conducted in the ICU setting reported that patients most value the timing, frequency, and content of communication.5 The most salient of these studies, published by Seaman et al,5 was not conducted in a restricted visitation or isolation scenario. Among those researchers who studied non-ICU settings, a French-Canadian team reported, measured, and validated the concept of telepresence, or the ability of a technology to establish a sense of one’s physical and social presence at another location, as an effective means of communicating virtually.14 Beyond simply teaching or exchanging daily numbers in a status report, telepresence holds the hope of achieving much more— establishing and building trust, compassion, and care in a situation imbued with concerns, anxieties, and fears that are potentially unique from those typically faced during an ICU experience.13Using evidence that electronic tablets could be applied successfully to educate patients and help plan discharges,9 our workgroup evaluated their use in allowing virtual visitation and communication in the ICU. We designed a clinical inquiry project to address the diminished sense of family presence in the context of restricted visitation and ensure accurate and timely communication between patient’s loved ones and their health care team. Specifically, we sought to address 3 questions: (1) Is the use of an electronic device to facilitate virtual visitation in the ICU satisfactory for patients and loved ones when in-person visitation is restricted? (2) Are the advantages of electronic tablets (video plus critical information exchange) perceived by patients and loved ones to be superior to those of telephone alone (critical information exchange only)? (3) Are the costs of electronic tablet use (initial investment in devices, maintenance costs and upgrade fees, time nurses spend initiating and facilitating interactions) offset by benefits in patient and family satisfaction and in the effectiveness of communication, thereby justifying more generalizable, long-term use?The resources needed to facilitate video chat as a method of communication were not readily available in our setting. On the day that a strict no visitation policy was implemented, the ICU team at our institution requested from the hospital’s incident command center the devices and technological support to pilot video chat in 2 ICUs. The leadership team approved the request the same day. Because technological support is a fixed resource within the organization, the ICU team accrued only the costs for the devices. A workflow and protocol for the video chat process were not readily available either, so the ICU implementation team, which consisted of 2 nurse leaders (MK and KK) and 2 hospital administrators (MM and MC), created them. Bedside nurses, advanced practice providers, and members of the Patient Family Advisory Council were also included in developing the workflow and tools to assess process measures.Last, the role of “facilitator”—the team member who would support the consistency of and follow-through on the day-to-day work associated with telecommunication and data collection—was identified as a gap. This role was proposed, approved, and implemented within the week. In anticipation of capacity issues related to COVID-19 cases, the Duke Heart Center ICUs postponed elective admissions to the ICUs. This decrease in ICU census freed up 2 nurses for 12 hours a day, 7 days a week to fulfill the facilitator role.In addition to the rapid changes in the clinical setting, the challenge of rigorously evaluating the proposed solution required a rapid response. The pace at which the work needed to be designed and implemented required the clinical team to engage partners from the university–health system partnership in order to prioritize a review of literature to identify tools and optimal study designs. In addition, the partnership provided expertise for efficiently creating a formal study design and expediting the institutional review board approval process. The university–health system partners identified an appropriate study design and a process for analysis, and they facilitated the selection of a validated instrument for measuring end points.Electronic tablets were approved for deployment in 2 ICUs: a 17-bed cardiac ICU and a 32-bed cardiothoracic surgical ICU. Preparing the units for implementation and preparing the devices to receive video calls required time, nursing workflow expertise, and administrative support.The first phase of decision-making addressed the most feasible video chat application to use. FaceTime and Zoom were the most user friendly and supported various cellular phone carriers; thus the team decided to pilot the process with these 2 applications. The 2 hospital administrators on the implementation team led efforts to simplify the technology for the end users. In addition, a device-cleaning process was established on the basis of evidence from a previously approved protocol for cleaning electronic devices.9A second, concomitant phase of activity was creating a workflow and documentation process that was flexible but could meet the goal of providing consistent communication between the health care team, patients, and their loved ones. The 2 ICUs and their respective patient populations required unique workflows because patients in cardiology medicine and patients in the postoperative phase have different communication needs. The team created 1 workflow to support both patients scheduled for ICU admissions (eg, those preparing to undergo a surgical procedure) and patients with unplanned admissions to the ICU, including those from the emergency department or being urgently transferred from referring hospitals or step-down units, or directly from their homes (Figure). The detailed workflow noted the timing and frequency of the use of multiple documents including staff training and education tools, communication scripts, and patient intake forms designed to capture data on patient preferences and the structure, processes, and outcomes inherent to improving communication in the context of ICU visitation restrictions related to COVID-19.Our team developed a virtual visitation communication tool to support consistent collection of data from patients and their loved ones, and from health care team members. Clinicians used section 1 of the tool to document intake information from patients who were scheduled for admission in order to identify the patient’s primary contact person and their contact information. It also introduced the patient to the ICU communication plan. Section 2 was developed for the initial communication between the health care team and the patient’s primary contact person. If the patient’s ICU stay was longer than 24 hours, the facilitator was to contact the primary contact person and complete section 3 of the tool, which includes a script and questions related to the electronic devices used by the primary contact person and their preferred method of communication. Clinicians also completed a daily communication log to document ongoing interactions. Once the patient was ready for transfer to a stepdown unit, the facilitator completed sections 4a and 4b of the virtual visitation communication tool (Table).A nurse on each unit filled the role of facilitator, which was designed to support consistent daily communication between the patient, their loved ones, and the health care team, and to collect the data required in order to measure and evaluate the newly designed workflow processes and outcomes (described in the next section). Although this role was considered optional and not required for the initiative to succeed, it provided a consistent, dedicated resource to ensure that loved ones’ expectations were being met regarding contact with the patient and the health care team.13 The facilitators ensured that data were consistently captured from patients, their loved ones, and health care team members and then integrated into the communication processes. They also promoted the timely and consistent collection of data and allowed for quick turnaround on any adjustments or updates to the protocol.Identifying outcome measures and defining methods for evaluation were critical aspects of the work that were supported by resources from the university–health system partnership. Despite the urgency imposed by the COVID-19 pandemic, quickly identifying evidence-based outcome measures and feasible approaches for analyzing data captured during the video chat intervention was critical to determining the ultimate success of the intervention. Thus our team used the opportunity afforded by the atypical circumstances surrounding COVID-19 to maximize the contributions from quality scholars (doctors of nursing practice), clinical nurse scientists, statisticians, and data management experts in order to address and solve the unprecedented challenge of measuring and analyzing the impacts of rapid clinical redesign on patient care outcomes.We designed a data source table around the newly created workflow to verify the accuracy and completeness of data captured at each end point. In addition, we designed analyses to evaluate preliminary data, which would ensure the reliability of documentation for measures established to capture patient-centered telepresence, communication workflow processes, and the cost and utilization outcomes associated with the clinical inquiry project. We selected key evidence-based indicators to evaluate each phase of care delivery and the associated quality of communication processes and outcomes; we assembled these indicators on 1 case-report form to make data entry easy and efficient (Table).To optimize efficiency, we selected a minimal set of questions for each phase of care. The effectiveness of video chat; assessment of loved-ones’ awareness of, understanding of, and inclusion in the plan of care; and engagement of the health care team in communicating decisions each were defined on a single form, but we paid particular attention to maintaining the integrity of their respective validated response scales (Table). To evaluate the effectiveness of communication through video chat, we included 6 questions from 2 subscales using a visual analog scale. We included 3 items using Likert scales and several with binary or open-ended narrative to evaluate the inclusion of patients’ families in health care decisions (Table). Each indicator and the level of measurement for each of the selected data elements then were included in the analysis and reviewed by the statistical team for accuracy.Overall, the project provided an opportunity to measure and test the quality of care delivery by applying existing evidence to the innovative use of proven approaches for solving complex patient and care-delivery problems under new circumstances and in new settings.Rapid staff education and training, and rapid initiation of the new workflow were required because of the pace in which the change occurred from open visitation to no visitation. We engaged unit stakeholders including nurses, advanced practice providers, and intensivists. The first educational goal was to address the rationale for streamlined communication and the priority to involve loved ones in a patient’s plan of care in the ICU. We developed training modules to allow clinicians to role-play the communication script and allow staff to practice talking points. Next, using the teach-back process (a skill-based educational strategy), we taught team members the proposed workflow for using the electronic tablet to communicate with patients’ loved ones and shared the key responsibilities of each stakeholder on the team. We introduced the role of facilitator; it was favorably received as a means of minimizing the burden for the team members providing direct patient care. Last, each group had an opportunity to ask questions and provide feedback. The workgroup worked through mock communication scenarios to test the workflow and confirm that the proposed process worked well.Overall, we created the design; developed the structures, processes, and outcomes; and performed the final steps of staff training, institutional review board approval, and implementation in less than 10 days. This demonstrates that teamwork, collaboration, and creative engagement of people and resources across clinical, administrative, and academic partnerships can allow workgroups to efficiently conduct evidence-based clinical inquiry projects within short time frames.The COVID-19 pandemic has introduced opportunities for rapid innovation and creativity that help to maintain high levels of care for patients and their loved ones. Because of the need for fully restricted visitation, our clinical team engaged members of a university–health system partnership to evaluate the use of electronic tablets to facilitate virtual visitation in the ICU. By thinking quickly and engaging stakeholders, our team swiftly implemented virtual visitation in 2 ICUs, providing patients’ loved ones virtual access to the patient and the health care team.