How a health system responds to COVID-19
This story was originally posted by the Yale School of Nursing and appeared in Yale Nursing Matters magazine (PDF).
Beth Beckman D.N.Sc. is the Chief Nursing Executive for Yale New Haven Health System (YNHHS) and the associate dean for clinical partnerships at Yale School of Nursing (YSN). Beckman also holds the distinction of being one of the earliest confirmed COVID-19 cases in New Haven, in March 2020. But no other COVID-19 case field-marshaled a system-wide pandemic response while personally recovering from that pathogen.
She started with a campaign of transparency and over-communication. That included daily calls with YSN, YNHHS, Yale Medicine, and a series of system-wide nursing town halls.
Personal protective equipment (PPE) was a big topic of discussion for the nursing labor pool. “Our real concern was how do we keep our staff safe?” Beckman said. “We’d never had a virus like this, had never tested our PPE supply level to this extent, and had never been required to innovate PPE stewardship that changed our practice almost on a weekly basis to manage the supply and demand quotient,” she said.
Like the rest of the nation, YNHHS providers followed the CDC’s evolving PPE guidance. “Our bedside leaders listened carefully, responded precisely, and kept themselves safe from contracting COVID-19. I am so very proud of how they managed their practice. Not everyone can do what they did — take great care of patients while taking great care of themselves.”
The numbers bear that out. As of Sept. 30, the cumulative COVID-19 positivity rate in Connecticut was 10–12%, while the YNHHS employees was 3% and nurses was 2%.
Beckman described an environment of innovation and agility. Nurses used baby monitors to keep audible patient vigil, facilities staff punched holes in patient doors and transformed entire wings into negative-pressure spaces overnight, and the Smilow Cancer Center was picked up and relocated to Saint Raphael’s campus within 24 hours.
Operating rooms were converted into ICUs, white boards became patient tracking devices, IT support added video equipment where needed, and “pop-up units” were quickly stood up to manage immediate COVID-19 volume. In Greenwich, conference rooms became holding areas, and even the café was examined for conversion into a clinical space.
“Everybody stretched in ways they didn’t believe possible and faster than they ever dreamed imaginable,” Beckman said. “It’s amazing what talented people can do when the pressure is on and the stakes are high.”
Outstanding bedside leadership
Beckman often refers to nurses as bedside leaders in an effort to recognize their highest level of care, and the pivot made by a group of pediatric nurses is a strong example.
“As elective surgeries/procedures were being shut down, we saw the overall pediatric volume dramatically reduced. Moreover, the pediatric population did not appear to be as vulnerable to COVID-19, so we were expecting a surge. In response to this shift, one of the pediatric units volunteered to lend their time and talent to caring for adult COVID-19 patients. This meant moving all personnel to an entirely new unit, adopting a completely new practice, and dealing with death for perhaps the first time in their careers. Within a few short days of moving to this new unit, it was decided that this would be one of the ‘comfort measures only’ COVID-19 units, and their entire practice was now managing COVID-19 end-of-life-care.”
“These pediatric nurses stepped up and put themselves in a place of maximum discomfort for months and just saved the day,” Beckman said. “These COVID-19 patients were often so sick that they were total care, and in the absence of family, these pediatric nurses went above and beyond to provide them with dignified and compassionate care.”
YNHHS allowed one visitor for patients receiving end-of-life care, but families were often too frightened to come in. And so it was the nurses who would FaceTime, holding up an iPad or a smartphone to give every relative the chance to say goodbye.
Beckman recalls one anecdote from a nurse who spent an hour and a half detangling and washing the hair of a female “comfort measures” patient, in preparation for a FaceTime call. Despite everything she was going through, the patient still wanted to look and feel her best when she talked to her family, and the nurse took the time to provide her with that dignity.
In the case of another patient who was constantly losing blood, the nurse hooked up unit after unit of transfusion until every family member had called and connected with the patient. The consensus among the nursing staff was that they’d never seen patients so sick, of such acuity and high volume, with such unpredictable clinical sequelae.
“Care like this happened every day, many times a day,” Beckman said. “Our bedside leaders took care of these remarkably ill patients and provided them with selfless, courageous, respectful care.”
“This was a once-in-a-lifetime experience that none of us were looking to experience,” Beckman said. “But I could not be more proud of how nurses conducted themselves. Knowing this team as I do, I’m not surprised.”
The power of teamwork
As COVID-19 marched from spring into summer and into fall, and information on the virus evolved almost daily, it took a toll on the nurses and the team.
Beckman was reminded that anything was possible in the presence of a strong team.
“Every day felt like a week, every week like a month, and we would often say every day was Monday,” Beckman said.
“But the teamwork was just exquisite. This was a high-pressure, fast-moving, difficult circumstance, and the way we worked together was so low-drama that it was just a pleasure. There were no egos. As organizational leaders, we all wanted the same things. We didn’t get upset about what had to change; we just kept our focus on taking great care of patients and employees.”
Beckman is preparing for the next wave that this time may collide with the flu. She says she will draw on many lessons learned from the spring and summer. Heading into another round, YNHHS has a more effective testing paradigm, a roadmap for what it takes to rapidly stand up COVID-19 ready units, and a set of best practices for how to best reallocate the nursing labor pool. To help with the last item, YNHHS has been surveying and recording the clinical backgrounds of its nursing workforce to keep an electronic inventory of a wide range of skillsets.
Additionally, a great deal of time and attention has been devoted to understanding how to best support the stress, and reaction to stress, of the frontline. YNHHS established a program called WELD (Wellness, Engagement, Leadership, Development) for programmatic support to address employee well-being. Beckman stated that “We can never forget those healthcare heroes who selflessly served our community during a once-in-a-lifetime pandemic.”