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  1. I used facebook to reach out to nurses working in hospitals in many places in the U.S. I’ve rounded all numbers to protect the identity of the nurses who agreed to be interviewed. I offered to pay all the nurses I interviewed for their time, but they all refused, so I’m making a donation to the American Nurses Foundation Coronavirus Response Fund in their honor. The fund focuses on1: Providing direct financial assistance to nurses Supporting the mental health of nurses – today and in the future Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need Driving the national advocacy focused on nurses and patients Ann works in a state that implemented a stay at home order in late March. It appears to be flattening the curve to the extent that many hospitals are almost empty. The state has only had approximately 10,000 confirmed cases with 300 deaths. In her county, there have been 150 cases with 12 deaths (total population of the county is 120,000). She used to work in a large, urban hospital but after four years started to feel burned out. Now she’s at a small hospital in the suburbs and is much happier, though there were some staffing issues at first. “I started in ICU 1.5 years ago and I wore many hats. At first, we were understaffed with a 1:4 ratio of ICU/stepdown patients (mixed) and no help. Now we have CNAs, and the ratios are now at a max of 3 (if you have 4, they are all stepdown).” Ann’s partner is also a nurse – she’s at a nearby hospital, but she is planning to give notice in a week to do travel nursing and relief work in areas that have been harder hit. I’m planning on interviewing her partner as soon as she gets settled. According to nurse.org2 travel nurses are earning over $10,000 per week to work in New York City right now. Changes? I asked Ann how her life as a nurse has changed since Covid-19 emerged. “I’m being flexed a lot – almost every shift. I went 2 weeks without work. Before Covid-19, I switched from full time to PRN, but I always had shifts 1-2 days each week.” Ann says the hospital is still paying a percentage of her pay. “For the last 3-4 weeks I’ve been getting paid to stay home.” There is currently a very low patient census with only 1 or 2 patients in the entire ICU. Ann continued, “COVID came in and all the other sick people disappeared -- no stroke, heart failure, COPD, pneumonia. People are afraid to come in and are staying at home.” Ann’s hospital has gotten creative with staffing. Healthcare workers who have reduced hours have been asked to be screeners in ER or to work as triage nurses at the phone for suspected Covid-19 patients, but they get paid their nursing pay. “The triage nurses take the calls and tell them to come in or not come in.” Testing Ann said they are only testing people who are admitted to the hospital. CDC guidelines recommend that state health departments modify guidelines to suit their state’s situation. The CDC says clinicians should, “use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Most patients with confirmed COVID-19 have developed fever1 and/or symptoms of acute respiratory illness (e.g., cough, difficulty breathing).”3 Priority Testing Priority 1 testing is reserved for hospitalized patients and symptomatic healthcare workers. Priority 2 testing is to ensure that those who are at highest risk of complication of infection are rapidly identified and appropriately triaged: Patients in long-term care facilities with symptoms Patients 65 years of age and older with symptoms Patients with underlying conditions with symptoms First responders with symptoms Priority 3: As resources allow, test individuals in the surrounding community of rapidly increasing hospital cases to decrease community spread, and ensure the health of essential workers Critical infrastructure workers with symptoms Individuals who do not meet any of the above categories with symptoms Health care workers and first responders Individuals with mild symptoms in communities experiencing high COVID-19 hospitalizations ER screening questions In the last 14 days have you: Traveled to China, Iran, South Korea, Italy or Japan Come into contact with a confirmed Covid-19 patient Had symptoms Fever greater than 100 Difficulty breathing Cough Are you currently experiencing fever over 100, difficulty breathing or cough? Triage protocol can be found here4 For areas with widespread community transmission, If there is fever or history of fever and at least 1 sign or symptom of respiratory disease, place a mask on the patient and then separate them from other patients in a single-person room with closed door. Droplet precautions should be instituted. At Ann’s hospital, if the patient is not sick enough to be hospitalized, they are told to go home and quarantine– right now her hospital is not testing them. She said, “Even if they are hospitalized, if they don’t present as a classic Covid-19 case, then they are not being tested. We are being told it is due to the lack of tests.” When I asked her if she knew how many testing kits were on hand and why they were in limited use, she said she didn’t know. I called labs and hospitals and had no success finding out the availability of testing kits in the area. Testing is ramping up in some states. On April 27th, 2020, I googled “Where is covid testing on the rise” and saw Minnesota, Indiana, Virginia, and Illinois are increasing testing due to a sharp rise in the number of cases. The same will likely occur in Ann’s state if Covid-19 gains a foothold there. How about training? “We’ve had training on how to take care of the prone intubated patient - how to put them on their bellies for safe care. I’ve gone online and read articles and we’ve done education on what it looks like and how it increases oxygenation.” “We also had a refresher course on PPE donning and doffing - how to do it and what is expected.” PPE? When I asked if there was enough PPE, Ann replied emphatically, “NO” “We get one new surgical mask daily. Prior to this they were one-time use. It says right on the box that they are to be worn a max of 40 minutes, but we are wearing them all day.” “It just feels so weird that we are rationing supplies when the hospital is so empty.” “We get an N95 that we have to wear for the entire week. We are wiping them down with sani wipes and placing them in paper bags when they aren’t in use, but the material will eventually break down.” “We turn them in and they are collected and are kept in case they need to be recycled or reused. As of right now we are not actively redistributing used masks. I think they are holding back because they are afraid we will run out.” “Gloves are not an issue. Gowns we are not reusing. We have those stupid paper gowns, the yellow ones, and we toss them. There’s an assigned nurse to guard the PPE – it’s locked up and you have to request PPE and sign a form.” I asked Ann how many times each day she had to visit the PPE distribution station? “In a 12-hour shift with 1 Covid patient I made about 7 visits and each visit took 2-3 minutes. You know, you’re a nurse, what impact that has on your day, on the care you can give.” Census I asked Ann if there had been many Covid-19 patients at her hospital. She said, “We are seeing patients trickle in. There are just a few between med surg and ICU, but there’s a larger hospital nearby that is supposedly full of Covid patients – we think they are coming here, but aren’t quite sick enough to be admitted, being turned away, waiting it out, getting sicker and then going to [the larger hospital].” “We tend to have one in the ICU at any given time and 2-3 on med surg floor. We are being told it’s coming and to brace for it. The entire third floor, which is a 40-bed med surg unit – is dedicated to covid with an additional 12 ICU beds. When asked how many Covid-19 patients she has cared for she said, “I have taken care of 2 – No deaths, all recovered, none required intubation, both middle aged, only one with comorbidities.” I wondered about the statistics about people going on ventilators – how do the Covid-19 patients compare with other patients who are ventilated? “In a year and a half in this ICU, I’ve only had 3 people not make it off the vent. Most are getting well compared to the covid patients.” Presentation “A lot of these patients present with low O2 sats, but are asymptomatic, they feel okay in terms of breathing. The O2 levels are really low because the virus is attaching where O2 would attach – it’s filling the receptors and blocking the O2 binding sites. It’s like Carbon monoxide poisoning. It’s affecting other organs in bodies. A positive is that patients with blood transfusions see a turnaround in 2-3 days and are not dying. That fresh healthy blood is making a difference.” According to Dr. Marc Moss, the division head of Pulmonary Sciences and Critical Care Medicine at the University of Colorado Anschutz Medical Campus, “There are other conditions in which patients are extremely low on oxygen but don't feel any sense of suffocation or lack of air. For example, some congenital heart defects cause circulation to bypass the lungs, meaning the blood is poorly oxygenated.” “A lot of coronavirus patients show up at the hospital with oxygen saturations in the low 80s but look fairly comfortable and alert”, according to Dr. Astha Chichra, a critical care physician at Yale School of Medicine. “They might be slightly short of breath, but not in proportion to the lack of oxygen they're receiving.” Chichra said it's becoming clear that patients who aren't struggling for breath often recover without being intubated. They may do well with oxygen delivered via nasal tube or a non-rebreather mask, which fits over the face to deliver high concentrations of oxygen. Hypoxic patients who are breathing quickly and laboriously, with elevated heart rates, tend to be the ones who need mechanical ventilation or non-invasive positive-pressure ventilation, Chichra said.5 What do you do when you get home? "I don’t wear scrubs home. My partner's facility keeps and launders her scrubs to sanitize them – so we both change at work, but I bring my scrubs home and wash them. I go straight to the shower, no hugs. I brush my teeth and gargle with antiseptic solution since the virus can live in your throat for 3 days. I bleach the bottoms of my shoes and leave them in the car, and I keep hand sanitizer in the car. “ “Since I have to change at work it poses this whole issue of changing in the ICU bathroom and then walking through the hospital without a mask. I wonder what is getting on my clothing. We have to leave our masks at work so I’m walking out to my car without a mask. I think I’m going to start bringing my own mask from home to do that.” When I asked about the rumors that some hospitals had told workers they couldn’t wear masks because it might frighten visitors, Ann said, “We are allowed to wear out masks at any time here.” Before we ended our phone call, Ann had a request for an article: “I think Covid-19 is showing where our hospitals are failing. Hospitals are having problems with payments, they’ve lost funding because we are cancelling all elective procedures – hospitals are taking a huge $ hit. It’s an interesting dynamic and I wonder where will things go with healthcare? Will folks realize that for-profit hospitals are a huge failure?” Well, Ann, I’ll look into that for you, but for now, stay strong and stay safe! What’s happening in your state? Do you have any stories to share? How many testing kits are available at your hospital? Thanks in advance for your comments.
  2. SafetyNurse1968

    At the Bedside with Covid-19 -Part 2: John

    I used facebook to reach out to nurses working in hospitals in many places in the U.S. I’ve rounded all numbers to protect the identity of the nurses who agreed to be interviewed. I offered to pay all the nurses I interviewed for their time, but they all refused, so I’m making a donation to the American Nurses Foundation Coronavirus Response Fund in their honor. The fund focuses on1: Providing direct financial assistance to nurses (RNS SEE ELIGIBILITY HERE) Supporting the mental health of nurses – today and in the future Ensuring nurses everywhere have access to the latest science-based information to protect themselves, prevent infection, and care for those in need Driving the national advocacy focused on nurses and patients John works in an ICU in a large, urban hospital with 50 confirmed cases and only 4 deaths in a county of more than 300,000 people. In John’s state, there are 12,000 confirmed Covid-19 cases with 450 deaths. Their stay at home order occurred on March 30 and has been extended to June 10, 2020. PPE situation I asked John if he feels safe at work. His response was disturbing. “No, because they aren’t following protocols. I’ve worked in the ICU for almost 20 years. I love my job, and I’m passionate about educating staff on best practice, but I just got written up for trying to get my fellow coworkers to follow isolation protocols.” “To take a Covid-19 patient off of isolation, you have to have 2 negative tests greater than 24 hours a part – and even then, if the patient is still febrile and symptomatic respiratory wise –they are to remain on isolation as if they have Covid unless the physician discontinues the isolation. But nurses are opening the door and taking away the isolation cart – they are deciding the patient is fine. My question is, who am I supposed to go to when I see a break in policy with covid and the supervisor has no idea what’s going on and it’s putting me and my patients at risk? Another issue is how we deal with aerosolizing procedures. Any time you break into the vent line --Respiratory Therapists have to do that to change the filters in the vent --every time you open that circuit, the CDC says for 3 hours afterwards, anyone going into the room needs and N95 mask, but my hospital is doing 2 hours. I mean, technically, covid patients should be in negative isolation since it’s droplet, but limited rooms make that difficult. For patients who are not vented, you used to need an N95 for any Bipap, cpap or vapotherm that was over 6 liters, but they just changed it to >20 liters. And it’s all about PPE.” John says the hospital is assuring them that there is plenty of PPE. “They won’t give us numbers and they are asking us to recycle surgical masks, eye wear, N95, into a bag – But we don’t know the method. When will it happen? No information is being given.” “I was one of those people wearing a mask prior to it being mandatory. People looked at me like I was nuts. Now it’s mandatory.” To protect employees, John says they’ve closed down almost all entrances to the hospital, and no visitors are allowed. “The staff come through one entrance and there are screeners who take our temp with an infrared sensor, hand you a mask, and you sanitize your hands. John describes three levels of masks. “The one you get at the door is the cheapest – for housekeepers – it’s a level 1 – much thinner. Level 2 is a true surgical mask. Here’s the problem, people are walking from the parking area, getting on an elevator unmasked, not maintaining a 6 foot distance. These people are filling the elevators to get the mask, without wearing a mask! It’s insane. The N95 are under lock up with a guard. The only way to get one is if you have a covid suspicious patient, and they count everything. There are five locations in the hospital where N95s can be obtained, all of them guarded by nurses or security guards. If you have a patient on isolation, they bring you a PPE cart. If you run low on the cart, they bring you what you need.” Reuse of N95s “You have to reuse the N95s – they keep changing it. Right now I think it’s 1 per shift. There’s an egg crate container for your mask and it goes in a paper bag, but my concern is that the next time you have to reach in the bag you are contaminated. The bag must be thrown away after holding the mask. I’m using a Tupperware method to let mask dry out without contaminating myself.” According to the CDC, extended use is preferred over reuse.2 “A key consideration for safe extended use is that the respirator must maintain its fit and function. Workers in other industries routinely use N95 respirators for several hours uninterrupted. Experience in these settings indicates that respirators can function within their design specifications for 8 hours of continuous or intermittent use. There is no way of determining the maximum possible number of safe reuses for an N95 respirator. Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses.” Testing kits When asked how many test kits are available, John replied, “No one knows. There is rumor that our hospital isn’t testing anyone because they want to keep the perceived numbers down, make us look like a nice place to visit.” Census “Our hospital has only had 5 truly positive Covid tests, we’ve had 10 or so presumed positive, and a ton of PUIs (patients under investigation). We are waiting for test results for more than 100 people. But all of them are coming back negative. So we shut down the covid unit and sent most of the nurses home on pandemic pay. There is no one to test, no one is coming in. Patients are coming in for open heart surgery, which is incredibly stressful to the body, and then are becoming covid symptomatic. The tests we are doing can’t be accurate. If they don’t have covid then what do they have? I saw a patient with classic symptoms. She had thrown microemboli, she had bruises in her toes, but both tests were negative. When they did a bronch – the bronch was positive. The nasal swabs aren’t getting it. My question is, before doing a nasal swab, the patient is supposed to blow their nose, but you can’t do that on a vented patient. So maybe it’s not deep enough. We are seeing many patients with symptoms of covid who are testing negative. We have two other patients who we are pretty sure are covid positive, but they are not sending the bronch washes for testing.” (A “bronch” is a bronchoscopy – a thin tube is passed through the nose or mouth into the throat and lungs. Common reasons for a bronch are to get a sample to send related to symptoms or something unusual seen on a chest X-ray, or to remove foreign bodies or other blockages from the airway.) John went on to say, “A heart patient came in with a PO2 of 45 and after getting open heart surgery, covid symptoms appeared. He had two negative nasal swab tests. He was bronched but the sample wasn’t sent for covid testing. You’re supposed to send all samples for covid testing. Another patient was tested multiple times with the nasal swab and came up negative. Finally she was bronched and it was positive.” Here’s a Youtube video3 from Mt. Sinai on how to do a proper Covid-19 test: Proning I asked John about proning patients. “Proning patients has been around for a long time – we used to do a lot of proning. Our staff are all young and none of them have proned, so last week we had two classes on how to prone.” According to a review of literature conducted on April 11, 2020, Covid-19 can cause pulmonary edema, multi-organ failure, and acute respiratory distress syndrome (ARDS). The prevalence of ARDS among COVID-19 patients has been reported to be up to 17%. The prone position can be used as therapy for improving ventilation in these patients. “The main mechanisms of prone position in improvement of ARDS patients’ condition are affecting recruitment in dorsal lung regions, increasing end-expiratory lung volume, increasing chest wall elastane, decreasing alveolar shunt, and improving tidal volume. Patients remaining in lengthy prone position sessions leads to decrease in mortality of patients. However, correct selection of patients and applying the proper treatment protocol for prone positioning are key to its effectiveness.”4 I had never seen this, so I asked John to describe it to me. Read this step-by-step article describing how to do it and what it looks like.5 “It’s like sleeping on your stomach. With your left leg on a pillow, your head is turned the same direction as the left leg and the right arm is behind the patient with the patient’s right shoulder touching the bed and the hand is palm up. We also turn them the other direction. You aren’t completely flat. They do have proning tables, but they are so expensive. The biggest problem with proning is keeping the face and ears from breaking down from the weight.” ECMO Another therapy that John is excited about is extracorporeal membranous oxygenation (ECMO) “We started doing this 4 years ago as a last resort. You insert a massive canula into the jugular, or the femoral artery, you can even stick the canula into the heart. It pulls the blood to the machine, filters it to remove carbon dioxide, oxygenates it and returns it.” John went to Emory to learn how to do it. “What I love about ECMO is that it is nurse driven. Most hospitals have perfusionists doing it, but here, we run them. It’s intense. You need 2 nurses to 1 patient. It totally works – saves lives.” ECMO essentially replaces the function of the heart and lungs. It can be used for months to support patients until lung and/or heart function can be restored. For more information on ECMO, read this.6 All of these nurses are experiencing skin breakdown behind the ears, so if you know of where I can get them a behind the head ear loop holder, please comment!

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