COVID-19 Caregiver Collaborative: Practical Insights and Notes from the Field

Added on Apr 22, 2020

By Jessica Dudley, MD, Chief Clinical Officer

New material added from the COVID-19 Caregiver Collaborative meeting on April 17, 2020 has been indicated in italics.

Jessica_Dudley_SBPress Ganey’s clinical leadership team has convened physicians, nurses, and administrative leaders from health care systems on the front lines of the COVID-19 crisis across the United States to participate in a virtual COVID-19 Caregiver Collaborative. Each week this group of approximately 50 leaders discuss and share practical experiences and tools for supporting caregivers and staff emotionally, physically, professionally, and socially while caring for patients during the pandemic.

As these leaders continue to chart the new normal and identify alternative routes to safe, patient-centered care delivery, we will update these notes and make executive summaries of each session available on Press Ganey’s COVID-19 resources page. The topics that have been addressed to date include surge preparation, scarcity of medical resources, hospital reconfiguration, staff shortages, caregiver and visitor screening, antidotes to emotional and psychological stress, navigating serious-illness conversations, bracing for ethical dilemmas, managing leadership in the era of COVID-19, tailoring effective communication, critical questions to ask during employee rounding, optimizing care for non-COVID patients, building meaningful partnerships, confronting financial concerns, and integrating emerging practices into the post-COVID norm. Following are some of the ideas and emerging solutions participants shared from their organizations.

Preparing for Surges

  • Pre-Surge: Collaborate with hospitals further along in their journey to gain insights and take advantage of their lead time. Use this time to strategize, plan, collaborate, and communicate in preparation of the surge. Discharge COVID-negative patients as quickly as possible, ideally within 48 hours. Utilize telehealth and virtual care offerings for discharged patients, sending them home with a packet of basic materials to have a virtual care visit with their doctor. Modify rounding practices during this period by issuing an iPad both inside and outside patient rooms in the ED for video conferencing. (April 17, 2020) 
  • Surging: Shift focus from planning and policy writing to survival. Build succession plans for all positions at least three people deep. Address caregiver needs, such as safety, showers, food, and emotional support. Make internal communications succinct to avoid information overload.
  • Peak Surge: Remain critically focused on survival. Increased patient volumes and workloads, along with the psychological stress of seeing their colleagues in the ICU, will impact staff. Continue to keep internal communications succinct and limited to avoid information overload. 
  • Post-Surge: Focus on addressing the full impact of the traumatic stress the pandemic has had on caregivers. Redeploy the next wave of staff to intensive care units and EDs to allow current staff time off to rest. Assign buddies to train redeployed employees working in new areas.


Coping
 with Limited Personal Protective Equipment (PPE) and Other Medical Resources

  • Institute daily leadership meetings or daily emails to update staff on the current state of PPE availability as well as to communicate guidelines for how to conserve and use PPE appropriately.
  • Look for creative solutions for conserving and reusing PPE without endangering patients or staff. For example, the Columbia Fu Foundation School of Engineering and Applied Science has started creating 3D-printed face shields that allow for an extra layer of protection over traditional N95 masks.
  • Build relationships with local donors and vendors of essential medical supplies as demand continues to increase.
  • Station safety officers in high-risk areas to advise staff on proper use of PPE to avoid injury.
  • Create a COVID Cart for every COVID-positive patient. Include in the cart laminated instructions for safe PPE use and clear instructions for how to properly use equipment.
  • Sterilize masks in hydrogen peroxide vaporized rooms so that they can be reused.
  • Set clear expectations for distancing and location (in patients’ rooms or through the window) for health care workers in relation to rounding, communication, and treatment of patients.
  • Listen attentively to patients and ask them if domestic violence is something they might be experiencing, as it is a rising concern with the social isolation measures in place.
  • Cluster care for patients with complex needs in the ICU to avoid going in and out more frequently than needed and adjust hourly rounding accordingly. (April 17, 2020) 
  • Have nurse managers round outside patient rooms and consider implementing telephone rounds. (April 17, 2020) 


Reconfiguring Hospital Layout

  • Designate specific floors in the hospital or certain ICUs within a larger hospital system to treat COVID-positive patients only.
  • Set up ancillary units for non-COVID patients to reduce their risk of contraction, treating them in separate areas of the hospital, if space allows, or in a different facility, such as a repurposed gymnasium or medical tent.
  • Decamp triage operations from the ED to tents outside the ED.
  • Allocate rooms for staff to change out of work clothes and shower before going home to reduce risk of exposure to families.
  • Wash scrubs in the hospital or an ancillary facility for caregivers so that they can travel to and from work in clean clothes.


Tackling Staff Shortages

  • Look into graduating nursing students early and granting them a temporary nursing license. See the most recent licensure requirements for nurses, advanced practice providers (APPs), and physicians here.
  • Redeploy to inpatient units APPs from primary care clinics that are not seeing a large volume of patients, granted the shift is within their skill set.
  • Develop educational programs to upskill nurses into units that have the greatest staff shortages.
  • Connect with local hotels and colleges that may be willing to provide lodging and meals to hospital staff to help retain caregivers who are afraid of infecting their loved ones at home.
  • Coordinate help within the community, such as dog walking, childcare, and grocery shopping, for the families of caregivers on the front lines.
  • Set up a virtual space for families and friends of staff to find helpful resources and have their questions and concerns addressed.
  • Reach out to nurses and physicians who have retired in the past three years for assistance in caring for non-COVID patients in ancillary facilities.


Screening Visitors and Caregivers
 at the Door 

  • Cordon off specific entrances for caregivers only and take all caregivers’ temperatures upon arrival. Many hospitals are also considering implementing a symptom check during the screening process. 
  • Have caregivers fill out online attestations prior to arriving at the hospital to speed up the screening process. Completed forms are used as tickets to pass into the facility and receive a protective mask.
  • Require all employees to take their temperatures twice daily. Any employee whose temperature is 100°F or above must return home.
  • Require employees who have been exposed to COVID-19 to take their temperature daily for 14 days and monitor themselves closely.


Addressing Emotional and Psychological Needs of Caregivers

  • Leverage technology wherever possible for patients and families to connect virtually, making iPads, phones, and other tools easily accessible for COVID-positive patients.
  • Use these circumstances as an opportunity to remind nurses, physicians, and other staff why they entered this field—they have an opportunity to be there for their patients when families can’t.
  • Cultivate a strong sense of teamwork, support, and community among caregivers who are away from their families at this time. Set up video-call lunches, happy hours, and other non-work-related opportunities for caregivers to connect.
  • Work with psychiatric and behavioral health professionals from the hospital and community to develop an employee assistance hotline.
  • Expand chaplain and spiritual team responsibilities to include check-ins with staff. Encourage spiritual leaders to post brief statements of intention and guided meditations submitted by staff on the internal website.
  • Encourage staff to share uplifting stories, positive feedback, and moments of gratitude they felt when caring for each other and their patients. These can be displayed on bulletin boards in the staff lounges.
  • Stock family rooms that are no longer in use with food so that staff have an opportunity to stop in and see each other for a brief reset during their shift.
  • Provide trauma support to address the suffering of caregivers, especially those faced with taking care of their colleagues, by implementing peer support groups by department to give employees a space to talk about what they are grappling with. Have the department of psychiatry and psychology provide a script to facilitate the process.
  • Recruit statements of gratitude from patient and family advisory councils and create posters that hang throughout the facility.
  • Gather comfort boxes and food donations from the community to show caregivers they are appreciated.
  • Create a “resilience lounge” that serves as a virtual hub where caregivers can go for weekly virtual support sessions, find caregiver wellness checklists, and hear personal testimonies by other caregivers about what works for them.
  • Integrate Expressive Digital Imagery® into technologies and practices at the hospital to help caregivers process complex emotions through outlets such as video, images, and poetry.
  • Proactively address PTSD by taking a preventive approach and working with caregivers to improve their coping strategies. Act on warning signs of PTSD, such as trouble with sleeping or nightmares, to avoid escalation. Remove the stigma around the disorder by providing outreach and support to those showing signs that they are struggling.
  • Institute coaching interventions led by people with backgrounds outside of health care, such as ex-military leaders, who have experience in high-stress decision-making and dealing with prolonged trauma. (April 17, 2020) 
  • Offer weekly remembrance and nondenominational services. (April 17, 2020)
  • Work with the psychology department to develop 1:1 video-chat mindfulness sessions for caregivers(April 17, 2020)
  • Convene chief wellness officers, bereavement leaders, and psychology leaders to start wellness rounding in the wake of an employee death. (April 17, 2020)
  • Encourage staff to call a “Code Lavender” if they see another employee struggling. Leaders will help find someone to cover for the employee so that they can go to a respite room, will lavender and chocolates, and reset. (April 17, 2020)
  • Reinforce to the workforce that this time will pass. (April 17, 2020)
  • Disseminate wellness offerings via nurse–physician dyads on each floor to make sure the information is being received by their direct reports. Reserve mass emails for information about PPE and procedure changes(April 17, 2020)
  • Measure the effectiveness of emotional support initiatives via surveying, attendance, and anecdotal feedback. (April 17, 2020)


Navigating Vital Conversations

  • Engage ethics committees and palliative care teams when making tough decisions to ease this burden for providers and families.
  • Share communication skills and resources for having serious-illness conversations.
  • Train front-line staff to use a standard language when addressing patients’ questions and concerns.
  • Prepare staff for communicating with patients who are being transferred to a COVID area. Many patients are fearful and unwilling to move locations before they receive positive test results, leading to situations where staff must negotiate with them to move to another unit while awaiting the results. (April 17, 2020)
  • Contact the health department in cases where patients refuse to be admitted so that they can quarantine at home. (April 17, 2020)
  • Routinely emphasize the importance of safety in conversations with both COVID and non-COVID patients to assuage fear and anxiety. Reassure them that staff are using PPE properly, washing their hands, and taking all precautions to keep all patients safe. (April 17, 2020)


Bracing for Ethical Dilemmas

  • Prepare staff for difficult choices regarding who receives life-saving treatment. Some organizations are changing how codes will be run in preparation for when there are no available ventilators, with the aim of reducing staff infection and properly managing resources.
  • Some organizations are working with critical care experts to develop statewide crisis standards of care that will determine how clinical decisions are made, seek to mitigate risks, and develop a state transfer center that will manage patient placement to avoid overwhelming hospitals.


Managing Leadership in the Era of COVID-19

  • Establish “hero huddles” designed to call out individual caregivers and patients as heroes.
  • Set up system command centers that enable organizations to manage contingency plans in case a leader becomes ill or requires time off.
  • Task each leader with training an individual who could fill their role.
  • Lead with positivity, regularly sharing the number of discharged patients.
  • Continue to do leader rounding but do it at the door rather than in the room to conserve PPE. (April 17, 2020)


Asking Critical Questions During Employee Rounding

  • Besides the critical resources of PPE and staff, are there additional resources that you need to help you be successful in this situation? Which do you need the most?
  • Do you know what support resources are available to you during this difficult time? Do you know how to access these resources?
  • What else can I be doing to help support you personally?
  • What thoughts or questions do you have for the command center?
  • Is there additional training and education that you need to help you be successful in this situation?
  • Are the policies, plans, and procedures we’ve put into place relative to COVID-19 clear to you?
  • Do you feel you can get help from your teammates when you need it?
  • Do you think we are engaging with the community enough to benefit from the support they are offering?


Tailoring Effective Communication

  • Set a limit of one institutional email per day from a senior leader to caregivers that summarizes important updates. This email can be part of a larger thread or link to resources compiled on a central website.
  • Consider disseminating a brief live-stream video from the health system’s CEO each day in lieu of an email.
  • Propose an opt-in newsletter that provides staff with exclusively positive content and a “safe space” to ease the feeling of being bombarded with negative information.
  • Have teams that are less busy in the face of the virus, such as radiology, volunteer to form a program to help improve communication with family members unable to visit their loved ones. Train them on communication tactics and connect them to ICU teams to learn patient plans for the day and collect critical medical information. These teams can then make individual calls to families with these updates.


Optimizing Care for Non-COVID Patients (April 17, 2020)

  • Implement drive-through testing if possible.
  • Focus on improving home health care and creating a robust telehealth program.
  • Manage the telehealth program by setting up an algorithm for the contact center to route patients to the right contacts within the hospital system to receive appropriate care.
  • Set up a lactation telehealth program for discharged inpatient mothers to prevent them from coming into the hospital with their newborns. Lactation consultants can be made available via iPads on the units and through Microsoft Teams on desktop computers.
  • Schedule a daily virtual care call with hospital chaplains to address the isolation felt by non-COVID patients. 
  • Establish standard communication with patients regardless of diagnosis. An example could be a triad communication model that establishes a standard of communication in light of visitor restrictions and limitations. This model could include three calls with the family per week: one call with a medical ambassador (usually a medical student assisted by a script), one call from a clinician who can answer general COVID-19 questions, and one call from case management.


Building Meaningful Partnerships (April 17, 2020)

  • Develop a virtual repository of ventilators so that hospitals can share their excess inventory.
  • Partner with Google and SADA to develop a national database—using unidentified health data—to evaluate surges and the spread of COVID-19 across the United States.


Confronting Financial Concerns (April 17, 2020)

  • Be honest with caregivers. Reiterate that it is uncertain how things will unfold with the virus, but that the organization has employees’ backs.
  • Transparently communicate the financials of the organization in terms of what it will take to recover and the dates the financial situation will be reevaluated.


Integrating Emerging Practices into the Post-COVID Norm (April 17, 2020)

  • Host memorial services for employees who have passed away and employ SOS (“Support our Staff”) moments and interventions for collective grieving.
  • Be open to cross-training and cross-functional teams. Organizations have seen their care teams remain resilient and step outside their comfort zones in pursuit of their shared mission of healing as many patients as possible.
  • Implement a buddy system for all members of the organization in which each caregiver is partnered with someone within their training level/role. All staff are expected to check in with their “buddy” daily regarding sleep, exercise, nutrition, and coping mechanisms to help reduce the burden of individual stress.
  • Continue to expand telehealth offerings, which have proven to provide countless operational and financial benefits for patients, caregivers, and institutions.

Visit our dedicated COVID-19 webpage for additional resources, including an Executive Summary of each week’s meeting.