High Reliability Strategy Facilitates End-of-Life Visits for COVID-19 Families

Added on Jul 8, 2020

patient-careVirginia Mason Uses High Reliability Framework to Facilitate End-of-Life Bedside Visits for COVID-19 Families
By Audrey Doyle

Since the onset of the coronavirus pandemic, hospitals nationwide have restricted visitors for inpatients who have tested positive or are under investigation for COVID-19 to prevent the spread of infection. A heartrending consequence of this difficult decision is that families of critical care patients who are dying from the disease can’t say their final goodbyes at the bedside.

By combining elements of kaizen and Lean management philosophies with high reliability principles, leaders at Virginia Mason Hospital created a process that enables families to safely visit COVID-positive loved ones nearing the end of their lives. Developed and launched in less than a week, the process is led by registered nurses who volunteer to be end-of-life support companions. In this role, they coordinate and oversee the visit between the family and their loved one in the critical care unit (CCU) and provide compassionate, empathetic support while ensuring that safety protocols are strictly enforced.

Prior to the pandemic, Virginia Mason allowed visitors 24-7 and allowed family members to remain at the bedside of a loved one nearing the end of life for as long as they wanted. But like other hospitals battling the early stages of the outbreak, Virginia Mason suspended routine in-person visits for safety reasons and instead offered alternative ways for families to interact with their loved ones, such as via phone, FaceTime, and Skype. The facility also amended its end-of-life bedside visitation policy so that only one family member was allowed in a patient’s room at a time.

This revised end-of-life visitation policy was put to the test one Saturday in early April. “One of our COVID-19 patients was dying, and her family wanted to come in and say goodbye,” recalled Dana Nelson-Peterson, vice president of nursing and associate chief nursing officer at the Seattle facility. “She was our first patient to die of COVID, and the visit did not go well.” In addition to inadvertent breaches in personal protective equipment (PPE) by the family members who visited, there were no formal guidelines in place for preparing them for the visit or safely navigating them through the process.

For Virginia Mason Hospital, which prides itself on delivering safe, high-quality, patient- and family-centered care and has consistently ranked in the 90th percentile or above for the HCAHPS global measures of Overall Rating and Likelihood to Recommend as well as for several key drivers, the incident was deeply concerning.

That Monday morning, the hospital’s executive leadership team discussed what had happened. While some of the leaders felt it was best to enforce a strict no-visitors policy moving forward, most wanted to continue to allow families of COVID patients an end-of-life visit at the bedside. “We just had to develop a visitation process that ensured the families’ safety,” Nelson-Peterson said.

Nelson-Peterson and a small group of leaders were able to quickly accomplish that goal thanks to an organizational culture that is based on safety and high reliability, supports continuous improvement, and encourages innovation. “This means that when we’re faced with a problem, we can turn on a dime, and our leaders will be confident our solution will be sound,” she said. “So, when the leadership team asked me to create a process for this, I agreed without hesitation because I knew it could be done.”

Nelson-Peterson quickly pulled together a team of colleagues from other departments—including Kellie Meserve, RN, director of Care Management Services, and Jessica Dunn, RN, director of Virginia Mason’s Kaizen Promotion Office—to brainstorm what the process would entail. Using an in-house management method that combines elements of the philosophies of kaizen and Lean with principles of safety and high reliability, the team created a flow map that they converted into a Process at a Glance chart. From that chart, they developed the standard work for performing each step in the visitation process, along with detailed instructions to ensure that the steps would be performed consistently. They also developed documentation for family members, including FAQs describing the process and what to expect when they see their loved one, and a consent form acknowledging that they understand that, even though they’ll be wearing full PPE, they’ll be entering a high-risk environment.

The leaders also began forming the team of end-of-life support companions. “We started by identifying the right role to do this work. Every attribute we came up with—understands infectious disease and the transmission process, is an educator, focuses on safety, is compassionate and caring, is comfortable with the dying process and death—led us to the role of RN,” said Nelson-Peterson. So, they looked to some of the nurses who had been furloughed due to the cancellation of elective surgeries and procedures. “We put out a call and seven nurses took on the role,” she said. The team went through the Process at a Glance chart and the standard work with each nurse so that they clearly understood the process.

That evening the leaders submitted their documentation to Virginia Mason’s Command Center, which was established at the onset of the pandemic to determine how best to allocate resources and handle internal and external communication. The Command Center leadership reviewed and approved the position the following morning, and the day after that the team had a nurse lined up and ready to step into the role. The nurse facilitated the first visitation that weekend.

The process begins with a CCU caregiver who notifies the family that their loved one is nearing death and gives them the option of saying goodbye over the phone, via iPad, or at the bedside. If the family chooses a bedside visit, the support companion does the following.
  • Contacts the family to describe the process, explain the guidelines (two people can visit, for no more than 30 minutes), reinforce that the purpose of the visit is for a final goodbye, and establish a time for the visit.
  • Meets the family at a special entrance and escorts them to a screening station where they’re screened for COVID-19 symptoms. They also review the consent form, answer questions, assist the family with hand hygiene and with donning a surgical mask, and escort the family to the CCU, where they help them don the rest of their PPE and reinforce key safety points related to PPE.
  • Escorts the family into the room and watches the visit from a distance, gently and compassionately redirecting them, if necessary, to ensure that infection control practices aren’t breached. At the end of the visit, the support companion escorts the family from the room, helps them safely doff their PPE, and comforts the family as they escort them out of the facility.
When the facility began to resume elective surgeries and procedures recently and nurses who had been furloughed went back to work, Nelson-Peterson was able to quickly gather a group of team leaders and nurses from across the organization to volunteer for the job. When a support companion is needed, the group’s members receive a page, meet for a virtual huddle, and determine who has the capacity to fill the role.

“It’s been heartwarming to see our staff step up to provide this support,” Nelson-Peterson said. “This is not easy work. These families are grieving, and while typically they’re beyond grateful, sometimes they’re angry—that they can’t spend more time in the room, that they’re being asked to put on PPE—so these nurses must absorb the angst, frustration, and grief along with the gratitude and thanks.” To ensure the nurses’ emotional well-being isn’t suffering, the team holds a debrief after each visit and will refer anyone who is struggling to the facility’s employee assistance program.

As of mid-June, the hospital had facilitated five bedside visits. “We’re fortunate to have had many more discharges of COVID patients than we’ve had deaths,” Nelson-Peterson said. When asked for feedback on how they felt about participating in the program, the nurses have indicated that it was highly gratifying and used such words as confident, trailblazer, intimate, valued, hard, and powerful to describe the experience. “They’ve also told me they felt it was a privilege to restore personhood to these dying patients and their families,” Nelson-Peterson said.

Moving forward, Virginia Mason plans to continue offering the service, and Nelson-Peterson said she’d like to start gathering feedback from families who’ve participated to continuously improve the process. “COVID-19 will keep presenting challenges,” she concluded. “But we’ll leverage our culture of safety and high reliability and our dedication to delivering an optimal care experience to patients and families to rise to those challenges.”