Margie Pensak: What is the general COVID situation in
area hospitals?
Baltimore Nurse: COVID numbers are picking up right
now, close to what they were in the beginning of the pandemic. At this time
there are fewer vented patients but still plenty of critical-care level
patients. Although these patients are not on a ventilator, they still need a
higher level of care, more intensive oxygen delivery, and much closer
monitoring, as their condition can deteriorate in seconds. The number of these
patients is climbing now. Hospitals, in general, are pushed to their maximum,
putting pressure and strain on the staff.
MP: What does this mean in terms of the
patients and the workload?
BN: On units where you would typically
require a 3:1 patient-nurse ratio (for example, intermediate care), you now have
one nurse to four patients, sometimes even five patients. One extra patient
might not seem like a big change, but it’s another person with his or her own
complex condition to navigate, needs to be met, and medical orders to be
followed. Charge nurses (supervisors) are taking on patients regularly to
accommodate the need to place patients in beds, causing major strain. It means
that the unit resource, the charge nurse, is no longer readily available to
help floor staff. This is especially stressful on night shift which operates
with barebones staff as it is.
MP: Can you describe what it is like to work
under max capacity conditions?
BN: Here’s an example: On my unit, we are in
the beginning stages of much-needed construction and updates that required closing
eight beds on our floor at a time and utilizing eight beds on a different floor
where there is extra space for the overflow. After a very short time,
construction had to stop because one of the construction crew members tested
positive for COVID, causing the entire crew to quarantine for two weeks. Within
a day, the powers that be – completely non-clinical executive level decision makers
– decided that since there are extra beds, starting the next day, five beds would
reopen on the unit and the eight overflow beds would also remain open. However,
the executive leadership made no plan to provide an extra nurse, so we still
have all our usual beds plus five more.
MP: What is your facility’s
current patient-to-nurse ratio?
BN: Patient ratios are unit
specific, some requiring 1:1 all the way up to 6:1, depending on patient
acuity. It is typical for patients to show up sicker to the hospital at
this time of year, being that it is winter and flu season. Coupled with COVID,
patients are in abundance and very sick, their care requirements are more
intense, and there is no extra staff to help. Right now, on my unit we
constantly operate at a 5:1 ratio, plus the charge nurse with a patient load,
instead of our typical maximum of 4:1 with a free charge nurse. Additionally,
unit nurse managers are stepping in and working the floor to help offset the
ratios, something that is not a part of their typical job description, although
they are qualified to take care of patients of course. Any nurse who can take
care of patients is assisting during this critical staff shortage.
MP: What are your feelings about this?
BN: I think that just because there are beds
doesn’t mean there is staff to take care of the patients in those beds. It is
no favor to admit a patient if they will not get the care they need and
deserve. Unfortunately, overloading staff with limited time and/or resources
really causes the patients to suffer. From an administrative viewpoint, I guess
the hospital executives think they are doing something good when, truthfully,
it actually works to the opposite effect. It’s the quality, not the quantity
that should matter.
MP: Does your hospital have a designated
COVID unit?
BN: My hospital has no single designated
COVID unit; COVID patients can be anywhere, depending on their presenting
symptoms when they enter the hospital. They are checked in to a particular
unit, whether general care or specialty, and they stay there unless they need
to transfer elsewhere. Although our hospital does not have a dedicated COVID
unit, it did convert several rooms to “negative pressure” for those patients on
more critical care units. That means that the airflow does not leave the
threshold of the room; rather, the air constantly cycles through the room.
MP: Wouldn’t it be wiser to have a
self-contained COVID unit?
BN: As far as infection prevention, it would
probably be best to separate these patients into a COVID-dedicated unit, but
hey, we are talking about a pandemic here. We already don’t have enough staff
to take cover our existing units. How much more so would this be true if we
created a designated unit in the hospital. Rest assured that, as long as the
staff members are doing what they are supposed to as far as PPE (personal
protection equipment) and infection prevention, it does decrease the risk of
spreading the virus. However, it all goes back to the root problem of
overloading staff with too many patients and the hospital cutting corners.
MP: What precautions do you have to take to
cut your risk of contracting COVID?
BN: To protect ourselves during patient care,
staff must put on a pair of gloves before putting on a special gown that either
ties or snaps in back, at the top and middle, to prevent exposure to our
clothing. Then, we put on a second pair of gloves on top of the other pair so
that when we exit the room, we remove the gown together with the dirty gloves
and the clean underneath pair of gloves can take off our protective face wear.
For our face, we
can wear either an N-100 or N-95 mask, and we must wear a face shield with it.
Or, if we are going to be involved in a high-risk aerosol-generating procedure
(for example a nebulizer treatment or a Code Blue) we have to wear a PAPR – a powered
air purifying respirator. It looks kind of like a space suit. It is a lot of
gear and a whole process to don and remove it. The PPE and process are
mandatory for all COVID-positive and suspected patients. For patients who
tested negative for COVID or are not a patient under investigation (PUI), we
must still wear gloves, a face shield, and a mask. In these rooms it is
personal preference whether one wears just a surgical mask, which is the
minimum, a N-95, or a N-100. Cloth masks are not permitted.
MP: Do patients have to wait longer now to
get their requests fulfilled?
BN: Like many, I do think twice before going
into a PUI or COVID patient’s room, considering how we must suit-up. I make
sure I have everything that I know I need and that I think I need. In addition,
we work together and usually let a “buddy” know – whether another nurse, a
patient care tech, or even a secretary, before entering a positive or PUI room –
so someone outside of the room is available to pass items or equipment into the
room if needed, to minimize entry and exit, thereby minimizing exposure. Also,
the nurse and the tech coordinate going into these rooms together to take care
of hygiene needs, transferring the patient from the bed to the commode and back
and other patient care activities since, as I previously mentioned, these
patients are generally sicker and therefore weaker, and they require two people
to assist with their physical needs. Care staff must still look out for their
own safety and minimize their exposure. It’s unfortunate, but these patients
will probably have to wait just a little bit longer to get their requests
fulfilled, but they do get taken care of, and we appreciate when
patients are cognizant of this. Ultimately minimizing exposure is for the
safety of our patients, coworkers, families, and, oh yeah, ourselves.
MP: How does this extra suiting up affect a
patient who is coding (experiencing a medical emergency)?
BN: Hospitals are now strongly saying that
even if a patient is coding in front of our eyes, we need to get in the proper
PPE gear, even if it takes an extra 30 seconds to get in the room. If we are
not well, how would be able to take care of patients? Even going from one COVID
patient’s room to another, I change my PPE.
MP: Do you wear your work clothes home?
BN: Before going home, I change my clothes
from head to toe in the staff locker room. I even wash my glasses with soap and
water. Before COVID, I might have changed my work clothes upon returning home.
Now, because we are also seeing asymptomatic positives, I want to make sure
that I am not giving myself anything or bringing home anything to my family. It
takes an extra 10 minutes, but it’s worth it.
MP: Your dedication to nursing is commendable.
You sound like you love what you do.
BN: After about a decade of working in the
field, I feel I take things pretty well. I’ve always found nursing challenging,
but I love it. I have always loved – not liked – my job, even though it is
hard. I feel that I learn and grow every single day at work, expanding myself
with the challenges – until now! I
don’t love what I do anymore. The way things are being handled by
non-clinicians is the biggest stressor, and it is causing a huge decrease in
job satisfaction for me and my coworkers.
MP: Are nurses leaving in light of this?
BN: My coworkers are leaving like an open
faucet. In the past six months, about half the staff on the day shift has left,
and we haven’t replaced them yet. Some are getting out of the inpatient setting
and opting for outpatient settings; others are leaving for other hospitals that
don’t have as intensive capabilities and are therefore less stressful. Some are
retiring in their early 60s, before they would have – because of the pandemic.
My fellow nurses and I feel that you can blame COVID up to a point, but you
also have to blame the way it was managed. In the first wave, a lot of nurses
left, but a lot stayed. Now, with the second wave, with ignorant mismanagement,
it has turned a lot of nurses away.
MP: How long are patients staying in the
hospital since the pandemic?
BN: The length of stay in the hospital has
probably quadrupled. Patients are now staying for weeks rather than days. In my
opinion, patients’ plan of care and progress isn’t being streamlined. I feel
that patients are staying for three-to-four days more than they have to because
they are not being efficiently managed in the hospital. Part of it, I think, is
because doctors are not doing as much face-to-face time with patients –
especially COVID patients. I also feel that family advocacy has taken a
backseat, so nurses have to step in a lot more to advocate for patients.
Although family members can be annoying and stressful when they are in the
doctor’s face saying, “Give me answers; tell me what is going on; tell me how
my Mom is doing,” things get done to get the family out of the doctor’s face.
Now they don’t have anyone breathing down their necks but us nurses, so they
take their time.
MP: With visitors no longer allowed in the
hospital, how are patients able to stay in touch with their relatives?
BN: I have to credit my hospital for setting
up a Family Communication Center, specifically for families to call in 24/7 to
get an update on their family member. They can also request to do Facetime,
where a family communication representative will bring a tablet to the floor so
patients can have a virtual family visit. A nurse can also request a tablet,
from the patient’s bedside, for Facetime.
MP: Can you please share a couple of
scenarios that will give our readers an idea of how things play out in
hospitals during these COVID times?
BN: Sure. A male patient was short of breath,
and his oxygen level was low. These can easily be COVID symptoms, but the
patient tested negative so he was treated for heart failure. From the time I
left my shift and returned 12 hours later, he was much worse. I knew something
was wrong. He was getting delirious and drooling. He ended up testing positive
for COVID.
Sometimes, we have
to calm down COVID patients about not dying alone. One patient wasn’t doing
well and was getting short of breath. After I called the doctor to order a
higher level of oxygen care, the patient said very matter-of-factly, “Well, I
haven’t said goodbye to my wife yet, but – oh well – I guess when you go, you
go!” I reassured him, “You’re not going anywhere yet, not physically or
otherwise!” He stabilized once he was given a more intense level of oxygen
delivery.
MP: Do you have any parting advice for our
readers?
BN: I encourage people, as a health care
professional and hospital employee, to call their primary care doctor or, if it
is after hours, their doctor’s on-call service or an urgent care facility – whether
they are virtual, telehealth visits or acute visits – for things that probably
can be taken care of by their primary care doctor or pediatrician. Also,
follow-up visits and routine checkups are still very important, as they were
pre-pandemic, as preventive health measures. Of course, emergencies are
emergencies, and need to be checked out. But please use your outpatient resources
before going to the ER, which adds additional pressure to our already
overwhelmed health care system.
Postscript
by Margie Pensak
As I was about to write this article, Governor Larry Hogan launched a
new initiative, called “MarylandMedNow.” It is meant to alleviate the burden on
our already spread-thin and stressed-out health care workers commensurate with
rising demand as Coronavirus cases surge in the state. Included was a request
for all colleges and universities to develop emergency policies and procedures
so students willing to work in health care during the pandemic – with students
in their final semester being given an “early exit” – can join the workforce as
quickly as possible.
