Editor's note: This special report highlights practices that were implemented by individual facilities in response to the COVID‐19 pandemic. Some practices may be inconsistent with evidence‐based practice and/or the AORN Guidelines and may be modified or obsolete by the time of publication. In addition, some practices (eg, N95 and other respirator reprocessing) have been approved by the US Food and Drug Administration for emergency use only in response to the pandemic.
The Coronavirus Disease 2019 (COVID‐19) global pandemic has required immediate changes in the health care delivery system. The qualities that make perioperative nurses so essential to health care—innovation, communication, flexibility, and adaptability—have been amplified during the COVID‐19 response. In some situations, leaders have learned new lessons; in others, the lessons they already knew have been reinforced. It appears almost certain that health care—and the world—will never be quite the same after this crisis has passed. The “new normal” will be something different, and perhaps better and safer for perioperative teams and their patients.
PANDEMIC CHALLENGES
The COVID‐19 pandemic has presented health care leaders with many challenges, not the least of which is its longevity. Other challenges that nurse leaders have had to address included rapidly changing information, fear, and constraints at their facilities’ physical locations.
Because of the novelty of COVID‐19, the science continually changed and leaders from various organizations (eg, the Centers for Disease Control and Prevention, state departments of health) presented new information and recommendations on a regular basis (eg, hourly, daily). “How do you have the grace to be forgiving about your understanding of this?” asked Stephanie McKoin, director of perioperative services and the surgery integrated practice network at Roper St. Francis Healthcare in Charleston, South Carolina. “We've learned so much more than what we knew in the early days,” she said. With time and new information, it has become easier for perioperative teams to understand the risks and know how to respond.
Fear of the unknown has affected everyone during this pandemic; even the presence of patients in the hallway who may be COVID‐19 positive or are undergoing testing contributed to team member anxiety. Fear also has contributed to patients avoiding the hospital. At the University of Pittsburgh Medical Center St. Margaret in Pennsylvania, Mary Barkhymer, MSN, RN, vice president of patient care services and chief nursing officer, has observed sicker patients entering the facility because they wait longer to seek help out of fear of COVID‐19 or worries that hospital staff members are overloaded.
Physical layout was another challenge, especially in larger facilities. As an example, Baylor University Medical Center in Dallas has 1,000 beds on a large campus with multiple buildings. Ensuring that patients who tested positive for COVID‐19 were contained was one thing; transporting them to the OR was quite another, according to Patricia M. DeFrehn, DNP, MBA, RN, NEA‐BC, vice president of surgery and neuroscience.
“We have 50 ORs but they're in two different large buildings that are not directly connected, and you have to go through two other buildings to get to them,” she said. To address the issue, they created transport teams and established routes to and from the ORs. This helped avoid potential cross‐contamination among people passing each other in hallways and also alleviated the fear of walking near people whose COVID‐19 status was unknown.
LEADERSHIP LESSONS
During this lengthy pandemic, perioperative leaders have been reminded not only of the importance of leadership, but of the skill and capability of their teams. Although the experience has been challenging, it also has been rewarding and has provided valuable leadership lessons. “The most rewarding to me is knowing what a difference that we made in so many patients’ lives,” said Patrice Osgood, RN, DNP, NE‐BC, CNOR, associate chief nurse of perioperative and gastrointestinal endoscopy services at Massachusetts General Hospital in Boston. “We changed our care delivery models rather quickly, we were able to come together from many different departments, create new teams, and we made a tremendous difference in the outcomes of patients.”
Specific leadership lessons and takeaways from the COVID‐19 pandemic include the following.
Be visible. The need to spend time with team members during a crisis is a lesson that was reinforced for Osgood. “Frequent rounding and getting [my] own view of what's going on in the units every single day has made a tremendous difference in keeping me informed as to what staff are dealing with,” she said. “Because unless you see what they're going through yourself with your own eyes, there's really no amount of words [that] can describe what we've asked them to do.”
Innovate. The need for innovation has been essential during this crisis to address new and different challenges. For example, facilities have developed processes for sterilizing and reusing N95 respirators. The Massachusetts General Hospital materials management team managed supplies at an enterprise level, according to Osgood. When supplies began running low, the hospital teams took steps to conserve them, and a manufacturer opened a facility nearby to disinfect and reprocess masks. Employees’ names were written on their masks so they could be returned after they were reprocessed and decontaminated.
Telehealth also has been expanded during this time and was implemented at Beth Israel Deaconess Medical Center (BIDMC), Boston, Massachusetts, to help stretch physician resources. This also affected patients, who may be more open to telehealth in the future. “The reality is, to some extent, we won't go back,” said Elena Canacari, BSN, RN, associate chief nurse for perioperative services at BIDMC.
Be flexible and adaptable. The ever‐changing situation required leaders to “pivot” frequently, according to DeFrehn. “[It] really required a lot of adaptability from a leadership standpoint. With that, you have to essentially be willing and able to step out of your comfort zone and do just about anything that's necessary.”
Masks are a good example of flexibility because of the struggle to obtain sufficient amounts of personal protective equipment (PPE). If a team member was fit tested previously and his or her designated mask size became unavailable, repeat fit testing would be necessary. To address this issue, the team at Baylor created groups of staff members who could perform fit testing 24 hours a day. The adaptability of the team was one of the most rewarding aspects of working through the pandemic response, DeFrehn added.
Communicate. Communication was both a challenge and a solution. According to Debbie Ebert, MSN, RN, NEA‐BC, CNOR, CCRN, CPAN, CAPA, vice president of perioperative services at MemorialCare Integrated Health System in California, nursing leaders were challenged to help their teams sift through the noise to get to the facts. “That's when leadership needs to be highly visible,” Ebert said. “The days that I put on scrubs and went in to help set up the hot zones, the team needs to see that. They need to see it, they need to feel it, and they need to not just hear it.”
To support team members and patients alike, LynnMarie Verzino, MHA, BSN, RN, NE‐BC, vice president of perioperative services at Emory Healthcare in Atlanta, Georgia, noted that a multipronged approach was necessary to help convey important information, including posting information on both the intranet and the public web site, holding regular leadership rounding discussions, and speaking directly with patients’ family members.
Talking to patients and their family members helps address fears and decrease anxiety, both of which have been heightened during the COVID‐19 pandemic. Perioperative team members’ role in decreasing anxiety is “more critical than it ever has been,” Barkhymer said. Sometimes this meant that nurses increased their flexibility when communicating (eg, taking phone calls) to let family members know that their loved ones were okay.
Share successes. Taking time to focus on the good is essential to help maintain morale. “While the information coming out about COVID certainly seemed daunting, we also focused on sharing our successes,” Verzino said. This included how quickly they implemented telehealth, deployed PPE resources, and launched COVID‐19 hotlines, in addition to taking time to recognize the patients who recovered and went home. “It's important to pause and celebrate that because it really speaks to the teamwork and the central commitment to improving lives and providing hope,” Verzino added.
THE NEW NORMAL
In time, OR schedules will ramp back up and perioperative teams need to be prepared to manage both staff member scheduling and patient safety. Not only will orientation and preadmission testing programs likely be different as a result of the pandemic, but perioperative services also will have changed.
Orientation Programs
Changes made to orientation and onboarding programs during the pandemic may continue. For example, the use of online platforms, distance learning, and simulations may become more common as ways to bring recently hired nurses up‐to‐speed and prepare them for work in perioperative services.
At Emory, orientation efforts for incoming nurses continued throughout the pandemic, although they were modified to include distance learning and reduce the number of nurses who were in the skills laboratories at the same time. Distance learning is something that Verzino sees as being included in orientation processes in the future, including for her facility's next Periop 101 cohort.
Resources.
COVID‐19 (Coronavirus) AORN Tool Kit. AORN. https://www.aorn.org/about-aorn/aorn-newsroom/covid-19-coronavirus. Updated July 1, 2020. Accessed July 24, 2020.
COVID‐19 FAQs. AORN. https://www.aorn.org/guidelines/aorn-support/covid19-faqs [member access only]. Updated April 20, 2020. Accessed May 22, 2020.
Croke L. Open communication and empathy during perioperative stage can ease patient anxiety. AORN J. 2020;111(2):P5.
Link T. Guideline implementation: transmission‐based precautions. AORN J. 2019;110(6):637‐649.
Simulation training on communicable diseases in procedural areas will become part of the new normal as well, she added. Simulation was beneficial for training interdisciplinary team members at Emory to care for COVID‐19–positive patients and patients awaiting test results. As a result of the simulation training, Verzino said they “have standardized workflows for all members of the team. We have committed to continuous training in that.” The workflows include patient transport, preoperative assessment, surgery, and care in the postanesthesia care unit.
At MemorialCare Integrated Health System, the nurses who were participating in Periop 101 at the time elective surgeries had to be canceled are being brought back in, according to Ebert; and onboarding continues for any recently hired nurses, although no definitive changes have been made to the onboarding process yet. One thing remains true, however, and that is the traits required of perioperative nurses, according to Ebert. “One must possess situational awareness; you need to be flexible, adaptable, nimble; you must be self‐directed, collaborative, and communicative,” she said. “And never more have we had to utilize those skills than during this period of time.”
Process Changes
Hospital and perioperative leaders have updated many perioperative processes as a result of the pandemic, including preadmission testing, the use of negative‐pressure areas, intubation and extubation protocols, and PPE requirements. Some of these changes may be short‐term, but several are likely to become standard practice.
Patient testing will remain important to ensure that COVID‐19–positive patients are cohorted and kept separate from other patients. As of mid‐May, Baylor required patients to be tested within 48 hours before their procedure. If the test result is positive, the procedure is rescheduled. If it must proceed, the team is notified and they use enhanced precautions, but “the team and surgeon would all know what they were dealing with,” DeFrehn said.
At first, only patients at BIDMC who were symptomatic were tested, according to Canacari. Then they expanded testing to include patients scheduled for high‐risk procedures before they entered the OR suite. At the time of this writing, teams at BIDMC are testing all patients and have received approval from the Massachusetts Department of Health to provide phlebotomy services in the ambulatory testing tent to help keep the patient experience as efficient as possible.
Another process change is the use of negative‐pressure areas when treating surgical patients who are COVID‐19–positive, according to Barkhymer. This includes new guidelines for RN circulators and OR leaders, especially related to intubating asymptomatic patients. Stepping out of the room for intubation and extubation may become more normal, she added, especially as more is learned about aerosol‐generating procedures and the associated risks to perioperative team members.
Patient interactions—which always have been critical—will increase in importance in the near‐ and long‐term future, according to McKoin. She added, “How do you help navigate them through this journey that they're on in a thoughtful and intentional way?” It will be important to provide reassurance because everyone will be more cautious about the choices they make regarding their physical health.
Editor's note: Periop 101 is a trademark of AORN, Inc, Denver, CO.
This special report features a collection of tools that leaders from some of the featured facilities implemented in response to the COVID‐19 pandemic. The tools have been left in their original format to preserve authenticity. To access the collection, visit https://www.aorn.org/AORN-Journal/COVID19-Tools.
Biography
Kimberly J. Retzlaff is a freelance medical journalist in Denver, CO. Ms Retzlaff has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.