The COVID-19 pandemic rapidly changed how ambulatory care responded to surges of patients and with each wave we learn more. Like many organizations, we sought to ensure our emergency department was not overwhelmed while minimizing the exposure of patients and staff to the virus. We learned quickly how to design and implement respiratory illness clinics. As we reflect on our evolving understanding of the virus and identified epicenters in our communities (Massachusetts Department of Public Health, 2020), we think it is important to highlight the lessons we learned.
As it became clear that the virus was spreading quickly through our communities of interest with varying degrees of illness, we sought to strategically open temporary clinics where we could consolidate respiratory care, thereby removing the burden of infective patients from our ambulatory practices where they regularly sought care. Our strategy involved creating an infrastructure that was nimble enough to respond to the unknown demand for care. We converted our ambulance bay, a sports medicine clinic, and one of our primary care practices into temporary clinics where chest radiographs could be provided while expanding and contracting operations as needed. Infection control measures were all consuming. Personal protective equipment (PPE), furniture cleaning, and physical distancing consistent with Centers for Disease Control and Prevention (n.d.) guidelines had been critical from the beginning. Our need to cover floors in plastic, minimize furniture, and require unidirectional patient flow, erect temporary walls, and use disposable stethoscopes were ultimately unnecessary. To minimize the movement of patients, clinicians and services were brought to patients rather than moving patients despite mask wearing. COVID-19 testing created the most anxiety for staff because of the need for patients to remove their masks and concerns about accurately collecting nasopharyngeal specimens. Today, we commonly perform anterior pharyngeal collections and accept home test results.
While being particular about testing requirements, we redeployed anyone willing and able to work in our respiratory clinics despite their professional expertise. Inpatient clinicians were instructed in outpatient care. Specialty clinicians were reminded how to auscultate lung sounds. Physical therapists were trained as PPE monitors. Administrative staff manned elevators and directed patients to our segregated locations.
In subsequent waves, we understood better that our primary care clinicians and staff were best suited for this type of care. Most importantly, we understood that not everyone was emotionally prepared to provide care in infectious disease clinics or had adequate support at home to balance the demands of home and work. We learned that assessing readiness to participate in care outside of one's usual role was key to staff engagement and the health and safety of staff. Training resources, on-site coaches, and reassurance were not adequate to ensure professional competence or to mitigate the fears of exposure for many.
One unexpected benefit was the rapid development of leaders, both formal and informal. Those who knew how to lead created a space for others to learn while demonstrating that no one knew all the answers. Others who stepped up flourished as emerging leaders and have now been promoted or have moved to roles that more fully use the leadership skills they developed. There was no better way for individuals to try a new role than experiential learning without the pressures of failure because everyone was learning simultaneously.
Yet, innovation thrived as concerns about the availability of PPE rose. Our sites tested the protype of a Hexapod, a plexiglass box with positive pressure that allowed the preservation of PPE while increasing the throughput of testing volumes (Olson et al., 2021). An individual, not in PPE, was inside the box using external sleeves to test individuals on 3 sides of the box. As the virus evolved, so followed changes in PPE recommendations, leading to increased fears that no one really knew what to do. The Hexapod provided a way to consistently perform nasopharyngeal testing that was not subject to varying guidance.
As we reflect on the thousands of patients moving through our respiratory clinics early in the pandemic and then in subsequent waves, we can see how much we learned, how much we learned by experience. Today, all respiratory care has moved back to regular practices where patients can receive care in locations convenient to them.
Moreover, we recognize that the pandemic is not over, and though there will be future infectious disease outbreaks, we are confident that we can care, learn, and innovate. Yet, we acknowledge that in our desire to be nimble and responsive to the rapidly changing needs of our patients, we must provide greater attention to our staff's emotional readiness and sense of professional competence.
-Jean M. Bernhardt, PhD, MSN, CNP
-Jacqueline Chu, MD
-Mark Seelen, MBA
Massachusetts General Hospital
Boston
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