Covid-19 Innovation

COVID-19 Exemplary Professional Nursing Care

Starting on March 22, 2020, when the first COVID-19 positive patient entered the Emergency Department, nurses courageously delivered on their pledge to care for those in need. Nurses were a daily lifeline to patients and families experiencing serious illness, isolation, and loss at a time when Goshen Hospital experienced the highest number of hospital deaths and Emergency Department visits in the history of the hospital. During the 4^th quarter of 2020, Goshen Hospital reached a peak historic number of 72 COVID-19 positive inpatients on a single day on November 23, 2020. While numbers of COVID-19 inpatients did subside, the surges continued, and the winter of 2021 brought increased volumes with the Delta and Omicron variants.

With the arrival of the emerging, unknown viral pandemic, nurses in both inpatient and outpatient areas quickly adapted to changing practice environments which included:

• New COVID-19 screening and assessments in all practice settings.
• Changes to patient flow throughout the facilities to protect patients and Colleagues including using separate entrances, ensuring compliance with Personal Protective Equipment (PPE), and communicating across disciplines.
• Implementing new protocols and standards for the care of COVID-19 patients with life-saving PPE and intensive treatments in outpatient care, intensive care, progressive care, medical-surgical and procedural areas.

Nurses and Colleagues across the organization cared for each other and for our community during the COVID-19 pandemic, demonstrating their deep commitment to their profession, their values, and their patients.

Starting on March 22, 2020, when the first COVID-19 positive patient entered the Emergency Department, nurses courageously delivered on their pledge to care for those in need. Nurses were a daily lifeline to patients and families experiencing serious illness, isolation, and loss at a time when Goshen Hospital experienced the highest number of hospital deaths and Emergency Department visits in the history of the hospital. During the 4^th quarter of 2020, Goshen Hospital reached a peak historic number of 72 COVID-19 positive inpatients on a single day on November 23, 2020. While numbers of COVID-19 inpatients did subside, the surges continued, and the winter of 2021 brought increased volumes with the Delta and Omicron variants.

• A tent was provided by Emergency Management to provide screening for patients outside the Emergency Department.
• The Emergency Department ambulance bay was converted to a low acuity patient care areas and was frequently used throughout the past 2 years to prevent over-crowding in the waiting room.
• The Arbor rooms were set up as an overflow, palliative care area for a short time in April and May of 2020. Thankfully, this area was never required to be utilized.
• The Ethics Committee drafted guidance for the thoughtful and conscientious management of potential ventilator and bed shortages.
• The Center for Cancer Care Infusion services and Surgical Oncology clinics temporarily relocated to the Wellness Center for several weeks in anticipation of a potential Emergency Department surge.
• Surgery West was created as a medical-surgical overflow area during multiple surges.

Adjusting to Change

In addition to increased demand, surgical and procedural areas adjusted to fluctuating demand, especially at the beginning of the pandemic. Statewide, surgery areas were shut down from March 18 to May 6, 2020, to allow for resources to be shifted to other areas experiencing high demand. Nurses with hospital experience were enlisted to help patients in areas of need or were curtailed. As hospital volumes increased in multiple surges, Colleagues, leaders and nurses in surgery and procedural areas worked daily over the past 2 years to manage patient flow and accommodate as many surgeries as possible, despite limited resources. Patients and families were very grateful for each surgery and procedure that was performed during this season of limited resources.

Staffing Innovations

The influx of COVID-19 patients and staffing challenges required creativity to respond to the need for resources to support the demand for high acuity patient care. Nursing and human resource leadership worked collaboratively to bring in additional nurses and support to assist in patient care areas. Professional Development Specialists in the Colleague Education department were instrumental in training these Colleagues for their new roles.

Labor Pool - In 2020, during the early days of the pandemic, services were shut down and nurses were re-deployed for training in patient care areas. Sixty-eight nurses and 179 Colleagues participated in an initial labor pool from areas such as primary care, surgery, cancer center and other areas. Unsure of how to prepare for a potential huge surge of patients, leaders adjusted plans to respond to changing demand.

Super Crew - In early 2021, another support model was piloted to respond to challenges within the clinical labor market and continued high demand for patient care. A small group of nurses (10) from across the organization were selected based upon previous experience to join the organization’s first Super Crew. This team was trained and had practical experience in Team Nursing and documentation in Meditech. Collaborating with their home departments, often in outpatient areas, these nurses provided needed assistance in hospital-based departments already stretching to meet the needs of sick patients.

Expanding Roles - As the needs continued, nurse leaders expanded the scope and roles of ancillary assistance that non-nurses could provide, evaluating the tasks and training required to supplement support for clinical nursing departments. In the fall of 2021, three new roles were implemented:

• Patient Safety Assistant – A person with clinical experience who may not be familiar with hospital setting.
  • Sit with suicidal or high fall risk/confused patients and record the suicide checks
  • Answer call lights
  • Set up meal trays
  • Assist RN or CNA in ambulating, turning, toileting and bathing patients
  • Document intake and output
• Patient Observer – A person that may or may not have clinical experience who wishes to help nursing Colleagues by supporting patients and meeting their basic care needs.
  • Sit with suicidal or high fall risk/confused patients and record the suicide checks
  • Pass ice water and set up & collect meal trays
  • Reassure and visit with patients and visitors
  • Facilitate/set-up phone calls to loved ones for patients
  • Does not assist in patient care
• Clinical Extender – A person who does not have clinical experience but is available to help with clerical and task-based roles in the clinical setting.
  • Assist with restocking department supplies
  • Run errands and assist with clerical duties as requested
  • Assist with cleaning rooms
  • Reassure and visit with patients and visitors
  • Facilitate/set-up phone calls to loved ones for patients
  • Pass ice water and set up and collect meal trays
  • Does not assist in patient care

Thirty-four Colleagues from non-clinical departments and those outside the organization voluntarily stepped forward to provide these vital roles and were assimilated into the clinical team.

National Guard - Leadership continued to advocate for resources to support clinical areas. They found a new source by partnering with Indiana State Department of Health and the Indiana National Guard, who were deployed twice in October and December in 2021. For the first time in the history of Goshen Hospital, National Guardsman medics and generalists served in various hospital departments. Based on their background and training, they were able to provide both clinical (phlebotomy, patient monitoring, etc.) and non-clinical support (housekeeping, environmental services, and food services). Nursing and clinical Colleagues greatly appreciated the help these public service men and women were able to provide during a season of weariness and relentless demand for care.

While still stretched with limited resources, these additional assistance programs contributed to patients receiving excellent care as reflected in our patient outcomes. See the Exemplary Professional Practice section for details.

Emergency Department program to deploy pulse oximeters

Goshen Hospital’s Emergency Department (ED) is the front line of any acute disaster response. This is especially important in a previously unknown viral disease. Our mission was demonstrated hour-by-hour as patients arrived at the ED distressed and uncertain about their course of illness related to COVID-19.

Both physicians and nurses faced sending some at-risk COVID-19 patients home from the ED. These patients often were not appropriate for hospitalization but had marginal oxygen levels. The situation was constrained by limited available inpatient beds at Goshen and in the region. In collaboration with the Goshen Hospital Community Foundation, funds were allocated to purchase pulse oximeters that nurses could distribute to patients at discharge from the ED.

• Modifications were made to the ED nursing assessment to flag patients who might need these monitors.
• Nurses developed COVID-19 Act Fast flyers which provided quick information for patients and families in everyday language.
• Over 200 oximeters were purchased and distributed out of the ED during 2020 and 2021, with higher distribution during surges.

ED physicians, nurses, and team members exhibited exemplary care and resourcefulness within the tension of resource limitations by continuing to provide high quality care. In review of ED patient outcomes, ED readmission rates at 48 hours, 7 days and 30 days after discharge remained steady with no significant rise in mortality. The quality of care provided by the extraordinary ED team to extremely sick patients saved lives and delivered on our mission to care for our community.

Care Coordination Collaboration

During the past two years, Acute and Ambulatory Care Coordinators facilitated planning for patients as they discharged from the hospital and across the healthcare system. The pandemic brought unprecedented challenges to access to care in multiple areas. High demand and limited staffing were daily stressors to a system focused on serving the community. The advocacy of care coordinators to manage patient flow through the system was incredibly valuable.

• Care Coordinators fluctuated between remote and in-person work, balancing the need for safety with access to patients and caregivers. Remote work required adapting technology and learning new software programs to maintain contact with all stakeholders and team members.
• During periods of COVID-19 surges, access to care reached crisis levels, requiring ingenuity, tenacity and endurance to find resources for our patients. When ventilator beds were used up in our community, care coordinators found access for one patient in a facility outside of the state of Indiana.
• During times of visitor restrictions, care coordinator calls were a vital link to families counting on their reassurance and timely information.
• Care Coordination nurses were required to learn the ever-changing infection prevention guidelines for not only Goshen Hospital, but every healthcare facility across the community to assure seamless communication and provision of care.

Care coordinators daily proved their value to every patient and family they served with respect and compassion.

Hospice and Home Care Response to COVID pandemic

Hospice and Home Care (HHC) nurses faced significant challenges navigating the risks to their own safety and the safety of their patients outside of the controlled hospital environment. As protocols and recommendations changed, they quickly adapted their routines to assure that these vulnerable patients received the care they needed.

• With the relaxation of regulatory standards for “home bound” status, care coordinators and home care nurses worked hard to arrange safe discharge plans for patients who needed timely post-hospital care and attempt to assure home care services for every patient who could benefit from them.
• Regulatory changes also allowed home care nurses and Colleagues to innovate to introduce telehealth visits into their care process using Backline video visits. HHC initiated telehealth visits for therapy and used remote patient monitoring devices to monitor oxygen levels for COVID-19 positive patients.
• Home Care leaders had relationships with the regional nursing homes who were also struggling to access resources and information, especially at the beginning of the pandemic. HHC leaders hosted sessions with the administrators of Skilled Nursing Facilities (SNFs) and Long-Term Care (LTC) facilities to provide education on COVID-19, the hospital’s response and share access to PPE in 2020. Their on-going communication and collaboration demonstrated our commitment to our community and improved coordination and safety for patients and healthcare workers.
• As testing supplies become more readily available, HHC was able to provide much needed COVID-19 testing to homebound patients
• Home care nurses recognized how vital the new COVID-19 vaccines were for their home bound status. The processes to access vaccines were not easily available at that time. HHC partnered with the Elkhart County Health Department to coordinate in-home vaccinations for homebound community members.
• HHC helped with tracers and patient notification for exposed patients that were discharged into Home Care.
• 2020 total visits: Home Care 11,555; Hospice 10,050; 2020 total: 21,605
• 2021 total visits: Home Care 12,805; Hospice 10,352; 2021 total: 23,157

Monoclonal antibodies provided a new opportunity to proactively care for at-risk COVID-19 positive patients to prevent serious illness and subsequent hospitalizations. With emergency room, urgent care and inpatient volumes at capacity, the Center for Cancer Care Infusion Center stepped up to add extra appointments to provide the infusions to end of treatment days. This required new processes for bringing patients safely into the infusion center, as well as short turnaround times for scheduling and treatment for this vulnerable population. This therapy provided a tangible benefit to our community as hundreds of patients received these new treatments.

Assuring Colleague Safety

Working tirelessly behind the scenes, the Performance Improvement and Colleague Health nursing teams worked collaboratively with the critical mission of keeping our Colleagues safe while caring for our community. Even before the public health emergency was declared, these nurses scoured regulatory and national health guidance from professional resources to understand this emerging viral illness and assure that Colleagues were protected by the most up-to-date information and guidance. Creating and managing policies, algorithms, educational materials, and endless forms to implement optimal PPE usage, direct patient flow, and care for critically ill patients required more hours and passion than had ever before. Facing what felt like unknown dire future conditions, nurses carefully considered safety aspects in every setting. Nurses were busy doing safety inspections, taking endless phone calls, and attempting to lead and reassure nurses at every level through the twists and turns of changing CDC guidance and state and federal mandates.
A few examples of innovations implemented by the team:

• Deployment of COVID-19 self-tests with QR Code/Form to record results
• New algorithms, processes and forms for reporting COVID-19 exposure and illness
• Daily contact tracing for both patients and Colleagues potentially exposed to COVID-19 in every work and practice setting.
• Modified policies and safety assessments for infection prevention practices in all clinical settings
• Oversight for fit testing and N95 deployment across the organization.

These nurses modeled the values of compassion, accountability, respect, and excellence in every project they undertook, laser-focused on protecting each nurse and Colleague that served at Goshen Health in the last 2 years.

Learn More About Our Accomplishments