|Year : 2021 | Volume
| Issue : 2 | Page : 84-90
Qualitative provider experiences in a repurposed COVID-19 surge ICU: Forewarned is forearmed
Nandita R Nadig1, Jillian Harvey2, Andrew J Goodwin1, Leslie Lenert3, Dee W Ford1
1 Division of Pulmonary, Critical Care, and Sleep, Medical University of South Carolina, Charleston, SC 29425, USA
2 Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC 29425, USA
3 Medical Bioinformatics in the Center for Health Care Quality, Medical University of South Carolina, Charleston, SC 29425, USA
|Date of Submission||19-Apr-2021|
|Date of Acceptance||04-May-2021|
|Date of Web Publication||15-Sep-2021|
Dr. Nandita R Nadig
Division of Pulmonary, Critical Care, Allergy, and Sleep, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC.
Source of Support: None, Conflict of Interest: None
SARS-CoV-2 has engulfed our world over the course of the last year. Hospitals have experienced case surges and have had to innovate and adapt to care for these patients. This article represents qualitative experiences of providers working in a surge ICU. The codes, subsequent themes, and challenges identified here bring forth perspectives of providers working in surge ICUs and can serve as practical resource set as hospitals continue to surge based on the numerous waves of the pandemic. In light of these findings, it is critical to develop and evaluate resources to optimize provider well-being and workplace experiences.
Keywords: COVID, provider experience, surge ICU
|How to cite this article:|
Nadig NR, Harvey J, Goodwin AJ, Lenert L, Ford DW. Qualitative provider experiences in a repurposed COVID-19 surge ICU: Forewarned is forearmed. Educ Health Prof 2021;4:84-90
|How to cite this URL:|
Nadig NR, Harvey J, Goodwin AJ, Lenert L, Ford DW. Qualitative provider experiences in a repurposed COVID-19 surge ICU: Forewarned is forearmed. Educ Health Prof [serial online] 2021 [cited 2021 Nov 29];4:84-90. Available from: https://www.ehpjournal.com/text.asp?2021/4/2/84/325995
| Introduction|| |
In December 2019, a widespread outbreak of the novel strain SARS-CoV-2/COVID-19 occurred in Wuhan, China. Since then, the virus has engulfed the world and spread to over 250 countries and officially declared a pandemic by the WHO in March 2020. In South Carolina, the first case was identified on March 6, 2020, which led us to anticipate a surge particularly in the populous Charleston area. Thus, our Medical University, a leading tertiary center in the state, established an internal COVID-19 task force for planning and preparedness. Learning from experiences through our colleagues in New York, the mandate was to create a cohort unit for COVID-19 patients. In this research letter, we report qualitative experiences of our first repurposed COVID-19 surge ICU. Our objective was to identify challenges, opportunities, and lessons learnt to adapt and configure future COVID-19 surge ICUs.
| Materials and Methods|| |
Our university is a tertiary-level academic hospital in South Carolina totaling 113 ICU beds at an average occupancy of over 90%. In January of 2020, a Children’s hospital was inaugurated leading to newly vacant space (neonatal ICU) that was repurposed as our first COVID-19 surge ICU. We conducted semi-structured key informant interviews (KIIs) with individuals who had leadership roles in the COVID-19 surge ICU. Respondents included ICU physicians, educators, environmental services, nurses, engineers, and respiratory therapists. We purposefully selected an interprofessional group of respondents based on their expertise and engagement. Respondents were recruited via email, and interviews were conducted during June 9–18, 2020.
We conducted an expediated literature review on surge capacity for mass critical care, and developed a semi-structured interview guide (Appendix)[Additional file 1]. We then conducted KIIs to examine decision points, needs, resources, and challenges encountered in the newly repurposed COVID-19 surge ICU. The guide had questions about physical layout, equipment, communication, patient experiences, education/training as well as care team wellness. Interviews were conducted until saturation was reached. Interviews were audio-recorded, transcribed verbatim, and ranged from 24 to 40 min. NVivoMac Release 1.4.1 (4361) software was used for analysis.
A general inductive approach was utilized, and an initial coding scheme was developed based on the key concepts of preparing ICUs for disaster. Next, the codes were independently tested on the interview transcripts by two investigators through an iterative process by reviewing and refining code definitions and to identify themes. Differences in coding were resolved through discussion, review of the data, and agreement. The manuscript was deemed “Exempt” by the institution’s IRB, given that the purpose of the work was programmatic improvement.
| Results|| |
Eight participants were invited to be part of the study and seven agreed to be interviewed. We identified seven codes and reported our findings organized by themes and its corresponding challenges. Exemplary quotations are in [Table 1].
Respondents noted, while repurposing a space to a COVID-19 ICU, the importance of examining the “layout” and “negative pressure zones.” The ICU that had been planned for 12 beds, however, was downgraded to 8 beds due to space limitations. Challenges providers dealt with included lack of privacy with no bathroom facilities for awake patients and adapting to low lighting traditional in neonatal ICUs. Additionally, due to cohorting of patients in negative pressure zones, awake patients were often witnessing adjacent patients clinically decompensate.
Themes noted in staffing the surge ICU were “staff champion,” “flexibility in staffing,” and “readiness to take on additional roles.’ The presence of a staff champion with expertise in patient prone positioning and initiating dialysis on every shift was vital. Staffing models had stakeholders from different specialty ICUs (e.g., neurologic ICU, surgical ICU, etc.) and training backgrounds and were embraced positively. Many nurses took on additional roles of environmental and dietary services due to hesitancy of these services to work in the COVID-19 ICU. Although staffing accounted for burnout and provided breaks, all providers expressed challenges due to isolation.
Themes related to stuff included “necessary equipment” and “placement of equipment.” Providers had to reassess what equipment was vital for an adult ICU caring for patients with respiratory failure. Additionally, utilization of personal protective equipment (PPE) and disinfection were major considerations during equipment placement (intubation and code carts) amid ensuring patient safety. In eliminating extraneous equipment, some challenges arose due to loss of essentials such as a water closet, inadequate emergency power lines, and patient lifts.
Communication in the COVID-19 ICU was described in two contexts “between health care workers (HCWs)” and “between patients and families.” Communication between HCWs evolved and improved through the course of working in the surge ICU. The basic principle was to conserve integrity of the negative pressure areas for patient care. They first utilized resources available (writing on glass doors, white board) and then attempted to use technology as an adjunct (touchscreen audio visual devices and walkie-talkies) to optimize communication. Conversely, communication challenges were encountered between the patient and family members due to visitation restriction with no uniform modality to facilitate communication.
Training was delivered through “structured modules” and “practical orientation.” The structured training included mandatory modules mostly on donning and doffing of PPE. The practical orientation involved touring (virtual and in-person) of the surge ICU to familiarize oneself with the negative pressure areas for patient care. Providers appreciated constant and adequate reinforcement of what was learnt in training by supervisors. However, certain groups including the environmental health services, physical therapists, and dietary services had hesitancy about working in the surge ICU mostly due to challenges with inadequate training.
Providers in the COVID-19 ICU had perceived anxieties related to “self” and “patients they cared for.” The anxieties related to self was about contracting COVID-19 due to the many unknowns and evolving guidance. On the patient care front, the disproportionate number of African-American patients in the ICU was distressing as providers first hand got to visualize healthcare disparities. Although, there were some avenues that existed for relaxation at work (roof garden, care packages), the major challenge was the sense of isolation as many had chosen to physically distance themselves from their families.
Providers reported increased satisfaction on account of being “a frontline provider” and “being part of a team.” Many felt like this was their calling and had volunteered to work in the COVID-19 ICUs. Furthermore, working in COVID-19 ICUs helped forge friendships that would not have otherwise developed. All commented on the effective teamwork and the can-do attitude demonstrated by their co-workers.
| Discussion|| |
Our project highlights the qualitative and lived experiences of providers during the early stages of working in a space repurposed as a COVID-19 surge ICU. The codes, subsequent themes, and challenges bring forth perspectives of providers and can serve as practical resource set as hospitals continue to open/repurpose surge ICUs based on the numerous waves of the pandemic. Hospitals across the world continue to grapple with patient influx and surge services have been operated at parks, trailers, gymnasiums, and convention centers., Although there is some guidance and precedent from the military in deploying field hospitals,, there are limited data on provider experience while working in these settings, which one could argue is more important and indeed the need of the hour.
Healthcare providers across the world have embraced their contributions to the pandemic as the front-line heroes; however, more recent reports denote burnout and exhaustion., Further, there are concerns of long-term implications with increased rates of anxiety, depression, and post-traumatic.,
The Latin proverb “praemonitus, praemunitus” which translates to “forewarned is forearmed” may seem irrelevant in the thick of a pandemic; however, it does apply to the lessons that we “can learn” due to current circumstances. These lessons have broadly ranged from adopting telehealth and embracing flexibility in hospital operations to circumspection of yet-to-be proven therapies.,, The lesson that this letter hopes to impart is to consider the “voice of the provider” on an ongoing basis to identify opportunities for improving safety, efficiency, and implementation amidst supporting provider wellbeing.
The project has several limitations; it was conducted in a single center. We purposefully selected an interprofessional group of respondents based on their expertise and engagement to obtain perspectives and hence decreased coverage bias. We found a high level of satisfaction in our surge ICUs; however, this may not be translatable as challenges faced by providers have likely evolved over the course of the pandemic. We implore future projects to explore resource needs of providers with a focus on short- and long-term psychological outcomes.
Nandita R. Nadig and Jillian Harvey had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Nandita R. Nadig and Jillian Harvey were active participants in all aspects of the study (design and conduct of the study, collection, management, analysis, interpretation of the data, and preparation of the manuscript). Leslie Lenert, Andrew J. Goodwin and Dee W. Ford—interpretation of the data and preparation of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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