The novel coronavirus forced hospitals to quicken the pace when it comes to safety improvement, which was a departure from what's normally a glacial pace. As the virus continues to mutate, hospital administrators now see that some of the changes they implemented to react quickly back in 2020 should stay in place.
From allowing patients to sleep longer to instituting daily escalation huddles, there are processes that will likely stick around long even after COVID-19's severe consequences fade because they've enhanced safety and quality.
"This has so changed the delivery of healthcare in many, many ways that there are some components that there's just no going back," said Charleen Tachibana, senior vice president and chief quality, safety and patient experience officer at Virginia Mason Franciscan Health in Seattle.
Virginia Mason Franciscan created a nurse observer and monitor role that proved critical as the system saw higher degrees of patient acuity coupled with a workforce shortage.
The not-for-profit health system already had a centralized mission control center. As a result of the pandemic, nurses now use that system to watch patients' vital signs remotely. The mission control center also serves as a consult service for remote hospitals in the network.
Virginia Mason Franciscan also uses this system to provide virtual supervision of bedside nurses to ensure tasks are correctly completed. "You would have a centralized nurse somewhere who could come in by camera remotely, and do that check with you," Tachibana said. "There's now another level of care oversight layered on top of a burdened and stretched workforce that's providing monitoring."
Workers inserted more catheters and more central lines, and there were more patients on ventilators because of the severity of their illnesses. Ultimately, these factors equate to more chances for patient harm.
Bassett Healthcare Network of Cooperstown, New York, recognized those risks, and started daily escalation huddles. Front-line staff on each unit meet at 8:30 a.m. every day to air concerns about safety and quality. Their managers then report on those gatherings during a director-level meeting at 9 a.m. Issues are handled on the spot and then communicated to senior executives.
"The executive leadership team really wanted to know the day-to-day concerns and that's key because traditionally, executive staff don't want to be bothered with the small stuff," said Russell Grant, the not-for-profit system's director of infection control and prevention. "That was a real shift, and I think a very positive shift for the organization. The plan is to continue these long after the COVID-19 pandemic."
Hospitals also had to figure out how to reduce front-line worker exposure to COVID-19 patients, and many did it through what's called "clustering." So, instead of a worker entering a patient area say, 100 times during a shift, that could be cut down by half.
NYC Health + Hospitals did this by tinkering with its electronic health record system and other technology. Usually, a worker would be prompted to do a routine task like taking blood for a lab test. Previously, an alert would go off every two hours for these tasks, interrupting patient rest, which has been shown to negatively impact recovery. So the New York-based municipal health system programed the alerts to block off six hours for patients to sleep, or to only sound when a patient is awake.
"Or if a call bell goes off, we are able to check in through video," and then deliver whatever a patient needed, said Dr. Eric Wei, senior vice president and chief quality officer at NYC Health + Hospitals. "(We had to) improve the monitoring of patients while decreasing the number of times that people had to go into inpatient rooms."
Medical procedures for which health workers would have to be exposed to patients' breath became big events. Hospitals routinely administer nebulizer treatments to asthma patients, which forces medicine into the airway through high-powered oxygen, and usually prompts coughing, for example. COVID-19 changed that routine.
"Before when people were having respiratory treatment, we would walk in and out without even a mask on—it just wasn't something that we thought about," said Daria Kring, vice president of clinical and patient education at Novant Health, based in Winston-Salem, North Carolina. "I can imagine where we won't think of them as benign events for a very long time."
Now, if a patient needs cardiopulmonary resuscitation, Novant employees have a guide to follow for this aerosol-generating procedure. Staff now must wear respirators during these treatments, and there are signs on doors warning others to not enter until a space has been long vacant.
Of course, some safety innovations can lead to unexpected negative outcomes, said Patricia McGaffigan, vice president of safety programs at the Institute for Healthcare Improvement. Many hospitals have wisely implemented so-called failure mode and effects analyses, she said.
"We've got to think about the unintended consequences of making a change—or what we think is improvement—that are not going to outweigh the benefits of it overall," McGaffigan said. "What we're looking at is an extension of the collective learning and the development of skill sets that we've seen be more broadly disseminated throughout organizations overall."
And despite the efforts to pivot quickly to keep patients safe, the Centers for Disease Control and Prevention showed various infection rates went up during the first year of the pandemic, despite significant reductions since 2015. This included catheter-associated urinary tract infections and MRSA cases.
"Ironically, it [the pandemic] exacerbated our ability to handle other kinds of infections besides COVID-19," said Leah Binder, president and CEO of the Leapfrog Group.
This might have been in part due to practices like putting IV lines in hallways outside patient rooms to decrease workforce exposure to the virus. Or it could have been because visitors were either limited or barred altogether.
"Visitors are actually another pair of eyes. They tend to be with the patient for a long period, they constantly come out and tell workers if their loved one didn't look right, or the IV didn't look right, and so many ways that they acted as advocates for the patients," said Ann Marie Pettis, president of the Association for Professionals in Infection Control and Epidemiology. "We lost that."
Other hospitals pivoted some in more administrative roles to work from home, like those in safety, quality and patient experience departments. That was the case at Pittsburgh-based health system Allegheny Health Network. Not only were these employees not present at hospitals to help mitigate patient issues but their quality-improvement projects fell by the wayside amid the pandemic, said Chief Nurse Executive Claire Zangerle.
"Those did not accelerate as fast as we wanted them to, because it's tougher to get on the phone [with clinicians and other frontline workers] when that kind of situation—maybe a length of stay issue—pops up," Zangerle said.
Those workers are now back working in person. And as visitors are allowed back in hospitals, Binder sees some positives that will likely stick around. "Now, visitors are just expected to wash their hands, wear a mask and they have certain responsibilities to protect against family and other patients from infection," she said.
There are still big questions around how regulators will integrate COVID-19 policies into how they measure hospitals' performances when it comes to quality and safety.
"When it comes to healthcare-associated infections, we've had some conversation about how we decide when SARS-COV-2 could be hospital-acquired or not," said Dr. Graham Snyder, infection prevention and hospital epidemiology medical director at Pittsburgh-based system UPMC.
The legacy of COVID-19 safety procedures will be lasting, and includes innovations that arguably should've been in place all along and lessons for the entire industry about what does and doesn't work. UPMC of Pittsburgh, for instance, is building a new hospital with single-patient rooms to anticipate the emergence of novel, highly contagious, and rapidly morphing viruses. The next pandemic could look very different.