Yale New Haven's COVID-19 nurse-staffing model has long-term benefits

Yale New Haven's COVID-19 nurse-staffing model has long-term benefits

Yale New Haven Hospital anticipated in March it would soon need as many as 500 more beds to treat an expected influx of coronavirus inpatients.

Although the 1,540-bed Connecticut teaching hospital used staffing agencies in part to help with the heightened demand, the closure of operating rooms and clinics presented an opportunity to leverage those nurses, too.

In a matter of weeks, front-line nurses at Yale New Haven created a new staffing model relying on the competencies of nurses across the system to determine which units they should be assigned to and what roles they could perform safely. The result is a new option for leadership to deploy going forward on units that are understaffed or overwhelmed.

“Our model now is no unit left unstaffed,” said Ena Williams, chief nursing officer of Yale New Haven Hospital. “In the old days, we would send (the nurse) home if they were not an ICU nurse, but now we are saying: You don’t have to go home, you can function in this support role and here is how you can do that.”

The model assigns nurses colors based on their skill level and expertise. Red represents a current intensive-care unit nurse; orange is nurses with ICU experience within the last three years and yellow is nurses with ICU expertise more than three years ago. Blue indicates nurses who work on medical-surgical units, while pink is med-surg or ambulatory nurses who haven’t practiced in more than a year. Nurse’s aides, patient-care assistants and technicians are assigned the color purple.

Yale didn’t have the information readily available to appropriately assign nearly 400 nurses to a color, so staff had to reach out to managers asking about the experience and competencies of their staff, a time-consuming process and big learning experience, said Jeannette Bronsord, executive director of surgical services.

Now Yale is working on maintaining a database of all nursing staff. An email has been sent to nursing staff to validate the data collected and Yale plans to ask staff to review it regularly. “Going forward we will be much more prepared,” Bronsord said.

During Yale’s surge, nurses assigned the color red acted as primary nurses on the COVID-19 ICU units and nurses assigned the colors orange and yellow acted as their support nurses, available to get supplies, bathe patients, check vital signs, administer medication, offer emotional support to patients and conduct video visits with family. On the medical surgical units, nurses assigned the color blue acted as primary nurses while those assigned pink were support nurses.

The support nurses and staff received training, developed by Yale staff, before heading into the units, including a day to shadow a nurse to understand the workflow, a crash course on the inpatient electronic health record and simulated lab time to reiterate clinical skills such as fall and ulcer prevention practices.

The model went through iterations in its first few weeks, Williams said. Initially, staff received their assignment to a unit and team the same day as their shift, but that generated complaints from nurses that they weren’t forming bonds with team members. In response, nurses were scheduled more consistently with the same staff and units. About 370 nurses were involved in the new staffing model by the end of Yale’s COVID-19 surge in June. And the hospital added about 380 beds at its peak.

Nurses have responded favorably to the experience, Williams said, with some nurses even staying on ICU or med-surg units after operations returned to normal. Some nurses also moved up in color assignment as the pandemic wore on.

Williams said the key to success was front-line nurses leading the model’s development. The nurses “were part of the design; they were right at the table at the very beginning and because it was built for them and with them, the adoption was so much easier,” she said. “I thought it was going to be mayhem, but they responded brilliantly.”

Yale

Source: Yale New Haven’s COVID-19 nurse-staffing model has long-term benefits

Europe, US reel as virus infections surge at record pace

Europe, US reel as virus infections surge at record pace

Coronavirus cases around the world have climbed to all-time highs of more than 330,000 per day as the scourge comes storming back across Europe and spreads with renewed speed in the U.S., forcing many places to reimpose tough restrictions eased just months ago.

Well after Europe seemed to have largely tamed the virus that proved so lethal last spring, newly confirmed infections are reaching unprecedented levels in Germany, the Czech Republic, Italy and Poland. Most of the rest of the continent is seeing similar danger signs.

France announced a 9 p.m. curfew in Paris and other big cities. Londoners face new restrictions on meeting with people indoors. The Netherlands closed bars and restaurants this week. The Czech Republic and Northern Ireland shut schools. Poland limited restaurant hours and closed gyms and pools.

In the United States, new cases per day are on the rise in 44 states, with many of the biggest surges in the Midwest and Great Plains, where resistance to masks and other precautions has been running high and the virus has often been seen as just a big-city problem. Deaths per day are climbing in 30 states.

“I see this as one of the toughest times in the epidemic,” said Dr. Peter Hotez, an infectious-disease specialist at the Baylor College of Medicine in Texas. “The numbers are going up pretty rapidly. We’re going to see a pretty large epidemic across the Northern Hemisphere.”

Dr. Anthony Fauci, the U.S. government’s top infectious-disease expert, said Americans should think hard about whether to hold Thanksgiving gatherings.

“Everyone has this traditional, emotional, warm feeling about the holidays and bringing a group of people, friends and family, together in the house indoors,” he said on ABC’s “Good Morning America.” “We really have to be careful this time that each individual family evaluates the risk-benefit of doing that.”

Responses to the surge have varied in hard-hit states.

In North Dakota, Republican Gov. Doug Burgum raised the coronavirus risk level in 16 counties this week but issued no mandated restrictions. In Wisconsin, a judge temporarily blocked an order from Democratic Gov. Tony Evers that would limit the number of people in bars and restaurants.

South Dakota on Wednesday broke its record for COVID-19 hospitalizations and new cases and has had more deaths from the disease less than halfway through October than in any other full month. Despite the grim figures, GOP Gov. Kristi Noem has resisted pressure to step up the state’s response to the disease.

Wisconsin hit a new daily high for confirmed infections for the second time this week. In Missouri, the number of people hospitalized with COVID-19 reached nearly 1,450, another record.

Dr. Marc Larsen, who oversees the COVID-19 response at Kansas City-based St. Luke’s Health System, said the system’s rural hospitals are seeing surges just as bad as in Kansas City.

“Early on in this pandemic, it was felt that this was a big-city problem, and now this is stretching out into the rural communities where I think there has not been as much emphasis on masking and distancing,” he said.

New cases in the U.S. have risen over the past two weeks from about 40,000 per day on average to more than 52,000, according to Johns Hopkins University. (Cases peaked in the U.S. over the summer at nearly 70,000 a day.) Deaths were relatively stable over the past two weeks, at around 720 a day. That is well below the U.S. peak of over 2,200 dead per day in late April.

Worldwide, deaths have fallen slightly in recent weeks to about 5,200 a day, down from a peak of around 7,000 in April.

Dr. Hans Kluge, the head of the World Health Organization’s Europe office, urged governments to be “uncompromising” in controlling the virus. He said most of the spread is happening because people aren’t complying with the safety rules.

Europe’s financial markets fell sharply Thursday on concerns that the new restrictions will undercut the continent’s economic recovery. Stocks were down slightly on Wall Street.

In France, which reported over 22,000 new infections Wednesday, President Emmanuel Macron put 18 million residents in nine regions, including Paris, under a curfew starting Saturday. The country will deploy 12,000 police officers to enforce it.

Italy set a one-day record for infections and recorded the highest daily death toll of this second wave, adding 83 victims to bring its count to nearly 36,400, the second-highest in Europe after Britain.

In Britain, London and seven other areas face restrictions that will mean more than 11 million people will be barred from meeting with anyone indoors from outside their households and will be asked to minimize travel starting this weekend.

European nations have seen nearly 230,000 confirmed deaths from the virus, while the U.S. has recorded over 217,000, though experts agree the official figures understate the true toll.

So far in the new surges, deaths have not increased at the same pace as infections.

For one thing, it can take time for people to get sick and die of the virus. Also, many of the new cases involve young people, who are less likely than older ones to get seriously ill. Patients are benefiting from new drugs and other improvements in treating COVID-19. And nursing homes, which were ravaged by the virus last spring, have gotten better at controlling infections.

But experts fear it is only a matter of time before deaths start rising in step with infections.

“All of this does not bode well,” said Josh Michaud, associate director of global health policy with the Kaiser Family Foundation in Washington. “Rapid increases in cases like we’re seeing now are always followed by increases in hospitalizations and deaths, which is what is likely to occur across much of Europe and the U.S. in the coming weeks and months.”

Among the areas hit by the new surge is Gove County in Kansas, where the sheriff, the emergency management director, the CEO of the local hospital and more than 50 medical staff members have tested positive.

Dr. Doug Gruenbacher, a physician who contracted the virus in September, said people around Gove County are concerned about their personal liberty and “not wanting to be told what to do.”

“That’s part of the reason of why we love it here, because of that spirit and because of that independence,” he said. “But unfortunately, it’s something that also contributes to some of the difficulties that we’re having right now.”

Europe

Source: Europe, US reel as virus infections surge at record pace

HHS orders Nevada to revoke ban on nursing homes using antigen tests

HHS orders Nevada to revoke ban on nursing homes using antigen tests

Federal health officials have ordered Nevada to allow nursing homes to use two rapid antigen tests after a review showed a majority of positive results were false, saying the action violated federal law and endangered lives. HHS

Nevada’s Department of Health and Human Services banned Quidel Corp.’s Sofe and Becton Dickinson and Co.’s Veritor antigen tests from long-term care facilities after receiving anecdotal reports questioning their validity. Those point-of-care tests’ positive results contradicted negative readings from reverse-transcriptase polymerase chain reaction tests, which are considered more accurate.

HHS Assistant Secretary Dr. Brett Giroir on Friday said the agency would take “swift and appropriate steps” if Nevada’s Department of Health and Human Services didn’t reverse course.

“The letter from Nevada officials can only be interpreted as reflecting a fundamental lack of basic knowledge about testing and interpreting results,” Giroir said. “Not just COVID testing but clinical testing in general.”

Nevada’s agency said spot checks of antigen tests found that only 40% were considered true positives; 23 of the 39 tests reviewed were false positives. Twelve skilled-nursing facilities performed more than 3,700 antigen tests with 60 positive results.

The state reported that Becton Dickinson tests had a 50% accuracy rate, and only one of the nine reviewed Quidel tests was a true positive.

“If the use of the outlined antigen tests continues within a SNF, the Bureau of Health Care Quality and Compliance will take necessary corrective action to ensure the safety of staff and residents within the facility,” state health officials wrote to nursing homes.

The conflicting tests results may have stemmed from inadequate training, complpiance issues or false negatives from the RT-PCR tests, according to state health official. Nevada said it would update its antigen testing guidance after it received more data.

Giroir said all tests are expected to have some false positives, especially when screening a patients with a low infection prevalence. Nevada has reported 84,593 confirmed cases as of Friday, with 766 new cases over the last day.

Across the country, nearly 246,000 nursing home residents have tested positive for COVID-19, with another 141,444 suspected cases, according to CMS.

In August, CMS started requiring long-term care facilities to routinely screen both residents and staff for COVID-19 or face financial penalties. The agency hoped the effort would help stem coronavirus outbreaks in nursing homes.

Giroir declined to elaborate on the actions HHS could take if Nevada health officials don’t comply with the demand, but noted there were several enforcement mechanisms at their discretion. He said he was confident they would comply after reviewing the facts.

“There really is no scientific reason, no medical reason to not comply with this and not to allow lifesaving testing,” Giroir said.

HHS

Source: HHS orders Nevada to revoke ban on nursing homes using antigen tests

COVID-19 tests remote work capacity

COVID-19 tests remote work capacity

CCM Health, a medical center based in Montevideo, Minn., shares continual COVID-19 updates from management and caregivers; daily emails to all employees about census, staffing, access and other stats; bi-weekly organizational updates from the CEO; and marketing communications that include facility updates as well as monthly department meeting recordings. tests

“We feel the key is through extensive and continuous communication,” said Kelly Johnson, CCM’s human resources manager.

Even though CereCore, which supports providers’ IT needs, initially saw its business decline, it kept more staff on than needed to help people transition to the new working environment, said Curtis Watkins, CereCore’s CEO.

They doubled down on personal check-ins, but managers had to strike a balance between checking in periodically and not overwhelming employees, he said.

“From an HR perspective, we try to treat people with grace and understanding,” Watkins said. “We were careful not to overdo it because people don’t want to feel like they always have somebody over their shoulder. So we made it personal, asking about their family or kids and had to be clear that this is about staying connected, not micromanaging.”

Ultimately, COVID-19 accelerated the Nashville-based company’s move to more remote work. Watkins expects about an 80%-to-20% ratio of remote to in-person work over the long term, up from around 60% to 40%. It will likely downsize its real estate footprint by about a third, Watkins said.

“It has been an interesting journey, and it is something we will try to figure out and get better at,” he said, adding that the biggest long-term challenge is around the void of face-to-face interaction between its senior level administrative team. “We need to find ways to build that teamwork and trust.”

Advocate Aurora launched its first ever virtual professional development initiative. To Brady’s surprise, about 40% of its leadership team tuned in to some of the 30 sessions.

“It is part of how this whole process drove more innovation,” he said.

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Source: COVID-19 tests remote work capacity

Keeping frontline healthcare workers physically and psychologically safe is paramount during the COVID-19 pandemic

Keeping frontline healthcare workers physically and psychologically safe is paramount during the COVID-19 pandemic

Source image: Pixabay by Hilary Clark.
Care teams are asking for a safer work environment. But what does “safe” actually mean? frontline

Fall is here, and as many had feared and predicted, COVID-19 cases are on the rise again in many parts of the U.S. Just last week, 3,400 nurses at Brigham and Women’s Hospital in Boston, an area that’s been hit hard by the pandemic, urged executives to give them a safer environment with universal N95 masking, shuttle safety, communication about infections and effective quarantines.

The message was simple: To adequately care for coronavirus patients, care teams need to be able to care for themselves. That’s a tall order, given that nurses and caregivers on the front lines are more at risk of infection than the socially distanced populace. But the concern over healthcare worker safety is well-founded, and administrative teams need to ensure that equipment and processes are in place that can reduce the risk of transmission.

Enter “The Person Behind the Mask,” a campaign launched by patient safety company RLDatix. It was created to increase awareness about the importance of keeping frontline workers safe, and a key component of that effort is ensuring that caregivers remain physically and emotionally healthy in order to deliver better and safer care.

“When harm events happen in hospitals, it’s devastating for patients and families, but also for the care team,” said Dr. Tim McDonald, RLDatix’s chief patient safety and risk officer. “They feel terrible when harm events happen. Traditionally the response had been the wall of silence — don’t talk to patients and families openly, and often don’t talk to each other. It was a sign of weakness to ask for help. We needed to shatter the wall of silence.”

It’s a pressing mission for a number of reasons, not least of which is morale. Physician and nurse suicide has spiked in the past decade. McDonald works with the suicide prevention team at University of California San Diego and was distressed to learn that an emergency department physician recently committed suicide due to pandemic-related stress.

Even taking suicide out of the equation, there’s been a massive increase in burnout. Doctors and nurses are leaving the profession because of the impact, and that extends beyond their own lives to those of their families. Divorce rates are high among care teams, and also among patients and families who have lost loved ones to the coronavirus — implying some pretty troublesome collateral damage.

Yet with care teams asking for a safer work environment, it’s constructive to ask: What does “safer” mean, exactly?

A BETTER ENVIRONMENT

Broadly speaking, better safety encompasses both the physical and the psychological. Hospitals and health systems have tended to fare better on the physical side, which entails procuring the requisite personal protective equipment and getting it to the right people at the right time. Sanitation protocols also make an environment feel more physically safe.

Psychological safety, said McDonald, can be fostered when health leaders are transparent and report when things aren’t going the way they should be. Event reporting systems can capture unexpected events so teams can learn from them in the future, which created a psychologically safe environment for people to report and act upon the data, thereby buttressing the overall work environment.

“I’m encountering devastating things I’ve never seen before,” said McDonald. “Organizations can put in place ‘caring for the caregiver’ programs to provide support on a proactive basis. It’s analogous to what aviation does. Whenever there’s a mishap in aviation, there’s immediate outreach to the people involved in that. We need to be doing more of that in healthcare.”

Data is a big component of that approach, as it allows leaders to educate care teams about things like infection management and patient safety. Many electronic health records systems are able to analyze infection surveillance data, for example, to see whether there are pockets of infections the organization should know about, allowing the provider to take action.

It can also pick up on medication errors, which are the most common errors that occur in healthcare. EHRs and other software can analyze and collate events to look for patterns, allowing teams to take preventive action. An example of this is preventing central line and catheter infections, which are linked to ventilator-associated pneumonias.

“It changes the way we deliver care,” said McDonald. “We need to do more to identify safety scientists to help design cate that prevents events in a more rapid way.”

THE OPPORTUNITY

Executives have a challenge, but also an opportunity, to improve safety in a manner that lasts well beyond the end of the pandemic. One way is to examine the ways care has changed during the public health crisis and implement those changes permanently across all areas of care.

Change in process, said McDonald, is one of the great lessons learned during the pandemic and one of the things health leaders can begin working on immediately.

“Empathy and compassion go along with candor,” he said. “It mitigates implicit bias. One of the things we’re seeing is these issues around implicit bias and racism. We know empathy and compassion can mitigate it. That means we need to use the data that identifies things around race, ethnicity, pronoun preference, issues around LGBTQ. That’s one of the things that has reared its ugly head during this pandemic.”

McDonald sees more and more providers adopting these kinds of approaches, and in fact, it’s a mindset that’s increasingly taught at the student level, meaning those just entering the healthcare workforce will have expectations of having their health and mental well-being protected and respected. It’s a mindset that in some ways defines the future of healthcare — and the future is now.

“We’re starting to get traction,” said McDonald. “We can’t afford not to do this.”

frontline

Source: Keeping frontline healthcare workers physically and psychologically safe is paramount during the COVID-19 pandemic

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New Laws Keep Pandemic-Weary California at Forefront of Health Policy Innovation

New Laws Keep Pandemic-Weary California at Forefront of Health Policy Innovation

SACRAMENTO, Calif. — Though COVID-19 forced California leaders to scale back their ambitious health care agenda, they still managed to enact significant new laws intended to lower consumer health care spending and expand access to health coverage.

When Democratic Gov. Gavin Newsom concluded the chaotic legislative year Wednesday — his deadline to sign or veto bills — what emerged wasn’t the sweeping platform he and state lawmakers had outlined at the beginning of the year. But the dozens of health care measures they approved included first-in-the-nation policies to require more comprehensive coverage of mental health and addiction, and thrusting the state into the generic drug-making business.

“We had less time, less money and less focus, but COVID makes the causes of expanding coverage and trying to control health care costs that much more important,” said Anthony Wright, executive director of Health Access California, a Sacramento-based consumer advocacy group.

The governor also signed into law a raft of COVID-related bills intended to address the biggest public health emergency in a century, such as measures to stockpile protective gear for health care workers.

This year’s legislative season took place against the backdrop of an unprecedented pandemic that sparked a statewide stay-at-home order, back-to-back emergency legislative recesses, the Capitol’s first foray into remote voting and a projected $54 billion budget deficit.

Among the most controversial changes Newsom signed into law was the largest expansion of the state’s family leave program since it was enacted in 2014, an upgrade opposed by the state’s business interests. The tobacco industry also took a hit when Newsom approved a measure banning retail sale of flavored tobacco products, including menthol, with exceptions made for flavored hookah products. And Newsom bucked the powerful doctors’ lobby by granting nurse practitioners the ability to practice without physician supervision.

But several contentious health bills stalled in the legislature and never made it to Newsom’s desk, including measures that would have given the state attorney general more authority to reject hospital consolidations, expanded the state’s Medicaid program, called Medi-Cal, to unauthorized immigrants ages 65 and up, and capped consumers’ out-of-pocket costs for insulin.

Among Newsom’s vetoes were a pair of bills that sought to expand telemedicine, as well as legislation to adopt patient privacy protections for COVID-19 genetic testing.

“I think we all wish we’d had more opportunities to move more things forward,” said Assembly member Jim Wood (D-Santa Rosa), who chairs the Assembly Health Committee. “Under the circumstances, I think we did a good job.”

Here’s a look at some of the major health measures Newsom signed into law this year. Most will take effect on Jan. 1.

Behavioral Health

Lawmakers made significant changes to mental health coverage, and perhaps the most consequential is a mental health parity bill. SB-855 requires state-regulated health insurers in California to cover all treatment deemed medically necessary for mental health and substance abuse disorders, from depression to opioid addiction. Health insurers opposed the bill, arguing it would drive up health care spending.

Mental health parity is already enshrined in state and federal law, but advocates say insurers regularly don’t cover the critical care that patients need.

Julie Snyder, a lobbyist for the Sacramento-based Steinberg Institute, which advocates for mental health care policy changes, called the new law a model for the rest of the country.

“There’s no other state that has anything this comprehensive,” Snyder said.

Another bill, SB-803, will allow peer providers — people with their own histories of mental illness or substance abuse who help other Californians navigate behavioral health issues — to be certified by the state. Once certified, they can bill Medi-Cal for their services.

Scope of Practice

Newsom gave nurse practitioners, who are nurses with advanced training and degrees, the power to practice independently, after years of failed attempts and despite major opposition from the California Medical Association, which represents doctors. Supporters say AB-890 will help address health care provider shortages, especially in rural and underserved communities.

Certified nurse-midwives will also be allowed to attend low-risk pregnancies in both hospital and home settings without a physician’s supervision under SB-1237.

Cutting Health Care Costs

California will enter the highly competitive generic drug market as a result of SB-852, a first-in-the-nation law that will put the state government in direct competition with private drug manufacturers.

“The cost of health care is way too high,” Newsom said in a statement upon signing the bill.

By January, California must forge partnerships with one or more drug companies to make or distribute a broad range of generic and biosimilar drugs that are cheaper than brand-name products. The bill specifically calls for the production of the diabetes medicine insulin, because makers have hiked prices sharply in recent years.

Newsom also approved an under-the-radar health care transparency measure requiring the state to collect data on the amount state-regulated health insurers pay for specific medical services, from knee replacements to asthma treatments. The data could help policymakers identify excessive spending on certain treatments and provide fodder for proposals to control health care costs.

“While the examination of cost has slowed down, it hasn’t ended,” said state Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee.

Newsom also signed legislation cementing into state law key provisions in the Affordable Care Act, a move guaranteeing Californians will not lose coverage protections should the U.S. Supreme Court strike down the law.

SB-406 will ban health insurers in California from imposing annual or lifetime limits on coverage, and also requires health insurers to cover a range of preventive care services, from cholesterol and blood pressure screenings to immunizations, without charging patients copays or deductibles.

COVID-19

As California continues to grapple with the highest COVID-19 case counts in the country, lawmakers approved a suite of bills in response to the pandemic, largely intended to protect essential workers.

Employers will have to provide written notice within one business day to employees who may have been exposed to the COVID-19 virus at their worksite. They must also report the details of workplace outbreaks to local public health authorities within 48 hours. AB-685 was prompted by major outbreaks this year at food-processing plants.

Newsom also signed legislation making it easier for firefighters, health care workers and other front-line workers infected with the coronavirus to get workers’ compensation. SB-1159 took effect Sept. 17, the day the governor signed it.

State law now presumes these front-line workers were infected with the virus on the job unless their employers prove otherwise.

Certain employees who have been exposed to the virus will also have more paid sick leave time. Under AB-1867, food-processing companies with at least 500 workers must provide two weeks of paid sick leave to workers who have been exposed to COVID-19 or have been advised to quarantine.

The law also grants health care workers and emergency responders two weeks of paid sick leave, closing a loophole in a COVID-relief bill Congress approved this spring.

Two new laws will address another major challenge exposed by the coronavirus pandemic: the lack of adequate personal protective gear for health care workers. AB-2537 will require hospitals to stockpile a three-month supply of protective gear by April, while SB-275 mandates that the California Department of Public Health establish an additional stockpile for health and other essential workers to last 90 days during a pandemic.

Nursing homes, which have been at the epicenter of COVID-19 deaths, will be required to have a full-time “infection preventionist” on staff to help stem the spread of disease. The bill, AB-2644, also will require nursing homes to report deaths from a communicable disease to the state within 24 hours during an emergency related to that disease.

And California’s roughly 40,000 licensed pharmacists will be allowed to administer COVID-19 vaccines that have been approved by the Food and Drug Administration under AB-1710.

Laws

Source: New Laws Keep Pandemic-Weary California at Forefront of Health Policy Innovation

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