Qatif central hospital critical care nursing surge plan and nursing care model during pandemic

1. 12 July 2020 Version 1

2. ICUs Surge Preparation &
Nursing Care Model Plan
during pandemic
qatif central hospital
nursing department
prepared by
Alhasan S. Almahrouq , RN, BSN
Critical Care Units Nursing Director
Mohammed Al Bazroun , RN, BSN, PgDip ACCN
Nursing Education - Clinical Instructor
approved by
Amal Al Hasawi , RN, MSN
Executive Director of Nursing

3. Introduction
COVID-19 pandemic in Saudi Arabia is part of the worldwide pandemic of coronavi-
rus disease 2019 (COVID-19) caused by severe acute respiratory syndrome corona-
virus 2 (SARS-CoV-2). On 2 March 2020, the Ministry of Health confirmed the first
case in Saudi Arabia.
High demand for Intensive care unit (ICU) services during pandemic and limited bed
availability have prompted hospitals to deal with capacity planning challenges. Un-
availability of ICU beds can adversely affect hospital-wide patient output, especially
within the Emergency Departments, and increase mortality of critically ill patients
secondary to prolonged waiting times for ICU bed assignment. Thus, numerous ini-
tiatives are implemented to optimize ICU beds but with a high number of critically
ill patient the best solution is to urge expanded. On the other hand, promoting the
culture of safety may be a core element of the many efforts to boost patient safety
and care quality. However, any new system may have a risk of failure and its pros
and cons.
A surge of critically ill coronavirus patients will require increased critical care bed
capacity. Therefore, a review of staffing due to the need to increase bed capac-
ity, potential staff absence and staff movement from other areas is necessary. Staff
moved from other areas may have limited or no knowledge of acute and critical
care services and will be required to support increases in critical care activity.
The principles for increasing the nursing workforce in response to exceptional in-
creased demand in adult critical care is another issue on Nursing department shoul-
ders, the best solution is to train a non- critical care nurse to be an adult critical care
nurse with special skills and knowledge related critical care environments.
Creating an appropriate nursing staff model helped us to be prepared to intervene
in the evinced escalating Covid-19 cases. However, the nursing staff model is not
achievable without significant prior planning/preparedness activities. Thus, this
document provides the guidelines we followed in the nursing department to man-
age a Surge ICU Nursing Capacity during Pandemic to ensure continued high-quality
clinical care.
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4. QCH ICU Beds Capacity and Nursing Staffing
Before the COVID Pandemic:
In October 2019 an expansion of Qatif Central Hospital ICU from 9 bed capacity to
20 beds capacity, the ICU operated by Dr. Sulaiman Al Habib Hospital with total of
66 Nursing staff On other hand the QCH ICU nursing staffs with total of 25 ICU nurs-
ing staffs was relocated to other hospital areas according to area’s needs (Resuscita-
tion Room in the emergency Department, Medical Ward, Apheresis team)
QCH ICU Beds Capacity and Nursing Staffing
After the COVID Pandemic
The emergence of human-health related the outbreak of COVID-19 pandemic has
become extremely severe, critically ill patients with COVID-19 need treatments of
high intensity and close observation, it is expected that there will be imbalance be-
tween the supply and demand for human resources especially critical care nurses.
With highly needs to increase the total hospital ICU beds capacity, the hospital ad-
min decided to increase the ICU beds capacity with total of 50 beds distributed in
Five deferent areas , with following details:
Nursing staff : Pt Ratio
Number of Nursing Staff
Bed capacity
1:2 , 1:1
66 Staff
Beds 20
Department Name Total Bed Capacity Total of Nursing Staff Number
ICU A 20 66
ICU B 7 20
ICU C 8 28
ICU D 6 24
ICU E 5 24
ICU F 4 20
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5. 1- ICU A : it was the original ICU before the pandemic and it is operated by the Dr.
Suliman Alhabib with total of 66 ICU nursing staff experience
2- ICU B : new area was opened and established after the pandemic in aim to ac-
commodate any critical care pt. surge needs , and it is operated by our previous ICU
staff with Adult ICU experience
3- ICU C : it was before the PICU area and converted to accommodate the adult criti-
cal patient and it is operated by PICU nursing staff
4- ICU D: it was before the CCU area and converted to accommodate the adult criti-
cal patient and it is operated by CCU nursing staff
5- ICU E: new area was opened and established in the OR recovery room and oper-
ated by the Post- anesthesia care unit, and operating room nursing staff
6- ICU F: new area was opened and established in the ER and operated by the NICU
nursing staff
ICU B
ESTABLISHED
8 MARCH 2020 26 MAY 2020 1 JUN 2020
PICU
CONVERTED
TO ICU C
CCU
CONVERTED
TO ICU D
OR RECOVERY
CONVERTED
TO ICU E
ICU F
established
IN OLD ER
4 JUN 2020 11 JUN 2020
- PRECEPTOR
GROUP CREATED
- JOUNIAR STAFF
STARTED DUTY IN
ICUs
1 JUN 2020
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6. Nursing Care Model used during
the pandemic
In QCH around 5 % of the total number of nurses is capable to work with
critically ill patients and they are distributed in different areas in the hospi-
tal. This leads to limited numbers of well-qualified critical care nurses, for
this reason we as nursing office in aim to manage the ICUs Surge, we cre-
ated our Nursing Care Model to help us to accommodate any staff short-
age in ICUs.
We started by classifying our staff according to their experience and work-
ing areas before the pandemic, and according to that we found that we
have four types of staff available to care for critically ill patients were
categorized as the following:
a) Nursing staff who worked before in Adult ICU and have
critical care experience
b) Nursing staff with experience of critically ill patients but not
in Adult ICU (e.g. coronary care nurses, PICU nurses, NICU
nurses)
c) Nursing staff in in procedural areas who are familiar with
a critical care environment (e.g. the post- anesthesia care unit,
and operating room).
d) Non-ICU RN nurses who is working in other hospital units with
minimum 3 years’ clinical experience and Passed COVID-19
Critical Care Crash Course for Nurses
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7. In aim to manage the staff shortage specially in the intensive care units we cre-
ate our care model to help us to accommodate any increasing of critical care staff
needs and for any increasing in ICU bed capacity
1- ICU Senior Charge Nurse
a) To do the daily staff –patient assignment
b) To supervise the staff work in daily basis
c) Arranging the patient admission and the discharge from ICU
d) Receive full endorsement for all patient needs and helth condition update
e) Team debriefs or huddles at the beginning and end of each shift is
recommended.
f) To check the other staff, work and monitor the performance for patient
safety
ICU Senior
Charge Nurse
Nursing
preceptor
NON- ICU STAFF
9 CRITICAL ILL PATIENTS
Fig. 2. Modified from the Ontario Health Plan for Critical Care During Pandemic
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8. 2- Nursing preceptor
To manage the limited numbers of well-qualified critical care nurses, we create a
new team called Nursing Preceptor Team, this team is highly qualified critical care
nurse with the following roles and responsibility:
a) Being as a role model for primary nurse by providing support and guidance at
any difficult times.
b) To enter with primary nurse to the patient bed side for supporting and
providing proper patient care.
c) To focus with the primary nurse about: ICU routine, time management,
patient assessment and documentations, preparing medication, patient care,
and proper patient endorsement to the physicians and to nurses for next shift.
d) To provide answers and correct any errors for primary nurse.
e) To report immediately any error to charge nurse in the area and
preceptor’s duty leader.
f) To attend in receiving endorsement for at least one patient based on
staff assessment and patient condition.
g) To update and communicate with duty leader to solve any issue.
3- ICU Nurses
We consider any staff who worked before in critical care areas (ICU, CCU, PICU,
NICU) is ICU nurse with following role and responsibility:
a) To take care and full responsibility for any adult critical patient
b) To handle 1 to 2 critical care patient
c) Observing and assessing patient symptoms and conditions
d) Recording patient medical histories, symptoms, and observations
3- Non-ICU Nurse:
Any staff is working in other hospital units with minimum 3 years’ clinical experi-
ence and Passed COVID-19 Critical Care Crash Course for Nurses with following
role and responsibility:
a) To take care and full responsibility for any adult critical patient under the
supervision of ICU preceptor
b) To handle 1 critical care patient
c) Observing and assessing patient symptoms and conditions under the
supervision of ICU preceptor
d) Recording patient medical histories, symptoms, and observations under
the supervision of ICU preceptor
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9. Training Needs for Non-ICU Nurses and non-
adult care nurses
In order to keep the patient on top of priority and to have a high quality of care
for all critically ill patients, the nursing office with cooperation of nursing education
department tried their best to put a clear plan for non-ICU nurses staff and special
training and competency as following:
1- COVID-19 Critical Care Crash Course for Nurses (online
course).
This program is a blended educational methodology including online learning
(open WHO platform and MoH webinars), and practical training to develop a
non-critical nurse’s skills to be ready to assist critical care nurses when need-
ed.
A- Part I: Open WHO “ Online Course “ With 2 module:
1− Module 1: COVID-19: Operational Planning Guidelines and COVID-
19 Partners Platform to support country preparedness and response.
2− Module 2: Clinical Care Severe Acute Respiratory Infection.
B- Part II: MoH Webinars
The MoH webinars delivered in two chapters through MoH platform
(https://moh.upskilling.sa/)
C- Part III: Clinical practice
It is conducted for 3 hrs. session twice a week by our ICU doctor in
QCH
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10. 2- Essential of Critical-Care Orientation program:
This program conducted by our nursing education department in order to
establish a knowledge base and skills with following topics:
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11. Continues evaluation and follow up for
staff improvement
To enhance the non-ICU staff performance and to be sure that we deliver high safe
of care for our critical ill patient we are doing continues evaluation method to evalu-
ate and to check the staff development in weekly/monthly basis .
Our Sources for non- ICU nurse evaluation:
1- Head nurse feedback
2- Charge nurse feedback
3- Preceptor staff feedback
4- Clinical instructor feedback
5- Knowledge related exam in monthly basis
6- Evaluation checklist have done for all non-ICU staff by the preceptor staff
with the following Evaluation Related Information
1- Administer blood and blood-products transfusions safely to patients in
ICU.
2- Administer Enteral and Parenteral nutrition.
3- Apply principles to nasogastric tube insertion and removal.
4- Assessment: intake and output.
5- Assist in central venous catheter (CVC) insertion and apply nursing care.
6- Assist in Endotracheal tube intubation and airway management.
7- Assist in Endotracheal tube extubation and tracheostomy tube decannula-
tion.
8- Assist with arterial lines insertion and apply nursing care.
9- Assist with chest tube (CT) insertion, monitoring, and nursing care.
Assist with external ventricular drain (EVD) monitoring, and related nursing
care.
10- Standards Infection Control Precautions for COVID 19 Pts:
a- Case Definition of confirmed COVID 10 /Signs and
Symptoms
b- State the method of scoreing/Isolation precautions/risk
exposure if of suspect COVID-19
c- Discuss the pathway for suspect COVID 19 patient
d- Discuss the airborne isolation for COVID 19 patient
e- Ensure Environment disinfecting/cleaning between and
after each patient
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12. f- Demonstrate correct Hand Hygiene technique
g- Demonstrate correct Respiratory etiquette techniques
h- Demonstration of Donning and Doffing of PPEs
i- Isolation precautions, types, requirements needed
j- Definition and notification of COVID-19
k- Management of suspected versus confirmed COVID-19
l- cases and use of the flow chart and form for screening.
m- Completed N95 mask fit testing
Date:_____________ Size:____________
n- Demonstrate collecting Nasopharyngeal swab and
sample collection
o- Waste Disposal and Housekeeping principles
p- Ensure proper cleaning of equipment between patients
q- Monitoring dietary and pharmacy interactions to reduce
contact with suspected and confirmed cases
r- Know your hospital protocol for watcher and family visit
for your unit/ward.
11- Calculate drug dosages for sedation and inotropic medication.
12- Care of patient on Mechanical Ventilator
13- Dealing with cardiac arrest.
14- Demonstrate the right nursing Care for pre and post-operative pa-
tients.
15- Demonstrate knowledge of health assessment skills.
16- Demonstrate Open and close suctioning.
17- Demonstrate Oral and nasal airway insertion.
18- Demonstrate the Oral care.
19- Demonstrate Transducer system setup and zeroing.
20- Identify how to deal with the High alert medication in critical care
area.
22- Identify the Bundle of care (VAP, CAUTI, and CLABSI) and How to ap-
ply it
23- Identify the indication of Defibrillator and pacer.
24- Identify the Oxygen therapy and oxygen delivery devices.
25- Identify the Restraint use and assessment.
26- Identify the signs of high ICP.
27- Know all ICU Forms and nursing related sheets and how to fill it .
28- Manage patients undergoing invasive hemodynamic monitoring.
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13. 29- Mechanical ventilation: volume and pressure modes, and weaning.
30- Monitor a cardiac ECG and familiar with alarm and monitor
31- Pain assessment and reassessment using the appropriate pain score.
32- Patient Fall: Risk assessment and prevention .
33- Pressure ulcer: Risk assessment and prevention.
34- Receiving and endorsement using the ISBAR .
35- Recognize the major classifications and types of medication used in criti-
cal care
36- Use the GCS and RASS in the clinical setting.
37- Wound assessment and Wound drain care.
referances:
1- Adams, L. M. (March 31, 2009) “Exploring the Concept of Surge Capacity”
OJIN: The Online Journal of Issues in Nursing; Vol. 14 No.2 .
2- Ontario Health Plan for an Influenza Pandemic Chapter 9: Primary Health
Care Services March, 2013
3- Coronavirus: principles for increasing the nursing workforce in response to
exceptional increased demand in adult critical care,25 March 2020 Version 1
4- Aziz S. et al. Managing ICU surge during the COVID-19 crisis: Rapid Guide-
lines. Intensive Care Medicine (2020)
5- Clinical guide for the management of surge during the coronavirus pandemic:
rapid learning 12 April 2020, Version 2
6-Goh, K.J., Wong, J., Tien, J. et al. Preparing your intensive care unit for the
COVID-19 pandemic: practical considerations and strategies. Crit Care 24, 215
(2020)
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14. The COVID-19 pandemic can place sus-
tained extraordinary demands on critical
care services. Critical care leaders must
take the lead to initiate surge planning
andrapidlyimplementmeasurestomain-
tain the healthcare services. It is equally
important to maintain critical care ser-
vices for non-COVID-19 patients, ensure
HCWs protection,and consider the ethi-
cal implications during a crisis.