Nurse Selection and Trainings

Because COVID-19 is a severe, highly infectious respiratory disease, each team needs 3-level protective suits to work as not only nursing but also house keeper in the red zone for at least 4 hours, and takes high risk of infection. Therefore, the nurses, on a volunteer basis, came from respiratory, emergency, cardiovascular, gastroenterology, neurology, and other specialized departments, and priority was given to those who had good physical and psychological health without related medical history and experience with epidemic infectious disease care, wearing and taking off protective clothing skillfully, and more than 2 years’ experience with respiratory intensive care. ^{Reference Smith, Ng and Ho Cheung Li3,Reference Zhang, Sun and Latour4} Among the 50 nursing staff of our group, 1 had experienced severe acute respiratory syndrome (SARS) in Xiaotangshan Hospital, 2 had experienced Ebola virus disease in Liberia, 14 had experienced an earthquake disaster medical rescue and medical exercise, 20 had experience with intensive care and ventilator use, and 3 had experienced extracorporeal membrane oxygenation (ECMO) nursing training. For example, as the chief nurse, the author encountered nursing experiences with SARS and Ebola infectious diseases. The group included 33 nurse practitioners, 16 nurses in charge, and 1 associate professor of nursing. The ratio of males to females was 13:37. The average age was 31.92 years (± 3.94 years) old.

The special trainings were as follows: COVID-19 prevention and treatment seminar, guidelines for the diagnosis and treatment of COVID-19, ventilator use, disinfection and isolation technology for COVID-19 and self-protection technology for medical staff, including the wearing and taking off of personal protective equipment (PPE). Seven key points of high-risk nursing procedures were practiced, such as nursing skills on noninvasive and invasive ventilator nursing, tracheotomy nursing, sputum aspiration nursing, atomization inhalation, nasopharyngeal swab sampling, vessel puncture techniques, endotracheal intubation, and fibrobronchoscope operation, and teaching, practice, and individual testing on wearing and taking off PPE (Table 1).

TABLE 1

Wearing and Taking Off PPE

The special PPE practices were to ensure proper covering of skin, air tightness of protective equipment, and no over tightening or intolerance. Hydrocolloid dressing, foam dressing, wound paste, etc. were used to prevent facial pressure injury caused by mask nose clip, goggles, and other protective equipment. Before donning PPE, baby diapers were worn and (or) energy and water were consumed according to personal preference to reduce the factors that may lead to intolerance. To ensure that everyone can wear and take off PPE properly, infection control monitoring was set up to supervise the process of nurses’ wearing and taking off PPE through video monitoring.

Conversion of Ward Layout

Because the Wuhan Taikang Tongji Hospital was a general hospital without an infectious disease department, the layout of the ward area was revised to meet the requirements of an infectious disease ward. The ward was divided into 3 areas: the contaminated zone (red zone), the relatively clean zone (green zone), and a buffer zone between the red and green zones. Two buffer rooms from green zone to red zone were unidirectionally locked. A password lock was set at the exit from the red zone to the green zone only for medical staff. The green zone could only be reached through 3 buffer rooms and 2 undressing rooms. All door joints were fitted with sealing strips to ensure air tightness. Because it was a nonnegative pressure isolation ward, exhaust fans were specially installed at both ends of the corridor in the ward. The mechanical exhaust fans continuously operated for 24 h/d to form negative-pressure ventilation. The ceiling of the ward and the working area was a movable cover plate, which was connected to the air. The ceiling was closed with plastic film to prevent air from the red zone flowing into the green zone. The whole ward was closed by management. Patient access only opened when patients entered and left the hospital or went out for examination, accompanied by medical staff. The camera monitoring system was installed in the ICU and the undressing room to monitor the condition and trend of critical patients and whether the process of PPE removal was compliant (Figure 1).

FIGURE 1

Revised Layout of the Department.

Nurses Position Setting

The nursing staff were divided into a nursing management group and a clinical nursing group. The members of the nursing management team were all chief nurses with management experience. They worked for 8 h/d but no more than 4 h in the red zone. The position setting of the nursing management group was as follows: infection control supervisor, for the supervision of the entire process of dressing and undressing as well as the supervision and inspection of the implementation of various infection control measures; equipment manager, for the requisition, sorting, and in/out registration of all equipment, consumables, protective articles, and materials; office nurse, for handling and checking the medical orders, entering the body temperature list, handling in and out of the hospital, oral medicine dispensing, and management of medicine in and out of warehouse; quality control nurse, for the nursing procedures, inspection of nursing documents, night rounds, and critical illness rescue (Table 2).

TABLE 2

Position Setting and Work Time

Each clinical nursing group included 6 members in a fixed arrangement, according to gender, specialty, seniority, work experience, critical respiratory disease nursing experience, etc. At least 2 persons in each group could operate the ventilator skillfully, and each group included 1-2 male nurses. The clinical nursing group entailed 4-h shifts in the red zone, so there were 6 groups covering 24 h/d. The posts of the clinical nursing group were set as follows: the team leader, who was responsible for the management and coordination of the whole shift group; the duty nurse, for management of the treatment, condition observation, health education, personal care, basic care, psychological care, accompanying nurse for inpatient transfer, and in and out of hospital transportation of patients, etc. The nurses with severe disease nursing experience were put in charge of critical patients. Each group had an infection control liaison person who was responsible for the implementation of infection control measures, and each group included a materials administrator who was responsible for the sorting, homing, registration, warning, and supplementary filling of materials (Table 2). Several special nursing teams were set up according to their specialty, including a team for treating wounds, thrombus, using the ventilator and providing airway care, providing diabetes care, and a team responsible for peripherally inserted central catheter (PICC).

The workflow for each position and each group was formulated according to the workload of each group. Full preparations were made in the green zone, and only doctor’s orders for immediate execution were performed in the red zone. In the green zone, the doctor’s order was processed; the doctor’s order form and execution of standing orders forms were printed; the oral medicine was checked; the injection medicine was prepared; the blood sampling inspection barcode was pasted, etc. In the red zone, only printing of the temporary execution form, delivery of oral medicine, injection, blood sampling, and other operations were performed. WeChat (a live social contact app) group was established for multiple mobile phones in the red and green zones, which was convenient for information transmission between red and green zones and connection process management and high efficiency operation between red and green zones.

Quality Control

The nursing team preliminarily established 8 items of responsibilities, 7 work systems, 6 nursing work processes, 6 infection control systems, 7 key points of high-risk nursing operations, and 7 emergency plans (Figure 2). Once problems arose in the ward, the chief nurse provided feedback in the WeChat group every day and held quality control meeting 1-2 times accordingly. Nurse meetings for all nurses, except those on duty, were held once a week regularly. Video or audio conferences were presented if the staff could not be present. The team leader in charge checked the nursing quality and documents every day, sorted out the documents by stages, preliminary drafted the documents at the peak stage of large-scale admission, and focused on the quality of critical disease care records at the stage of concentration of critical patients. During the stage of sorting out the discharged medical records, the doctors and nurses coordinated with each other one-on-one to sort out the medical records, strictly regulating the management of high-risk drugs, anesthetic drugs, first-aid drugs, and equipment in the ward to ensure quality and safety.

FIGURE 2

Quality Control Regulations.

Humanistic Care

It has been reported that 96.2% of COVID-19 patients have significant posttraumatic stress symptoms, and half of health-care workers (49.8%) considered psycho-educational services to be helpful. ^{Reference Bo, Li and Yang5} Feelings of isolation, fear of family infection, and fear of neurosis were the main factors leading to anxiety and depression. The nursing group advocated the concept of people-oriented nursing, which entailed establishing a sincere and kind caring relationship between nurses and patients for solving the practical problems of patients. A WeChat group for doctor-patient communications could be used to unblock the communication channels between patients and their families, reply to the questions of patients and their families in a timely manner within the group, appease patients’ emotions, and often let patients and their families make video calls to obtain family support. ^{Reference Bao, Sun and Meng6} Wish trees and cartoons for encouraging patients were arranged in the corridor of the ward to create a warm and positive atmosphere and help patients build up their confidence in disease recovery. Baduanjin mindfulness exercises psychology in traditional Chinese Medicine were integrated into the nursing of patients with COVID-19. Psychological experts provided group counselling online and individual counselling for patients with prominent psychological problems. Nurses who had received psychological training provided face-to-face counselling and reduced the anxiety, depression, insomnia, and other problems of patients.

Safety and Comfort of PPE

Donning and doffing of PPE was practiced and individually tested by infection control specialist beforehand (Table 1). Attention was paid to checking the air tightness of protective equipment and whether it covered all skin in addition to testing its comfort to avoid adverse reactions and intolerance caused by over-tightening. We used hydrocolloid dressing, foam dressing, and wound paste to prevent facial pressure injury caused by mask nose clip, goggles, and other protective equipment. Before putting on PPE, diapers were worn and/or energy and water were consumed on an individual basis to reduce factors that could increase intolerance. To ensure that everyone could wear and take off PPE without any problems, infection control monitoring was set up to supervise the process of nurses’ wearing and taking off PPE through video monitoring.

In the 3-level protection, nurses could encounter vomiting, fainting, needle stabbing, and other accidents in the red zone. An emergency plan was set up in advance. In the early stages, work time in the red zone was initially capped at 2-3 h so that the nursing staff could gradually adapt to it. In the case of headache, dizziness, or other discomfort, staff were encouraged to sit down immediately and rest as necessary. If these adjustments did not relieve the discomfort, 2 staff were to withdraw from the red zone at the same time. The red zone was set up with an emergency room, which was equipped with face screens, gloves, boot covers, alcohol, and other items in the case of an accident, such as exposure.