By: Bud Pate, REHS, Director of Content Learning – Clinical Compliance & High Reliability Practice
As I write this post at the end of 2020, beginning of 2021, we are at the height of the COVID 19 pandemic. Hospital beds in Southern California, my home base, are filled. Patients overflow into lobbies and tents. Healthcare professionals are stretched, being asked to do things they’ve never done before. Specialty physicians such as plastic surgeons and radiologists find themselves staffing overcrowded emergency departments. Caregivers are practicing with licenses from other states. Professionals who’ve been away from the bedside for years are becoming reacquainted with providing care. Nurses are responsible for more patients than they ever were in the past. Many are finding themselves in unfamiliar territory, and unfamiliar situations are uncomfortable.
In my role as a Greeley consultant, my team and I keep current with regulation, and we have ongoing interactions with regulators and accreditors to update and clarify our understanding. As such, some of our caregiver clients have been asking for insights to a few key questions resulting from working in unfamiliar and stressful circumstances during the pandemic.
As the name suggests, a surge standard of care is the level of care and services a hospital can provide during significant increases in patient volume, typically due to short-term or long-term “emergency” situations. A short-term surge may be caused by a multi-vehicle accident on the highway or the closure of a nearby facility. Longer-term surges can be stimulated by natural disasters such as earthquakes or hurricanes or, like our current situation, epidemic infectious diseases.
A useful paradigm was described in a 2009 article about refining surge capacity. The authors describe three possible standards of care that can apply to surges in patient census: conventional, contingency, and crisis standards of care.
- The Conventional (or normal) Standard of Care applies when surges can be accommodated with existing staffing, services, and space.
- Contingency plans such as boarding inpatients in the emergency department or the post-anesthesia care unit are often sufficient to accommodate moderate excesses in patient census.
- However, most of the nation currently finds itself in a situation where Conventional and Contingent Standards of Care are insufficient to meet the demand, necessitating a Crisis Standard of Care, which is what we will be addressing in the rest of this post. During a crisis, normal contingencies are overwhelmed, and the hospital must use unconventional spaces and expand the role of care givers.
- Non-hospital buildings are converted to hospital beds using temporary partitions.
- Nurses are asked to care for more patients than the pre-crisis maximum.
- Medical and nursing students may be called upon to shift roles from learner to doer (or even teacher).
- Care might even have to be rationed, denying some aspects of care to patients who are very likely to die so scarce resources can be available to patients with better chances to survive.
A crisis standard of care equates to “you’ve got to do what you’ve got to do.” Put another way, per a recently-published article by the Association of American Medical Colleges (AAMC), “[w]hen crisis conditions exist, the goal is to ‘gracefully degrade’ services to the minimum degree needed to meet the demands, maintaining the maximum patient and provider safety … crisis standards of care have the joint goals of extending the availability of key resources and minimizing the impact of shortages on clinical care.”
Ethics are a very personal paradigm. However, The National Academies of Science, Engineering, and Medicine recently published consultation related to ethical issues. As summarized by AAMC, “crisis standard of care must uphold the following core principles:
- Fairness (e.g., ensure consideration of vulnerable groups);
- Duty to care (aided by distinguishing triage decision-makers from direct care providers);
- Duty to steward resources (balances duty to community with duty to individual patient);
- Transparency in decision making (candor and clarity about available choices as well as acknowledgement of the painful consequences of resource limitation);
- Consistency (treating like groups alike through institution/system/region policies, with careful deliberation and documentation when local practices do not follow common guidance);
- Proportionality (burdens should be commensurate with need and appropriately limited in time and scale); and
- Accountability (maximizing situational awareness and incorporating evidence into decision-making).”
Regulatory and accrediting bodies have issued broad waivers of existing requirements during the pandemic. For example:
- Medicare (The Centers for Medicare and Medicaid Services or CMS) requires hospitals to notify the state agency whenever a surge or crisis standard of care is implemented. The agency allows individual hospitals to take advantage of “blanket” waivers published on the CMS web site. It also allows individual hospitals to request the waiver of other requirements during the pandemic during the public health emergency. For more information visit the CMS web site. You may hear such relaxations for CMS requirements referred to as “1135 wavers” since they are authorized under section 1135 of the Social Security Act.
- The Joint Commission also published a number of waivers that apply during the pandemic. These waivers track closely with the CMS waivers discussed above (.
- Most states have waived many hospital and health facility licensing requirements. For example, the California Governor waived many of state regulatory requirements during the pandemic. Nurse staffing ratios may only be relaxed, however, when the hospital obtains a hospital-specific waiver from the state.
- Professional licensing boards are providing temporary flexibility, especially with respect to reciprocity for practitioners licensed in other states. The steps taken by the California Board of Registered Nursing, for example, are listed here. Licensed and certified healthcare professionals should check directly with the licensing/certification authority in the state where they intend to practice.
“I’m a nurse and I’m being asked to do unfamiliar things (e.g. I’ve never used this piece of equipment; or I’ve never worked on this unit).”
“I am not a telemetry nurse, but I have a telemetry patient that is being monitored by a central telemetry system and staff. There are other trained telemetry nurses working with me on my unit, but I do not feel comfortable.”
The practice of registered nursing is very broad. In most states, the registered nurse scope of practice is somewhat self-defining, i.e., registered nurses are allowed to do what registered nurses do. So, nurses and other healthcare professionals who are acting in good faith to perform the care and services they are directed to perform have very little jeopardy with respect to license-related sanctions. However, a healthcare professional should not perform patient care or services for which they lack fundamental knowledge or skills. It is the caregiver’s duty to inform the healthcare team when they lack the knowledge or skill to safely perform a requested patient care duty. The healthcare team, in turn, has the duty to either educate/train the caregiver to safely perform the treatment or service or to arrange for an alternate, competent individual to provide the care or services required.
Our response to the next question below also addresses this concern.
No. Some states specify a minimum nurse-to-patient ratio for various hospital units. If the hospital exceeds the maximum number of patients per nurse, it can request a waiver from public health authorities. Increasing the number of patients per nurse is usually approved by the state if the hospital can demonstrate that it has no alternative other than leaving some patients completely without nursing care.
To protect themselves and their patients, nurses should pay attention to very basic considerations, such as:
- Voice concerns: If the nurse is falling behind and treatments are not being completed, the nurse should immediately notify the charge nurse or manager responsible for the unit and continue to do his/her best to provide the care and services required by the plan of care and treatment and the patient’s evolving condition.
- Raise questions: The standard of care adopted by your hospital during a crisis may allow individuals who would not normally be involved in clinical functions to participate in patient care as long as they are competent to do so. The nurse is typically responsible for coordinating and overseeing the care given by others. Make sure you understand the role you and others are being asked to play, especially if certain members of the healthcare team are asked to perform novel duties.
- Prioritize: When there is insufficient time to attend to all duties, the nurse should use his/her critical thinking skills to prioritize care and services. The physician or team overseeing the care of the patient should be promptly notified if any ordered medications or therapies are delayed or missed.
- Tell the patient story: Some hospitals cope with surges in patient census by streamlining nursing documentation. Regardless of the hospital’s approach to streamlining, the basic functions of the medical record should be sustained. These fundamental functions of the medical record are:
- To record the care and services provided to the patient;
- To capture the patient’s reaction to care and service;
- To track the patient’s condition and progress; and
- To communicate the patient’s condition and progress to the rest of the healthcare team.
Greeley typically finds that a streamlined medical record (fewer checkboxes and pull-down menus) is actually a better way for nurses to fulfill these imperatives. For example, ongoing assessments are often best documented in a brief narrative note rather than pages of “structured” data where all patients appear the same.
Don’t misunderstand. There are many elements of the medical record that require a high degree of granularity. Obvious examples include documentation related to medications and objective signs/symptoms. But we’ve found that eighty percent or more of the documentation nurses are asked to do is unnecessary and does not contribute to the care process. The best method of telling the patient’s story over time, their condition and progress, is a brief narrative note, which can substitute for hundreds of daily “clicks,” and, at the same time, do a much better job of tracking and communicating the patient’s condition.
- Be professional: Follow the nursing process: assess, plan, provide nursing care, repeat. And always do the right thing.
Human error has been an unfortunate side effect of modern healthcare, which seems to be growing in complexity every day. An important strategy for reducing medical error is the hospital’s adoption of a “Just Culture,” which emphasizes learning from mistakes instead of automatic discipline. Just Culture algorithms help hospital leaders distinguish between errors that are a result of the process of healthcare (most errors in our experience) and errors that result from negligence or malicious intent.
Caregivers that are concerned about their hospital’s approach to Just Culture should initiate and open discussion with leadership.
Although we cannot offer an opinion about potential liability or accountability, there are a few principles that should be observed.
Delegation of nursing duties to others on the healthcare team is often addressed by state nursing boards on their website, which should be the first place to check when seeking guidance about a specific situation. Nursing practice boards often limit the kind of task that may be assigned to these non-RN team members.
In general, before delegating a patient task to non-RN nursing personnel, the RN should be knowledgeable about the patient’s condition and delegate only those clinical duties that are within the competence of the individual non-RN team member assigned. The RN typically remains responsible for evaluating the patient progress and condition, but RNs often rely on data collected by non-RN team members (e.g. vital signs, blood glucose levels) in completing their nursing assessment.
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These are difficult times – particularly for those who have been personally affected by this pandemic, and those who are selflessly caring for the sick. We hope this discussion sheds light on some common questions as care providers cope with an extraordinary worldwide challenge.