Abstract
The purpose of this project is to explore the measures for the control and prevention of an infectious disease outbreak that can result in a pandemic. The focus is the hospital setting and the target is medical-surgical nurses. In the hospital setting, the spread of infection is extremely likely due to many contributing factors including exposure rate, patient load, and frequent contact with ill people. Nurses are at a high risk of contracting the disease and spreading it if appropriate infection control protocols are not followed strictly. This project examines the current outbreak of the COVID-19 virus also referred to as the Coronavirus.
COVID-19 is spreading rapidly, and the Centers for Disease Control and Prevention (CDC) have declared a state of emergency. Mainly, this project reinforces the infection control and prevention of spread measures that are suggested by the CDC. It also goes in-depth on the role of the nurses and how they can assist in disease containment by using such tools as a simple checklist to help educate and spread awareness.
Introduction
Highly infectious diseases such as the one that develops with the novel coronavirus, otherwise known as COVID-19, put additional pressure on the healthcare sphere. The risk of a pandemic increases the patient load of every hospital and clinic, and healthcare personnel (HCP) have to adapt to the new standards of care. At present, the pandemic of COVID-19 is the central problem that concerns the whole world. The urgent need for changes is clear – according to the latest findings, most hospitals and countrywide healthcare systems are not adequately prepared to handle the growing rate of new cases (World Health Organization [WHO], 2020). Thus, this project aims at looking at the existing evidence and investigating guidelines that are based on evidence and should be included in the intervention.
Problem Statement
The nursing staff is among the first responders that are affected by this outbreak. HCP does not know much about COVID-19, and many of its features and risks are underexplored. The current strategy is symptom treatment and control of spreading, which implies that nurses and other healthcare professionals are under great pressure to prevent the growth of cases. Nonetheless, the lack of awareness about proper crisis responses is evident when analyzing the speed of the infection in the United States and other countries. The focus on nurses’ actions, as a result, is essential to ensuring that the industry is prepared to meet the challenge of COVID-19.
Purpose
The purpose of this project is the development of an intervention for HCP and medical-surgical nursing staff, in particular, that would help them respond to the pandemic and cap the number of cases in the US. Therefore, it is necessary to consider how nurses should prepare to control the spread of the disease, including measures for prevention and containment. For this purpose, one has to research the latest information about the infection and explore the nursing responses to previous outbreaks similar to the novel coronavirus. Furthermore, the contemporary guidelines from the Centers for Disease Control and Prevention (CDC) need to be reviewed to see which of them have to be included in the plan for the hospital and unit under investigation.
The Nature of the Project
The project has an investigative purpose – thus, its design is based on the review of the literature and the synthesis of knowledge. Several research papers are considered to see how this particular outbreak is characterized, including the features of the disease, its spread patterns, and potential treatments. Next. Scholarly resources appraising the effectiveness of responses to previous epidemics as well as COVID-19 are analyzed to reveal the possible pitfall in nurses’ behavior and actions. Finally, the CDC guidelines are taken as the basis for the intervention, making the final product of this project a plan that can be used by nurses to respond to the novel coronavirus disease’s spread.
Background
To determine what steps are the most important for the intervention, one has to understand what is currently known about the virus and the disease it causes. Furthermore, it is vital to assess its progression in the world, previous responses to similar outbreaks, and the current state of the selected hospital. The first cases of pneumonia of unknown origin were identified in December 2019 in Wuhan, China (Chen, Tian, Li, & Li, 2020).
The researchers identified that the disease was caused by a new enveloped RNA beta coronavirus that bared resemblance to other coronaviruses. This version is named SARS-CoV-2, or “severe acute respiratory syndrome coronavirus 2,” and it leads to the development of the coronavirus disease 2019 (COVID-19) (Guan et al., 2020, p. 1). It is believed that the virus has a zoonotic origin, having spread from bats to humans.
Other types of coronavirus infections generally present with mild symptoms, although there have been several instances where the number of cases reached the level of an epidemic. For example, both Middle East respiratory syndrome-related coronavirus (MERS-CoV) and SARS-CoV could be considered as major outbreaks of a similar nature (Alfahan, Alhabib, Abdulmajeed, Rahman, & Bamuhair, 2016).
Nonetheless, the present virus seems to have an even stronger impact on the world population, as the number of infected people grows every day. Currently, there are more than 120 thousand cases in the US alone, and the global numbers are much higher (WHO, 2020). This amount is notable as the infection was identified in December of the last year in China, thus showing that the disease spread significantly in less than four months. Another important fact is that the majority of reported cases started appearing at the beginning of March – the first case quickly grew into a large number of new infections.
This acceleration in the speed of the virus spreading is indicative of its highly infectious nature. According to the latest findings, SARS-CoV-2 is most commonly transmitted during person-to-person contact when infected individuals sneeze or cough. Respiratory droplets that are produced during these actions travel from one person to another, being inhaled into the lungs or landing on one’s eyes, mouth, or nose (Huang et al., 2020). The current investigation does not confirm that the virus can travel long distances while airborne, and some concerns are raised over SARS-CoV-2 being transmitted through fecal matter (Huang et al., 2020). Nevertheless, the fact that SARS-CoV-2 easily spreads through close contact is enough to make the disease extremely contagious.
Another problem is that SARS-CoV-2 does not cause one to develop symptoms immediately. A person may not know that they have the virus while spreading it further (Millar, 2020). The incubation period may last anywhere between two to seven days, during which the infected individual is as contagious as when they have symptoms. COVID-19 is a respiratory disease, but the first signs may differ from one person to another. For example, the most common symptom is fever, but it is present in less than half of all cases during the first days of the infection (Guan et al., 2020). Cough is another usual sign, with almost 70% of all people having it (Guan et al., 2020).
Other characteristic symptoms are dyspnea, chest pain, diarrhea, fatigue, and myalgia, but their presence without cough and fever does not signify the presence of the virus (Guan et al., 2020). The description of the coronavirus disease does not define it as an easily identifiable condition. In contrast, COVID-19 resembles a variety of respiratory infections, which could have contributed to its rapid uncontrolled spread.
Furthermore, it is vital to note that the disease affects certain populations in different ways. Older adults and people with underlying health problems are at increased risk of suffering from a severe case of COVID-19. In particular, lung problems and asthma, heath disease, diabetes, renal or liver failure, and compromised immune system are among the factors that put people at the highest risk of difficult recovery (Chen et al., 2020). Moreover, pregnant persons and people who cannot access high-quality care are exposed to additional dangers. Therefore, a response to this outbreak should consider the effect of the infection on different communities.
The comparison of SARS-CoV-2 with previous infections caused by other types of coronavirus (MERS-CoV and SARS-CoV) reveals that the current pandemic is even more impactful. According to Patel, Bell, and De Perio (2020), both of the older infections caused more than 10 thousand cases in the span of two decades. To compare, SARS-CoV-2’s rates have surpassed 100,000 cases in one country (the US) in less than four months (WHO, 2020). This great difference between the epidemics demonstrates the danger of SARS-CoV-2, although its mortality rate is much lower than that of previous coronaviruses.
COVID-19 is possible to diagnose using laboratory testing or imaging. According to the CDC, Real-Time Reverse Transcriptase (RT)-PCR Diagnostic Panels are the main tests that can be performed to confirm the presence of the virus. These diagnostics usually take up about four to six hours to show results. Analyzing radiologic findings, ground-glass opacity seems to be the most indicative of the infection, and no other abnormalities are as conclusive (Guan et al., 2020). However, not all people are currently tested to lower the burden on the hospitals and to encourage self-isolation to control the number of new cases. Therefore, most clinicians are encouraged to disseminate self-checkers that list major symptoms for individuals to seek appropriate treatment after they have concluded whether they have COVID-19.
This decision to prioritize self-testing is one of the measures included in the CDC’s interim infection prevention and control recommendations. Overall, the organization acknowledges the highly contagious nature of the virus and the current shortage of personnel, protective equipment, and testing capabilities in the US. Thus, its guidelines are based on these factors, and they focus on the restrictions that HCP have to establish to limit the spread of the disease. Notably, the center of the advice provided by the CDC is the shortage of personal protective equipment (PPE). PPE includes such items as masks, respirators, goggles, gowns, and gloves. It is stated that.
At the present moment, the US and other countries have shortages of such equipment, as reported by local distributors (Centers for Disease Control and Prevention [CDC], 2020). While this level of protective measures is the least effective, this problem signifies a larger issue of health care professionals and the system being unprepared for the crisis. Therefore, the background of this investigation shows that nurses have to take additional steps to protect patients and themselves from contracting and spreading the virus.
Finally, it is essential to show why the chosen hospital needs this project. As can be seen from the previous paragraphs, medical establishments in the country are largely unprepared for the crisis. Apart from the lack of necessary protection, the rapid spread of the disease implies that the hospitals and government organizations did not succeed at detecting and containing the virus on its initial entrance to the country.
As a result, the medical sphere is overwhelmed with the continuously growing number of cases, and crisis measures now impact all hospital departments, including the chosen medical-surgical unit. Thus, nurses in this unit, who usually deal with pre-and post-operative patients, now have to focus their time and attention on COVID-19 cases and the protection of existing patients. This response is the reason why a consistent crisis plan and additional knowledge are vital and why this project was developed.
PICO Question and Lewin’s Change Theory
Based on the background of the problem and the purpose of this research, one can determine that the PICOT question has to consider a nursing intervention in the unit to control the infection’s spread. According to Lewin’s Change Model, there exist three major steps in which any new initiative is implemented – Unfreeze, Change, Refreeze (Hussain et al., 2018). The first activity is to motivate people and prepare them to embrace the new process.
A change agent has to analyze the problem and create a plan as well as show others why change is necessary and beneficial. Next, all involved entities enter a transition state, during which they overcome barriers and implement new processes. Finally, during the refreezing stage, people get accustomed to the new routine. Based on this theory, one may propose the following PICO question. “In medical-surgical nurses, is the implementation of a crisis plan with awareness materials, compared to no crisis strategy, more effective for preparing them to deal with the COVID-19 outbreak?” While the time frame is not explicitly discussed, the progression of COVID-19 suggests a quick project to be implemented in the next month.
Summary
The issue under investigation deals with the presently evolving COVID-19 crisis that was caused by a coronavirus SARS-CoV-2. This virus was identified in December 2019, and, in less than four months, it has penetrated most countries in the world, leading to hundreds of thousands of infected people. While the initial symptoms of the novel coronavirus disease are similar to most respiratory conditions, the virus is highly contagious and dangerous to the elderly, immunocompromised individuals, and persons with underlying health concerns.
Currently, not much is known about the treatment or vaccination for COVID-19, and most clinicians are only able to address symptom relief. Thus, the combination of the virus’ speed of spread, its risks, and the lack of a cure, outbreak containment is the primary choice of action. Healthcare professionals are at the center of disseminating this knowledge and controlling the pandemic – thus, an advanced change plan is necessary to raise awareness among nurses and ensure their preparedness.
Literature Review
Introduction
The sources used above provide an overview of the virus and the disease, as well as some details about how it is being handled by the CDC in the US. However, one also has to consider how such outbreaks were controlled previously as well as review the current guidelines with a focus on medical care. Therefore, the literature for this project was chosen on the basis of these research questions. The literature matrix provided below contains scholarly sources that discuss the previous experiences of HCP in regards to such epidemics as MERS-CoV and SARS-CoV. Moreover, it shows how COVID-19 was handled in China during the first weeks, and what steps nurses consider necessary to be included in the intervention.
Literature Matrix
Historical Overview
Several studies were chosen to showcase how the previous outbreaks of coronaviruses were handled and what knowledge nurses can use for this intervention. Interestingly, one can observe the same issues during the epidemics of MERS-CoV and SARS-CoV that nurses encounter now – the lack of information about hand hygiene, absent training for crisis situations, and unclear optimal control measures for the infection’s spread.
For instance, Wiboonchutikul et al. (2016) investigate the MERS-CoV infection that was first reported in 2012. They describe the disease as transmitted during contact and droplets released during one’s coughing or sneezing (Wiboonchutikul et al., 2016). Moreover, the symptoms are close to those of the novel coronavirus disease. The authors consider how HCP who come into contact with infected patients control the spread by using protective measures. Their guidelines suggest that full compliance with the hand hygiene routine, as well as proper techniques for wearing protective equipment, are crucial. Thus, these two elements can be considered as the basis for protecting both HCP and patients from increasing the number of cases.
A similar historical finding is presented by Al-Dorzi et al. (2016), who examine another hospital’s response to MERS-CoV. Nonetheless, it appears that, along with hand hygiene and PPE, there exists a need to control patients’ interactions with visitors, the location of their hospitalization, and the nurse-to-patient ratio. Here, one can see that, although protective measures are important for keeping the rates of new infections down, they cannot fully shield nurses from outside influences and high workload.
It is also vital to consider how nurses are educated about these measures and whether the hospital has any problems with staffing or organizational environment that may disrupt the adherence to guidelines. The research by Alfahan et al. (2016) is especially notable as it examines which factors negatively or positively impact HCP’s adherence to hand hygiene standards. The hospital’s nurses have to address a variety of aspects, including the environment, social interactions, fear of punishment, and individual beliefs.
Overall, the guidelines seem to focus on the lower levels of protection that are directly related to nurses’ protective wear and their ability to separate infected patients from other individuals (uninfected patients and visitors). Nevertheless, while hospitals under study were able to deal with the outbreak with a small number of cases, the necessary nurse-to-patient ratio to achieve such success is nearly impossible for other organizations. Another important detail is that the previous crises were not regarded as a precaution to fix the issue with PPE supplies – a problem that is at the center of the contemporary guidelines.
Current Findings
The chosen literature about COVID-19 describes its features as well as the crisis response that should be implemented by all healthcare organizations in the US. As shown in the Background section of the project, COVID-19 is similar to the previous coronaviruses, but the inconsistency of symptoms creates a need for a stricter response. For example, a large portion of all infected persons do not show symptoms immediately, and fever is not the first sign of the disease (Guan et al., 2020). Therefore, the crisis response should be based on the presumption that all individuals that enter the facility are already infected. This measure is vital to control the spread of the virus further.
This approach can also be described as proactive planning – the anticipation of the worst-case scenarios by medical professionals. Crisis Standards of Care (CSC) are a response to major epidemics, and they are based on the limits of HCP’s abilities (Hick, Hanfling, Wynia, & Pavia, 2020). This means that the emergency plan devised for each unit has to be adjusted for its staffing, capacity, and equipment. However, such basic principles as fairness, transparency, consistency, and duty to care have to be the foundation for each choice (Hick et al., 2020). Hick et al. (2020) propose six main steps – prepare, conserve, substitute, adapt, re-use, and re-allocate. This strategy seems to be in line with the current instructions provided by the CDC.
The CDC recommendations encourage hospitals to focus on resource conservation due to the shortages and the limited capacity of the healthcare system. This decision is viewed by nurses as a lack of support for the HCP in times of crisis. According to Mason and Friese (2020), such a lack of success in establishing local sources of PPE is a failure to prepare for unpreventable emergencies. Nonetheless, nurses have to advocate for adequate resources while also adhering to conservation practices. Millar (2020) suggests that nurses should prevent the intrahospital spread, protect patients and themselves, reassure patients, quarantine infected persons, adhere to proper hand hygiene, limit visitations, and support HCP through material and psychological measures.
Conclusion
The analyzed literature suggests a crisis plan that is based on the CDC guidelines, but that is also updated to fit the unique capacity of the selected unit. Conservation, focus on the infected, and hygiene seems to be the main aspects of the plan, which shows the importance of the current project in preparing medical-surgical nurses for the crisis. The evidence from previous outbreaks shows that low adherence is detrimental to the success of controlling the virus. Furthermore, it also demonstrates a lack of preparation on the organizational and governmental levels, which calls for strict measures to be implemented.
Summary
The response of the HCP to previous epidemics was based on proper hand hygiene, PPE, staff reallocation, and visitation control. COVID-19 is more challenging to diagnose than the previously detected coronaviruses. At the same time, it is highly contagious; thus, HCP are urged to focus on preventive measures, assuming that all incoming patients are infected. Current guidelines are developed with such issues as PPE shortage and the limited hospital capacity in mind. Nurses have to protect themselves and patients while also conserving resources.
Intervention
The research explored above outlines the main steps that nurses and other HCP have to take to control the outbreak. It should be noted that the majority of the patients report to the emergency department, while the intensive care unit (ICU) seems to be the most equipped to handle the infected persons. Nevertheless, the capacity of these units has its limits, and the size of the crisis would likely affect all parts of the hospital. Therefore, medical-surgical nurses must prepare to accommodate patients with COVID-19. At the same time, it is clear that the unit’s patients have to be protected from the infection.
The first part of the intervention deals with training for proper hand hygiene and PPE donning and doffing. Although all HCP need to follow these guidelines daily, the outbreak requires additional precautions – frequent handwashing and the use of alcohol-based hand rub have to be enforced (Patel et al., 2020). Respirator and facemask use guidelines need to be updated to fit in with the current shortage of PPE supplies. In essence, these resources have to be allocated to HCP that interact with infected patients or perform procedures requiring direct contact.
Second, the unit needs to cancel all elective procedures and reschedule as many visits as possible. The patients that have to come to the hospital have to be assessed for COVID-19 symptoms, using a checklist provided by the CDC. Before visitations, nurses have to determine which rooms or parts of the unit can be used to separate infected individuals from other patients. Negative pressure rooms seem to be the preferred placement for patients with COVID-19 to control the flow of air (CDC, 2020). Isolation is necessary to limit patients’ exposure to the virus.
Additional education may be necessary for some nurses who do not possess the skills to deal with the infection. As the workload of the unit is likely to increase and shift toward COVID-19 patients, nurses have to know how to treat the infection and what procedures are performed. To achieve this, a combination of posters, pamphlets, and task-specific training has to be implemented. While all staff members have to receive refresher training, they may not respond to completely new information (Millar, 2020).
Thus, nurses have to learn only those activities that do not require extensive learning. Nurses with the most experience and specialized knowledge necessary for the surgical unit may be appointed to look after non-COVID-19 patients. Moreover, cleaning, bathing, and other regular, but unspecific tasks can be delegated to other HCP or appointed caretakers.
Information channels for the unit and other parts of the hospital have to be established to quickly report the presence of symptoms or any news related to the infection inside the facility. Reporting to public health authorities is important as well, as communication is the key to controlling the outbreak (CDC, 2020). Before transferring any patient to another department, appropriate HCP have to be made aware. Additionally, all nurses have to know who they have to contact in case they develop symptoms.
Nurses working in a crisis are under significant stress, and they often cannot seek help or deal with burnout. Thus, another part of the intervention deals with mental support – nurses can allocate a short period daily to meet and discuss existing problems, obstacles, and solutions (Millar, 2020). A conversation not focused on specific tasks is vital to relieving stress without taking away much of the nurses’ time. Nurses should be reminded that they are not alone in this crisis and that their work is appreciated by the community. Colleagues can assist each other through conversation and psychological support.
Finally, the unit can create a standardized list of the procedures and protection measures. Each nurse has to perform them before, during, and after a patient visit to assist HCP in adhering to the recommendations. This list should include hand hygiene, PPE, cough etiquette, symptoms and questions for patients, precautions and patient transportation routes, and equipment sanitization. This checklist is a measure that includes all previous steps and presents them in a simple way for nurses to refer to when they are unsure of their actions.
Conclusion
The present crisis is unfolding quickly, and all HCP are under great pressure to contain the virus and treat the infection. The overloaded healthcare system requires medical staff to deal with COVID-19 patients, even if they usually work in other departments. The previous crises did not affect the preparedness of the organizations for SARS-CoV-2, and, as a result, the US suffers from resource shortages and a growing number of cases. Therefore, nurses must educate themselves and adopt crisis standards of care. The proposed intervention covers training, resource conservation, proper hand hygiene, and support networks for nurses, offering guidelines and checklists for high adherence.
References
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