As of April 9, Vanderbilt University Adult Hospital (VUAH) had admitted 79 patients with COVID-19, 55 of those admitted had subsequently been discharged, and three patients had died. Vanderbilt Wilson County Hospital had admitted 10 patients with COVID-19, none had died, and one of those admitted had subsequently been discharged.
On March 20, to accommodate COVID-19 admissions, a COVID-only unit opened in VUAH, on MCE8, a 37-bed unit located on the eighth floor of the north tower of Medical Center East. The unit normally serves cardiac and medicine patients, now accommodated elsewhere in VUAH.
In short order, MCE8 was emptied of its usual patients and volunteer ICU nurses from elsewhere in VUAH arrived to cover the unit’s new intensive care beds.
“MCE8 was the obvious choice for a first COVID unit, given its flexibility to support clinical care across the acuity spectrum, from relatively stable to critically ill patients,” said Shubhada Jagasia, MD, MMHC, chief of staff, Adult Hospital and Clinics.
MCE8 patient rooms have built-in features such as dual ports for fluids suctioning and delivery of medical gases, allowing the unit to accommodate intensive care beds as needed. As of April 2, the unit had 27 standard floor beds, complemented by 10 newly installed intensive care beds.
In addition to taking new admissions, MCE8 is receiving patients transferred from elsewhere in VUAH as their lab tests prove positive for COVID-19. Currently the only COVID-19 inpatients at VUAH who are not on MCE8 are critically ill patients admitted prior to testing positive for COVID-19 or prior to the conversion of MCE8 to COVID care.
Within VUMC’s electronic medical record system, eStar, Health IT has configured a new type of hospital unit with specially delineated roles and workflows to support the care of COVID-19 patients.
“Consolidating COVID patients on designated units will yield benefits for patients, clinical teams and the institution as a whole,” Jagasia said.
“The geographic collocation will facilitate communication amongst the various teams, which in turn translates into a rapid iterative learning environment to optimize clinical care.”
The move benefits hospital infection control and allows VUMC to make the most of its stores of personal protective equipment, or PPE.
“In the relatively short interval since starting widespread testing in patients potentially infected and then separately cohorting the potentials and positives, we have not had many patients pop up with unsuspected COVID infection throughout the rest of the house,” said Warren Sandberg, MD, PhD, chief of staff, VUAH Perioperative And Critical Care Services.
Biostatisticians at VUMC are exploring predictive models for the timing and amplitude of an expected surge in COVID admissions.
“We have a lot of planning going on in the background to ensure that we have adequate surge capacity in terms of beds and clinical staffing and supplies, as well as adequate training for teams new to COVID-19 care,” said Shon Dwyer, MBA, RN, who joined Vanderbilt early last month as president of VUAH.
- As MCE8 converts entirely to intensive care, lower-acuity COVID patients will be admitted to MCE7, a new floor with 36 beds, currently empty and ready to receive patients. Should MCE7 become full, lower-acuity COVID patients would be admitted to MCE6, which has 37 beds (the transplant patients served there will be accommodated elsewhere). Should MCE6 fill up, lower-acuity COVID patients will be accommodated on 8 North and 8 South (27 and 22 beds, respectively).
- As MCE8 fills with intensive care patients, any additional critical COVID-19 patients will be accommodated in the Critical Care Tower, first in the 35-bed medical intensive care unit, and, if that unit should fill up, next in the 35-bed surgical intensive care unit. (This inpatient strategy echoes VUMC’s tiered strategy for managing patients isolated at home with COVID-19.)
Passion and selflessness
On MCE8, pulmonary and critical care specialists are following critical patients with COVID-19, and hospitalists are following lower-acuity patients.
“I would like to express gratitude to the hospital medicine and ICU teams who have risen to the occasion and are providing excellent care to our patients,” Jagasia said.
“Our team has focused on not only solving problems but also anticipating them and creating innovative solutions. The passion, selflessness and seamless cross-disciplinary collaboration of the team has been critical.”
Many of the ICU nurses who have volunteered to manage critical patients on MCE8 are members of the Communicable Disease Response Unit (CDRU), a cadre of specially trained nurses that was formed in 2014 in response to the Ebola outbreak in West Africa. They’re well practiced in, among other things, proper ways of donning and doffing the personal protective equipment, or PPE, used in the care of highly contagious patients.
“Our regular staff nurses are also becoming experts in the use of PPE, for sure,” said Kim Hurt, MSN, RN, manager of MCE8. Nursing Education and Professional Development staff have been on hand to observe and coach MCE8’s staff nurses.
“I will say that the staff has remained very positive. There was initially some anxiety as nurses arrived for their first shift (with COVID patients), but they’ve supported each other and they’ve done remarkably well. They’ve taken it in stride and excelled.”
Uncertainty nonetheless hovers around the care of COVID patients.
“What adds difficulty is not knowing the disease trajectory,” said Kim Carter, MSN, RN, manager of MCE6 and the CDRU. “What we have learned is that we need to remain prepared to act very quickly, because there’s no telling when these patients might decompensate and suddenly need more support. We have the right tools in place and we’re ready to respond, but not knowing the trajectory is a challenge.”
Another challenge is not knowing when the wave of admissions is going to come.
“No matter when that surge hits, due to the thousands of hours dedicated to this effort by those in the command center and others across our organization, not to mention our supporters throughout the region, VUMC will be well positioned to provide the best care to patients and ensure the safety of staff, clinicians and the community,” said Robin Steaban, MSN, RN, chief nursing officer for VUAH.