key: cord-0913659-p96vjopp
authors: Yang, Bo; Gao, Yang; Kang, Kai; Li, Jing; Wang, Lei; Wang, Hui; Bi, Ying; Dai, Qing-Qing; Zhao, Ming-Yan; Yu, Kai-Jiang
title: Holistic care model of time-sharing management for severe and critical COVID-19 patients
date: 2020-11-26
journal: World J Clin Cases
DOI: 10.12998/wjcc.v8.i22.5513
sha: 3003b71e59bc82a11eb21d1cccd98207fc5c9410
doc_id: 913659
cord_uid: p96vjopp

The rapid global outbreak of coronavirus disease 2019 (COVID-19) and the surge of infected patients have led to the verge of exhaustion of critical care medicine resources worldwide, especially with regard to critical care staff. A holistic care model on time-sharing management for severe and critical COVID-19 patients is proposed, which includes formulation of individualized care objectives and plans, identification of care tasks in each shift and making detailed checklist, and management of quality of care. This study was conducted in the COVID-19 treatment center of Harbin, Heilongjiang Province. The data collected from the treatment center were recorded and analyzed. From the results we can deduce that it is especially suitable for non-intensive care unit (non-ICU) nurses to adapt care management mode of ICU as soon as possible and ensure the quality and efficiency of care during the epidemic. The holistic care model on time-sharing management for severe and critical cases with COVID-19 proposed based on our daily work experiences can assist in improving the quality and efficiency of care, thus reducing the mortality rate of patients in ICU.

open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and it mainly spread by human-to-human transmission through close contacts via droplets, aerosols, and contaminated hands or surfaces [1] [2] [3] [4] . It presents varied clinical manifestations, ranging from asymptomatic carriers to pneumonia, acute respiratory distress syndrome, septic shock, coagulation dysfunction, and even multiple organ dysfunction syndrome [5] [6] [7] . Till date, there has been no effective vaccine or targeted intervention for SARS-CoV-2 infection, but only a supportive therapy [8] [9] [10] . Approximately 15%-20% of patients with SARS-CoV-2 infection develop into severe and critical disease [11, 12] , and so a series of advanced medical technologies and measures, including high-flow nasal cannula, non-invasive mechanical ventilation, invasive mechanical ventilation, prone position ventilation, blood purification, critical care ultrasonography, intra-aortic balloon pump, hemodynamic monitoring, extracorporeal membrane oxygenation, and multidisciplinary cooperation, are required. With the swarming of COVID-19 patients, the shortage of critical care staff has become much more apparent [13] , especially experienced critical care personnel. In our COVID-19 treatment center of Harbin, the ratio of nurses to patients is 1:2 for severe COVID-19 patients, while it is 1:1 for critical cases. The shortage of critical care nurses has been an urgent issue since the outbreak, and this is supported by the fact that the proportion of nurses in the national medical teams supporting Hubei Province has exceeded 60%.

In addition, the three-grade prevention measures are quite indispensable for critical care staff to fight against COVID-19 and avoid infection due to high transmissibility of SARS-CoV-2 [14] [15] [16] . Prolonged care and treatment for severe and critical patients with higher viral shedding represents a substantially higher exposure risk for critical care staff [17] . The physical and psychological health of critical care staff is considered to be the utmost for heavy and cumbersome three-grade preventive measures [17, 18] , seriously limiting the working hours and further exacerbating the shortage of the personnel. It is necessary to pay more attention to the mental health of critical care staff under such enormous pressure, and this is because serious conditions can induce different degrees of mental health and sleep problems, affect quality and efficiency of work, and also have a long-term effect on their own health [19] [20] [21] . In our COVID-19 treatment center, critical care nurses are shifted and handed-over to other nurses after every 4 h, and this is in line with other treatment centers around the country, and is only one-third of the normal daily working hours. Therefore, a large number of non-ICU nurses play the role of professional ICU nurses after short-term specialized training. How to make these non-ICU nurses more familiar with the care mode of ICU as soon as possible and ensure the quality and efficiency of care for severe and critical cases is a practical problem that urgently needs to be resolved.

To better address this issue, a holistic care model of time-sharing management for severe and critical COVID-19 patients is proposed based on our daily work experiences in this article, which assists in improving the quality and efficiency of care and thus reducing the mortality rate of patients in ICU. November 26, 2020

Volume 8 Issue 22

In our COVID-19 treatment center, only severe and critical cases are admitted, and the total case number is 61. A total of 225 nurses from eight hospitals in Heilongjiang Province work in the first-line of clinical care, including 137 professional ICU nurses and 88 non-ICU nurses. According to the comorbidities and severity of COVID-19, individualized care objectives and plans have been developed, and hierarchical management is carried out (Table 1) , which in turn facilitates more reasonable utilization of severely inadequate critical care resources. Heart rate, respiratory rate, blood pressure, and mean oxygen saturation as routine vital signs are obtained from both severe and critical COVID-19 patients in real time. It is a very intuitive approach to represent COVID-19 patients based on different disease severities by hanging different color signs on eye-catching location. Comorbidities of each patient and optimal target values for management are written on the prompting board beside the bed, so that critical care nurses can quickly understand the condition and master the key of care as well as action.

The daily care plan is divided into six shifts on average, and the care tasks are identified in each shift. An absolute average is practically impossible. The workload of night shift is usually less than that of day shift due to well-known reasons. A detailed checklist is made for each shift to implement, avoid negligence of care, and facilitate frequent shift handover ( Table 2 and 3). Through these detailed checklists, both professional ICU nurses and non-ICU nurses can understand the work content of each shift as soon as possible and complete the care tasks within the timeframe.

There is never a lack of good care model in clinical practice, but how to implement them strictly remains a big challenge. Based on our experience, there are three methods to provide supervision for the quality of care in severe and critical COVID-19 patients. First, critical care nurses who finished the care tasks of the previous shift have to face supervision of the succeeding ones. Second, each group of critical care nurses has a care team leader, who will be in charge of checking as well as completing the checklist. Care team leaders are usually experienced senior ICU nurses who distribute and coordinate the care work for each group to ensure smooth implementation of pre-defined care plan within 4 h. Lastly, the on-duty nurses who are in charge of ward care management are responsible for formulating individualized care objectives and plans, guaranteeing smooth completion of 24-h care plan, evaluating care effect, and timely giving of feedback to adjust care objectives and plans. Multifaceted supervision and management enable implementation of the holistic care model of time-sharing management successfully without becoming a dead letter.

The rapid spread of COVID-19 has given rise to a huge threat to the health-care system worldwide. Presently, epidemic prevention and control in China have been on the verge of victory, but in some other countries the situation is much worse. Our holistic care model of time-sharing management for severe and critical COVID-19 patients is of great practical significance for them. It is especially suitable for non-ICU nurses to adapt the care management mode of ICU as soon as possible and ensure the quality and efficiency of care during the epidemic, which may be an important cornerstone to overcome the epidemic. 

Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges

China Critical Care Clinical Trials Group (CCCCTG)

Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

Staffing With Disease-Based Epidemiologic Indices May Reduce Shortage of Intensive Care Unit Staff During the COVID-19 Pandemic

Stability and infectivity of coronaviruses in inanimate environments

High Contagiousness and Rapid Spread of Severe Acute Respiratory Syndrome Coronavirus 2

SARS-CoV-2: A comprehensive review from pathogenicity of the virus to clinical consequences

Correction to: COVID-19: a novel coronavirus and a novel challenge for critical care

Mental health care for medical staff in China during the COVID-19 outbreak

The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus

The Effects of Social Support on Sleep Quality of Medical Staff Treating Patients with Coronavirus Disease

Emergency Responses to Covid-19 Outbreak: Experiences and Lessons from a General Hospital in Nanjing, China

We are grateful to all colleagues who worked with us in our COVID-19 treatment center in Harbin, and all those who provided selfless advice and help for this article. We pay tribute to the medical staff that lost their lives in the national fighting against epidemic.