Medical assistance infighting against COVlD‑19 in Wuhan, China: A frontline nurse’s experience and lessons learned

Qian‑Qian LI, Feng‑Li GAO

Division of Nursing, Beijing Chao‑Yang Hospital, Capital Medical University, Beijing, China

ABSTRACT

This article shared personal experiences of encountering challenges during the work at the frontlinefighting against COVID‑19 in Wuhan, China, and found solutions and suggestions to overcome the challenges during the period,including solutions to address challenges encountered during work, suggestions for smooth communication among different parties, and suggestions for optimizing work regulations and workflow and establishing behavior habits and professional knowledge and practices. These experiences would be helpful for health‑care workers tofight against the pandemic.

Keywords: COVID‑19, experiences, health‑care worker, infection control, medical assistance

INTRODUCTION

The COVID-19 situation in Wuhan was very severe in January and February 2020, and so far, a total of 346 medical assistance teams, consisting of 42,600 health-care workers (HCWs) from other parts of China, have been sent to support the Hubei province, including Wuhan. Among those, 19,000 HCWs were specialized in intensive care.[1]None of them were reported to have COVID-19 due to the extremely careful strategies taken, such as having personal protective equipment (PPE) use team, treating each team member as a case pending for results, and establishing an infectious disease supervision team.[2]This article shares my personal experience and lessons learned during the period fighting against COVID-19 in Wuhan from January 28, 2020,to March 30, 2020.

While I was on duty in a 3A-level hospital in Beijing on January 27, 2020, I was suddenly informed by my hospital that I would join the Beijing medical assistance team to support a 3A-level hospital in Wuhan to fight against COVID-19. A few hours later, I was on the way to Wuhan without much preparation.Fortunately, our hospital provided 3-h specific training regarding COVID-19 prevention and control before I set off. Despite all the concerns I had, I believed that it was important to fulfill my own mission as a HCW: Respect and protect lives; save the injured and dying. After we reached the hospital in Wuhan, we had 1 day to complete the handover. It was the most tormenting and stressful day since we needed to familiarize with the new working environment to make work deployment, consolidate the team, and prepare everything, including the final check of the proper protection strategies against COVID-19.

On the first working day, two colleagues and I formed the first group that entered the isolation ward. This was a temporarily built isolation ward, and all HCWs were temporarily deployed from a variety of departments or hospitals. Everything was new to everyone: the environment, team members, the locations and types of equipment, the number of patients,the number of critically ill patients, and the workflow, etc.,As experienced HCWs, we digested the information quickly and organized and executed work to ensure that it would run smoothly. Just within 10 min, we built up the team reasonably by considering each other’s strengths. A local nurse was assigned to work during the main shift to handle prescriptions and the rest of the team was divided into three groups, with each group consisting of local HCWs and HCWs from other provinces. We gradually got familiar with each other and the work routine. We worked together smoothly for 65 days and no one was infected with COVID-19.

DIVIDING THE ISOLATION AREA AND ITS MANAGEMENT

An isolation ward was reconstructed from a general ward so that it was suitable for treating patients with COVID-19 overnight. The ward was divided into three zones: contaminated, semi-contaminated, and clean.[3]We then simulated the routes of the entry and exit processes.According to the routes and the sequence of the steps regarding the use of PPE, including fluid-resistant gowns,goggles, gloves, full face shields, shoe covers, and N95 masks, we placed disinfected items accordingly and pasted step-by-step tips for the wearing and removal of PPE and disinfection issues.[4]

We also restricted the number of HCWs when entering and exiting the ward each time. Since changing PPE is an important infection control step, a strict schedule was planned for each shift to allow HCWs who were working in the same shift to change their PPE in different time slots. Each time slot allowed only two HCWs to enter the changing area while being at least one meter apart from each other.[4]They also monitored each other’s correctness and safety during the changing process.

Another important matter was related to the management of the ward environment, including the clean zone, the contaminated zone, and the semi-contaminated zone. The clean zone was a rest area for HCWs, which was reconstructed from a wardroom. Each medical team from the same hospital was assigned to a dedicated room (with a bathroom) to avoid cross-infection between teams. The used scrub suits were placed in a designated area outside the room. Each team cleaned and disinfected the room by themselves after use.Everyone should take a shower before leaving the hospital.The contaminated zone was the working area. The ward environment was cleaned and disinfected twice a day, and the equipment was cleaned and disinfected every 4 h by nurses using a disinfectant that contained chlorine (2000 mg/L).[5]The patients’ excreta, secretions, and used items, which were viewed as contaminants, were fully soaked by the disinfectant for 30 min, placed in a yellow double-layer garbage bag, and discarded as contaminants.[5]To treat a dead body, firstly sprayed the disinfectant, filled the pores of the body with the disinfectant soaked cotton ball, followed by completely covered the body by a bedsheet, and then sprayed the disinfectant again, finally wrapped the body with a waterproof bag, and transferred out through the contaminated lift. In principle, the isolation ward should be kept clean and neat with sufficient sunlight, good ventilation,and regular disinfection. All garbage generated by patients should be disposed of timely. The semi-contaminated zone was a changing area for HCWs to take off their PPE, where easily generated lots of garbage, overflow of garbage, and insufficient disinfectant. Thus, during each shift, the garbage would be disposed and the disinfectant would be replenished by a specific person timely.

Additional attention was also paid to the HCWs’accommodation area after working hours. Each HCW was assigned a single room. Despite the similar disinfection requirements to the whole area, special steps were taken for infection control: at the gate, disinfectant was placed so that the HCWs could disinfect their hands and shoes before entering the living area and in the elevator, disinfectant was also available for HCWs who were required to use disposable tissue papers to press the buttons without touching any surface with their hands or other parts of the body. The room was also divided into three zones from outside-in:contaminated, semi-contaminated, and clean. Everyone was required to disinfect their hands after opening the door, and then to remove the jacket, change shoes, go to the bathroom,remove the clothes which were soaked with the disinfectant,take a shower, and finally enter the clean zone in the room.We cleaned and disinfected the room and changed bedsheets regularly.

FAMILIARIZING WITH THE WORK AND ENVIRONMENT

Working in an isolation ward to fight against COVID-19 as a frontline HCW was a big challenge. First, we had to familiarize with the work routine. After getting familiar with our new colleagues, we conducted nursing rounds by groups to familiarize with the patients and the environment to ensure that everything was in place. The detailed work included: (1) Understanding patients’ medical conditions and emotions through simple conversations and determining who needed special attention. Checking whether patients wore their masks correctly and tightly, whether the masks were replaced timely, and whether they had an awareness and proper behaviors to prevent infection. (2) Familiarizing with the layout of the environment and checking if anything was needed. With regard to the environment, check whether the types of rooms were single, double, triple, or six-bedded rooms. For multiple-bedded room, the distance between bed units and physical barriers (e.g. curtains) should meet the requirements of the infection prevention guidelines. (3)Ensuring HCWs’ awareness of protective practices: changing PPE properly, protective standing positions while performing procedures, performing hand hygiene,[4,5]and closing the door after entering or leaving a room. After a nursing round, nurses would handle prescriptions by doctors and communicate with the doctors based on assessments during the nursing round.

CHALLENGES ENCOUNTERED DURING WORK AND SOLUTIONS

We encountered many work-related challenges, mainly psychological challenges, and PPE-related challenges. As HCWs, we encountered great psychological challenges due to many reasons, such as anxiety related to uncertainty and concerns about work and having no sense of belonging.[6]During this special period, it was very important to have the courage to face difficulties and problems and solve them.There were PPE-related challenges such as foggy goggles and uncomfortable feelings and physical burdens while wearing PPE. Usually, our whole bodies would be soaked in sweat after each shift with a variety of skin lesions. It was difficult to perform work with multiple layers of gloves and foggy goggles.

We tried various solutions to address the challenges encountered during work. For psychological challenges,we adjusted the working schedules for each shift while considering a balance of different genders, working experiences, and personalities and patients’ conditions so that everyone could find a sense of belonging and feel more confident at work, with complementarity in emotions and capabilities. We tried many methods to solve the problem of fog generation on the goggles during work, such as applying detergent, iodophor, anti-fog spray, or hand oil on the goggles to generate a protective layer and prevent fog generation. We found that, except for the hand oil, the other three methods could form a protective layer on the goggles when they were applied evenly. We avoided wiping the goggles with a tissue paper or other cloths as these would destroy the integrity of the protective layer. Two methods were used to help us look through the goggles clearly: looking through the upper corner or staying at a place with good ventilation and lower temperature (near the window or the refrigerator) to dissipate the fog and complete procedures as soon as possible.

To improve our comfort levels while wearing PPE, we suggest the following based on our experiences: (1) Regarding gloves,the inner layer should be one size bigger than the outer layer to improve flexibility, (2) regarding fluid-resistant gowns,choose a suitable size and ensure the tightness of the gown,and (3) regarding goggles, choose a suitable size to ensure that it fits the shape of the nose, covers the whole periorbital area and the forehead part of the gown, and ensure that it is tight and stable.

SUGGESTIONS FOR SMOOTH COMMUNICATION AMONG DIFFERENT PARTIES

At the early stage, establishing an effective communication mechanism among different parties was very important:

1. Communication between HCWs working in the isolation ward and outside the isolation ward: since the isolation ward is a closed environment, specific equipment (e.g. phones) and staff at both sides were needed to facilitate timely communication for information

2. Doctors-nurses communication: since the temporary medical team was formed with doctors and nurses from various provinces throughout China and we were not familiar with each other, we tried to address each other’s name and build trust during communication

3. HCWs-patients communication: For patients with mild symptoms, HCWs-patients communication was mainly through a pager while the patient was in an isolation room and the HCW was outside the room. This practice could have helped to prevent the HCWs from being infected by reducing the frequency of entries to the room. However, for patients who were critically ill or unable to verbally communicate with others or had hearing problems or tracheal intubation, we had to communicate face-to-face with them to evaluate their conditions. We tried to complete all possible work and procedures at the same time

4. Communication with regard to medical equipment: since the isolation ward was reconstructed temporarily from a general ward, medical equipment such as monitors,ventilators, micro infusion pumps, and defibrillators were insufficient due to a sudden increase of patients.Thus, they were prioritized for critically ill patients’ uses and specific personnel were assigned to communicate and replenish the equipment timely. All equipment was made ready to use at any time. Regarding general supplies, effective evaluation of the needs, and timely replenishment were very important to avoid either overstocking or insufficiency that would cause delayed treatments to patients

5. Communication between patients and the outside world:isolation can lead to anxiety and uncertainty among patients.[7]Most patients expressed the need to contact their loved ones and shared that it was very important for us to help them establish social connections as soon as possible so that they would know what was happening outside.

SUGGESTIONS FOR OPTIMIZING WORK REGULATIONS AND WORKFLOW AND ESTABLISHING BEHAVIOR HABITS AND PROFESSIONAL KNOWLEDGE AND PRACTICES

Work regulations and workflow were adjusted based on the needs during the COVID-19 epidemic to ensure efficiency and practicability. All regulations related to infection control, disinfection, and isolation were optimized based on evidence-based practices to ensure that all activities and procedures were performed smoothly and in order. workforce and workload should be reasonably allocated.

To avoid infection during work, it was important to establish the behavior habits of patients and HCWs: wearing a mask at all times, washing hands frequently, opening the windows to ventilate regularly, closing the door whenever entering or leaving a room, keeping a proper distance from others, and monitoring and protecting each other. All HCWs’ behaviors were monitored and evaluated until their behaviors became standardized to establish the behavioral barrier to infection.

HCWs should establish professional knowledge and practices.HCWs should be able to judge when a patient’s condition is deteriorating and to generate a continuous and personalized holistic care plan. For instance, HCWs should judge how a patient’s condition will develop, what kind of treatment the patient will need (e.g. nasal high-flow oxygen, noninvasive/invasive ventilator, hemofiltration machine, or even extracorporeal membrane oxygenation), which instruments will be needed, health-care team members’ capabilities,patients’ nursing care issues, and what problems can be prevented.

In a word, while Wuhan has passed its most difficult period,COVID-19 has unfortunately affected over 200 countries, with 1,709,315 confirmed cases and 106,696 deaths among these countries as of April 12, 2020.[8]Seeing that thousands of HCWs were infected by COVID-19 in both China and Italy,[9,10]especially those who are not specialized in infectious disease,it is of utmost importance to remind policy-makers and HCWs about the importance of using PPEs while taking care of patients with COVID-19. We hope that the experiences shared and suggestions made in this article will be helpful to HCWs in other countries in fighting against COVID-19.Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.