Good morning, everybody, and welcome to our Achieve Track session this morning. My name is Thomas Nash, and I work at the American College of Cardiology in the NCDR division. And it's my pleasure this morning to introduce you to Diana Ingram. Diana is a clinical nurse specialist and chest pain coordinator for cardiovascular services at Centura Health Littleton Adventist Hospital in Littleton, Colorado, which is just outside of Denver. She brings 30 years of experience as a nurse and in various cardiovascular clinical roles. Diana is a member of the American College of Cardiology cardiovascular team section and is currently a cardiovascular clinical nurse specialist. In this role, Diana facilitates the implementation of cardiovascular evidence-based practices at her hospital, and she manages the process improvement strategies to help improve patient care for cardiovascular patients. Diana received her Bachelor of Science in Nursing from University of Cincinnati and her master's degree from the University of California, San Francisco. So please join me in welcoming Diana, and thank you for your time today. Thank you, Thomas. So today we're going to talk about the post-COVID response, getting back to basics. When I was preparing this PowerPoint, I really kind of struggled because as probably some of you or most of you, all of you, maybe even, I was one of the ones that was taken out of the cath lab to take care of COVID patients, and it really had an impact on me. And I feel passionate about some of the things I'm going to talk about, and I'm happy to share my story with you. So just something to share with you guys, wake up, we decided COVID is over. Wouldn't that be nice? As we are still feeling the impact that COVID has had on all of our lives. So I want to talk a little bit about the way we were. And it reminds me of the song way back, I don't know, 60s and 70s, The Way We Were. We had lots of supplies for procedures. We had lots of PPE for patients, for infectious patients. We had a healthy staff, you know, minus the occasional flu or whatever else, but they were basically healthy physically and emotionally. We had heard rumblings of technology advancements with laser, just other things, and our data abstraction, believe it or not, was pretty much close to real time, which is hard to achieve. Then came COVID. There is a huge shift in where nurses were needed. Nurses and respiratory therapists, other members of the health care team are also confronted with physical and emotional impact of COVID and, you know, worrying about their own safety and the safety of their family. Our governor of Colorado shut down our elective procedures. So we wondered which cardiac procedure is elective, really, because these patients come to us to fix them of their cardiac issue that's impacting their life. But believe it or not, you know, we, our patients, came to a screeching halt. And with that also came a lack of data abstraction. Our nurses that typically do our data abstraction were floated to other areas of the hospital, mainly the ICU, to help out with patients. So one thing I want to emphasize is that this put a lot of internal turmoil amongst our cath lab team. Sure we wanted to help out our fellow team members within the hospital, but we were also missing our home team, a team that we trust, and preference for taking care of cardiac patients. I mean, I have been in cardiac pretty much my whole career as a nurse, with the occasional non-cardiac, but for the most part cardiac. And we were forced to take care of patients with extreme respiratory disorders, and it was difficult. So all of, all except one RN was deployed to the ICU, and we helped cover their shifts five, seven days a week, days, nights. In addition to some, a lot of the nurses, I personally do not take call anymore in the cath lab, but other nurses had to perform their duties in the ICU in addition to taking call for the cath lab. Our techs also had to deploy up to the floors to help with CNA duties type things. So it was really, it was, it was really a strain. And to add to that, the RNs that were deployed had a strong sense of unfairness related for the nurse that actually got to stay in the cath lab. There was a lot of animosity, and just added to the struggles that we encountered related to our deployment. Looking back, there were some unpredicted positive sides of deployment. The cath lab RNs did, served as content experts for the ICU nurses. A lot of these nurses were not very well-trained or not versed in STEMI care, and where the coronary arteries were located and how that impacted the function of your heart. So our cath lab nurses were able to assist with their professional, with ICU nurses' professional development, and also to serve as access site super users as well. Because we are pretty much the content experts related to access site management, and we were able to help with that. It was great relationship building for the ICU staff, for the cath lab staff in the ICU, and their providers. The intensivists often felt that cardiology did not respond appropriately, and we did help mend some of those fences with the providers and the nurses, and that was a positive. Also there was a lot of support from the hospital and community. So not only were we provided with food on a nightly basis, I personally work night shift, but food was available, families of patients, community, businesses provided us with treats and food, and that really helped you feel better about what you were doing. But it still took its impact. There were numerous physical challenges of deployment, juggling work and family needs. A lot of our cath lab nurses had little kids at home, and school was also virtual or just came to a halt. So as a cath lab team, the nurses, we tried to assist those other nurses that had to work different shifts for their kids, and that was tough. I put alterations in sleep patterns related to a different shift, and the cath lab were Monday through Friday day shift. I personally chose to work nights. I could not sleep more than five hours at a time. So I would come home, get five hours of sleep, and then I was wide awake and have to go back to work in the evening time, and that was tough. I did work night shift during my early years as a nurse, and it brought me back to that, how you never feel rested while working night shift. You don't. So also it was the physical demands were very different. I think nurses go into procedural areas for certain reasons. I know my personal reasons I have, but the physical demands of a bedside nurse are very different, providing personal care that you're maybe not used to giving to a patient, turning patients, putting patients prone. A lot of times these patients, the patients that were really sick, were quite obese, and that really takes a toll on your body day and night, as most of you know. And to add to all of that, our personal care routines were kind of taken away from us. The gyms were closed. So everyone was moved to exercising outside. Gym classes, yoga classes, everything was closed. And it made self-care a lot more difficult, and for those that use exercise as a coping mechanism, like myself, it made coping less effective, which kind of segues into the psychosocial impact of deployment. And I really want to spend a lot of time on this, because I think while we were going through this acute pandemic early phase, we had no idea how this would impact our teams from the psychosocial standpoint. There was, as I mentioned before, concern for our own safety and the health of our family, not wanting to contact COVID, because we saw in the ICU the sickest of the sick. And we were concerned that that could happen to us or our family members. One thing I did, and I don't know if it helped or not, but fortunately our cath lab has a shower. I would finish my 11 to 7 shift, I go straight to the cath lab, shower, and then go home. I didn't want to bring this back to my loved ones, and I didn't want this in the house. So safety was a real concern. Animosity, as I also mentioned before, towards others that worked in the cath lab, we were really missing our home team. Working with an unfamiliar team and the unknowns of their skill levels was really difficult. Those of you that have worked in the cath lab know how important your team is, know that you spend more time sometimes with your cath lab team than your own family. You rely upon them like family. It was really, really, really tough. And coping with everything became more difficult, from having to wear a mask all the time wherever you went. For people that get kind of claustrophobic like myself, it was a real challenge. Burnout was prevalent before the pandemic. So in the acute phase, when some of our healthcare workers were asked to stretch beyond even what they were already capable of doing, working longer hours, taking care of sicker patients, burnout was very obvious and no amount of money being thrown at you could really make you feel better. So after three months of being deployed into the ICU, our manager, bless her heart, and we were all just trying to survive, and we didn't know what we didn't know. One thing we did do was have our manager had a debriefing with the deployed staff. This was not a bitch session, so to speak, but it was more talking about how you felt, how she could improve the response, and what she could have done better. And we gave her some honest feedback with that, and that we felt that the psychological impact of us being deployed from our team was really striking, and that it was not fair for one cath lab nurse to stay back while the rest of us worked in the ICU. So we came to an agreement that if this happened again, we need to rotate because you need some sense of normalcy for the nurses, for their mental health. One thing it did do was it did strengthen the natural support with our nurses within the cath lab, especially the ones that were deployed. We did depend upon each other for support, emotional support, physical support. So that was really helpful, and we do have a great group of nurses that I work with, so I feel fortunate. Grace became the word of the hour. You know, we all don't know what each other is going through in their personal lives unless you share that, but sometimes you need to give people grace. And coming from a faith-based organization, grace became a really strong word, and one that we would say on a daily basis for each other, to take care of each other. Also the skill sharpening, it is amazing what skills you become rusty on when you are not in the cath lab for three months, from medication administration to technology, setting up an impella, a balloon pump, and the nurses shared that it was really tough getting back to doing these skills because that had not been a priority for three months. So I didn't know it at the time, but our staff, including myself, really suffered from grief. And I do want to spend some time talking about some mental health issues that I think all of our healthcare workers were frequently impacted with, and prior to COVID, and then COVID kind of magnified what these mental health issues, and one of them is grief. Grieving for our teams that we were forced to leave, grieving for our sense of competency and mastery within the cath lab field, we were moved to an area, like I said previously, that was mainly respiratory because of the COVID. So there were not a lot of cardiac patients coming to the hospital because they were too afraid they would get COVID. Grieving for our safety, not only were there PPE shortages, we were having to wipe down our masks, our gowns, reused gowns and masks, and it was a real safety concern. And then there was the loss of patients. So after taking care of these COVID patients, for some of them, one and two months in the ICU, some making it, some not, you did form a connection with these patients when they and able to communicate, and that was also a real loss. And add to that the separation from our families and friends, everyone encouraging you not to travel to go see your family, you know, grieving for families that maybe were, that had COVID and were hospitalized, not being able to bring families in to see their patient, their family member that was maybe dying of COVID was really tough. I want to talk a little bit about disenfranchised grief. This is, so what do I mean by disenfranchised grief? So this was originally conceived by a man named Kemeth Doka, and disenfranchised grief refers to grief that results when we experience losses that aren't openly acknowledged or publicly mourned. So this could be with patients. This could be with loss of our current job status and having to move to a different role. It's grieving in silence that's unrecognized by others. So our grief of not being in our home base was quite apparent, and we, I don't think it was going through this, and we couldn't, I could not put, I did not feel emotionally well, but I could not put a finger on what it was that I was feeling. And I believe that grief and disenfranchised grief, I was suffering from, and so were my coworkers. And we get caught up, oh, it's my job. It's my job to take care of these patients. It's my job to not grieve. But really, it is, it is, and so then we don't talk about our feelings, our grieving feelings, and which makes coping very difficult. I believe there was also a lot of compassion fatigue. Repeated exposure to working with those in pain and suffering. So the repeated exposure of these sick patients on ventilators, pressers, being proned for prolonged periods of time, and not having family present for them was really tough. And I equate it to emptying your own bucket without replenishing. This is where self-care is very important to help fill our bucket. But oftentimes, we did not have the resources to fill the bucket to help us to continue on. And the information here I'm presenting about compassion fatigue and grief, I actually received from a webinar taken from Allegheny Health in Pittsburgh. A family member actually worked with nurses in the neuro ICU during COVID about their grieving and their compassion fatigue. So I wanted to share this with you, recognizing compassion fatigue on individuals. As you can see, some of the signs there, feelings of numbness, substance abuse, irritability, impaired concentration, poor work performance. And in the workplace, high rates of absenteeism, mistrust among coworkers, high turnover, resistance to change, and actually complaints from care recipients about the integrity or the emotional awareness of the caregiver. So workforce support. You know, it's funny that it took COVID to actually come to light the implications that mental health has on our health care workers. So there's an article from David that summarized the initiative or the programs that were established during COVID-19 to support health care workers' emotional well-being. And most programs provided support by offering basic needs services. At my hospital, we were able to receive free food from the cafeteria. We were also able to bring home family-sized meals for our family. And also, they did offer some workplace training. So although the nurses in the cath lab felt okay about working in the ICU, there were still some needs there with ventilators. You know, the personal care required around ventilators and making sure that, you know, we don't have all the infections that are monitored by the hospital. Some programs also offered peer support programs, psychoeducational and counseling services. But one thing David did mention was it's uncertain if these programs continued after the acute phase, which is a shame. Because I believe that they really, they need to continue. Because COVID has not gone away, unfortunately. So there's a mental health framework from LaMontagne that David cites. And these are actually interventions to help improve resilience and help the mental health of your staff. The first one is protect by relieving work-related risk factors. Promote, encouraging positive aspects of your work and workers' strengths. And address mental health issues irrespective of cause. So promote, oops, protect, sorry. Harm prevention initiatives. Unfortunately, this was not a luxury we had. PPE shortages were a concern. So I would have to say that harm prevention was really not available at our time. And the goal is to reduce work-related risk factors. We did, with the amount of COVID patients, we felt our possibility of receiving COVID increase. And especially, that was even highlighted with our PPE shortages in the initial phase. Next is promote. And this one, promote positivity. Acknowledging the co-worker's strengths. Building positive work relationships. Engagement in important activities and decisions. There's a couple of peer support interventions that take place called Swartz Rounds and Battle Buddies. So Swartz Rounds, they would have a mental health professional and have two or three healthcare workers talk about their experience with their mental health in a venue similar to this. Battle Buddies, this was taken from the US Armed Forces. When a situation occurred, your Battle Buddy would have a pocket card containing resources on what to say, how to say it, to help facilitate support for the co-worker that was struggling. Now my boss tried really hard to promote positivity. It sometimes worked, sometimes didn't. It's really hard to promote positivity when people are struggling emotionally. But she did give it a try and it worked a little, but not so much. Next is address. So to promote mental health illness techniques to treatment. Mental health literacy. This is something I struggled from. Recognizing, putting to words things that you were feeling. Tools to help self-identify common symptoms of disorders. This was something I struggled with. I was not right emotionally, but I didn't know how to put it to words. And that really, it was tough. And a lot of institutions created online resources. In New York City, NYU Langone, they created a mental health app so that their health care workers, it would help them self-identify how they were feeling, give them interventions to do to help them feel better, and to help them cope with what was going on. As you know, New York City had a huge COVID, a lot of COVID institutions. And a lot of health, a lot of areas also did, because of COVID, remote health care, mental health care resources, which seemed to help. And there's also articles out there about what Spain, France, the UK provided for their health care workers as well. So I'm sure you are all familiar with Maslow's Hierarchy of Needs. And what David found in his article was that health care workers were less likely to engage in psychological support resources if their basic needs were not being met. So this, this Maslow said it all several years ago, that if we are not, if our safety needs are not being met, our other physiological needs, food, shelter, were not being met, then our emotional needs take a back seat and are not, we will, we will not respond to treatment. So in summary, we start by the basics by fulfilling physiologic and safety needs. And the mental health or psychosocial health of our health care workers is of the utmost important for positive team function. And utilize the mental health framework and interventions to help build resilient staff. So in this COVID-19 era, resiliency became the buzzword. But sometimes resiliency just wasn't enough. And to take on what my facility encouraged was grace for people. And to know that we were all struggling at these times and sometimes people needed a little bit of grace to help them, to help them get through this. To help them on their way. So returning to the cath lab, also we, our volumes were slow to return. So sometimes we were also deployed out to other areas of the hospital post-deployment after our three months of duty to help out other areas. I know one time I spent like four hours starting IVs on patients, which is something I love to do. So that. I also took care of a cardiac patient on a non-cardiac floor. Because unless you're cardiac, a lot of non-cardiac nurses do not like taking care of cardiac patients. They scare me, is what I'm frequently told. And I always say there's nothing to be scared of. Because the ACC provides us with guidelines, but they don't know that. Supply shortages. So we all know about the contrast shortages we had earlier this year, or may still continue to have. But also since a lot of our supplies are made in other countries that also shut down, our supplies were in short supply. And nothing creates a hoarder more than going through a pandemic. So we all hoard supplies in our offices. You know, even just recently, we only had five 3J wires to get us through the weekend. None of our sister hospitals had wires to lend us because they were too afraid that they would need them for their procedures. So it is ongoing. Our guide catheters, it is a constant struggle and it does make you a hoarder. If not, the pandemic made me a hoarder of toilet paper because I could not find toilet paper for two months. So I now hoard toilet paper in my house. And now, fortunately, during the first acute phase of COVID, our co-workers were healthy. They were healthy. My manager encouraged us not to go out to gatherings with vendors as a sister hospital gathered with vendors and they all got COVID. And they had to shut down their cath lab. So we, our team was very respectful of each other and of, to not gather in large quantities of people. One thing we did find as well, the patients that did come to the hospital were sick. And they were very sick. And we used a fair amount of Impella. Patients were in the hospital for extended periods of time that were very sick because, as you know, when you wait one or two weeks after your heart attack to come to the hospital, your heart does not like it. So we had some very sick patients. We had a couple of nurses that were new to the cath lab that did not know how to take care of these patients. So we had to allocate staff to help train the nurses with these really sick patients. Kind of changing gears here on managing the data in our fallouts. Our volumes of our patients were less. So our fallouts were more pronounced. Our door-to-balloon times remained the same. And actually, our STEMI numbers decreased only by about 10% or 15%, whereas most of the nation, I believe it was in the United States, our STEMI numbers decreased by about 10% or 15%. I believe that they, calculators, more like 38%, 40%. Our provider documentation needed a lot of attention. And our data needed a lot of attention. So my manager designated me to help with this data management. So I just wanted, here's a couple ideas. Here's a couple examples of our data. So during the COVID period, as you can see, quarter one, 2020, this is for a chest pain MI. Our overall AMI composite was less than desirable. In the low 90s, 80s, and with me focusing on all of our initiatives and working well with the cardiologist, we have been able to increase that up to the high 90s. I would like to get close to 100%, but I am happy with 97, as opposed to 89. In our defect-free care, as you can see here, a lot of our patients do not receive some of the care that they should be receiving, as no one was there to kind of monitor and make sure these patients receive the care. Or if they were not eligible for the care, specifically guideline-directed medical therapy, that documentation was present. Our beta blocker, a discharge documentation, horrible. We are currently up to 100%, which is good. We are currently up to 100%, which is good. ACE or ARB for LV systolic dysfunction. So we were down in this 60s percentile. All of this was documentation from our physicians and our nurse practitioners. And documentation for ACE, ARB, and ARNI, they were not even documenting a reason for not starting a patient with let's say an EF-25 on an ARNI. Our acute kidney injury spiked up. I have no idea why. I don't know if it is — I have no explanation. Although when I did return, I was able — I did start keeping a lookout for the amount of fluid we were giving. If their EF was normal, encouraging staff to pre-hydrate, hydrate afterwards. The only thing I can really figure is that since these were sick patients, we actually did not calf a lot of COVID patients. So I'm at a loss as to — if anybody else saw this happen, I welcome your comment on that. Our door-to-balloon times pretty much remain the same, if not a little lower. We average in the 50s for our balloon time. So that pretty much stayed the same. Our post-procedural length of stay for STEMI patients actually went down because we wanted these patients, if they were stable, to go home and recover at home. And for a couple of reasons. Number one, the hospital needed the bed. Number two, we all know that recovery happens best at home if they were clinically stable to do that. Also, I did not put it in here, but our length of stay for our PCI patients also went down. And this is something we are continuing to do, is we — if our patients were stable post-PCI and had a very — we recovered our patients and sent them home the same day. And actually, we did that so that the hospital would not shut down our procedures. So if we could show that we could take care of these patients, rather than requiring a bed for them, we were allowed to stay open and our cardiologists were allowed to continue bringing our patients. So we do have a very robust — I'd have to say 75% of our PCIs are now same day. Obviously the more complex procedures or patients that become unstable during the procedure do stay overnight. But mainly it's patients that come in for an elective procedure and they end up getting a stent and is stable, they do go home the same day. So a couple data improvement strategies I implemented. Real-time monitoring. I gather a list of our STEMIs and non-STEMIs and I make sure that they are meeting the metrics. If their LV function is down, that they are prescribed beta blocker, ACE or ARB, that type of thing. Also I did find because people were entering data that maybe were not used to entering data and maybe did not have a lot of education entering the data, I mitigated some of those errors and did feedback, real-time feedback, and gave them the resources within the ACC to — for education on how to data abstract. We did monthly review in our monthly heart section meeting of our NCDR metrics and our fallouts. I also gave instruction and documentation requirements to the cardiologists and MPs that were discharging these patients. And relationships, relationships with the cardiologists. Cardiologists, you have to have a relationship with them in order to — in order for them to see the value in improving their data. Unfortunately for me, I've worked with these cardiologists for 15 years. They know me, they've worked with me in the cath lab, and they — it was an easy transition. And — and also saying thank you a lot for documentation that — that helped us, and really show some appreciation for the things that they have improved upon. So, unfortunately, we still do have some impediments to returning to normal. Our staff in this last round, they didn't have it during the acute phase, but now they're — we're making the rounds with COVID. There are — that means there's less staff for our cases, extra call coverage, which is really weighing heavy on our staff, and our supply issues are continuing, as I talked about. But one good thing is that we've — I've been able to return to my activities that I do so enjoy after to help me cope with things. One of them is going to the mountains, as you can see here is a picture I took a couple weeks ago. This is up at like 9,000 feet, and that's a picture of me mountain biking. I have quite the passion for mountain biking, and if you're a mountain biker and have never mountain biked in Colorado, please come out and — and join. It is a beautiful, beautiful sport, and — but very difficult, and you have great views and quite the sense of accomplishment. So, that is all I have for you guys today. Thank you. Great. Thank you, Diana. I think that's all we have time for, so appreciate your time, and this concludes our session. Thank you.

Diana Ingram

healthcare workers

COVID patients

deployment

mental health impact

ICU nurses

relationships

data management

resilience