covid -19 nursing challenges

1. NURSING CHALLENGES DURING COVID-19
MRS. JISHA SRIVASTAVA
RNRM, MBA HCS

2. CHALLENGES
1. EPIDEMIOLOGY AND CLINICAL FEATURE DIAGNOSIS
2. MANAGING OF NURSES
3. INFECTION PREVENTION
4. MANAGEMENT OF ACUTE RESPIRATORY FAILURE
5. ICU INFRASTRUCTURE
6. ICU CAPACITY
7. ICU STAFFING
8. ICU TRIAGE
9. OTHER ICU MANAGEMENT
10.ICU RESEARCH
11.CONTINUING USUAL CARE, RESEARCH AND TEACHING
ACTIVITIES

3. 1.EPIDEMIOLOGY AND
CLINICAL FEATURE DIAGNOSIS
Challenges
Prediction of disease trajectory from the time of symptom
onset is difficult.
Clinical features are non-specific; risk of missing a case
early in a local outbreak is substantial.
RT-PCR (Reverse Transcription Polymerase Chain Reaction)
assays might not be available in many ICUs; if available,
assays will take time to complete.
Sensitivity of RT-PCR assays for critically ill patients is
unknown.
3

4. Recommendations
1. Support research to develop and validate
prognostic tools and biomarkers.
2. Adopt for a diagnostic testing, where there is
available time to complete.
3. Maintain a high index of suspicion for
COVID-19.
4. Repeat the sampling if necessary, preferably from
lower respiratory tract (sputum and endotracheal
aspirates)

5. 2.MANAGING OF
NURSES
Challenges
Increased need for healthcare workers.
Risk of health-care workers might become infected with
Covid-19.
Avoiding conflicts between healthcare workers who take care
of the suspected and confirmed cases and those who do not.
Increased anxiety, depression and post traumatic stress
disorders in Healthcare workers.

6. Recommendations
1. Press conference to the general public in order to limit the spread of
rumours coming from outside.
2. Real-time information of the healthcare workforce and of all the
hospital staff.
3. Effective leadership by the heads of department and the hospital
management.
4.WHO recommends that PPE for health-care workers providing direct
care to patients with COVID-19 should include medical masks, gowns,
gloves, and eye protection with goggles or face shields to prevent the
risk of infection.
5. Organising psychological support by limitation of shift hours and
provision of rest areas where feasible, and mental health support
through multi- disciplinary teams, including psychiatrists, psychologists,
and counsellors.

7. 5.Systematic surveillance of exposed healthcare workers.
6. Mobilisation within the pool of hospitals or at the
regional level and thus ensuring a rotation of healthcare
workers who are involved in covid-19 management.
7. Creation of pairs of healthcare workers with an
experienced nurse in order to rapidly increase the
number of trained healthcare workers.
8. Regular team meetings to keep proximity.

8. 3.INFECTION PREVENTION
Challenges
A global shortage of PPE, medical masks and respirators threatens
efforts to prevent transmission.
N95 respirators that do not fit facial contours might not provide the
necessary protection.
Self-contamination often happens during removal of PPE .
Viable virus on health-care worker’s mobile phones and hospital
equipment can cause nosocomial transmission .
SARS-CoV-2 might be transmitted faecally.
ICU visits pose a risk of infection to visitors.

9. Recommendations
1. Consider reuse of masks and use beyond the
manufacturer-designated shelf life .Conduct regular mask
fit testing, preferably before outbreaks.
2.WHO recommends that PPE for health-care workers
providing direct care to patients with COVID-19 should
include medical masks, gowns, gloves, and eye protection
with goggles or face shields.92
For aerosol-generating
procedures (tracheal intubation, NIV, tracheostomy,
cardiopulmonary resuscitation, bag- mask ventilation, and
bronchoscopy), masks should be N95 or FFP2-equivalent
respirators, and gowns or aprons should be fluid resistant.

10. 3. Train on both the donning and doffing of PPE .
4. Conduct surface decontamination and consider
wrapping mobile phones in disposable specimen
bags.
5. Practice immediate and proper disposal of soiled
objects.
6. Restrict or ban visits to minimise transmission; use
video conferencing for communication between
family members and patients or health-care workers.

11. 4.MANAGEMENT OF ACUTE
RESPIRATORY FAILURE
Challenges
Benefits of NIV(Non Invasive Ventilation) and HFNC(High Flow
Nasal Cannula), and associated risks of viral transmission through
aerosolisation, are unclear.
Intubation poses a risk of viral transmission to health-care
workers.
ECMO(Extracorporeal Membrane Oxygenation) is extremely
resource-intensive, even if centralised at designated centres.

12. Recommendations
1. NIV and HFNC should be reserved for mild ARDS, with airborne
precautions, preferably in single rooms who have a low threshold for
intubation.
2. Perform intubation drills; the most skilled operator should intubate with full
PPE and limited bag-mask ventilation since it can cause aerosolisation.
3. The use of closed suctioning systems post-intubation will reduce
aerosolisation.
4. Focus on avoidance of ventilator-induced lung injury during facilitating gas
exchange via lung-protective ventilation.
5. Extracorporeal Membrane Oxygenation (ECMO) can be reserved for the
most severe of ARDS patients in view of evidence that it might improve
survival.

13. 5.ICU
INFRASTRUCTURE
Challenges
Airborne infection isolation rooms with negative pressure are not
universally available, especially in resource-limited settings.
Recommendations
1. Consider adequately ventilated single rooms without negative
pressure or, if necessary, cohort cases in shared rooms with beds spaced
apart.
2. If AIIRs (airborne infection isolation room) are unavailable, patients
can be placed in adequately ventilated single rooms with the doors
closed, as recommended by WHO

14. 6.ICU CAPACITY
Challenges
Surges in numbers of critically ill patients with COVID-19 can
occur rapidly.
Low-income and middle-income countries have insufficient ICU
beds in general, and even high- income countries will be put
under strain in an outbreak like COVID-19 .
Increasing ICU capacity requires more equipment, consumables,
and pharmaceuticals, which might be in short supply .
Ventilators are in short supply .

15. Recommendations
1.Implement national and regional remodelling of needs for intensive
care
2.Adding beds into a pre-existing ICU is a possibility, however space
constraints and nosocomial transmission from crowding limit this
option.6
3.Provision of intensive care outside ICUs, such as in high-dependency
units, remodelled general wards, post-anaesthesia care units,
emergency departments etc.
4.A substantial increase in ICU capacity involves increases not only in
bed numbers, but also in equipments , ventilators, consumables,
pharmaceuticals and staffing.
5.Consider transport, operating theatre, and military ventilators.

16. 7. ICU STAFFING
Challenges
High ICU workload-to-staffing ratios are associated
with an increase in patient mortality.1
Risk of loss of staff to illness, medical leave, or
quarantine after unprotected exposure to COVID-19.
Staff are especially vulnerable to mental health
problems such as depression and anxiety during
outbreaks .

17. Recommendations
1.Make plans for augmentation of staff from other ICUs or
non-ICU areas and provision of appropriate training (eg.
standardised short courses).
2.Minimise risk of infection; consider segregation of teams
and physical distancing to limit unprotected exposure of
multiple team members, and travel restrictions to limit
exposure to COVID-19, which is now global.
3.Reassure staff through infection prevention measures,
clear communication, limitation of shift hours, provision
of rest areas, and mental health support.

18. 8. ICU TRIAGE
Challenges
ICUs can become overwhelmed as surge strategies
might not be sufficient in an emerging pandemic like
COVID-19.
Critical care triage is ethically complex and can be
emotionally draining.

19. Recommendations
1.Consider implementing a triage policy that prioritises
patients for intensive care and rations scarce resources.
2.A triage policy implemented by clinicians trained in triage
or senior ICU practitioners, complemented by clinical
decision support systems, might identify patients with
such a low probability of survival that they are unlikely to
benefit from ICU care;5
older adults with co morbidities,
higher d-dimer and C-reactive protein concentrations and
lower lymphocyte counts do worse.
3.The short-term and long-term prognoses of critically ill
patients have to be clarified.
4.

20. 9.OTHER ICU
MANAGEMENT
Challenges
Patients often develop myocardial dysfunction in addition to
acute respiratory failure .
Transfer out of the ICU for such as CT scans poses risk of viral
transmission.
Bacterial and influenza pneumonia or co-infection are difficult
to distinguish from COVID-19 alone.
Benefits and risks of systemic corticosteroids are unclear.
Viral shedding in the upper respiratory tract continues beyond
10 days after symptom onset in severe COVID-19.
Repurposed and experimental therapies that are not supported
by strong evidence are being used.

21. Recommendations
1. Administer fluids cautiously for hypovolaemia, preferably with
assessments for pre-load responsiveness; detect myocardial
involvement early with troponin and beta-natriuretic peptide
measurements and echocardiography.
2. Minimise transfers by using alternatives such as point-of-care
ultrasound .
3. Avoid routine use of medicines until more evidence is available.
4. De-isolate patients only after clinical recovery and two negative RT-
PCR assays performed 24 hrs apart .
5. Seek expert guidance from local or international societies and enrol
patients in clinical studies where possible.

22. 10.ICU RESEARCH
Challenges
The traditional pace of research might not match
the pace of the outbreak.Multiple challenges to
research exist during pandemics. First, the surge of
disease often outpaces the traditional steps for
research, including protocol design, securing of
funding, and ethics approval, all amidst busy clinical
work.
Studies are often single-centred and underpowered.
Rapid conduct and sharing of research might
compromise scientific quality and ethical integrity.

23. Recommendations
1. Use and adapt pre-approved research plans and platforms prior
to an outbreak are useful.
2. Collaborate through international research networks and
platforms such as the International Severe Acute Respiratory and
Emerging Infection Consortium (ISARIC) and the International
Forum for Acute Care Trialists (InFACT)—formed during the 2009
H1N1 pandemic—enable large research networks to share
common goals and standardise data collection globally.
3. WHO has also produced a master protocol for trials on
experimental therapeutics for COVID-19.
4. The pace of research and data sharing must be balanced with
scientific quality and ethical integrity.

24. 11. CONTINUING USUAL CARE,
RESEARCH AND TEACHING
ACTIVITIES
Challenges
Evaluating and anticipating collateral effects
of treatment.
Increasing the availability of beds for care
and research.
Maintaining teaching activities.

25. Recommendations
1.Putting in place a “crisis cell” for research
purposes.
2.Pre-validation of circuits to deal with research
during epidemics.
3.Harmonising clinical research with patient
care.
4.Seizing opportunities to teach students and
Nurses about outbreak management.
5.Organising the training of healthcare workers.

26. KEY MESSAGES
• Clinical features of coronavirus disease 2019 (COVID-19) are
non-specific and do not easily distinguish it from other causes
of severe community-acquired pneumonia.
• As the pandemic worsens, intensive care unit (ICU) practitioners
should increasingly have a high index of suspicion.
• Many questions on clinical management remain unanswered,
including the significance of myocardial dysfunction, and the
role of non-invasive ventilation, high-flow nasal cannula,
corticosteroids, and various repurposed and experimental
therapies≥

27. • ICU practitioners, hospital administrators, governments, and policy
makers must prepare early for a substantial increase in critical care
capacity, or risk being overwhelmed by the pandemic
• Surge options include the addition of beds to a pre-existing ICU,
provision of intensive care outside ICUs, and centralisation of intensive
care in designated ICUs, while considering critical care triage and
rationing of resources.
• Preparations must focus not just on infrastructure and supplies, but also
on staff, including protection from nosocomial transmission and
promotion of mental wellbeing.
• Clinical features should be included in the curriculum for future
reference.

28. QUESTIONS?

29. QUESTIONS
1. What are the nursing challenges during covid-19?
A. Prediction of disease trajectory from the time of
symptom onset is difficult.
B. Increased anxiety of Healthcare workers.
C. Increased need for healthcare workers.
D. All the above

30. 2. Nursing challenges in managing Acute Respiratory
Failure?
A. Intubation poses a risk of viral transmission to health-
care workers
B. Evaluating and anticipating collateral effects of
treatment.
C. Increasing the availability of beds for care and
research.
D. Maintaining teaching activities.

31. 3. Give some recommendations to avoid conflicts between healthcare
workers who take care of the suspected and confirmed cases and those
who do not.
A. Organising psychological support and team feedback.
B. Systematic surveillance of exposed healthcare workers.
C. Mobilisation within the pool of hospitals or at the regional level and
thus ensuring a rotation of healthcare workers who are involved in
covid-19 management.
D. Creation of pairs of healthcare workers with an experienced nurse
coupled with a nurse in training in order to rapidly increase the
number of trained healthcare workers.

32. 4. Recommendations for Infection prevention.
A. Train on both the donning and doffing of PPE .
B. Conduct surface decontamination and consider
wrapping mobile phones in disposable specimen bags.
C. Practise immediate and proper disposal of soiled
objects.
D. Restrict or ban visits to minimise transmission; use
video conferencing for communication between
family members and patients or health-care workers.
E. All the above

33. 5. Recommendations for Increased anxiety of Healthcare
workers.
A. Real-time information of the healthcare workforce and
of all the hospital staff.
B. Effective leadership by the heads of department and
the hospital management
C. Organising psychological support and team feedback
D. A&C

34. THANK YOU