Linda Ohler MSN, RN Interview with Mary Saputo MSN, RN disussing the role of ICU nurses during COVID in New York 2020

00:00 And I worked at NYU in New York, and I'm going to be during COVID and I want to introduce some of my colleagues to you. The first will be in a series. This first will be with Mary Saputo. Mary is a clinical nurse specialist who worked with the transplant intensive care unit. Mary's role is as a specialist in care of critically ill patients, and she has worked at NYU for 35 years. So I'd like her to tell a little bit about her experience with COVID at NYU. When did you first realize that New York was becoming ground zero for the pandemic?

00:42 Mary, I want to say that NYU had first started putting out some data in the beginning of March just about this virus, and that it was in Europe, and it may be coming. And we had a town hall the first week in March. And at that town hall, they had asked that travel be completely restricted for any NYU employees. They had stated that this virus was there and that if you wanted to work at NYU, you could not travel outside of the country. That we were completely restricted. We weren't quite restricted to the state yet, but they had said, you know, to please be mindful that we didn't want this virus to spread at all. And then it was probably about right before we shut everything down. So that was 315. So it's probably like 310 when we started to see some patients coming in through our medical ICU, and that had fevers that were in severe respiratory distress, unsure, as soon as they were coming in, what they had, but then shortly thereafter, figured out that they had had Covid. And after that, our numbers just kept increasing and increasing. Our leadership was speaking with the governor's office prior to this, just getting updates on what they were seeing in the New York area. We were learning about different hotspots that were around, and it was the governor's office that was looking at our occupancy levels. So they would send out decrees just to be where to be aware that we would need to have increase our occupancy level by 25%. And then it would just go on and on. As the time went by, we would just be told to. We had to increase our occupancy.

02:37 What was the peak of COVID admissions.

02:40 At NYU for the entire enterprise? Our peak was April 6. So if you think of when the world shut down to April 6, what a short amount of time that is, it's pretty incredible. And at that point, we had seen 1283 patients with COVID So those patients had occupied our beds.

02:58 Then how did your role change with the realization that we were in a pandemic situation.

03:06 Well, it was such a foreign concept for all of us. So I was able to utilize the clinical nurse specialist listserv. And unfortunately, Covid had already gone to the west coast. So Washington state had already seen some Covid, and they were very good about sharing information. So were letting us know that this was coming, that these patients were very, very sick, that they required a lot of care, that we should start thinking about how we were going to look at our documentation per se, and look at how we were spending our time and how we were going to utilize our staff. They mentioned things such as pruning, where patients were so ill and under such bad respiratory distress, that the only thing that really helped them, even after they were put on a ventilator, was to lay them on their stomachs so that you are able to aerate the bottom parts of their lungs and get them the oxygenation that they needed. And they had first talked about that in those Washington lists of messages. So I was able to then prepare my critical care team that we are going to have to start proning patients. This was not something that we were used to doing. So I think in comparison, I could say maybe two patients a year in the medical intensive care unit were ever prone for severe respiratory distress. And from what we were hearing, this was going to be a much, much larger number. So I actually got together with our nursing educators. We created a video to show people how to do this, since we were so unfamiliar and had to make sure that that went out, that the staff had, that I was the only critical care clinical nurse specialist left during the COVID pandemic. So as we were trans making all of our floors, Covid ICU floors, we needed to make sure that they were properly equipped so that we could do the things that we needed to do at a rapid pace. These people came to us so, so ill, and when they got to us, we were putting them on ventilators. We were putting in central lines, we were putting in arterial lines. We needed to have that equipment available and at the ready because you didn't have any kind of time. So we put together some big steel cages, made sure that each of these floors were equipped right before we turned them over. You had to teach the nurses how to don and golf. That was not something that people were used to show them how to do that. The enterprise deployed that nurses, not nurses, but personnel that weren't nursing, were able to monitor the nurses doing their donning and doffing, and had safety monitors on the floor. So different people were deployed, redeployed in different areas than they were used to. So just making sure that that education was out there. Every time a piece of equipment went, we ran out of piece of equipment. We needed to substitute it, and it wasn't always being substituted for something that was familiar to anyone. So I needed to be on top of that. I needed to know what we were substituting for what, and make sure that the staff knew what that equipment was, why it was different, how we can utilize it. We, unfortunately, everyone in the northeast was looking for the same exact equipment at the same exact time. So there was a lot of shortages that were happening. So it was. This was something that needed to be communicated a few times a day. So my job was to do that. I was there to just educate and teach the staff and support them to the best of my ability, and that's how my role changed. So I was the clinical nurse specialist on one floor, and then as all the icus turned over to icus, I became the clinical nurse specialist for many floors.

07:08 It sounds like you were kept pretty busy during this time. That's amazing. Were you able to test patients for Covid at what point?

07:19 I don't remember exact dates, but I know by the time that they were coming over to the Kimmel Pavilion. So that was in March, towards probably the latter part of March, we were testing those patients, so we didn't know that they were COVID positive when they came over. And we were also had then begun test staff as well. So that was probably the end of March that we.

07:45 What was the communication like with hospital leadership at this point?

07:50 Email was the first way, so we were receiving emails constantly, and then they would have meetings a few times a day to make sure that everybody was abreast of what was going on. And then you would have a big meeting with all of hospital leadership, and then you would bring it down to the ICU leadership. So then we would be talking to them about how many patients we were proning, what kind of support we needed, what kind of equipment we had, how many ventilators we had, different things like that. So that communication, we had to send a report out three times a day to make sure that they were aware of what was going on on the floors.

08:29 Well, it sounds like it was a rapidly changing environment. So what were the directives? Were you getting any directives from New York state?

08:38 The directors that I was privy to were coming from my director, so I'm not exactly sure where they came from, if they came from the health department or from the governor's office. But we were getting told to increase occupancy just as the days were. As the days were going on. So we were lucky in the fact that we had just opened a brand new building and had had closed some units in our old building, because with the idea that we were renovating those. So as they were telling us that we had to increase by 25%, 50%, we were able to levy those empty units and have those as occupancy. All during this time, our building services, our engineers, were working, and they were. Our Kimmel building was a building that we were able to do. We were able to. They were private rooms, and we were able to control the airflow. Our Tisch building was an older building, and we were not able to get negative airflow into each of those rooms. So our building department and engineers were able to go into those rooms and change the airflow. Like, they literally had vents going out, windows going out, walls. This is what they built while we were dealing with what we were dealing with in the Kimmel pavilion, so that we were able to make more beds in the Tisch building that could then house COVID patients. So it was an ongoing. Everyone working and pivoting.

10:10 So each one of your intensive care units was 34 beds, and you added how many?

10:18 I think we added. We think we added over 100. Our unit was 34. And if we include the medical ICU, there was 34 there as well. We didn't really use them for Covid. As I said, they didn't have the right airflow. So then we added 160 on the Kimmel side.

10:39 Wow, that's impressive. How did the hospital respond to long Covid cases?

10:45 So that was tough, because these patients came in and you took care of them acutely, but then they didn't get better in a week and go home. Like, this was a very serious illness. And it really took a lot out of these patients who were so ill. So what they were able to do was one of our Kimmel units, we turned into a respiratory care unit, and we were able to take those patients who we couldn't quite get off the ventilator, but were doing much better than they had been. So they didn't require iv medications, they didn't require blood pressure medications. They just required some time to work to get off of those ventilators. So we created that unit, and then we also turned our orthopedic hospital into a physical therapy rehab respiratory therapy hospital. So we were able to transport. As they got better, we were able to transport over to that hospital so that we could admit more patients into the acute phase of the hospital. But I don't think people realized at the time how long these admissions were going to be. So it was. It was quite eye opening when we.

11:51 Realized that added to the complexity then, of the care and the capacity of each hospital.

11:58 Right?

11:58 Yeah. How are you able to maintain safe nursing practices? How are you able to keep the nurses safe?

12:10 Because everything had shut down. We were no longer having conferences. We were no longer having live in person meetings. So all of those spaces were opened up for the nurses. So all the conference space on the Kimbell floors was then open so that people were able to at least go in there and get something to eat, take your mask off for a few minutes because you had some extra spaces. All of the cafeterias were kept open 24 hours, so that that was also another place to go. And like I said, any empty space was just considered break space. So as long as it was empty, then you could use it. So that was really helpful.

12:51 What safety measures were put in place for patients and families?

12:57 So we, unfortunately, as you've heard, we were not able to let families in. We just didn't have the personal protective equipment that we needed to make sure that they were safe. So we had to restrict their visiting. And that was really hard on the staff. It was really hard on the patients, and it was incredibly difficult for the families. So they did create a family liaison team. So what that was, was there were medical students that they graduated early because we needed people. And there was a team of a couple of the doctors who, they would go on rounds with a computer, so they would do a webex for rounds. They would get information on every single patient. And then it was their responsibility to call the families with any updates that they had. And then they documented those updates in the chart, so that at least alleviated some of that pressure from the teams that were rounding and taking care of the patients. And then the families at least felt a little bit more connected to the patients. We also had a nurse liaison team. So those. Those nurses. And it was a rough job. Those nurses came in and were using iPads and would go into any patient room that the family member had called, and they would facetime with the patient and the family so that they were able to at least see their loved one. And then we were able, once we had more PPE, we were able to let families in, but usually it was at end of life, so that was very difficult. So we had to teach them how to maintain safety for themselves. We had to, you know, put the personal protective equipment on them, show them how to put the masks and the shields on, and then they went in and saw their loved one before they passed. So it was very emotional.

14:44 There was a lot of concern by people not in New York that were wondering why we didn't have enough PPE. But the PPE is usually used by clinicians and not necessarily by people in the cafeterias and people in the others. Can you explain that a little bit better so that people understand why there was a shortage of PPE?

15:07 Well, first of all, the amount of patients that required PPE was astronomical. So typically, even now, I would say maybe three patients in a 34 bedded ICU may require the staff to wear PPE in order to go in and take care of them. Now, it was 34 patients on a given unit that all require PPE. So that just made the number go higher. Then anybody who could be exposed to Covid at all needed to be in PPE. We also had community spread, so we needed to be in some form of PPE between each other so that we weren't spreading it to each other other. So there was always a mask being worn. But then once you went into the n 95s, if you entered a patient's room, you needed to have PPE. If you were. That meant if you were emptying garbages, if you were cleaning the floors, if you were cleaning the rooms after the patients left, if you were bringing food trays, if you were taking diet orders, any of those things, if you were social work and telling them where they needed to go from, you know, that room to the next steps, you needed to have PPE on. So it just. The sheer number of people that needed to wear it just was expanded exponentially. So.

16:27 So anybody who went into a room with patients that had Covid or were this sick had to wear PPE, whether it was a clinician or the cleaning crew, everybody had to wear PPE. It wasn't the patient wearing it. It was everybody who went into that room.

16:46 Exactly right.

16:48 What lessons, what positive things came out of COVID Were there any positive lessons learned?

16:55 Yeah, there was a lot of positive lessons, because our teams needed to spread out to cover all of these icus. We found that our HR people were wonderful and went through all of our list of nurses to see who had a critical care background, and whoever had a critical care care background they brought into the ICU. So we created new teams almost every day, and you had to learn how to really work well within your team. And we created new medical teams every day. So it just taught you how to work differently with different people and how to trust the people that were around you and that you could pivot the way that you needed to pivot was pretty amazing. The community was amazing. I don't think that we went without a meal for any shift for at least a month after Covid started. We were either getting them through charities or just people were cooking and leaving them for us. They were just absolutely wonderful. So that community love was definitely felt. I remember there was, I think it's even up on our website where little children had done chalk drawings outside of NYU saying, thank you so much. So that was very, very cute. So, like, those were all positives and that we could pivot, you know, that we did. We were able to pivot was pretty amazing.

18:20 I remember the New York fire department came around, too, and they surrounded the hospital, and all the firemen were on top of the fire trucks, clapping for the staff in the hospitals. That was beautiful. That was a very positive experience, too. Any lessons learned that you will do differently next time? For instance, one thing, you needed more ventilators, and you needed more ECMO machines. How did nurses learn to use those machines if they had never used them before? ANd now Their patient was on an ecmo machine.

19:00 So we have a fantastic eCMO team here, and Brigitte Tory was the leader of that team. What they did was they just educated. They, I think, educated 130 nurses over a period of just a couple of weeks. And at one point, our peak, ECMO was 30 patients we had on ECMO at one time, which was very unusual for us. I could look right now, and I think that we have four in the entire hospital. So 30 was a very big number. So we were just. They just taught as many people as they could teach. We had to. That's where we had to separate our teams a little bit, because KP 13 was the floor that ECMO was on, and we had actually moved them to KP 15. So we had to send some of our senior nurses who were equipped in ECMO just to give everybody a little bit of backup so that they had a senior person there as well as the new people that had just learned how to take care of ECMO. So we always made sure that someone was there. Our perfusionist really stepped up and stayed on the floor so that if there was anything that came up, they were on the floor, they were ready to take care of it with OUr ventilators. Our respiratory crew really took that on. Our supervisor came in and showed us the ventilators. And then we worked together and we came up with tip sheets. We had to use anesthesia machines. So our nurse anesthetists were wonderful. They came up and stayed up on the floors where any of those machines were, and made sure that they were there to troubleshoot them, so that any questions that people had, they were right there, they could answer. They were never really left alone. And the same thing with the ventilators and ECMO. And we housed all of our ECMO on one floor so that everybody had someone that knew how to do it.

20:50 Can you describe ECMO? A little bit? Might not be familiar to everyone.

20:54 So ECMO is extracorporeal membrane oxygenator. So what that, in essence, means is we have COVID patients who we were unable to oxygenate. They were not able to bring enough oxygen into their bodies to have it go into their tissues. So their lungs just were not capable of doing it. So what this machine does is it takes the blood on the outside of the body, it oxygenates it, and then brings it back into the body to reduce the work that the lungs had to do to oxygenate all those tissues. So the hope with this, also for COVID patients, was that we could rest their lungs a bit so that we would be able to let them Heal, so that they would be able to eventually come off ECMO and come off the ventilator. We actually had a very high success rate with the ECMO patients that we took care of. So that was something to be proud of.

21:45 That's great.

21:46 Yeah.

21:47 Are there any questions that you would like to discuss? Any things that you would like to discuss that maybe we didn't touch upon?

21:58 I think that our leadership support was amazing, actually, during this, we have a group in the leadership suite that, because they knew that we were afraid to travel, especially in New York, it's public transportation. Buses, trains. They were able to get parking lots to give us free parking, so that we knew that when we came in, we would be safely able to park and did not have to rely on public transportation. For anyone who lived with someone who might be immunocompromised or were just afraid to go home, because this was a scary time. They were able to get blocks of hotels so that if you worked three days in a row, you were able to stay in a hotel for that time and not have to go back to your family and not have to worry that you, you know, were infecting them, which was absolutely wonderful. I mean, it was. It was a scary time. And to be worried about your family on top of being worried about what you could be bringing home, at least that alleviated this worry. So I think that they really were looking at so many different ways that they could, you know, help to support us and help to support any. Anyone could have requested one of these beds, and anyone could park anywhere. It was not restricted to just nursing or medicine. It was anyone who worked in the institution. So I thought that that was a really nice thing and just lessen the burden.

23:29 Well, if we ever have another pandemic, it sounds like we've learned some lessons and we will be more prepared. Do you think?

23:36 I think. Well, it's funny. We did have meetings, post like debriefs, and we did sit down and talk about what worked and what didn't. We look back at our policies. We made sure that our policies were correct. We're still looking at our proning policy to make sure, you know, that we're doing the right thing and we're trying not to, you know, do any harm to patients while we're doing it. And they did come up with proning teams, which was great. Our anesthesiologists who weren't in the orlando, and our or teams were part of those teams so that they were able to go around and help us with that. So that was something that came out of this. So we have that already set. So if, heaven forbid, something should happen, we would be able to recruit those teams right back again. They did realize that they have to find a way to warehouse supplies more than they thought that they did. So there's a team that's working on that, so that there's supplies that should be readily available should this happen again. We took pictures of everything that we did. We took pictures of the equipment, cages. We took pictures of what the doors look like. So we gave report off of our glass doors, and all of that is going to be brought forward if this should ever happen again. So I think we did really, like, look at those lessons and say what worked, what didn't, and that's where I think our lavender team came from. So we have a team now for any staff who's feeling at all distressed by an event that happened on the floor or something that's going on, where you can call this team lavender, who can come and help debrief, either with the unit or with the individual staff to talk about what it is that is so distressing and how can we get you help and different relaxation methods and things like that. So that actually came out of COVID So that was another positive that came out of the pandemic.

25:34 Thank you very much, Mary. I really appreciate your time and sharing your experiences with members that will be reviewing this through the Library of Congress and storybooks. Story core. Sorry? Story core. Thank you very much.

25:50 Thank you so much for talking to me. Yes.

26:11 Okay, we're done.