COVID-19 Special Report: Lessons in returning to the fundamentals of patient care

For Rachel Hartley — an ICU nurse — COVID-19 has meant paring down to the essentials.

Hartley quit her job at a Lynchburg, Virginia, hospital in the early days of the pandemic to pack up and make the 35-hour sailing voyage to the epicenter of the pandemic: New York City. For eight weeks, she and her husband lived on their 50-foot boat named "The Turning Point" in a marina on the banks of Brooklyn while she worked in a nearby ICU. 

They were accompanied by friends who were also healthcare providers working in New York.

"It really blew us away. That was definitely when COVID was peaking in New York City and what we saw in the hospital and what we walked into was just unreal," Hartley said.  

And while it was a stressful time, Hartley said it was also a lesson in getting back to the fundamentals of patient care.

As she joined dozens of other travel nurses helping at the hospital in the midst of a crisis, the typically strict documentation rules fell away, becoming secondary to patient care and safety measures. She was reconnecting to the part of her job she loved most: patient care. After her eight week stint was up in New York, she and her husband set sail again for Connecticut where she was set to begin a new contract with Yale New Haven Health.

Here's more from a recent conversation with her about her experience.

Fierce Healthcare: How did you decide you wanted to make this leap to travel nursing in the beginning of the pandemic? 

Rachel Hartley: My experience and my background, especially in ICU nursing, really was what motivated me to quit my job in Virginia. I was working in the operating room world and we had slowed way way down. Elective procedures weren’t happening. We were only doing a few cases here and there so I wasn’t needed. And I saw how desperate New York was for ICU nurses, specifically. So it took a couple of weeks just thinking about it and praying about it. The one thing I was hung up on was, I didn’t have a New York state nursing license. When Governor Cuomo removed that requirement to have the New York State license, I was like: “OK, this is real." 

FH: What did you have to do to prepare? 

RH: I reached out to a travel company that had contacted me previously ... within 48 hours, I think I’d already talked to NYU Langone Health in Brooklyn and signed a contract. We set sail a week later. It was really quick once we decided to go. ... Our boat is three hours from our home in Virginia. So I still had to work out the rest of the week so my husband and some friends we had and some local businesses really pitched in to get the vessel ready. We’ve never actually lived aboard. The boat is definitely equipped for it and the previous owners did live aboard. But there were a few things here and there we had to fix and we had projects we had to do just to get it ready for the passage. Then I had to go tell my employer what I was doing. They were able to let me leave with only giving them a week while still being able to resign in good standing. That was really great. 

FH: What was it like arriving in New York? 

RH: We arrived Easter Sunday, it was really cold and windy. It was a really harsh spring in the city this year. We got to settle in for two days and then I settled at the hospital. We had a dear friend with us who is a physician assistant student and she was doing some volunteer work in the city. Another friend Tom, an ICU nurse working in the same hospital as me, came that first week we were here. We were all getting ready, going to the hospital and getting trained. It really blew us away.

FH: How so? 

RH: I think the sheer amount of patients that have COVID was just overwhelming. It overwhelmed the whole hospital system and its staff so much so they had to transform different units and recovery rooms, med surg units into intensive care beds. They had to double up a lot of care rooms with two patients in each room just to accommodate the volume of patients. We were just two of 122 ICU travel nurses they had hired from across the United States. That number is insane because NYU Brooklyn is not a huge hospital. They normally have 26 intensive care beds. When we got there, they had transformed over 100 intensive care beds. It was just absolute chaos. With COVID itself, there was so much unknown. There still is. We still don’t fully understand the disease or the best course of treatment. That was interesting working with the different providers, the physicians, the nurse practitioners, figuring out what is it we can do for these patients. We don’t know. That was wild.

FH: What was the condition of the patients you were seeing? 

RH: Once the patients hit intensive care, I think upwards of 90% of them were intubated and sedated. They were already very sick by the time they got to me. They were some of the sickest patients I’ve ever taken care of. They were on multiple medications: blood pressure medications, sedation, pain medication, paralyzing medicine, a lot of them ended up on dialysis because their kidneys were failing quickly. We had to put a lot of them on anti-coagulation therapy. I mean for me personally, I never saw a patient get better. I know that there patients that were. I was never personally involved with a patient that did turn around and recover from this.

The majority of my experiences was in Ohio at a Level 1 trauma ICU and the acuity there was some of the highest acuity in the state of Ohio. So I’ve seen a lot of people die and some really sick or injured people. That exposure did prepare me in a sense. But I’ve never seen 100% of my patients die like that before. 

FH: Wow, that must have been jarring. What was it like at the hospital as you finished up your eight week stint there? 

RH: I kind of look at the hospital and say: What happened to COVID? In a really good way. Things are really quiet and I hate saying that word as a nurse. Our unit last time I was there had six COVID ICU patients and I don’t think any more than 15 COVID patients in general in the whole hospital while back in April, 90% of the patients had COVID. It was a huge turnaround. Of course, it's still really far away from normal. 

FH: What were some of the biggest lessons you think can be learned from your experience with COVID-19?

RH: Especially in the beginning, it felt like we were nursing in the wild Wild West. Just going in there it was a free for all in the beginning. They were like: Get in there, try to keep your patients alive, do your best. There was not a big emphasis on documentation because there wasn’t the time to do the training. There was so much focus on actually caring for the patient which was really cool to see because I think that’s something in healthcare that I think can be lost amid the need for all the documentation and managerial oversight and whatnot. It was good to just get back to medicine and nursing. 

Another big thing that stood out was the need for flexibility and real teamwork. We were constantly having rapid response calls and code blues. We really relied on our team heavily. All these nurses and these providers are from all over the U.S. and have never worked in this hospital before and aren’t familiar with what the typical polices are. It was really stretching and challenging for everyone. But we had this shared feeling of unity and desire to help. We were one in our goal in our minds and our compassion. It was nice to be able to join a team like that. 

FH: What are some of the changes you think might stick in healthcare? 

RH: It’s hard to say what changes are going to be permanent versus what are just our anxieties playing out.

Our hospital had a system where we had to check our own temperatures and disclose if we had any symptoms. If we couldn't do that ahead of time, you could get screened when you walk in. So some system like that is going to be in place for a while. In terms of the visitors policy, probably won’t be in place too much longer and I hope they don’t because they are very important to the families and loved ones so patients can have support networks. I hope that can be safely lifted soon. Mask wearing, I think, it going to be around for a while with healthcare workers especially.

But also, there is a saying in healthcare: "If it’s not documented, it’s not done." I think especially with the era of the electronic health record, we’re all about document, document, document. It’s really important. but in a lot of ways our system has flipped to an extreme. We’re clicking all these boxes and making sure our charts look perfect when that takes so much time away from the bedside and can preoccupy our healthcare workers with our focus on our computers rather than our patients.

Walking in at the beginning at the peak of this pandemic, there was just so much that the hospital system had to say: you know what: You don’t have to do all of this documentation. They cut things in half and I think a lot of that had to do for time's sake. Part of it was: there’s a whole bunch of nurses now that have never used your computer charting system before which is a challenge in itself and it reduces the amount of time we had to be in the room and exposed to the COVID, which was a factor too.

But it allowed us to go into the room, assess the patient, care for them, give them meds, whatever we’re doing for them and not just be standing behind the computer the whole time. I really enjoyed that.

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