I am writing to recognize the entire nursing team of the Cardiac Care Unit (CCU) at the Hospital of the University of Pennsylvania (HUP). In February 2020, hospital leadership was just beginning to plan for the anticipated COVID-19 pandemic that seemed to be moving across the globe. Part of this planning included the designation of specific units for COVID to concentrate the resources needed to provide high-quality care while protecting staff. Because the virus we were facing was new, we knew that there would be a large amount of rapidly evolving information and guidelines on how to care for these patients while reducing transmission between patients, providers, staff, our families and the community at large.
As we know, even the best-laid plans often go awry. One Saturday, in early March, the first COVID positive patient was admitted to HUP and to the entire Penn Medicine Health System from an outside hospital with a strong suspicion for COVID given his clinical presentation and recent travel history. Upon receiving report, the nurses in the CCU quickly identified that this patient was likely coming into the health system with a novel infectious disease and special attention should be given to this situation. Although the ordered level of isolation was droplet and contact, the charge nurse quickly identified that it would be safest for this patient to be admitted into a negative pressure room, and that staff should be wearing proper PPE. N-95 masks were already removed from the supply rooms in order to regulate their use, and PAPRs were not something we had been trained on their use. There were no critical care practice guidelines, subject matter experts, or signage to walk the staff through donning and doffing of PPE. The patient was incessantly coughing as the providers stood close to provide care as his oxygen requirements escalated until finally he was intubated. The CCU staff ensured that all staff and providers were aware of needing to utilize the highest level of PPE out of an abundance of caution.
Over the next day or two, nurses took the initiative to independently review the CDC recommendation for PPE and proper donning and doffing technique. Each shift, the primary nurse and charge nurse partnered to review the procedures for proper PPE use, make sure they had the proper equipment, cluster care while limiting exposure to any other staff and develop a plan for communication. They carefully supervised each other, assisted each other, supported each other. All of this was unfolding over a weekend. The nurses reached out for support and their fresh leadership team helped to mobilize the resources the nurses needed immediately. The CCU nurses were at the core while the entire hospital focused on watching us solve challenges and overcome obstacles associated with the many aspects of caring for the first patient with COVID in the entire health system.
Over the next few days, while HUP's index patient remained in the CCU, things changed rapidly, sometimes during the course of a twelve-hour shift. The questions came fast and furious: What PPE was required, what PPE was single patient use and what could be decontaminated, how frequently could these be decontaminated, can they be shared between providers, should we be limit sharing in the same shift, how will lab samples be handled, how will we communicate with the nurse in the room, how will we do rounds, are we at risk, will we be tested, will other patients in CCU be at risk, can this patient travel to the operating room or do a diagnostic test, can I get scrubs, can I cover my hair or shoes, should I be quarantined from my family?
They continued to raise great questions, suggesting workflows that worked and giving feedback about challenges, pushing the unit and hospital leadership to provide guidelines quickly that were based on what little evidence existed. Although everyone was affected deeply by the pandemic coming to our front door so unexpectedly, the team in CCU did a tremendous job at remaining professional. It was a difficult shift for a group of nurses who so value the health of their patients to ask them to turn their focus to protecting themselves, as they were now the resource that had to be conserved for the greater good. Asking them to take their time to put on proper PPE before responding to a clinical emergency was like asking them to betray their Nightingale pledge, but they understood the rationale and they remained focused on the big picture.
Once the COVID units were established, CCU leadership advocated to have this individual cohorted with these patients, but the family strongly opposed this idea citing the excellent care that had been delivered thus far. Eventually, the patient was transferred, but only for a short period of time before he came back once he was able to clear the virus. Although the media likely had rumored him to be one of the first mortalities, this patient is still alive, fighting for his life in the CCU with the help of our amazing team of nurses and support staff. I am simply not sure he would be alive had he been taken anywhere else. What stronger outcome is there to measure?
CCU is often overlooked, likely because of its smaller size. History will often remind us not to overlook the little guy. Although CCU has less than 50 staff members, each one of them embodies the values and mission of this hospital. We are Penn Medicine. We are relentless. We are CCU.