By Jeanie Davis
A dramatic dip in emergency department (ED) volume has been a concern for hospital providers across the country. People experiencing stroke, heart attack, and other serious symptoms have been avoiding hospitals, fearing coronavirus, according to reports.
How can a nurse case manager calm fears in new patients? In Nashville, one nurse practitioner has been on the front lines with this situation.
As the region’s only Level 1 trauma center, it is critical to reassure people, says Jessica Van Meter, DNP, MSN, RN, APN-BC, CCRN, A-EMT, an emergency and Life Flight nurse with Vanderbilt University Medical Center.
“We’ve always had sympathy for patients coming into a hospital filled with sick people, especially at peak times like flu season,” Van Meter says. “This unprecedented pandemic has really given us greater perspective on how patients may feel and the fear embedded in them about coming to the emergency department.”
In the regional media, Vanderbilt took proactive steps to educate the public via multiple news stories. “We wanted to reassure people in our area that we remain open and are here to meet critical needs despite the COVID-19 crisis,” says Van Meter.
A hotline staffed by nurses helped with patient triage so patients would know if an emergency visit was necessary or if their symptoms could be managed at home. Telehealth calls also are available to connect providers with patients to add reassurance that emergency staff are ready to care for them.
Vanderbilt has long provided limited telehealth services, especially in assessing stroke symptoms. The pandemic vastly increased the range of services telehealth can provide, as the Centers for Medicare & Medicaid Services lifted many restrictions on these services.
“If you’re at home and have health concerns, you can chat with a nurse practitioner or physician via FaceTime or Zoom, walk through the symptoms, and determine whether you should be seen in urgent care, a primary care clinic, or the ED,” Van Meter says. “We hope this trend is sustainable. This could really change healthcare in a positive way going forward.”
The ED is triaging patients in two locations: one for respiratory and/or COVID-19 symptoms, another location for non-COVID-19 patients, including cardiac, stroke, and trauma patients. All healthcare providers are screened for symptoms every day to ensure a healthy workforce. Limited visitation also has kept patient care areas safe.
“Communicating all these measures to patients has helped relieve anxiety,” says Van Meter.
Despite these precautions, patients still express COVID-19 fears. In some instances, delays in treatment of stroke symptoms has led to “really devastating” results, she says. “There have been a few sad situations where the family waited outside the window for tPA or necessary interventions. It’s been difficult wondering if circumstances would have been different if they would have come in right away.”
Some patients think symptoms may resolve if they wait it out. For example, diverticulitis is a common problem seen in the ED. “We educate patients that it can be managed at home with antibiotics and a telehealth call with their primary care provider,” says Van Meter. “They can even have the local pharmacy deliver medication to avoid coming into the pharmacy. There really is no need for an emergency visit.”
Many media reports focused on protecting vulnerable populations, especially the elderly and children, by keeping them at home instead of the ED. However, Van Meter says Vanderbilt’s media messages have focused on explaining the vulnerability and the need for treatment in a timely manner, “or face the risk of worse outcomes.”
Vanderbilt’s media message also applies to abuse, she explains, as both adults and children are at greater risk for abuse during this time due to stress and social isolation. Children are at high risk as they are isolated from people who can help them, like neighbors and teachers.
Crisis lines can provide guidance and resources. Emergency services and police always are options for those in threatening situations at home, Van Meter adds.
In calming a patient’s anxieties, the most critical factor is separation from family caused by limited visitation. “We ensure that patients have their cellphone and charger so they can stay in touch,” Van Meter says. “Even though we previously discouraged patients from using cellphones in certain hospital areas, we’ve relaxed that rule. It’s much more important that they have contact with their families.”
Families and patients receive iPads so they can FaceTime with family members, she adds. “The whole situation is stressful, and anyone coming to the ED will have to be alone without family during admission — which adds an extra layer of anxiety,” Van Meter says. “The ED nurses have really tried to step up and be reassuring to meet the patient’s needs, including emotional needs, as best we can, and facilitated communication with loved ones.”
Her Life Flight team also has taken steps to ensure more communication with families about medical transport patients. “We always have called to inform them we’ve arrived safely,” she says. “Now, those calls last a little longer because visitation is limited.”
One positive aspect of the situation, she says, is the decline in automobile-related trauma cases. “Because of the stay-at-home orders and the focus on working from home, we’ve had far fewer commuters — resulting in 65% decrease in trauma cases from a year ago. We attribute it to the drop in road-related accidents,” she explains.
There also has been a drop in primary care issues treated in the ED, she reports. “This gives us a bit more time to talk with patients and decrease their anxiety in a much more therapeutic way than is usually possible.”