Zhao?Jia WANG, Yan?Rong SUN, Jing ZHANG,Hui JU, Ling TANG

1Coronary Care Unit, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 2Outpatient Department,Economic Development Zone, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China; 3School of Nursing, Beijing University of Chinese Medicine, Beijing,China; 4Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, Beijing, China

ABSTRACT

Objective: To explore the application of feedforward control in the nursing emergency management of COVID?19.

Methods: The feedforward control theory was applied to the emergency management of COVID?19 nursing, including grasping the latest epidemic information, preparing for the early stage, formulating nursing workflow, implementing flexible management, standardizing isolation and protection measures, unifying nursing document record format, and implementing humanistic care.

Results: During the period of support to Wuhan, the nursing work in the isolated area was orderly, the nursing staff's job satisfaction was high, no nursing errors and hospital infections occurred.

Conclusion: Efficient feedforward control in the nursing emergency management that could avoid work blindness to a certain extent and play a guiding role in maintaining the normal operation of treatment and nursing work and protecting the safety of patients and medical staff in the ward during the epidemic period of COVID?19.

Keywords: COVID?19, feedforward control,flexible management, infectious disease, nursing emergency management

INTRODUCTION

Since December 2019, new infectious diseases caused by novel coronavirus belonging to the beta genus have emerged in China. The disease, named COVID-19, is predominantly attacking the lungs. COVID-19 is an acute respiratory infectious disease with rapid transmission and wide infection range. It is mainly transmitted by droplets and close contact. The population is generally susceptible; the elderly and people with underlying diseases are seriously ill after being infected; and severe patients rapidly progress to acute respiratory distress syndrome, septic shock, metabolic acidosis, and coagulation disorders that are difficult to correct and even brings death to patient, which all seriously threaten social stability and human safety.[1]Due to its unpredictability,urgency, complexity, and variability, COVID-19 epidemic indeed leads to serious challenges and tests in the nursing management.[2]As a key place and outpost for discovering and treating infectious diseases, hospitals play an irreplaceable role in coping with and controlling them and are an important part of the emergency system,[3]while nursing work is an important part of hospital work, and efficient nursing emergency management is also particularly important in the face of major epidemics.Feedforward control, also known as precontrol, refers to the prediction of the consequences of management activities before the start of management work and the adoption of preventive measures so that possible deviations can be avoided in advance. It is an effective and preventive control method to reduce the losses.[4]As one of the first batch of medical teams from the Dongfang Hospital of Beijing University of Chinese Medicine in support of COVID-19 frontline in Wuhan, Head Nurse Wang Zhao-Jia applied the feedforward control theory into emergency management of the epidemic outbreak and summarized the nursing experience of COVID-19, to provide reference for the nursing of patients with COVID-19.

GENERAL INFORMATION

In order to ensure the high efficiency of the antiepidemic work, reduce the occurrence of adverse events, and conform to the principle of humanism, the members of the nursing team met the following conditions: (1) all members declared that they were volunteers and obtained their families’ support and consent through communicating with them, (2) they had working foundation in the respiratory department, intensive care unit, etc., and (3) they were required to have strong antipressure ability and adaptability in the high-intensity work in the epidemic area. All members were selected through the Department of Nursing, Dongfang Hospital of Beijing University of Chinese Medicine, including 12 nurses.The general information of nurse team is shown in Table 1.Members of the medical team formally entered the isolation ward on January 31, 2020, after prearranged coordination,formulated nursing workflow, and protective training.

FEEDFORWARD CONTROL EMERGENCY MANAGEMENT OF COVID?19

Paying close attention to the latest information on epidemic situation

The information of epidemic situation was checked every day through the network and news platform. We paid a close attention to the trend of epidemic situation and early warning information, understood the various guidelines of diagnosis,treatment and prevention and control recommended by domestic authorities, and grasped the latest effective treatment and nursing programs in time.

Making effective communication and timely preparations in advance

At the beginning of arrival in Wuhan, facing unknown and severe situation, a rapid, timely, and necessary preliminary preparation is the first step to carry out work smoothly after entering the isolation ward. Effective communication is the premise to complete the preliminary preparation quickly.Through communication, nurses, doctors, and managers can obtain complete information, make and implement correct decisions, greatly improve the efficiency of nursing work, and achieve twice the result with half the effort.[5]To ensure that the isolation wards were delivered on time and protective measures were in place, the following issues were communicated with local hospital leaders. The first issue was nursing staffing. In the early days of the outbreak,the patients admitted in the ward were all suspected cases,one case in one ward. Due to the shortage of protective equipment, each shift of nurses was arranged to last as long as 6 h for the maximum duration of protective equipment is 6 h. The “three, three, two, and two” mode was adopted for scheduling. The specific scheduling mode were as follows:The first group consisted of three nurses: from 7:00 a.m.to 1:00 p.m.; the second group consisted of three nurses,from 1:00 p.m. to 7:00 p.m.; the third group consisted of two nurses, from 7:00 p.m. to 1:00 a.m.; the fourth group consisted of two nurses, from 1:00 a.m. to 7:00 a.m.; the remaining two nurses served as the mobile group and were on standby at any time in case of shortage of hands or special circumstances. The second issue was the preparation of nursing supplies. In order to ensure the safety of patients and nurses, the local hospitals were requested to be equipped with a certain number of protective articles and safe nursing supplies. The other issues were the rational placement of protective equipment and connection of nursing work inside and outside the isolation ward. The above issues were solved through the effective communication.

Table 1: General information of the nursing team

Establishing nursing workflow and on?duty responsibility system

During the period of waiting for ward reconstruction,members discussed some issues with each other, such as what preparations should be made in the early stage, the progress of ward reconstruction, what solutions should be taken after communication and coordination with the local hospital for the existing problems, so that each member had a specific understanding of the work progress. At the same time, through communicating and coordinating with other hospital leaders and teachers of the medical team, we unified their opinions and laid a solid foundation for the subsequent smooth nursing work. The last nursing work meeting was held the day before entering the ward, and the specific nursing work arrangement was made to guide the members in nursing work, including nursing operation required by various treatments, patients’ life care, cleaning work, and meal delivery in the ward, as well as handover work with other nurses separated from the ward. The importance of protection and safety first were emphasized again. The persons on duty shall be responsible for the overall situation of the ward, including disinfection and isolation,water and electricity safety, setting and placement of fixed articles in the ward, nursing of patients’ condition, all kinds of drainage pipes and intubation pipes, skin state of patients,and treatment required for patients. On the 1stday, the three persons on duty unified the 24-h work flow and sent it to WeChat group to provide reference for the members who would enter the isolation ward for nursing work in future.

Performing scheduled workflow andflexible management

Traditional Chinese medicine (TCM) nursing pays attention to “holistic concept”, “nursing based on syndrome differentiation”, “prevention first”, “special disease,special nursing”, and “innovation and improvement”. TCM,especially emphasizes “innovation and improvement”, in which “innovation” refers to the innovation of TCM nursing practice mode, “improvement” refers to the improvement of specialized nursing level, meeting the diversified health needs of patients, and expanding the scope and responsibilities of nursing work.[6]In the implementation of the nursing workflow, the characteristics of TCM nursing were highlighted. The health problems of patients were analyzed and judged through the methods of dialectical nursing, and finally, nursing diagnosis was made.

Many unknown possibilities in the outbreak of COVID-19 made nursing work face various problems. Therefore, the implementation of flexible management is particularly important to ensure that the staff on duty are sufficient and the staff off duty can get sufficient rest. When an amount of patients with COVID-19 admitted made the workload of the ward increase sharply and resulted in a shortage of nurses on duty, through active consultation with the local hospital,two more nurses were sent to assist the tasks of day shift and night shift. When the patient’s condition in the ward tended to be stable, and the treatment times also decreased, the implementation of flexible management allows the nurses to have a full rest physically and mentally. In addition, we changed the original “three, three, two, and two” mode to“two, two, one, and two” mode, specifically, two nurses in the first group, from 7:00 a. m. to 1:00 p. m.; two nurses in the second group, from 1:00 p. m. to 7:00 p. m.; one nurse in the third group, from 7:00 p. m. to 1:00 a. m.; two nurses in the fourth group, from 1:00 a. m. to 7:00 a. m. This mode can allow more nurses to have a full rest, which is conducive to reserve follow-up strength.

Standardizing isolation and protection to ensure the safety of the ward

Correct and effective personal protection is a powerful measure to control cross infection and protect human resources.[7]Improper use or lack of use of personal protective equipment is one of the important factors in the occurrence of infection of medical personnel. The wrong use of personal protective equipment may even increase the risk of infection exposure.[8,9]During the period of waiting for the ward to be delivered for use, all members of the medical team strengthened disinfection and isolation knowledge and personal protection education and repeatedly practiced wearing and taking off protective clothing because protective clothing is the only guarantee to ensure safe access to the isolation ward. Every member of the medical team must be proficient in it to ensure that there was no risk and be familiar with the spatial distribution of isolated disease areas to ensure that the protection process was flawless. Before entering the ward, they were led to go through from the entrance into the ward, familiar with the treatment room,warehouse and office of the ward, then from the infected area to the semi-infected area and finally to the buffer room.The important process links and precautions were repeatedly emphasized, with the disinfection and protection process chart pasted on the door of each area for reference to help and urge everyone to implement the protective measures to ensure their own safety. In addition, the in and out process of all kinds of articles and logistics support were clarified to ensure the orderly flow of medical waste, disinfection articles, contaminated articles, specimens, etc., so as to prevent cross infection.

Unifying the format of nursing documents to keep efficient work

The computer network in the isolation ward was limited,and the writing of nursing documents cannot be completed in the isolation ward. Each shift could only rely on A4 paper to record the vital signs of patients, treatment and nursing,shift handover of special patients, and then, sent photos to the nurses outside the isolation ward for computer recording.The format of each shift record was different and messy, which was not conducive to the smooth handover of nursing work.In the face of these problems, a unified nursing shift record form had been developed. By unifying the nursing shift record format, it was convenient for nurses to record the patients’condition, highlight the key points of nursing, and make the nursing shift work in an orderly and efficient manner.

Implementing humanistic care and gathering team strength

The occurrence of all kinds of sudden epidemics has brought huge psychological burden to the front-line medical staff,which makes them in a state of severe psychological stress,seriously affecting the physical and mental health of medical staff, and the quality of medical care.[10]In view of this,teachers were specially arranged in the team to take care of the members’ lives, so as to ensure that each member was in the best physical condition. At the same time, in the case of minimizing the assembly, the team leader teacher chatted with each member after work, understood their psychological status, grasped each member’s psychological dynamics,relieved their fear, anxiety and other bad psychological emotions, and kept them in a good psychological state.By forwarding some positive energy reports or articles to WeChat group, the medical team members could feel full of positive energy and enhance their determination to overcome the epidemic. During the rest time, members relieved the psychological pressure by doing Baduanjin exercise and other things they like. The application of humanized management in daily nursing management can effectively relieve the psychological burden of nursing staff,improve the work enthusiasm of nursing staff, and reduce the failure rate of nursing work.[11]At the same time, we should establish a co-operative mode between doctors and patients to encourage nurses to strengthen communication between doctors and patients in their work. Nurses play an active role in the relationship model of “doctor-nurse-patient,”in which model, nurses convey doctors’ advice to patients through daily care.[12,13]In addition, nurses play a leading role in team cooperation, which not only significantly improves the working environment of nurses but also improves the quality of medical services.[14]

DISCUSSION

Satisfaction of antiepidemic nurses after the emergency management of feedforward control

A month after the COVID-19 management mode was implemented, the nursing department of the hospital conducted a survey on the satisfaction degree of the staff members who went to Wuhan to participate in the fight against the COVID-19. The findings are shown in Table 2. In terms of personnel arrangement, 83.33% of the nurses werevery satisfied, 8.33% of the nurses were relatively satisfied,8.33% of the nurses felt general; in terms of the adaptation degree to the anti-epidemic work, 58.33% thought they were very adaptable, 41.67% said they were relatively adaptable,and the overall adaptability was good; 58.33% of the nurses were very satisfied with their work status and adaptability,41.67% said it was relatively satisfactory. In addition, 25.00% of the nurses said that they were not comfortable with the work intensity in Wuhan at the beginning, which made them feel exhausted, and 75.00% of the nurses said that they would not feel exhausted. In response to the work of fighting against the epidemic, 12 nurses all expressed positive attitude and good working condition, but some nurses also raised such issues as “inadequate protection at the initial stage of the epidemic”, “a little long working time”, “the proportion of nursing staff should be increased”, etc., It can be found that most of the nursing staff supporting Wuhan can adapt to the feedforward control nursing emergency management mode.Under this management mode, they can maintain a positive working attitude and state and get enough rest time.

Table 2: Survey results of satisfaction of nursing antiepidemic personnel

Significance of feedforward control in the nursing emergency management

Feedforward control is a part of control theory mainly to evaluate unsafe factors and intervene in advance before a certain work starts. Applying feedforward control to hospital infection management can control all kinds of unsafe factors before various operations and control unsafe factors in the bud.[15]A previous study[16]show that the application of feedforward control in nursing risk management of respiratory medicine can ensure the safety of patients and prevent nursing risk events. Some researches[17]have applied the theory and method of feedforward control to the nursing management of influenza A (H1N1) epidemic situation and achieved better clinical effect. Studies[18,19]showed that introducing the management concept of feedforward control into catheter safety management, analyzing the risk factors of catheter infection, and formulating relevant management measures can reduce the incidence of catheter adverse events and catheter-related infections.

After collecting and sorting out the known information,through the feedforward control theory and method,effective communication and coordination shall be carried out before the formal work is carried out, sufficient preparation shall be made in the early stage, and each process shall be coordinated and unified, so as to avoid work blindness to a certain extent and increase the safety of the operation and the reliability of the measures. At the same time, emergency management can ensure the orderly work of medical staff,stabilize the structure and quantity of medical staff, reduce the psychological obstacles and bad emotions of medical staff, and effectively strengthen the success rate of treatment and nursing quality.[20,21]

In conclusion, COVID-19 is characterized by sudden onset,complexity and severity of the patient’s condition and wide spread range, which seriously damages the public health. To deal with the epidemic outbreak, we need to face great risks,and there are uncertain factors in every link. Therefore, active,effective, and timely feedforward control of the nursing emergency management plays a guiding role in maintaining the normal operation of treatment and nursing work and protecting the safety of patients and medical staff in the ward.

Acknowledgment

We would like to thank Peng-Zhi ZHANG and Xue-Song WANG for their assistance in nursing workflow sorting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.