Glossary
TL - Transformational Leadership

TL5: Describe and demonstrate how nurse leaders guide the transition during periods of planned or unplanned change

Findings

The first example, PCA usage, described how nurse leaders guided the transition during a period of planned change

  • Except for a request form to purchase the pumps, no other verifying evidence was provided for the various activities used by nurse leaders to guide the transition period that were described in the narrative

For the cardiac cath and critical care examples:

  • Verifying evidence was provided for the results of the change, not for how nurse leaders guided the transition during periods of change

Resolution

  • New Examples provided

Please note that I have utilized new examples

Planned Change

On October 29, 2012, Super Storm Sandy barreled through the Eastern Seaboard ranking as one of the deadliest storms in the United States history. The storm produced high winds of 115 miles per hour, and a storm surge of 14 feet leaving much of Jersey City under water.

Jersey City Medical Center has a long history of rising to the occasion during any emergency situation. Jersey City is a part of the New York metropolitan area and lies between the Hudson River and New York Bay and has eleven miles of waterfront. Our very location has predisposed us to many life threatening emergencies going back to 9/11 when many victims were treated at the Medical Center. Jersey City Medical Center was in a state of readiness to receive patients from the “Miracle on the Hudson.” When a plane was forced to land in the Hudson River.  Nursing Leadership in the Medical Command Center during Sandy  

Nursing Leadership in the Medical Command Center during Sandy

Education on managing emergency situations, (Appendix TL5-A, TL5-B, TL5-C ) both internal and external is mandatory for all leadership personnel. Simulated drills are conducted periodically to reinforce educational modules. Educational offerings to leadership personnel include an introduction to the Incident Command System, Incident Command System Resources and Initial Action Incidents, National Incident Management System (NIMS) introduction and an Intermediate Incident Command System for expanding Incidents.

The Thursday prior to the storm date, October 25, 2012, Rita Smith DNP, RN, CNO and Senior Vice President of Patient Care Services met with Bill Cook Executive Director of Facilities, Housekeeping, Dietary and Purchasing to discuss plans for the impending storm and a timeline for convening the management team to ensure adequate preplanning for the necessary resources. On the same day, Ms. Smith convened the nursing leadership team and the Case Management team to review all emergency plans to include staffing, patient census, need for supplies over the next week and availability of all essential personnel. Staffing plans were discussed based on the use of 12 hour shifts, relief plans, the need for housing staff and the availability of all per diem and agency staff. Nursing leaders spent two days finalizing these staffing plans. During the course of the next few days, Thursday and Friday, the nursing leaders and Mr. Cook as well as Ed Hvitfelt, Director of Purchasing, participated in huddles to update plans. On Friday morning, October 26th, Ms. Smith discussed opening the command center with Joe Scott, CEO to ensure that all departmental plans were coordinated through central command. During the session with all leadership in the Command Center on Friday, plans were made to open the center on Monday morning, October 29th, during and throughout the storm period.

Jersey City’s Medical Command Center (MCC) is the regional medical coordination center in Hudson County. This Command Center allows us to readily communicate with the Emergency Medical System (EMS), the Office of Emergency Management (OEM) and the Department of Health (DOH). The Command Center is the portal for all levels of healthcare and provides direct contact with all regional hospitals command centers.

As a result of lessons learned from Hurricane Irene, which occurred the previous year, we established a transportation plan for employees as well as a discharge task force, which assesses patients to be discharged in order to reduce the numbers of patients remaining in the hospital.

The State of New Jersey began preparations as early as October 26, 2012 prior to the storm. Voluntary evacuations began along the New Jersey coastline, in particular, the Barrier Islands. By October 28, 2012, the residents of Hoboken, particularly those occupying street level or basement apartments were mandated to evacuate. All air flights were cancelled in and out of local airports by October 27, as well as Railroad travel.

Nursing, following each emergent situation, had established mobile carts containing seven (7) days of supplies that could be utilized in the Emergency Department. The carts are restored and revised following each disaster and are maintained in readiness and kept in storage on the campus of the Medical Center. Our nursing staff is trained to immediately respond and mobilize in order to rapidly address any emergent incident.

Immediately prior to Sandy, the senior leadership lead by Ms. Smith assembled all of management to review a plan specific to the hurricane. The team insured that we would have enough medical/surgical supplies, food, water, generator fuel as well as sufficient staff availability. The Nurse Managers from each unit prepared a staffing plan that would insure coverage for the next three days. Rotating shifts were established allowing staff to work 12 hour shifts and insuring that enough staff would be available for coverage.

Administration established rotating shifts to staff the command center to include Nurse Managers, Directors and Vice Presidents.

A transportation system was established in order to transport all essential personnel prior to and immediately following the storm. Preparations were made to house and provide sleeping arrangements for all nursing staff and other essential personnel. Security prepared to secure the building to insure our safety. Facilities prepared to secure the building as far as flood control and fuel to run the generators.

Nursing leadership worked aggressively with physicians and Case Managers to reduce census in anticipation of reduced staff. Nursing staff collaborated with area nursing homes and the community in order to safely transfer patients prior to the storm, knowing that these institutions were on higher ground. Clinics, Outpatient Psychiatric services as well as all elective surgery and cardiac catheterization were cancelled.

Carpooling was established for nursing staff to insure that they could come to work and to minimize the number of vehicles located in a low lying area. Security arranged for the pick-up of all critical staff, nurses and residents and advised all staff who were driving to fill their tanks with gasoline. It was determined that patient visiting hours would be discontinued the day of the storm.

Erin Salmond BSN, RN, Nurse Manager of Critical Care was present throughout the storm and after and closely managed the Critical Care Units. Three days prior to the storm, working both from the hospital and home, she began to assess her nursing staff for the upcoming week, particularly that Monday (day 1 of storm) and Tuesday. She telephoned each and every staff member asking the following: where do you live? What is your availability? What transportation modality do you normally use? She assembled a list of personnel who would cover the unit throughout the storm. Additional staff members were recruited in order to assure that staff would be given time for meal breaks and sleep. On Sunday evening, the day prior to the storm, she spoke to the night shift and requested that they stay into the morning so that she could assess the staffing, they agreed. Water penetrating ED entrance during Super Storm Sandy  

Water penetrating ED entrance during Super Storm Sandy

The following day, October 29th, Ms. Salmond, along with the Case managers lead by Leigh Baillie, and the physicians downgraded as many patients as possible and either discharged them to home or to the long-term care facilities. This freed multiple beds on the unit for emergencies/trauma.

Ms. Salmond instructed the team on preparations for the storm, such as, insuring that ambu bags were available at every bedside, and ascertaining that all essential equipment was connected to red outlets (generator driven). She made sleeping arrangements for her nursing staff which was orchestrated through the Command Center, and, at her own expense bought snacks in for the staff.

Kelly Loo MSN, RN, Nurse Manager for Perioperative Services developed a plan pre-storm to insure that her areas of concern were covered. On Friday, October 26th, before the storm she reviewed the operative schedule with the Scheduler, Janet Nieves, and Dr. Landauer M.D., Vice President and Chief of Anesthesia, to cancel the elective procedures and to make a determination when they could be done later in the week. This being completed, and under Ms. Loo’s direction, the unit scheduler began the process of calling the patients and physicians and discussing an alternate plan.

Ms. Loo then determined the number of staff that she would have available starting on Sunday, October 28th. She determined that she would have two (2) open heart teams, so that they could relieve each other and three (3) regular OR teams. She requested that the Operating room staff volunteer who would be able to provide this coverage and the staff volunteered. All teams were required to stay in-house during the time period from Sunday to Tuesday (10/28-10/30).

On Monday, October 29th, all non-essential personnel were sent home by noon. The surgical supplies that were ordered were double the amount usually ordered. This ordering process started on Thursday, October 25th and was to be shipped the same day to be received on October 26th. Ms. Loo also ascertained that each anesthesia machine was equipped with at least one ambu bag and flashlights were distributed to all the rooms. Ms. Loo also insured that all essential equipment was plugged into the red outlets which are fed by the generator. Same-Day-Surgery and Pre-Admission Testing (PAT) Departments were closed on the day of the storm.

Nursing had planned well ahead and made ample preparations for the rain, wind and power outages almost certain to occur during the storm. We had ensured enough supplies and food were available to care for our nursing staff and for our patients. All of nursing leadership assembled periodically during the course of day 1 of the storm to assess and reassess the situation. As the storm began in earnest, nursing leadership, particularly Ms. Smith and Cheryl Owens MSN, RN Director of Nursing rounded on all the units on an hourly basis to address issues and insure that the units were adequately covered.

Unplanned Change

As the roads quickly became rivers, it became clear that we had not predicted the amount of flooding that would occur. Although we were prepared for the rain and the wind, it was the tidal surge that caused most of the flooding. Monday, the 29th began as business as usual, however, as the day wore on the rain and the winds became much more pronounced. By 9:00 PM, immediately outside the Emergency Department three (3) feet of water accumulated. Inside of the Emergency Department 4-5 inches of water was on the floor and it was rising. The ED staff, led by Michele Lopez MSN, RN, CEN, Nurse Manager of the ED, began to salvage the computer equipment off of the floor. They placed all equipment on stretchers to ensure that water damage would not occur. There were about 12 patients in the ED during this time period. Ms. Lopez informed Ms. Smith of the rising water in the ED and Ms. Smith, who was Senior Leadership in the Command Center, determined that the ED should immediately be evacuated to the second floor (Same-Day-Surgery) area. Ms. Lopez guided her staff into action as she began moving patients, staff and equipment to the second floor. She divided her staff so that as they moved the patients upstairs, staff remained with the moved patients and organized the supply carts as they were being brought upstairs. The code cart, the IV fluids cart and the emergency supply carts were all transported to the second floor. The response of the team was extraordinary. Everyone worked together to effectively transport patients.

Around this time the Medical Center lost power and water poured through the front door of the hospital and the ED doors. Facilities and Security sandbagged the doors in hopes of deterring the rising water, but to no avail. In the city, the police had closed all the Roads and bridges leaving the Medical Center virtually stranded. The hospital went on divert because of the inability to transport patients. Two other hospitals in Hudson County evacuated their patients and closed their doors during the storm.

During this time period in the ED, a cardiac arrest occurred. The nurses performed resuscitative measures on the patient with only limited generator lighting. Also, during this time period, a critical pediatric patient was brought to the ED. This patient was severely burned and in need of a helicopter to transport her to a Burn Center, however, because of the storm, no transportation was available. The ED nursing staff provided her with one-to-one care and insured that she was comfortable. Another patient was attempting to swim up to the ED, and was overcome by the currents and the rapidly rising water. Our Security staff swam out to rescue him and brought him into the ED.

Throughout the night, nursing manned the Command Center and continuously made rounds to the units. They made arrangements to transport the nursing staff into the hospital the following day, particularly those who lived within the city limits. Many bridges and roads leading into the city continued to be impassable and littered with debris.

The ED was reopened on Tuesday, October 30th at noon. Once the storm had abated, the tides receded and the roads opened we began to receive walk-in patients. These were people in the community who had homes damaged and/or had no power and needed assistance. People arrived in droves for a myriad of reasons, not all of them medically related. They couldn’t get prescriptions filled, they didn’t have food, formula or diapers or they needed a treatment which required electrical power. A tertiary Center was established at the nearby armory by the Office of Emergency Medicine to house and care for these people. Restoration of the ED post Super Storm Sandy  

Restoration of the ED post Super Storm Sandy

Cristina Simeone, BSN, RN, Nurse Manager for Critical Care, Mabel LaForgia MSN, CNL, RN, and Claudia Garzon-Rivera MSN, CNL, RN both Clinical Nurse Leaders in Critical Care took the initiative and established a holding area in the Same-Day-Surgery area. Most of the patients treated there were triaged from Ms. Lopez in the ED and in need of respiratory treatments, medication refills and food. This nurse led unit provided care to over 100 patients in need following the storm. Ms. LaForgia recalls one patient who had run out of hypertension medication. He brought his empty medication bottle to the hospital. Ms. LaForgia noted that his pressure was very high and obtained a dose of medication from the inpatient Pharmacy for him to take. She monitored his B.P. readings over the next hour until it returned to a more normal rate. She then obtained a prescription for a one-week refill for the patient. She further located the nearest opened pharmacy for him to fill his prescription.

Ms. Garzon-Rivera assisted a patient whose daughter was on a ventilator. They had no power to charge the battery on this equipment and it was extremely cold in their home as a result of no power. Ms. Garzon-Rivera insured that the generator was charged and that the suction machine was working properly. Since it was not safe for them to return home, Ms. Garzon-Rivera in collaboration with Ms. Simeone secured a spot for them and arranged transfer to the armory.

An ED physician, Dr. Bessette, was stationed on the second floor lobby to write prescriptions for people in need, directing them to our nearby Pharmacy which is located on the second floor. Many patients required methadone which was provided when necessary. Many of these patients walked from as far as Newark to obtain their medication.

Once again, nursing rose too the occasion and assumed a leadership role in ensuring that the patients triaged to the armory were provided with optimum patient care. Ms. Smith assembled nursing staff, Ebony Samuel RN, MSN-Ed, Nurse Educator, Nancy Rodriguez BSN, RN, Diabetic Educator and Jessica Babich MSN, APN, RN were dispatched to the Armory to assess and treat patients. All non-emergent health care issues were diverted to the Armory in order to ensure that patients who needed emergency care were provided for. Many homeless and displaced persons were housed at the Armory and EMS as well as National Guard personnel were present there. Ms. Samuel, Ms. Rodriguez and Ms. Babich assembled supplies and medications to take to the Armory with them. Most of the patients had respiratory needs. They rounded on all the patients and provided care and education as necessary. Ms. Samuel described one terrified family who walked from their home to the Armory because their daughter was experiencing an asthmatic attack. The family stated that it was very cold in their home and that helped to trigger the attack. A nebulizer treatment was given followed by oxygen therapy until the attack abated. Ms. Samuel convinced the family to stay at the Armory instead of going home because food, shelter and treatment were available there. The family elected to stay overnight. Another experience directly involved Ms. Rodriguez. A patient had depleted her supply of oral diabetic medication. Ms. Rodriguez was able to obtain more medication and provided her with a weeks supply. She also used the opportunity to educate this patient regarding her diabetes. One patient with AIDS had depleted his antiviral medication and Ms. Babich insured that it was provided to him. The table below demonstrates consecutive nursing leadership hours provided throughout the storm, nursing staff also contributed many consecutive hours. For evidence of FTEs and salary expenses during and after the storm please refer to (Appendix TL5-D)

Nursing Hours (Consecutive Nursing Leadership Hours during Storm)

   Nursing Hours Table

Total Number of Nursing Hours=476 and 661 (Working hours for the week)

Following the storm there were long-lasting power outages. Power was not restored for up to eight (8) days. This resulted in a massive gasoline shortage in the New York/New Jersey areas. Long lines for gas for both cars and emergency generators formed and often were 3-4 hours long. This became a dilemma for insuring that professionals could get to work. Our President and CEO, Joe Scott appealed to the state and a gas station that catered to medical personnel was opened so that staff did not have to wait in line for gas.

 Front of hospital during Super Storm Sandy

Front of hospital during Super Storm Sandy

Please refer to Appendix TL5-E and TL5-F for media coverage of the storm.

Remediation

Assessing the damage after the storm began immediately after flood waters receded. Many millions of dollars in renovations were performed in the Emergency Department and the entire first floor of the Medical Center. Many of the hospital employees vehicles were destroyed as a result of the storm and eight (8) of the hospitals 42 ambulances were lost. During the process of renovating the ED we borrowed a mobile ED van from a neighboring hospital so that services to our patients would not be disrupted during the renovations. This van was fully equipped with x-ray, monitoring devices, medications and telephones. Michelle Lopez planned and managed the use of this mobile unit. She determined the type of patient, the staff coverage, hours of use and transition of patients seen in the mobile unit. Ms. Lopez determined that all patients would flow through triage and then be transitioned either to the mobile unit or to the main ED. Even though the unit was equipped to take care of all patients, except maybe trauma, she decided that only level 4 and 5 patients would be seen there. This unit was primarily used for the Fast Track patients. This unit remained operational at the Medical Center for a 6 week period.

As far as the remediation process, the ED nurses, under the direction of Ms. Lopez and Kim Palestis BSN, RN, CEN Assistant Nurse Manager of the ED, determined where the work would start, and how many bays could be down at a time. Vicki DeChirico MSN, RN CIC, Infection Control Director provided guidance and oversaw the entire project. The work started in Fast Track which was initially moved to the mobile unit. Next was Trauma and the first three bays in the ED were temporarily used for the Trauma patients. Ms. Lopez coordinated the work flow with the ED and Trauma physicians, Security, EMS and Housekeeping. The nursing team met with Facilities on a daily basis to make certain that the work was progressing and all required precautions were in place. As a result of the flood much of the cabinetry needed to be replaced. Nursing decided at that time to redesign the rooms and remove all cabinetry and institute all mobile carts for more flexibility and space in the rooms. This work was completed well within the allotted time frame even though we were seeing high numbers of patients.

Lessons Learned

As a result of Sandy, blueprints have been drawn-up for a $7 million dollar flood prevention system that will include a wall which surrounds the facility to decrease the chances of flooding. Ambulances have since been replaced and the hospital reimbursed all employees their insurance deductible for the loss to their cars. Please refer to Appendix TL5-G for after action report.

Other lessons learned included setting-up a secure well-care site off the premises prior to the event, request for the mobile ED before the event since we are in a flood area, secure Gas for employees, and establish a car-pooling list starting from where employees actually live that can be a workable list to use in any emergency, consider a day care facility for nurse’s children during the storm and secure safe parking on higher ground.

Specific issues pertaining to nursing involve caring for the nursing staff who are working long shifts such as providing movies for relaxation, establishing a lounge for downtime, providing healthy food and snacks and extra scrubs for them to wear.

Although Super Storm Sandy wreaked much devastation locally and statewide, our teamwork and commitment to our patients and our community prevailed. Some nursing staff went above and beyond by reporting to work after being evacuated from their homes, and despite their own personal losses they worked long hours to provide care to our patients. The nursing staff also pulled together, rallying around those coworkers who had lost everything in the storm, providing food, clothing, money and emotional support.