Clustering care with COVID-19 Patients

Kathy Quan RN BSN PHN

Kathy Quan RN BSN PHN

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Clustering care is one of many techniques for improving time management and reducing fatigue for the patients. It can work well to reduce fatigue for the nurses as well and ensure efficiency. It has also taken center stage in 2020 for nurses working on COVID-19 units to reduce their exposure to the novel virus. 

Nursing care in the COVID-19 environment presents many new and different challenges. With all family and friends banned from hospitals and other facilities, it puts even more burden on the nursing staff to anticipate and meet the needs. But nurses are strong, resilient and innovative and should meet the challenges head on. 

In clustering care, nurses typically plan their patient care around several tasks that need to be completed so that they can all be done at one time and not require multiple trips in and out of the patient’s room. This helps keep nurses organized and efficient with their time. It also allows the patient to rest for longer intervals and improve recovery outcomes. It is absolutely essential in caring for patients requiring isolation and associated infection precautions.

Clustering care is a beneficial technique for both the nurse and the patient, but it must never preclude meeting the patient’s needs as they arise. Needs can sometimes be unexpected or urgent and they cannot wait for the next session of planned clustered care! 

For example, Mr. R. was admitted due to a fall and a back injury. (This scenario is HIPAA compliant.) Upon admission he was routinely tested for COVID-19 and the results came back positive despite the fact that he was completely asymptomatic. He was placed on isolation on a converted COVID 19 unit. The staff were required to don PPE (including gowns, gloves, shoe covers and masks) upon entering the room to care for Mr. R. Due to pain and weakness, Mr. R. was bedbound. He tried his best to remain as independent as possible and not “disturb the nurses.” However, one evening shift he had slid down in his bed and was increasingly uncomfortable and unable to reposition himself. His back pain was quickly reaching 8/10 pain. He needed to urinate, but being unable to stand, he had difficulty using the urinal. Consequently, he spilled most of it on the chux underneath his bottom.  He called for the nurse and asked for pain medication (including stating his pain level of 8/10.) He also requested some assistance to reposition in bed and get a dry chux because his was soaking wet with urine. The nurse responded by telling him he had to wait another hour until his insulin was due because she was “not coming in now and then have to return in an hour for the insulin!” 

FAIL!!! This is NOT what clustering care is about! The patient was in 8/10 pain. That alone called for an immediate intervention, and actually placed the patient in immediate jeopardy. In an hour, sitting on a chux soaked with urine, this patient’s already susceptible skin will begin to breakdown and could result in a significant decubitus. Combined with the fact that his position in the bed is not optimal, his potential for skin breakdown and severe pain also puts him in immediate jeopardy. 

According to the Centers for Medicare and Medicaid, CMS, immediate jeopardy is described as: “Immediate Jeopardy (IJ) represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death. These situations must be accurately identified by surveyors, thoroughly investigated, and resolved by the entity as quickly as possible. In addition, noncompliance cited at IJ is the most serious deficiency type, and carries the most serious sanctions for providers, suppliers, or laboratories (entities). An immediate jeopardy situation is one that is clearly identifiable due to the severity of its harm or likelihood for serious harm and the immediate need for it to be corrected to avoid further or future serious harm.”

Clustering of care is never for the convenience of the nurse! Nursing is never about doing things for people when it’s convenient! Nursing is always demanding and hard work physically and emotionally. The COVID-19 virus has made nursing even more challenging. But nurses always rise to the challenge.

In the case of COVID-19 it can be beneficial to reducing exposure to the virus in caring for patients who test positive, but meeting patient’s needs is always to take precedence! That is exactly why CMS along with the state department of health services and accrediting agencies such as the Joint Commission on Health Care Organization (JCAHO) will jump on an immediate jeopardy complaint and issue deficiencies that can result, if found to be severe enough. in shutting down of the facility if they have not been sufficiently corrected and managed. The nurse’s job is also in jeopardy due to the inexcusable patient neglect. 

Nurses caring for COVID-19 patients in most cases have been reinstructed in the importance of prioritizing and clustering care for their own protection as well as for the patients. However, to some extent it has to be presumed that the nurses possess the necessary skills in critical thinking and a strong knowledge base that care is patient centered. Anticipating the needs of patients is a huge part of quality nursing care. NursingCE.com offers multiple continuing education courses for nurses to improve their understanding of the additional responsibilities and challenges for patient care in the COVID-19 era. 

Just as Mr. R’s care involved management of his diabetes and insulin administration and assessing for any signs or symptoms of organ compromise due to the COVID 19, his admitting diagnosis was for injury to his back from a fall. Pain management is an essential part of his care plan. His bedbound status puts him at high risk for falls, and for skin breakdown. All of this must be part of his comprehensive care plan. Whether the nurse completes a formal care plan or not, each patient requires a unique plan to meet his or her needs on an ongoing basis. This plan has to be at the forefront of the mind of every nurse involved in that patient’s care. 

In this scenario, Mr. R was placed at high risk for skin breakdown, his out-of-control pain issues were ignored and the basic care of positioning the patient was also neglected. The physician could have been called and asked for permission to give the insulin a little early. Take the insulin into the room and by the time the nurse got him cleaned up and repositioned comfortably in the bed, it would be even closer to the time the insulin was due. It’s not rocket science. It’s basic nursing care. 

Critical thinking skills are essential to quality patient care. Clustering patient care works well for both nurses and patients as long as his unique patient care and needs are not ignored. An essential part of clustering care means the nurse contacts the patient before going into the room to assess for any needs that can and need to be met now so that needs are met in a timely manner, time is consolidated, and the nurse is protected from prolonged exposure. The scientists predict COVID-19 is not going away any time soon. Nurses need to regroup, adapt to the changes thrust upon us and rise to the challenge.  

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