Emory Chief Nurses Embrace the Benefits of Rapid Decision-Making

Even as the COVID-19 pandemic winds down, nurse leaders are holding fast to rapid decision-making and the advantages it brought to their systems.

As COVID-19 began tightening its grip on U.S. hospitals and health systems, nurse leaders were forced to make rapid decisions about everything from diagnostic testing procedures to when to wear a mask to whether to allow visitors.

Now that vaccines continue to roll out, hospitalizations are decreasing, according to the Centers for Disease Control and Prevention (CDC), and normalcy looks to be on the horizon, some nurse leaders are holding fast to rapid decision-making and the advantages it brought to their systems.

At Emory Health System in Atlanta, Georgia, the chief nursing officer huddle, which began as a four-day-a-week meeting as the pandemic intensified, is now a scheduled weekly event, says Sharon H. Pappas, PhD, RN, NEA-BC, FAAN, the health system's chief nurse executive (CNE).

"We established [meetings] four days a week at the beginning and no one wants to let it go, so we're down to one day a week where we come together in what we call a huddle," Pappas says. "That is the place where, during the year of the pandemic, we used for more COVID decision-making, and now we use it for other things that need to be quickly communicated or things that need to have rapid decision-making."

Each of the health system's eight chief nurses sat on one of the incident command workgroups such as care model, clinical operations, or the emergency department, and "our huddle was a point where they could bring information in and take it back out," Pappas says.

One of the CNO huddle's earliest rapid decisions involved streamlining documentation.

"We realized early on that with the [COVID-19] volume we had, we might need to alter the requirements that we had for documentation," Pappas says, "and we used that huddle as a way for us to say to our CNIO (chief nursing informatics officer), 'What are the things that you would recommend to us that we remove from daily or maybe even twice-a-day documentation requirements, so that we're meeting minimal regulatory requirements but yet we also have information that the next shift will find useful?' And so, we would use that huddle to be able to turn on and turn off our crisis documentation plan."

Pappas was impressed with the efficiency of the huddle.

"That was an example [of decisions] that I could not believe we made in a 15-minute timeframe without a lot of discussion," she says. "We were confident that what our CNIO was bringing us was accurate, and we all trusted each other that we would speak up and say so if we disagreed with it and so that let us get to the deployment part of it."

Engaging governance groups in decisions

Rapid decision-making became essential as Emory's leaders realized that their unit for treating serious communicable disease, including Ebola, which the health system dealt with in 2014, wouldn't be able to contain COVID-19 patients.

"Initially we thought we could use that framework to care for these patients as we had successfully done with Ebola, so some of the first early decisions from my perspective were to begin broadening our thinking to something that exceeded beyond the capacity of that unit, and 'Where were we going next?'" says Nancye R. Feistritzer, DNP, RN, NEA-BC, vice president of patient care services and chief nursing officer of Emory University Hospital and Emory Wesley Woods Hospital. "And that roadmap for where we would go next was some of the toughest and most rapid-cycle decision-making we had to do."

Those decisions had to answer such challenges as how to maintain consistencies and standards of care for COVID patients spread across the health system's 11 hospitals, how to manage patients in the critical care and acute care units, how to get enough personal protection equipment (PPE), and how to conserve PPE, just to name a few.

Nurse leaders worked to answer those questions while also engaging the health system's professional governance groups so decision-making was more than top-down, Pappas says.

"It probably felt top-down because of the speed we were having to work, but if we made a decision, we kept ourselves loyal to circling back with those professional governance councils in getting their feedback on things, which really did help us to refine a decision that we may have had to make real very quickly," she says.

Rotating incident commanders of a six-member executive steering group—which led the entire Emory healthcare system's COVID-19 incident command response—were accountable for facilitating the rapid-cycle decision-making that needed to occur.

In some instances they made those decisions almost in real time, Feistritzer says.

A small group of clinicians within the hospital would be handed a particular problem or issue and charged with coming back later that afternoon with proposals to solve that issue. Decisions would quickly be made and communicated out, she says.

"It was very structured and consistently done," Feistritzer says. "People stopped in their tracks to devote the attention to the often very weighty decisions that needed to be made."

"That framework meant that we as nurse leaders could tap into our interprofessional partners in ways that was very facile; we were able to talk to someone else and hear what the impact of any given decision might be on that interprofessional partner and adjust accordingly," she says. "It was very well thought out and a framework we are using to this day as we keep our finger on the pulse of COVID."

Making good decisions for patients

Rapid decision-making also led to the creation of Emory's Care Partner program when the health system's chief nurses realized that having a "no visitors" policy like most other hospitals around country was not good for most patients, Pappas says.

The chief nurses realized that patients needed family members with them as part of their healing, so they came up with a concept called Care Partner, which was different than a visitor," she says.

Where a visitor comes to socialize and boost a patient's spirits, the Care Partner, who can be a family member or trusted friend, has a purposeful role and actually contributes to patient care, she says.

"It became very important to our frontline clinical nurses who were having to spend an extraordinary amount of time on FaceTime or on the phone, updating families," Pappas says. "The Care Partner could also, with a patient's permission as appropriate, communicate with broader family constituents who were interested and worried."

Better communication through technology

Pieces of Emory's rapid decision-making processes will remain long after the pandemic is a memory, both nurse leaders agree, particularly Zoom calls that helped facilitate the quick decisions

"I think we'll see ourselves beginning to come back together in some personal meetings, but the power of reaching across wherever someone is, whatever time of day, through Zoom is definitely something we'll keep," Feistritzer says. "That ability has enabled us to be more broadly informed and interactive with our teams through these open forums that there was just never any way to do previously. So, the technology has helped us be better informed, which contributes to rapid decision-making."