key: cord-0790220-y66u3bvq
authors: Minissian, Margo B.; Ballard-Hernandez, Jennifer; Coleman, Bernice; Chavez, Jose; Sheffield, Lorraine; Joung, Sandy; Parker, Amy; Stepien, Sarah J.; Romero, Joan; Floríndez, Lucía I.; Simons, Cristina D.; De Jesus, Millicent; Marshall, David
title: Multi-Specialty Nursing During COVID-19: Lessons Learned in Southern California
date: 2020-09-07
journal: Nurse Lead
DOI: 10.1016/j.mnl.2020.08.013
sha: 9fc1235b3aa139e52c1d4b03bad36e7da87ac384
doc_id: 790220
cord_uid: y66u3bvq

Background A multi-specialty nursing team plays a crucial role in key decision making, education, prevention, screening, assessment, diagnosis, management, data collection and dissemination of best practices during the novel coronavirus disease (COVID-19) pandemic. Methods Using examples from a large, tertiary medical center in Los Angeles, this manuscript highlights contributions made by multi-specialty nursing specialties to optimize health and safety for patients and frontline healthcare workers. Conclusion Recognizing nurses ongoing critical role encourages and informs further collaboration and serves as a catalyst to innovation for a healthier tomorrow. The result of the COVID-19 pandemic will be felt for years to come.

The outbreak of novel contagious coronavirus (SARS-CoV-2, herein called COVID-19) is complicated by severe acute respiratory syndrome that requires hospitalization, intensive care utilization, and for a percentage of patients, mechanical ventilation. (Chen et al., 2020) The prevalence and severity of the infection is greater in comorbid persons with underlying diabetes, (Singh, Gupta, Ghosh, & Misra, 2020) obesity, (Simonnet et al., 2020) , (Kalligeros et al., 2020 ) cardiovascular disease such as hypertension or African American and other minority communities. (Chowkwanyun & Reed, 2020 ) COVID-19 is considered a pandemic emergency, spanning across the globe with 4,782,539(Medicine, 2020) confirmed cases as of May 18, 2020 and 91,921 deaths in the United States to date. (Medicine, 2020; Organization, 2020a Organization, , 2020b When treating COVID-19 patients, multi-specialty nursing teams are responsible for managing critical care environments, and improving screening, diagnosis, treatment and education about ever changing patient care models. Using experiences from a major tertiary medical center in the Los Angeles area, this manuscript highlights perspectives from the multi-specialty nursing care team, their evolving roles, and their strategies used to improve patient outcomes and ensure frontline healthcare worker safety.

When senior leadership is faced with a crisis, they first and foremost need to assess their current workforce and resources to ensure they can rise to meet anticipated/ unanticipated challenges and increasing demands. A keen chief nurse executive (CNE) is key in ensuring the nursing teams are well equipped, prepared and nimble to handle dynamic house-wide changes. Table 1 highlights early realworld experiences from a CNE at a large-tertiary medical center in Los Angeles. In partnership with senior nursing leadership, the CNE determined to shift some areas of the medical center closed as other areas began to surge. As registered nurses (RN) became the eyes and ears of the entire healthcare team, nursing leadership and staff not only confronted the enormity of work brought on by this pandemic, but they did so with speed, dexterity and an unwavering sense of collaboration. The nursing institute J o u r n a l P r e -p r o o f developed, taught and implemented a team nursing model in which medical-surgical nursing staff were redeployed and retrained in new critical care-based roles lead by a critical care RN. (King, Long, & Lisy, 2015) These surge planning and redeployment efforts led by senior leaders were imperative to ensure crucial staffing needs were achieved. A multi-specialty nursing team composed of Nurse Practitioners (NPs), Nurse educators, Clinical Nurse Specialists (CNS), frontline RNs and Nurse Scientists worked synergistically together to form teams, educate staff and patients, to streamline performance improvement and implement clinical trials across the medical center.

NPs play a crucial role in the prevention, screening, diagnosis, and management of COVID-19 (See Figure 1) . Given the rapidly evolving nature of COVID19, NPs have the professional responsibility to remain current on the most up-to-date evidence for efficacious treatment. Both primary and acute care NPs serve as frontline providers and expert consultants implementing evidence-based care for the management of COVID-19.

NPs provide trusted education and counseling to patients on nonpharmaceutical interventions (NPIs) including proper hand hygiene techniques, social distancing, environmental disinfection procedures, and barrier mask recommendations(Prevention, 2019). Prevention of virus transmission remains the cornerstone of halting the cycle of infection and spread of disease. NPs are using innovative methods to deliver care focusing on prevention, which includes the use of telehealth visits with video capability, telephone follow-up visits, and electronic consultations, thus preventing virus exposure to patients and healthcare workers.

NPs also play a pivotal role in helping our chronically ill patients continue to receive care despite reductions in in-person clinic visits and patients avoiding the emergency department for non-COVID-19 illnesses. NP telemedicine visits have several advantages. A few specific examples include: 1) provide J o u r n a l P r e -p r o o f frequent video-telemedicine visits for improved blood pressure/ cholesterol/ chronic stable angina medication titration for elderly patients who are working to optimize medication therapy and avoid sideeffects and polypharmacy; 2) Video-telemedicine visits also help the young. In the Postpartum Heart Health program management of complications associated with postpartum hypertension and preeclampsia via video-telemedicine is convenient for new mothers who prefer not to pack up a newborn and travel to higher risk areas to discuss titrating down on medications or may be experiencing symptoms such as headache, visual changes that would result in an emergency department visit; 3) reduced institutional overhead costs while having the ability to bill for professional fees.

Nurse Practitioners serve as the first contact in the COVID-19 surge screening and triage tents.

They play a key role in determining whether the patient can be treated and discharged on the spot or directed to the most appropriate care setting in the hospital or at an alternative site. The clinical presentation for COVID-19 is quite variable, ranging from asymptomatic, to severe illness and death, making screening algorithms imprecise. The cardinal symptom of COVID-19 is fever and in general, the majority of cases may experience cough, fatigue, anorexia, shortness of breath, and or myalgias. (Huang et al., 2020) Less commonly reported symptoms include headache, rhinorrhea, sore throat, vomiting and or diarrhea. (Guo et al., 2020) Anosmia (loss of smell) or ageusia (loss of taste) have been anecdotally reported preceding the onset of respiratory symptoms and during mild illness. (Huang et al., 2020) Screening protocols for COVID-19 should query for these cardinal signs of new onset fever and respiratory tract symptoms.

Laboratory testing for COVID-19 should be performed for suspected cases based on the updated World Health Organization (WHO) case definition criteria. The CDC recommends collection of an upper respiratory sample by a health care professional, utilizing one of the following techniques: Nasopharyngeal swab, oropharyngeal swab; or nasopharyngeal wash/aspirate.(Prevention., 2019) If a J o u r n a l P r e -p r o o f patient is suspected of having COVID-19, the NP should immediately implement isolation and recommended infection prevention practices.

It is imperative that the NP appropriately triage and classify patients with mild/moderate disease and or severe illness. Patients with mild COVID-19 illness (without hypoxia) and those who do not require hospitalization may be able to manage their illness in the home setting with supportive care, home isolation, and close healthcare provider follow-up.(Prevention, 2020) As an integral part of the critical care team, acute care NPs are responsible for managing hypoxemia, performing intubation, and monitoring/ treating COVID-19 sequelae including pulmonary, cardiac and or vascular complications.

Acute care NPs practicing in the inpatient setting with a care-team will need to follow management strategies as outlined in the Society of Critical Care Medicine's (SCCM) Surviving Sepsis Campaign:

Guidelines on the Management of Critically Ill Adults with Corona Virus Disease 2019. (Alhazzani et al., 2020) To date, there is no current evidence to recommend specific treatments for patients with suspected or confirmed COVID-19. On May 1, 2020, remdesivir received Food and Drug Administration (FDA) Emergency Use Authorization for the treatment of COVID-19 in select patients based on severity of disease for compassionate use. (Grein et al., 2020) Preliminary, non-peer reviewed findings from the RECOVERY trial show dexamethasone may reduce mortality in patients with COVID-19 who require oxygen or a ventilator. (Horby et al., 2020) Additional treatment options include investigational drugs and off-label use of FDA-approved medications risks and benefits should be a team-based discussion with the patient at the center of the discussion.

Guidelines produced by SCCM were incorporated into the education delivered to the Critical Care RNs (CCRN) (Alhazzani et al., 2020) . The Critical Care nurse educators and CNS team facilitated J o u r n a l P r e -p r o o f immediate training for all Critical Care staff on indications and technique on prone positioning, as one example. (Alhazzani et al., 2020) The training was due to an assessment that multiple CCRNs needed preparation to treat patients with Acute Respiratory Distress Syndrome (ARDS), a complication of critical COVID-19 patients. An assessment was conducted to evaluate where the COVID-19 patients should be admitted. A cohorting approach was determined as the most efficient and safe practice within the Medical/ Respiratory intensive care unit (ICU) and the Cardiac Observation Unit. The nursing units chosen were previously prepared to accept respiratory patients, with the appropriate monitoring needed.

In preparation for surging cases of COVID-19, the CNS and Educator team assisted multiple units in preparation for admitting COVID-19 patients. Ensuring appropriate precaution signs, adequate training for donning and doffing PPE, and treatment for patients. Staff on all units were educated and instructed on the importance of safety and making sure PPE was worn correctly. Recommendations from the CNS and Educator team were implemented into a practice change for a COVID-19 Rapid Response or Code Blue. The protection of the staff has always been a priority, and measures were put in place, including: 1) limiting the amount of staff in the room, 2) use of a bag-mask valve only in intubated patients to decrease viral transmission via aerosolized exposure to the team, and 2) implementing the use of a Mechanical Chest Compression device during resuscitation as an option to minimize exposure and potential transmission of COVID-19 during chest compressions.

Women's and Children's Services (WCS) incorporates models of care for a wide array of patients, including prenatal through postpartum women, neonatal care, and pediatric patients up to 21 years old. With the CDC recommending separation of neonates from COVID-19 positive mothers at birth, normal delivery, inpatient care, and discharge processes needed to be modified. The Pediatric

Intensive Care Unit (PICU) was selected as the cohort unit for all pediatric COVID patients, including these newborns that would have usually remained with their mother in postpartum or in nursery settings.

The CNS and Educator team collaborated with other WCS nursing leaders, physicians, social work, J o u r n a l P r e -p r o o f lactation consultants, case managers, and child life specialists to support the educational needs of nursing staff across all these units, as well as the unique COVID-19 discharge needs of the separated mother/baby dyad. These processes included educating PICU staff on state mandated newborn screenings, creating discharge material, incorporating best practices for breastfeeding while under COVID-19 home isolation guidelines, and supporting maternal/family bonding using technology such as video chats.

The centralized nurse educators in the Department of Nursing Education provide institution-wide education for continuing, specialty and needs-based education ( Table 2 ). Nurse educators provided in unit rounding 7 days per week for COVID-19 related education and developed an online "source of truth" for up to date COVID-19 information. (Table 3) was completed via redcap with 68 responses (57% overall response rate). Most Redeployed RNs were from PeriOperative areas and 56% were redeployed to medical-surgical areas and 41% redeployed to intensive care areas. Results located in Table 3 and redeployment successes and areas for improvement highlighted in Table 4 . has not only changed the way nurses care for patients, but also the way that we educate and enhance the professional development of our nursing staff. It has also provided nursing with J o u r n a l P r e -p r o o f a unique opportunity to reimagine the best strategies to engage adult learners outside of the traditional didactic and skills-based classroom, when social distancing is required for everyone's safety. Transferring PowerPoint lectures into a Learning Management System (LMS), can help meet the need of introducing topics, reviewing institution specific policies and other knowledge-based learning activities. The challenge remains in taking didactic learning objectives from the classroom and redesigning how they can be achieved in the virtual setting to improve critical thinking skills. The utility of artificial intelligence is the wave of the future to assess, deliver and test the professional nurse learner. The goal is to intrigue as well as challenge the learner, both individually and within an interprofessional team, to effectively provide safe, quality care at the top of their licensure. The increased need for virtual and online nursing education is self-evident in a social distancing environment. (Liaw et al., 2020) Challenges to providing an interactive learning environment include: 1) cost, 2) access to technical talent and 3) connectivity issues (teaching less technical nurses to use the new software programs, securely logging in, wireless connectivity issues). Table 2 lists pre-post COVID-19 learning management delivery methods that are currently being implemented.

Despite the COVID-19 pandemic and difficulties associated with it, interprofessional collaboration has ignited innovations to sustain the health and safety of patients and front-line healthcare providers.

At the forefront of this flurry of new research and inquiry is the nurse scientist, who serves multiple roles of generating new knowledge, supporting staff nurse curiosity in applying best practices, and testing new interventions. In the creation of new science, the nurse scientist team initiated and supported a number of innovative projects investigating the impact of COVID-19 on the interplay of physiology and psychology of healthcare providers. A Nurse Surveillance study was designed to provide point of care proteomics monitoring of inflammatory markers. Qualitative methods have been J o u r n a l P r e -p r o o f implemented to understanding the lived experience of nurses caring for COVID-19 patients. In addition, a study has been undertaken to investigate the impact of pandemic stressors on deoxyribonucleic acid (DNA) function in nurses, physicians and non-clinical staff.

Beyond designing research studies, nurse scientists have supported staff in innovative COVID-19 patient care improvement projects. With collaboration from pharmacy and IV team members, nursing teams have developed extended intravenous tubing, allowing for expedient changes in IV flows without the need to don and doff PPE, preserving scarce resources. As continuous use of PPE is expected as a viral spread mediation, wound ostomy and continence nurses contributed to national guidelines and made recommendations to prevent de novo skin injury in patients in the prone position.

The central and unit-based nurse educator teams have created and implemented several staff trainings to ensure patient safety in the prone positioning for intubated patients (Sheffield et al., 2020) as well as educating staff on self-proning for ambulatory patients known as "tummy time". By validating a pediatric shortness of breath tool ( Figure 2 ) nurses are empowering their COVID-19 patients by teaching them to complete 3 hours of tummy time every 8 hours. For those patients who are non-ambulatory, patients are performing hourly incentive spirometry with programmed reminders utilizing the Alexa device and self-log by using a bar-code to access and document their incentive spirometry scores in redcap.

Since the COVID-19 pandemic began, a race to find answers has been underway. The necessity of conducting research must be balanced with the burden of managing patient load for the frontline nurses. It is imperative that clinical research is well organized, thoughtfully coordinated, with ample support for both operational and clinical research activities. Nurse scientists play a key role in assisting non nurse investigators in the construction of studies with nurses as intended subjects.

During an unprecedented time, nurses have risen to the forefront across the United States and the world. RNs are on the front line redeployed into unfamiliar practice environments; advanced practice J o u r n a l P r e -p r o o f nurses improve screening, diagnosis, treatment and work with nurse educators to ensure nurses remain updated on ever changing patient care. Nurse scientists generate new knowledge, support staff nurse curiosity in applying best practices and test new interventions. Future implications for nursing education as a result of the COVID-19 pandemic will be felt for years to come. The message is consistent; nurses are leading the way in 2020 to a better, healthier tomorrow. High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sars-cov-2) requiring invasive mechanical ventilation. Obesity (Silver Spring 

Initial experience with one family of three (late January) handled with full special pathogen level use of personal protective equipment. Later expansion of cases led to that level of protection not being feasible.

Confusion caused by a lack of agreement on proper healthcare worker personal protective equipment for SARS-CoV-2 resulted from shifting isolation guidelines between airborne and droplet isolation precautions by the WHO, U.S. CDC, local Los Angeles County Department of Public Health and the State of California Occupational Health Administration.

Organization of resources to deliver up-to-date information on the disease, proper use of personal protective equipment, and testing protocols.

Planning for an anticipated surge beyond traditional capacity into non-traditional clinical areas. Staffing using a tiered approach with a nurse with population-specific supported by nurses without those competencies.

Activating advanced practice registered nurses to expand capacity into nontraditional clinical areas J o u r n a l P r e -p r o o f In-person didactic classroom lectures with hands-on simulation and skill application of scenario based-learning

Using a web-based conferencing platform to transition in-person lectures to interactive learning with break-out group activities built in. In-person skills are done by virtually reviewing the skills, and setting up office hours approach for those nurses that need 1-on-1 practice and clarification in a safe environment.

Next goal: Creation of interactive online lectures for critical thinking development and assessment. These are shorter in length (no-more than 20 minutes, using adaptive learning technology to assess knowledge, by creating clinical scenarios with Q&A pop-up boxes that drive clinical decision making)

Live stream panel discussions and procon debates.

Pre-recorded skills demonstration videos using a 360-degree camera in a simulated clinical setting. Nursing Professional Development Programs (i.e. Preceptor Workshop) 8-hour day of in-person lecture with group activities to apply content in real-world situations 4-hours of didactic content review through our LMS, followed by 4-hours of virtual group activities through a webbased conferencing platform to apply the content and enhance situational based learning and critical thinking.

Next goal: Online knowledge assessment that allows for nurses to test out of certain knowledge-based didactic learning, and pre-post evaluation. Basic, Pediatric, Advanced Cardiac Life Support (BLS/PALS/ACLS) training 4-8 hours of in-person training using AHA's classroom content of practice while watching video approach, team dynamics, skill validation and knowledge assessment of the overall content 3-6 hours of online blended learning with interactive scenarios to improve clinical decision-making skills and knowledge assessments, followed by hands-on skills validation using ARC. Uses adaptive learning technology for learners to testout of certain content and tailor the learning based on their needs. J o u r n a l P r e -p r o o f When treating COVID-19 patients, multi-specialty nursing teams are responsible for managing critical care environments, and improving screening, diagnosis, treatment and education about ever changing patient care models. Using experiences from a major tertiary medical center in the Los Angeles area, this manuscript highlights perspectives from the multi-specialty nursing care team, their evolving roles, and their strategies used to improve patient outcomes and ensure frontline healthcare worker safety.

When senior leadership is faced with a crisis, they first and foremost need to assess their current workforce and resources to ensure they can rise to meet anticipated/ unanticipated challenges and increasing demands. A keen chief nurse executive (CNE) is key in ensuring the nursing teams are well equipped, prepared and nimble to handle dynamic house-wide changes. Table 1 Health program management of complications associated with postpartum hypertension and preeclampsia via video-telemedicine is convenient for new mothers who prefer not to pack up a newborn and travel to higher risk areas to discuss titrating down on medications or may be experiencing symptoms such as headache, visual changes that would result in an emergency department visit; 3) reduced institutional overhead costs while having the ability to bill for professional fees.

Nurse Practitioners serve as the first contact in the COVID-19 surge screening and triage tents.

They play a key role in determining whether the patient can be treated and discharged on the spot or directed to the most appropriate care setting in the hospital or at an alternative site. The clinical presentation for COVID-19 is quite variable, ranging from asymptomatic, to severe illness and death, making screening algorithms imprecise. The cardinal symptom of COVID-19 is fever and in general, the majority of cases may experience cough, fatigue, anorexia, shortness of breath, and or myalgias. (Huang et al., 2020) Less commonly reported symptoms include headache, rhinorrhea, sore throat, vomiting and or diarrhea. (Guo et al., 2020) Anosmia (loss of smell) or ageusia (loss of taste) have been anecdotally reported preceding the onset of respiratory symptoms and during mild illness. (Huang et al., 2020) Screening protocols for COVID-19 should query for these cardinal signs of new onset fever and respiratory tract symptoms. Intensive Care Unit (PICU) was selected as the cohort unit for all pediatric COVID patients, including these newborns that would have usually remained with their mother in postpartum or in nursery settings.

The CNS and Educator team collaborated with other WCS nursing leaders, physicians, social work, J o u r n a l P r e -p r o o f lactation consultants, case managers, and child life specialists to support the educational needs of nursing staff across all these units, as well as the unique COVID-19 discharge needs of the separated mother/baby dyad. These processes included educating PICU staff on state mandated newborn screenings, creating discharge material, incorporating best practices for breastfeeding while under COVID-19 home isolation guidelines, and supporting maternal/family bonding using technology such as video chats.

The centralized nurse educators in the Department of Nursing Education provide institution-wide education for continuing, specialty and needs-based education (Table 2) (Table 3) was completed via redcap with 68 responses (57% overall response rate). Most

Redeployed RNs were from perioperative areas and 56% were redeployed to medical-surgical areas and 41% redeployed to intensive care areas. Results located in Table 3 and redeployment successes and areas for improvement highlighted in Table 4 . has not only changed the way nurses care for patients, but also the way that we educate and enhance the professional development of our nursing staff. It has also provided nursing with J o u r n a l P r e -p r o o f a unique opportunity to reimagine the best strategies to engage adult learners outside of the traditional didactic and skills-based classroom, when social distancing is required for everyone's safety. Transferring

PowerPoint lectures into a Learning Management System (LMS), can help meet the need of introducing topics, reviewing institution specific policies and other knowledge-based learning activities. The challenge remains in taking didactic learning objectives from the classroom and redesigning how they can be achieved in the virtual setting to improve critical thinking skills. The utility of artificial intelligence is the wave of the future to assess, deliver and test the professional nurse learner. The goal is to intrigue as well as challenge the learner, both individually and within an interprofessional team, to effectively provide safe, quality care at the top of their licensure. The increased need for virtual and online nursing education is self-evident in a social distancing environment. (Liaw et al., 2020) Challenges to providing an interactive learning environment include: 1) cost, 2) access to technical talent and 3) connectivity issues (teaching less technical nurses to use the new software programs, securely logging in, wireless connectivity issues). Table 2 lists pre-post COVID-19 learning management delivery methods that are currently being implemented.

Despite the COVID-19 pandemic and difficulties associated with it, interprofessional collaboration has ignited innovations to sustain the health and safety of patients and front-line healthcare providers.

At Since the COVID-19 pandemic began, a race to find answers has been underway. The necessity of conducting research must be balanced with the burden of managing patient load for the frontline nurses. It is imperative that clinical research is well organized, thoughtfully coordinated, with ample support for both operational and clinical research activities. Nurse scientists play a key role in assisting non nurse investigators in the construction of studies with nurses as intended subjects. 

Initial experience with one family of three (late January) handled with full special pathogen level use of personal protective equipment. Later expansion of cases led to that level of protection not being feasible.

Confusion caused by a lack of agreement on proper healthcare worker personal protective equipment for SARS-CoV-2 resulted from shifting isolation guidelines between airborne and droplet isolation precautions by the WHO, U.S. CDC, local Los Angeles County Department of Public Health and the State of California Occupational Health Administration.

Organization of resources to deliver up-to-date information on the disease, proper use of personal protective equipment, and testing protocols.

Planning for an anticipated surge beyond traditional capacity into non-traditional clinical areas. Staffing using a tiered approach with a nurse with population-specific supported by nurses without those competencies.

Activating advanced practice registered nurses to expand capacity into nontraditional clinical areas J o u r n a l P r e -p r o o f 3 Days of on-line modules through our LMS, and just in-time training on the floors for SPHM equipment training

Next goal: Create online pre-recorded lectures for knowledge-based learning and introduction to topics, updated institution-specific policies and procedures with pre-and post-knowledge assessments-built in. New Graduate RN Residency Program

In-person didactic classroom lectures with hands-on simulation and skill application of scenario based-learning Using a web-based conferencing platform to transition in-person lectures to interactive learning with breakout group activities built in. In-person skills are done by virtually reviewing the skills and setting up office hours approach for those nurses that need 1-on-1 practice and clarification in a safe environment.

Next goal: Creation of interactive online lectures for critical thinking development and assessment. These are shorter in length (no-more than 20 minutes, using adaptive learning technology to assess knowledge, by creating clinical scenarios with Q&A pop-up boxes that drive clinical decision making). Live stream panel discussions and pro-con debates. Pre-recorded skills demonstration videos using a 360-degree camera in a simulated clinical setting. Nursing Professional Development Programs (i.e. Preceptor Workshop) 8-hour day of in-person lecture with group activities to apply content in real-world situations 4-hours of didactic content review through our LMS, followed by 4-hours of virtual group activities through a web-based conferencing platform to apply the content and enhance situational based learning and critical thinking.

Next goal: Online knowledge assessment that allows for nurses to test out of certain knowledge-based didactic learning, and pre-post evaluation. Basic, Pediatric, Advanced Cardiac Life Support (BLS/PALS/ACLS) training 4-8 hours of in-person training using AHA's classroom content of practice while watching video approach, team dynamics, skill validation and knowledge assessment of the overall content 3-6 hours of online blended learning with interactive scenarios to improve clinical decision-making skills and knowledge assessments, followed by hands-on skills validation using ARC. Uses adaptive learning technology for learners to test-out of certain content and tailor the learning based on their needs. J o u r n a l P r e -p r o o f Khan, Reddy, & Baptist, 2009 (Khan, Reddy, & Baptist, 2009 

Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19)

Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: A descriptive study

Racial health disparities and covid-19 -caution and context

Compassionate use of remdesivir for patients with severe covid-19

The origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak -an update on the status

Effect of dexamethasone in hospitalized patients with covid-19: Preliminary report

Clinical features of patients infected with 2019 novel coronavirus in wuhan, china

Association of obesity with disease severity among patients with covid-19

Pediatric dyspnea scale for use in hospitalized patients with asthma

Effectiveness of team nursing compared with total patient care on staff wellbeing when organizing nursing work in acute care wards: A systematic review

Nurse-physician communication team training in virtual reality versus live simulations: Randomized controlled trial on team communication and teamwork attitudes

Johns hopkins coronavirus resource center

Global surveillance for covid-19 caused by human infection with covid-19 virus: Interim guidance

Interim guidelines for collecting, handling, and testing clinical specimens from persons under investigation (puis) for coronavirus disease 2019 (covid-19). Retrieved Accessed on

Pronation therapy training video

High prevalence of obesity in severe acute respiratory syndrome coronavirus-2 (sars-cov-2) requiring invasive mechanical ventilation

Diabetes in covid-19: Prevalence, pathophysiology, prognosis and practical considerations