Military Medicine

King, Heather C; Talbot, Laura A

doi: 10.1093/milmed/usab009pmid: 34468003

ABSTRACT Military nurses have been placed in the forefront of clinical and leadership roles during the COVID-19 pandemic. Serving in critical roles, military nurses have spearheaded innovations in clinical practice, conducted research, and implemented evidence-based practice projects that have advanced the capabilities of the Armed Forces Nurse Corps. This collection captures and highlights many of these military nursing contributions combating the COVID-19 pandemic. INTRODUCTION The coronavirus pandemic has placed nurses from the Army Nurse Corps, Navy Nurse Corps, and Air Force Nurse Corps in the spotlight as essential members of the military healthcare team. Although every member of the healthcare team is important, the role of military nursing is unique. The COVID-19 pandemic has provided military nurses unprecedented opportunities to display their mission readiness in a rapidly evolving environment across the continuum of care. Innovations in clinical practices, implementing the best available science, continual education on evolving developments, and creating new and enduring collaborations have all contributed to readiness during this extraordinary demand for nursing care. Nurses are known for their important clinical position at the bedside, but they are also demonstrating their unique ability to quickly identify patient care priorities, manage crises, improve healthcare environments, and provide exceptional leadership decisions and guidance during the current pandemic. With each new challenge during COVID-19, military nurses have responded with clinical solutions to provide safe, quality health care to our service members and their beneficiaries. The challenges of this pandemic include nursing staffing shortages, limited personal protective equipment, extended personal protective equipment wear times, rapidly evolving clinical knowledge and clinical care policies, staff quarantines, deployments, mental health concerns, telehealth, and virtual communications with patients, family members, and the healthcare team. As always, nurses meet these challenges while maintaining constant flexibility and adaptability during uncertain circumstances. The response of military nurses has been extraordinary and led to the supplement highlighting some of their most important contributions. Military Nurses: Top Clinicians and Scientists Military nurses comprise one of the largest percentages of military healthcare personnel and one of the most deployed military specialties. These highly educated professionals frequently hold advanced academic degrees and professional certifications (Table I).1 One of the most important distinctions military nurses hold is their dual roles as clinical nurses and as commissioned officers in the Armed Forces. While military nurses’ role within the Defense Health Agency healthcare systems is similar to civilian clinical practice, their operational practice environments are unique and diverse—from field and surgical hospitals in operational theaters, to hospital ships serving global health engagement missions abroad, to large populous healthcare systems in the United States. These clinical practice settings span the globe and provide a unique perspective that encompasses diseases and scenarios that are uncommon in the United States, but prevalent in worldwide locations. Military nurses make tremendous sacrifices on behalf of our country to care for our nation’s wounded, injured, and sick service members. Military nurses are one of our country’s greatest assets as they serve the nation anywhere, anyplace, any time. TABLE I. Armed Forces Nurse Corps Educational Levels FY20 Navy Nurse Corps Active duty component = 2,825 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,926 68% Master’s degree 696 25% Doctoral degree 203 7% Reserve component = 1,310 Commissioned Nurse Corps Officers Educational data unavailable for reserve component Army Nurse Corps Active duty component = 3,224 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,968 61% Master’s degree 902 28% Doctoral degree 354 11% Army Nurse Corps Reserve component = 4,084 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 2,741 67% Master’s degree 1,081 26.6% Doctoral degree 262 6.5% Air Force Nurse Corps Active duty component = 3,225 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,976 61% Master’s degree 1,016 32% Doctoral degree 233 7% Air Force Nurse Corps Reserve component = 1,352 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 859 65% Master’s degree 425 31% Doctoral degree 68 5% Navy Nurse Corps Active duty component = 2,825 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,926 68% Master’s degree 696 25% Doctoral degree 203 7% Reserve component = 1,310 Commissioned Nurse Corps Officers Educational data unavailable for reserve component Army Nurse Corps Active duty component = 3,224 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,968 61% Master’s degree 902 28% Doctoral degree 354 11% Army Nurse Corps Reserve component = 4,084 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 2,741 67% Master’s degree 1,081 26.6% Doctoral degree 262 6.5% Air Force Nurse Corps Active duty component = 3,225 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,976 61% Master’s degree 1,016 32% Doctoral degree 233 7% Air Force Nurse Corps Reserve component = 1,352 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 859 65% Master’s degree 425 31% Doctoral degree 68 5% Open in new tab TABLE I. Armed Forces Nurse Corps Educational Levels FY20 Navy Nurse Corps Active duty component = 2,825 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,926 68% Master’s degree 696 25% Doctoral degree 203 7% Reserve component = 1,310 Commissioned Nurse Corps Officers Educational data unavailable for reserve component Army Nurse Corps Active duty component = 3,224 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,968 61% Master’s degree 902 28% Doctoral degree 354 11% Army Nurse Corps Reserve component = 4,084 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 2,741 67% Master’s degree 1,081 26.6% Doctoral degree 262 6.5% Air Force Nurse Corps Active duty component = 3,225 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,976 61% Master’s degree 1,016 32% Doctoral degree 233 7% Air Force Nurse Corps Reserve component = 1,352 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 859 65% Master’s degree 425 31% Doctoral degree 68 5% Navy Nurse Corps Active duty component = 2,825 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,926 68% Master’s degree 696 25% Doctoral degree 203 7% Reserve component = 1,310 Commissioned Nurse Corps Officers Educational data unavailable for reserve component Army Nurse Corps Active duty component = 3,224 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,968 61% Master’s degree 902 28% Doctoral degree 354 11% Army Nurse Corps Reserve component = 4,084 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 2,741 67% Master’s degree 1,081 26.6% Doctoral degree 262 6.5% Air Force Nurse Corps Active duty component = 3,225 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 1,976 61% Master’s degree 1,016 32% Doctoral degree 233 7% Air Force Nurse Corps Reserve component = 1,352 Commissioned Nurse Corps Officers Educational level n % Bachelor of Science in Nursing 859 65% Master’s degree 425 31% Doctoral degree 68 5% Open in new tab One military nursing specialty is nurse scientist, professionals who bring their education and training in scientific writing and data analysis skills to mentor clinical nurses and encourage the dissemination of their important contributions to a wider audience. Though a small core group, military nurse scientists are prolific, productive, and essential to bringing research into military nursing practice settings. Military nurse scientists expand scientific knowledge related to the nursing care military nurses provide in austere and operation environments, but also inform military requirements, threats, and manning, identify new capabilities, and contribute to important healthcare policies. They also provide scientific mentorship to military nurses—to look for the best available science, to find gaps in military nursing care, to utilize data for clinical and leadership decisions, to use psychometrically sound instruments to capture meaningful data, and to implement evidence into all clinical settings.2,3 They challenge nurses to advance the scholarship of their practice. Recently, military nurse scientists have also worked tirelessly with nurses of all specialties, ranks, and services to advance evidence-based care in the Military Health System. The combined efforts of advancing research and evidence-based practice in the Military Health System are powerful tools to address the COVID-19 response and future health crises. COVID-19: Military Nursing Response The current DoD’s priorities for COVID-19 are to maintain mission readiness, support interagency government endeavors to address the pandemic, and protect the troops, DoD’s civilian employees and contractors, and their families.4 Military nurses have contributed to the DoD’s COVID-19 priorities both at MTF locations and at civilian hospitals throughout the United States (Table I). The contributions of military nurses in these operational settings have provided invaluable clinical care. In addition to the required after-action reports, disseminating and publishing the contributions of military nurses in peer-reviewed journals is important. This supplement brought together nurses serving in clinical and leadership roles on the front lines of COVID-19 with nurse scientists serving as scholarly mentors to facilitate capturing these clinical experiences and lessons learned. This collaboration enhances the capability to disseminate innovations in nursing practice and optimally prepare for future crises. Nurses serving in primarily clinical and leadership roles bring a fresh perspective and ability to view gaps in military healthcare systems and military nursing practice and ask hard questions that are important. Military nurse scientists bring their education and training in scientific writing and data analysis skills to provide mentorship to nurses to encourage the dissemination of their important contributions to a wider audience. Additionally, this supplement serves to disseminate a variety of experiences during COVID-19: first-hand accounts, practice innovations, collaborations, case reports, educational efforts, research, evidence-based practice projects, commentaries, and tactical lessons learned from COVID-19 by military nurses. Relevant Research and Evidence-Based Practice for Future Pandemic Threats COVID-19 has brought new awareness on the impact of worldwide pandemics and the need for future research to generate essential knowledge that will enhance the readiness of the Armed Forces. Future areas of research include Current and emerging issues with direct application to military nursing care during wartime, peacetime, and humanitarian and national response. Current and emerging issues related to healthcare readiness of individual service member and the military nurse force readiness. Diversity and health disparities of service members as related to the military and military nursing. Expanding research collaborations with multidisciplinary teams to address gaps in pandemic response and readiness. Equally important is the ability to effectively implement evidence-based nursing care when limited effective treatment options are available for new and emerging health threats. Because of the unique clinical position of nurses, they are optimally positioned to readily define, implement, and evaluate the best available practices that advance quality and safety in military health care. Areas important to address include Evidence-based practice projects that define, implement, and evaluate infection prevention and control practices during wartime, peacetime, and humanitarian and national response. Evidence-based practice projects that define, implement, and evaluate communication tools, such as telehealth technology, to expand access to healthcare services for military service members and their families during the COVID-19 pandemic and beyond. Evidence-based practice projects that assess readiness, gather evidence, set up training, promote staff safety, and bolster peer support to strengthen the military healthcare system. Evidence-based practice projects that assess healthcare provider risk (both physical and mental), reduce harm, and apply workplace safety interventions and evaluate outcomes during COVID-19 and other emerging pandemic threats. Evidence-based practice projects that define, implement, and evaluate leadership decisions, leveraging data analytics to drive time-sensitive decisions to improve patient outcomes in military health care. Empowering military nurses in these areas is the key to reducing mortality and improving patient outcomes across the continuum of care. TriService Nursing Research Program The TriService Nursing Research Program (TSNRP) provides modest, but needed, infrastructure support for military nurses to conduct research and to collaborate across the Armed Services. Building professional relationships is a hallmark of the TSNRP and is evidenced by the collaboration between the frontline clinicians and military nurse scientists who created this supplement. These identified research gaps and evidence-based implementation areas align with the TSNRP’s long-standing funding priorities of (1) force health protection, (2) nursing competencies and practice, and (3) leadership, ethics, and mentoring. This supplement is also aligned with the TSNRP’s strategic goal of developing and strengthening the community of nurse scholars to generate new knowledge and translate it into practice. It is hoped that this experience will serve as a future model to continue to develop the scholarship of military nurses and encourage the next generation of military nurses to disseminate important military nursing contributions through professional publication. Undeniably, the greatest strength of the TSNRP community are the military nurses—passionate, determined, resolute, and laser focused on readiness. Ironically, the COVID-19 pandemic occurred during the International Year of the Nurse as declared by the World Health Organization. It seems appropriate that in 2020 military nurses continued the legacy of advancing nursing scholarship to advance the care our service members and beneficiaries receive. Working with this dedicated group of nurses has been an incredible experience and truly contributes to paving the way for advancing military nursing. FUNDING Publication of this supplement was funded by the TriService Nursing Research Program. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Nurse Corps Manpower Databases . 2020 . 2. Bridges EJ : Research at the bedside: it makes a difference . Am J Crit Care 2015 ; 24 ( 4 ): 283 - 9 . doi: 10.4037/ajcc2015586 Google Scholar Crossref Search ADS PubMed WorldCat 3. Werley H : Promoting the research dimension in the practice of nursing: through the establishment and development of a department of nursing in an institute of research . Mil Med 1962 ; 127 ( 3 ): 219 - 31 . doi: 10.1093/milmed/127.3.219 Google Scholar Crossref Search ADS PubMed WorldCat 4. US Department of Defense : Esper lists DOD’s top priorities during COVID-19 pandemic . Available at https://www.defense.gov/Explore/News/Article/Article/2123100/esper-lists-dods-top-priorities-during-covid-19-pandemic/, March 24 , 2020 ; accessed February 9, 2020 . Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Davis, Jack M

doi: 10.1093/milmed/usab244pmid: 34469523

ABSTRACT A new strain of coronavirus (COVID-19) emerged in 2020 changing the way the nation looked, worked and lived. In response to this unprecedented COVID-19 pandemic, the Army Nurse Corps (ANC) reexamined our capabies and agility to respond to a new and rapidly evolving environment. Maintaining the pivot to readiness, providing sustainable support and protecting our most valuable asset-our people-were and continues to be in the forefront of leaders’ thoughts as we faced this invisible adversary. With every new challenge, lessons learned provide an opportunity to re-examine challenges and successes of the response to COVID-19. Organizational restructuring, balancing risks, expanding capabilities and educational platforms were reassessed and adjusted to fill the needs of the environment as they evolved. The year 2020 will stand throughout history as another example where our readiness, resilience, and flexibility as an Army Nurse Corps was tried and tested. We demonstrated our ability to adapt and overcome-displaying our willingness to stand up as part of the Army Medicine Team and face an unknown adversary to protect the nation we vowed to serve. The ANC supported the DoD, U.S. Army, and Army Medicine as it executed a multifaceted response to the COVID-19 pandemic (Fig. 1). Active and Reserve components supported a novel Urban Augmentation Medical Task Force (UAMTF) to deploy across the nation. UAMTF rapidly erected alternate care facilities and provided direct civilian hospital support for U.S. communities with the greatest need of additional resources and nursing care. Simultaneously, individual states and territories activated their National Guard to assist high-risk communities to protect their most vulnerable populations (Fig. S1). Army nurses stationed at military treatment facilities (MTFs) implemented a cross-cover plan to utilize nursing staff across multiple units. Additionally, Army nurses provided cross-coverage nursing care at Air Force and Navy MTFs within Defense Health Agency (DHA) Enhanced Multiservice Markets. Behavioral health teams, Combat Operations Stress Control teams, and chaplains were activated around the world to build resiliency, maintain the mental health and welfare of our Soldiers, and address potential for burnout across the force. ANC officers also supported Operation Warp Speed, the wide-scale national operation to produce and deliver safe and effective new COVID-19 vaccines in record time. FIGURE 1. Open in new tabDownload slide Joint Force Land Component Command (JFLCC) infograph. Ongoing since March 26, 2020, U.S. Army North as U.S. Northern Command’s Joint Force Land Component Command has deployed over 4,500 military medical personnel to 71 hospitals, in 51 cities, in 14 states and the Navajo Nation, at the request of the Federal Emergency Management Agency and the Department of Health and Human Services in support of the whole-of-America response to the COVID-19 pandemic (U.S. Army graphic by Lauren Padden/U.S. Army North Public Affairs)2. FIGURE 1. Open in new tabDownload slide Joint Force Land Component Command (JFLCC) infograph. Ongoing since March 26, 2020, U.S. Army North as U.S. Northern Command’s Joint Force Land Component Command has deployed over 4,500 military medical personnel to 71 hospitals, in 51 cities, in 14 states and the Navajo Nation, at the request of the Federal Emergency Management Agency and the Department of Health and Human Services in support of the whole-of-America response to the COVID-19 pandemic (U.S. Army graphic by Lauren Padden/U.S. Army North Public Affairs)2. Our public health team’s unique knowledge base, training, and talents were vital to our ability to implement a rapid response to the COVID-19 pandemic. Army public health nurses served as community leaders and installation advisors (Fig. 2), providing evidence-based recommendations to assist garrison commanders in determining Health Protection Condition (HPCON) levels and installation response. These public health nurses rapidly expanded contact tracing teams (Fig. S2) for surveillance and disease containment interventions, deployed with each of the field hospitals to support civilian communities and across the globe to places such as South Korea, Guam, and U.S. Naval Ship Theodore Roosevelt (Fig. 3). FIGURE 2. Open in new tabDownload slide Army public health war room. Capt. Celeste Singletary, Army Public Health Nurse, briefs Brigadier General Paula Lodi, Regional Health Command – Atlantic Commanding General – regarding Public Health Nursing's efforts to track and provide up-to-date installation level COVID-19 information to improve commanders' abilities to make informed decisions. The Public Health team worked to identify cluster cases, upward and downward trends, positivity rates, and conducted unit trainings for Team Clean, Team Trace, and Contact Tracing (Official U.S. Army photo). FIGURE 2. Open in new tabDownload slide Army public health war room. Capt. Celeste Singletary, Army Public Health Nurse, briefs Brigadier General Paula Lodi, Regional Health Command – Atlantic Commanding General – regarding Public Health Nursing's efforts to track and provide up-to-date installation level COVID-19 information to improve commanders' abilities to make informed decisions. The Public Health team worked to identify cluster cases, upward and downward trends, positivity rates, and conducted unit trainings for Team Clean, Team Trace, and Contact Tracing (Official U.S. Army photo). FIGURE 3. Open in new tabDownload slide Camp Lemonnier, Djibouti professionals’ host vaccine information booth. U.S. Army Capt. Shantyl Galloway of Fort Knox, Ky., assigned to the 443rd Civil Affairs Battalion, sets up a COVID vaccine information booth on Camp Lemonnier, Djibouti, February 2, 2021. The informational booth is part of a regional campaign to help educate military members about the voluntary COVID vaccination. (U.S. Navy photo by Mass Communication Specialist 1st Class Natalia Murillo)3. FIGURE 3. Open in new tabDownload slide Camp Lemonnier, Djibouti professionals’ host vaccine information booth. U.S. Army Capt. Shantyl Galloway of Fort Knox, Ky., assigned to the 443rd Civil Affairs Battalion, sets up a COVID vaccine information booth on Camp Lemonnier, Djibouti, February 2, 2021. The informational booth is part of a regional campaign to help educate military members about the voluntary COVID vaccination. (U.S. Navy photo by Mass Communication Specialist 1st Class Natalia Murillo)3. Army forces participated in numerous Defense Support to Civil Authorities (DSCA) missions across the nation serving as a support element within the national response framework. This critical support was achieved by working with interagency partners including the Federal Emergency Management Agency and local and state government agencies (Table I). The utilization of UAMTF deployed in support of these efforts. In Seattle, Washington, UAMTF-627 under Task Force 46 West set up a 250-bed hospital in CenturyLink Field from March to April 2020, providing full-spectrum Role 3 medical care hospitalization. From July to September 2020 under Task Force 51, UAMTF-627 deployed again to San Antonio, Texas, to provide Health Service Support (HSS) to COVD-19 patients by embedding these teams into five civilian hospitals. In those three months, staff worked 2,288 shifts and provided over 25,682 hours of HSS1. According to the 44th Medical Brigade Chief Nursing Officer, Colonel D. Phillips, Army nurses helped comprise Joint Task Force Silver Dragons—a multicomponent, joint interagency force. This task force supported six northeastern states from Virginia to Maine with 12 UAMTFs embedding medical assets into 21 civilian hospitals, stood up seven alternate care facilities such as the Javits Center (Fig. S3), and supported the USNS Comfort (T-AH 20) in New York. Their support was crucial for the success of local response in major cities across the USA during a rapid onset of COVID-19 outbreaks. TABLE I. U.S. Army North COVID-19 Hospital Support Since November 2020 State . Personnel . Locations . Arizona Approximately 70 military medical personnel from U.S. Army Reserve and U.S. Air Force Two hospitals in two cities: Kingman Regional Medical Center from March to April 2021 Yuma Regional Medical Center from January to February 2021 Navajo Nation (in Arizona and New Mexico) Approximately 50 military medical personnel from the U.S. Army Reserve and U.S. Navy-supported DHHS, Indian Health Service, and Navajo Nation Four hospitals in four cities: Tuba City Medical Center from January to March 2021 Chinle Comprehensive Health Care Facility from December to March 2021 North Navajo Medical Center from December to March 2021 Gallup Indian Medical Center from January to March 2021 Texas Approximately 140 military medical personnel from U.S. Army Reserves, U.S. Navy, and U.S. Air Force Six hospitals in four cities: Hendrick Medical Center from January to February 2021 CHI St. Luke’s Health-Memorial Hospital from January to February 2021 Fort Duncan Regional Medical Center from January to February 2021 Hospitals of Providence Transmountain Campus from November to December 2020 University Medical Center of El Paso from November to December 2020 Las Palmas Del Sol Medical Center from November to December 2020 California Approximately 225 military medical personnel from U.S. Army and U.S. Air Force Eight hospitals in seven cities: Arrowhead Regional Medical Center from December 2020 to January 2021 Dameron Hospital from December 2020 to January 2021 Harbor-UCLA Medical Center from January to February 2021 Adventist Health Lodi Memorial Hospital from December 2020 to February 2021 Adventist Health White Memorial from January to February 2021 Community Regional Medical Center from December 2020 to February 2021 LAC + USC Medical Center from December 2020 to February 2021 Riverside University Health System Medical Center from January to February 2021 Wisconsin Approximately 45 military medical personnel from the U.S. Army Four hospitals in four cities from December 2020 to January 2021: Marshfield Medical Center in Marshfield Marshfield Medical Center in Eau Claire Marshfield Medical Center in Beaver Dam Marshfield Medical Center in Rice Lake State . Personnel . Locations . Arizona Approximately 70 military medical personnel from U.S. Army Reserve and U.S. Air Force Two hospitals in two cities: Kingman Regional Medical Center from March to April 2021 Yuma Regional Medical Center from January to February 2021 Navajo Nation (in Arizona and New Mexico) Approximately 50 military medical personnel from the U.S. Army Reserve and U.S. Navy-supported DHHS, Indian Health Service, and Navajo Nation Four hospitals in four cities: Tuba City Medical Center from January to March 2021 Chinle Comprehensive Health Care Facility from December to March 2021 North Navajo Medical Center from December to March 2021 Gallup Indian Medical Center from January to March 2021 Texas Approximately 140 military medical personnel from U.S. Army Reserves, U.S. Navy, and U.S. Air Force Six hospitals in four cities: Hendrick Medical Center from January to February 2021 CHI St. Luke’s Health-Memorial Hospital from January to February 2021 Fort Duncan Regional Medical Center from January to February 2021 Hospitals of Providence Transmountain Campus from November to December 2020 University Medical Center of El Paso from November to December 2020 Las Palmas Del Sol Medical Center from November to December 2020 California Approximately 225 military medical personnel from U.S. Army and U.S. Air Force Eight hospitals in seven cities: Arrowhead Regional Medical Center from December 2020 to January 2021 Dameron Hospital from December 2020 to January 2021 Harbor-UCLA Medical Center from January to February 2021 Adventist Health Lodi Memorial Hospital from December 2020 to February 2021 Adventist Health White Memorial from January to February 2021 Community Regional Medical Center from December 2020 to February 2021 LAC + USC Medical Center from December 2020 to February 2021 Riverside University Health System Medical Center from January to February 2021 Wisconsin Approximately 45 military medical personnel from the U.S. Army Four hospitals in four cities from December 2020 to January 2021: Marshfield Medical Center in Marshfield Marshfield Medical Center in Eau Claire Marshfield Medical Center in Beaver Dam Marshfield Medical Center in Rice Lake U.S Army North, U.S. Northern Command’s Joint Force Land Component Command, has overseen the DoD’s COVID-19 response operations in support of the Federal Emergency Management Agency and the Department of Health and Human Services since March 2020. Approximately 590 military medical personnel from the U.S. Army and U.S. Army Reserve, the U.S. Navy, and the U.S. Air Force recently worked alongside civilian health care providers in civilian hospitals, helping threat COVID-19 patients in six states and the Navajo Nation as part of the whole-of-government response to the pandemic. (U.S. Army North Fact Sheet, 2021)4. Open in new tab TABLE I. U.S. Army North COVID-19 Hospital Support Since November 2020 State . Personnel . Locations . Arizona Approximately 70 military medical personnel from U.S. Army Reserve and U.S. Air Force Two hospitals in two cities: Kingman Regional Medical Center from March to April 2021 Yuma Regional Medical Center from January to February 2021 Navajo Nation (in Arizona and New Mexico) Approximately 50 military medical personnel from the U.S. Army Reserve and U.S. Navy-supported DHHS, Indian Health Service, and Navajo Nation Four hospitals in four cities: Tuba City Medical Center from January to March 2021 Chinle Comprehensive Health Care Facility from December to March 2021 North Navajo Medical Center from December to March 2021 Gallup Indian Medical Center from January to March 2021 Texas Approximately 140 military medical personnel from U.S. Army Reserves, U.S. Navy, and U.S. Air Force Six hospitals in four cities: Hendrick Medical Center from January to February 2021 CHI St. Luke’s Health-Memorial Hospital from January to February 2021 Fort Duncan Regional Medical Center from January to February 2021 Hospitals of Providence Transmountain Campus from November to December 2020 University Medical Center of El Paso from November to December 2020 Las Palmas Del Sol Medical Center from November to December 2020 California Approximately 225 military medical personnel from U.S. Army and U.S. Air Force Eight hospitals in seven cities: Arrowhead Regional Medical Center from December 2020 to January 2021 Dameron Hospital from December 2020 to January 2021 Harbor-UCLA Medical Center from January to February 2021 Adventist Health Lodi Memorial Hospital from December 2020 to February 2021 Adventist Health White Memorial from January to February 2021 Community Regional Medical Center from December 2020 to February 2021 LAC + USC Medical Center from December 2020 to February 2021 Riverside University Health System Medical Center from January to February 2021 Wisconsin Approximately 45 military medical personnel from the U.S. Army Four hospitals in four cities from December 2020 to January 2021: Marshfield Medical Center in Marshfield Marshfield Medical Center in Eau Claire Marshfield Medical Center in Beaver Dam Marshfield Medical Center in Rice Lake State . Personnel . Locations . Arizona Approximately 70 military medical personnel from U.S. Army Reserve and U.S. Air Force Two hospitals in two cities: Kingman Regional Medical Center from March to April 2021 Yuma Regional Medical Center from January to February 2021 Navajo Nation (in Arizona and New Mexico) Approximately 50 military medical personnel from the U.S. Army Reserve and U.S. Navy-supported DHHS, Indian Health Service, and Navajo Nation Four hospitals in four cities: Tuba City Medical Center from January to March 2021 Chinle Comprehensive Health Care Facility from December to March 2021 North Navajo Medical Center from December to March 2021 Gallup Indian Medical Center from January to March 2021 Texas Approximately 140 military medical personnel from U.S. Army Reserves, U.S. Navy, and U.S. Air Force Six hospitals in four cities: Hendrick Medical Center from January to February 2021 CHI St. Luke’s Health-Memorial Hospital from January to February 2021 Fort Duncan Regional Medical Center from January to February 2021 Hospitals of Providence Transmountain Campus from November to December 2020 University Medical Center of El Paso from November to December 2020 Las Palmas Del Sol Medical Center from November to December 2020 California Approximately 225 military medical personnel from U.S. Army and U.S. Air Force Eight hospitals in seven cities: Arrowhead Regional Medical Center from December 2020 to January 2021 Dameron Hospital from December 2020 to January 2021 Harbor-UCLA Medical Center from January to February 2021 Adventist Health Lodi Memorial Hospital from December 2020 to February 2021 Adventist Health White Memorial from January to February 2021 Community Regional Medical Center from December 2020 to February 2021 LAC + USC Medical Center from December 2020 to February 2021 Riverside University Health System Medical Center from January to February 2021 Wisconsin Approximately 45 military medical personnel from the U.S. Army Four hospitals in four cities from December 2020 to January 2021: Marshfield Medical Center in Marshfield Marshfield Medical Center in Eau Claire Marshfield Medical Center in Beaver Dam Marshfield Medical Center in Rice Lake U.S Army North, U.S. Northern Command’s Joint Force Land Component Command, has overseen the DoD’s COVID-19 response operations in support of the Federal Emergency Management Agency and the Department of Health and Human Services since March 2020. Approximately 590 military medical personnel from the U.S. Army and U.S. Army Reserve, the U.S. Navy, and the U.S. Air Force recently worked alongside civilian health care providers in civilian hospitals, helping threat COVID-19 patients in six states and the Navajo Nation as part of the whole-of-government response to the pandemic. (U.S. Army North Fact Sheet, 2021)4. Open in new tab ORGANIZATIONAL RESTRUCTURING With every new challenge, there are lessons learned. At the onset of the pandemic, the unknowns about COVID-19 vastly outweighed the knowns of the disease. The necessity to respond expeditiously required preparations that had not yet been defined from both the individual services and the DHA. This resulted in many parallel lines of effort. Each service had command and control of their respective MTFs responsible for collaborating with their supported installations and other major military commands supporting the national response. Reporting requirements was challenging during the initial phases of the pandemic response because of overlapping multiple lines of authority and communication. One solution implemented by the Medical Command (MEDCOM) team was ensuring that clear and concise messages were provided for status reporting, expansion, and degradation of capabilities, and managing expectations, projecting needs, and finding shared concept of operations became necessary to bring structure to a chaotic situation. Balancing Risks In the process of readjusting and resetting capabilities, leaders were tasked to balance the protection of people, residual risk reduction, and a high operational tempo. A consensus on levels of risk and acceptable risk had to be made for each unique organization. Time-sensitive decisions with minimal information demonstrated the use of prudent risk to the fullest extent. Leadership made challenging decisions on the supply chain, exploitation of nursing skill sets while maintaining quality and safety, and modification of available services under emergency situations. UAMTFs were rapidly deployed to high-risk locations with an initial plan that changed in the short distance from concept to implementation. As the missions and locations shifted, equipment and personnel support configurations shifted (Fig. 4). Embedding UAMTF personnel into civilian hospital facilities later became the preferred support response (Fig. S4), and retiree recalls were in effect because of nationwide staffing shortage. The scope of implementing large-scale contract tracing and surveillance within our public health teams quickly surpassed their organic capabilities. Expeditious expansion of contact tracers through volunteers was imperative to reduce transition in high-prevalence areas. FIGURE 4. Open in new tabDownload slide 44th medical brigade health system support. 44th Medical Brigade Chief Nursing Officer outlined planning considerations required during Task Force 261 support to the northeastern section of the United States during the Portuguese 3rd International Meeting of Military Nursing on September 17, 2020. (U.S. Army graphic by Col. Douglas Phillips)5. FIGURE 4. Open in new tabDownload slide 44th medical brigade health system support. 44th Medical Brigade Chief Nursing Officer outlined planning considerations required during Task Force 261 support to the northeastern section of the United States during the Portuguese 3rd International Meeting of Military Nursing on September 17, 2020. (U.S. Army graphic by Col. Douglas Phillips)5. Military Treatment Facility Patient Bed Expansion Plans MTFs historically had bed expansion plans to accommodate a large influx of inpatients during an influenza pandemic. Upon activation for the COVID-19 pandemic, testing of those plans for operability identified gaps that were addressed. Nurse leaders began reworking on existing bed expansion plans, factoring in decreased staffing because of the potential loss of activated reserve nurses to support missions outside the MTF and loss of staff to COVID-19 infection. Hospitals erected field tents in parking lots, and drive-through testing sites were designed to provide external space for an influx of patients requiring screening and testing. Our supply chains were instantaneously strained with the increased need in personal protection equipment and the growing requirement for new laboratory testing capabilities. Operational Capabilities Re-Examined Our operational unit structures were developed and designed for combat operations. We soon recognized that the skills and talents of the whole unit were not ideal in facing this new threat and would require adaptation. With COVID-19 conditions, traditional Role 3 operation force structure provided excess capacity in primary care, emergency medicine, and surgery while straining inpatient nursing assets with the provision of high acuity, prolonged care. Individual augmentees were utilized to fill professional shortages. Our Role 3 and Role 4 structures needed the flexibility to quickly reset and adjust to get the right mix of personnel to the response to this unique threat. The critical wartime areas of concentrations (AOCs) of critical care nurses, emergency nurses, and certified nurse anesthetists proved highest in demand. With the inventory shortages already felt in these specialties, the pandemic emphasized the imperative for all ANC officers to maintain clinical competence and cross-train to assist in a clinical response. By pulling necessary skills across the force to supplement the expanding needs within Role 3 and Role 4 units going to high-risk locations, we risked leaving local MTFs to sustain home installation health care operations with diminished numbers of staff. Alternative staffing plans were developed to include setting up skills training and education to allow ambulatory and administrative nursing staff, who were normally far away from the bedside, to have the flexibility and confidence to support inpatient and critical care environments should the need exceed current capacity. Adaptations to ANC Educational Programs The ANC modified our education programs as instructors, and students were critically needed to support the COVID-19 response. The Clinical Nurse Transition Program temporarily modified from a 24-week program to a 14-week program with a primary focus on clinical training to assist with the growing demand for inpatient nurses at the bedside. Adjustments were made to alter required training and education, including AOCs producing courses, through reduced seating capacity, modified training capabilities, and leveraging of virtual learning opportunities. Medical Center of Excellence nursing courses, such as the Clinical Nurse Officer in Charge and Non-Commissioned Officer in Charge (CNOIC/NCOIC) Course and Entry-Level Nurse Executive Course (ELENC), transitioned to Microsoft Teams for fully virtual offerings, whereas other courses such as Sexual Assault Medical Forensic Examiner formatted to a hybrid approach. Students completed a 2-week restriction of movement: completed week 1 training virtually from their hotel room and finished week 2 hand-on practicum in class socially distanced or at facilities using trained preceptors. Although initially challenging to adapt courses into new delivery platforms in such a short time, course quality and information remained intact. These newly modified virtual courses provided a greater reach across the force while simultaneously continuing the training mission in a safe environment. ANCReadiness Indicators From these lessons learned, the ANC is focusing on reassessing current structures and readiness indicators. One focus area is the Individual Critical Task List (ICTL). This is an Army Medicine initiative focused on identifying and measuring proficiency in the critical wartime skills required for deploying a Ready Medical Force. The ANC is actively re-engaging our ICTL tasks with the consultant for every AOC to review, revise, and reintroduce to the field, highlighting the critical need to maintain proficiency in our skills. The ICTL directly enables the operational unit’s proficiency to perform collective tasks. In turn, collective tasks enable the operational unit’s capability and readiness to execute its mission essential task list (METL) (Fig. S5). We are also relooking our organizational structures and doctrinal plans to ensure efficient and effective skill mix, expansion and restructure abilities, and position descriptions. As understanding and scientific knowledge of this rapidly evolving threat became clearer, our ability to fill needs of the environment as they evolved showcased the diverse talents and unique value of the ANC to Army Medicine. The year 2020 will stand throughout history as another example where our readiness, resilience, and flexibility as an ANC were tried and tested. We demonstrated our ability to adapt and overcome, displaying our willingness to stand up as part of the Army Medicine Team and face an unknown adversary to protect the nation we vowed to serve. One thing was made clear through it all—we have outstanding leaders who courageously held the torch in the darkest of night and lit the way for others to follow. Anytime, Anywhere, and Always Ready. ACKNOWLEDGMENTS I thank all the ANC officers for their tireless dedication and continuous service during this global crisis. Their tremendous dedication supporting warfighters and our nation has profoundly contributed to the continued success of Army Medicine. I am proud of the work they are doing, and I am grateful to serve alongside them on our Army Nursing Team. I especially thank all the executive nurse leaders who contributed and reviewed this article. SUPPLEMENTARY MATERIAL Supplementary material is available at Military Medicine online. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Williamson-Younce H : 627th hospital center COVID-19 response [PowerPoint] . Presented at: Army Nurse Corps Key Leader Meeting . September 15, 2021 . San Antonio, TX , 2020 . 2. U.S Army North : 2020 Joint Forces Land Component Command hospital support to COVID19 response . Available at https://www.arnorth.army.mil/media/factsheets/Horizontal-JFLCC-Infographic-3-2-21.pdf, March 02, 2021 ; accessed May 10, 2021 . 3. Defense Visual Information Distribution : Camp Lemonnier, Djibouti professionals host vaccine information booth . Available at https://www.dvidshub.net/image/6506473/cldj-medical-professionals-host-vaccine-information-booth; accessed May 10, 2021 . 4. U.S. Army North : Fact sheet: U.S. Army North COVID-19 hospital supp ort since November 2020 . Available at https://www.arnorth.army.mil/media/factsheets/Fact-Sheet-US-Army-North-COVID-19-Hospital-Support-Since-November-2020-1-Apr-21.pdf, April 01, 2021 ; accessed May 10, 2021 . 5. Phillips D : Clinical operations in COVID support chief nurse summary [PowerPoint] . Presented at: Portuguese 3rd International Meeting of Military Nursing . September 17, 2020 . Portugal , 2020 . Author notes The views expressed in this publication are those of the author and do not necessarily reflect the official policy of the DoD, Department of Army, U.S. Army Medical Department, TriService Nursing Research Program, USUHS, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Hopkinson, Susan G; Jennings, Bonnie Mowinski

doi: 10.1093/milmed/usab066pmid: 34468004

ABSTRACT The COVID-19 pandemic requires military nurse leaders in various patient care settings to engage in disaster response. Evidence supports essential leadership attributes for nurses that include skilled communication, organizational influence, and personnel management. Yet, nursing expertise that shapes nurse leader responsibilities during disaster management remains unclear. A description of how military nurse leaders contributed their nursing expertise during the COVID-19 pandemic response at one U.S. Military health care facility is provided to begin to delineate disaster management responsibilities. INTRODUCTION Nurses’ integral role in disaster preparation and response is well-recognized worldwide.1 Nurses often feel ill-equipped, however, to respond during disasters.2 Moreover, little attention is given to preparing nurse leaders for their responsibilities during disasters.3,4 Nurse leaders, both military and civilian, play a particularly important role in influencing and facilitating the preparation and response of nursing personnel during disasters.4 Thus, looking at how nurses enacted leadership at one military treatment facility during the current COVID-19 pandemic response serves to highlight nursing expertise essential for future disaster response. Background China first reported a cluster of pneumonia cases from an unknown cause on December 31, 2019.5 The pathogen was identified as a new coronavirus, SARS-CoV-2, that yielded the disease known as COVID-19. Within 2 weeks, the first case of COVID-19 outside China was reported. By the end of January 2020, there were 82 cases in 18 additional countries. A pandemic was declared on March 11. Sources of uncertainty surrounding COVID-19 included lack of clarity on its transmission mode, a potentially prolonged incubation, varied symptom presentation, and diagnostic testing inconsistencies.6,7 The uncertainties and rapid spread of COVID-19 present challenges for nurse leaders. Although it is recommended that nurse leaders take courses in incident management and incident command systems as part of disaster preparedness training, that knowledge is not enough.4 Nurse leaders must also exhibit essential leader skills and abilities such as problem solving, decision making, skilled communication, and ability to prioritize. Evidence supports that having positive leadership styles and traits is essential for the nurse to be an effective leader during disaster management.3,4 Although management and leadership are both important functions, they are different. Leadership is about relationships while management focuses on maintaining order, planning, organizing, and attending to rules and details. Despite these differences, in the U.S. Army, leadership and management are often merged and used as one concept.8 This overlap of terminology is also true for nursing.9 Because disaster management can be interpreted as part of leadership,4,7 the term nurse leader is used to describe nurses in either leadership or management positions. Missing from the literature is a clear statement about the nursing expertise that a nurse leader brings to disaster management, and how that nursing expertise drives how the nurse leader uniquely contributes to the interdisciplinary team response. Nursing expertise encompasses the accumulated experiential knowledge that nurses as leaders have developed over time.10 This knowledge is developed based on the activities that nurses engage in that are distinctive to the nursing profession. The purpose of this article is to describe how military nurse leaders at one U.S. Military treatment facility applied their nursing expertise in response to the COVID-19 pandemic. The Military Treatment Facility Tripler Army Medical Center (TAMC) is a tertiary military health care facility located on Oahu, the most populated of Hawaii’s islands. The only inpatient military facility in the state, TAMC, health care beneficiaries comprise about 170,000 of the 1.4 million people living in Hawaii.11 The beneficiaries include active duty military, retirees, and family members of active duty and retirees. Because there is no Veterans Affairs (VAs) inpatient facility on Oahu, TAMC also provides inpatient care to veterans when space is available. The primary VA outpatient clinics are co-located with TAMC. NURSING STAFF The nursing staff at TAMC comprises registered nurses, licensed practical nurses, medical technicians, nursing assistants, and administrative personnel who are either active duty military (mostly Army personnel) or government civilians. The outpatient nursing staff is primarily government civilians, whereas the inpatient nursing staff is about 60% military and 40% civilians. Similar to nurses working in non-military facilities, all nursing personnel working in military facilities participate in competency training to sustain clinical skills appropriate to their assigned care units. Remaining competent in clinical skills minimizes the additional preparatory training needed for disaster response or when military nurses are deployed to areas of combat. Distinctive to military nursing personnel, including leaders, is a requirement to demonstrate physical fitness and soldier skills (e.g., weapons proficiency and survival know-how). These requirements help mitigate the risk of illness and/or injury through optimizing physical fitness and well-being as well as ensuring endurance during adverse conditions. Military personnel are also required to attend resiliency training to assist them in coping with stress and anxiety. NURSE LEADERS AT TAMC At TAMC, the nurse leader at the highest organizational level is the Chief Nursing Officer (CNO). The CNO has administrative supervision of all nursing personnel. Before the pandemic, the CNO strategically aligned nurses in leadership positions within departments traditionally dominated by physicians (e.g., medicine, surgery, and quality improvement). Nurse leaders, therefore, collaborated with multiple departments on a daily basis. Military nurses undergo leadership training throughout their careers, often alongside military leaders from professions outside of health care. All military leaders receive training in personnel management and operations planning. Additionally, the military rank of officer nurses often places them in a peer-level relationship with leaders from other disciplines such as physicians and health care administrators. Military health care leaders face unique demands related to keeping active duty military, including health care personnel, ready to deploy to areas of conflict. For instance, some TAMC military nursing personnel have secondary assignments to mobile units located in other areas of the USA or in other countries. When health care needs are increased because of a disaster or military conflict, these military personnel are mobilized to serve where they are needed. The personnel remaining at TAMC adjust to safely cover needed nursing care. Especially for the inpatient nursing units, the nurse leaders maintain open communication with other leaders in the facility regarding current inpatient capabilities based on staff availability. At times, this might necessitate reducing the available inpatient beds. Emergency Preparedness An ∼175 page appendix in the existing emergency preparedness plan was important in TAMC’s initial response to the COVID-19 pandemic. The appendix addressed establishing an emergency operations center (EOC) comprised of interdisciplinary experts knowledgeable in areas such as infection prevention and control (IPC), facility management, logistics, and health care administration. The appendix included detailed information about patient flow into the facility, access restrictions, patient/visitor education, and staff education regarding anticipated IPC measures specific to a respiratory infection. Mentioned in less detail were bed expansion parameters, internal patient flow, and just-in-time training. Biannual exercises conducted at TAMC focus on mass casualty preparedness for a natural disaster. Fortuitously, an interdisciplinary exercise conducted in January 2020 was based on a highly infectious disease scenario. The exercise tested and provided feedback on IPC procedures for highly infectious patients as they entered the emergency department (ED) and moved through admission into adult critical care. The Initial Response As outcomes from the January exercise were being evaluated, TAMC staff members found themselves focusing on the real-life scenario of COVID-19. The ED leadership, including nurses, knew they had to identify patients who potentially had COVID-19. Personnel safety for ED staff was emphasized, including training in the proper use of personal protective equipment (PPE) and attaining recommended supplies. Large tents were erected outside the ED to screen and test patients suspected of having COVID-19 before their entry into the patient waiting area. The initial ED preparation represented an interdisciplinary effort. Based on organizational structure, the TAMC ED was part of the department of medicine, a department that also included medical primary and specialty care outpatient clinics. The nurse leader aligned with the director of the department of medicine had the authority and flexibility to move nursing personnel from the outpatient clinics to work in the COVID-19 screening tents and assist with staffing in the ED. The nurse leaders in the ED then assumed responsibility to ensure that the appropriate just-in-time competency training was completed with the nursing personnel as they moved into unfamiliar work environments. The TAMC EOC was activated mid-March 2020 to provide a centralized communication hub. Non-essential health care appointments and procedures were cancelled. Visitors were restricted, with few exceptions. Only TAMC personnel and select outpatients were allowed into the facility via two controlled entries, one of which was the ED. With the ED flow of patients established, the EOC personnel focused on expansion efforts for an expected surge in COVID-19 inpatients. Although the numbers of COVID-19 positive cases were not yet high in Hawaii, TAMC leaders had to respond to deadlines for expanding bed capacity driven by a combination of DoD guidance, state mandates, pandemic prediction models, and the presentation of patients to health care facilities throughout Hawaii. Nurse Leader Areas of Expertise (See Fig. 1) The absence of detailed information in the emergency preparedness plan prompted the CNO to assign nurse leaders to spearhead-specific efforts that fell within the realm of nursing expertise. These efforts included collaborating inter-departmentally to develop a bed expansion plan, establishing the internal flow of patients suspected or confirmed for COVID-19, identifying nursing personnel to cross-train, implementing just-in-time training, and providing emotional support for the staff. FIGURE 1. Open in new tabDownload slide Contributions of nurse leader expertise to the pandemic response by topic area. FIGURE 1. Open in new tabDownload slide Contributions of nurse leader expertise to the pandemic response by topic area. Bed Expansion Using national pandemic prediction models, TAMC inpatient beds needed to increase 3-fold. This required identifying space, refitting rooms for patient occupancy, procuring beds, and acquiring needed equipment and supplies. The nurse leaders were respected as experts regarding bed expansion requirements, with leaders from other departments such as facility management and logistics providing additional expertise and support. Interdisciplinary meetings always included nurse leaders to ensure all contingencies were identified. The nurse leaders guided the expansion based on their knowledge of the essential equipment and supplies needed to provide nursing care in the identified spaces. In just 1 month, TAMC achieved the 3-fold increase in projected bed demand within the existing physical structure by increasing capacity on existing units, refitting three non-inpatient areas into inpatient units, and reconfiguring space for a large open-bay unit. Internal Patient Flow A focal point of patient flow concerned moving patients suspected of or positive for COVID-19 between levels of care, as well as designating restricted corridors and elevators to limit exposure. In collaboration with other departmental leaders, nurse leaders helped determine how these patients would move from the ED to inpatient units as well as between inpatient units. Contingency plans included the order in which additional beds and/or units would open and be designated for COVID-19 positive patients. The nursing knowledge of expected patient movement between units and support departments for procedures provided critical insight to establish a safe flow of inpatients. Identifying Nursing Personnel to Cross-Train Inpatient units at TAMC have a core staff of nursing personnel who have demonstrated appropriate competencies based on the unit type. The bed expansion to accommodate projected numbers of patients with COVID-19, however, stressed the inpatient areas, especially the critical care and medical-surgical units. Simultaneously, military nursing personnel with secondary assignments to mobile units were being moved to areas where greater numbers of COVID-19 patients were anticipated. This left fewer competency trained nursing personnel on the inpatient units. Nurse leaders drew upon their expertise in personnel management, understanding of staffing models, and knowledge of patient care needs to expand and optimize nursing staff. Through interdisciplinary collaboration with the non-nurse department directors, nursing personnel not working on inpatient units were identified to support existing inpatient staff. A priority was placed on identifying nurses with past critical care experience or those interested in supporting critical care. Requests for and identification of nursing personnel to work in the inpatient areas were guided by nurse leader understanding of safe staffing models and the possible need for contingency surge staffing. Additional nursing staff were identified by reaching out through the EOC to other civilian and military organizations on Oahu. The American Red Cross identified 20 volunteers, over half of whom had a nursing background. The Chief Nurse of the co-located VA outpatient clinics also identified over 25 nursing personnel who volunteered to train for inpatient care roles. Other medical military units on Oahu that did not have inpatient beds also identified potential personnel to help with staffing. These medical units, however, had the concurrent challenge of juggling mission requirements to support areas outside of Oahu. The non-health care military units did, however, provide soldiers to assist with non-clinical tasks (e.g., gate guard and facility entry screener). Just-in-Time Training Directed by a senior nurse leader, a team of clinical nurse specialists identified essential competencies for nurses who were assigned to new units, developed a training plan, and coordinated the just-in-time training for COVID-19 nursing care. The critical care physicians and nurse leaders developed additional, specialized training. The hospital education department provided logistical support for the training. During the month of April 2020, about 200 nursing personnel received just-in-time training—50 to support the critical care units and 150 to support the medical-surgical units. The just-in-time training included skills laboratories, didactic on-line materials and/or videos, computer documentation, and rotations to the inpatient units for hands-on experience. The just-in-time training emphasized personal safety regarding PPE use. Another focus of the training was how to interact with patients who were isolated, unable to have visitors, and experiencing a disease about which little was known.12 A pamphlet with expected patient and family concerns was created and provided to all inpatient staff. Emotional Support for the Staff Nurse leaders recognize that effective patient care is underpinned by staff who feel supported. Efforts to decrease anxiety and stress for the nursing personnel were integrated into the pandemic response. The uncertainties of the potential surge in patients, changes in roles, changes in routines, concerns for personal safety, and dealing with the different stressors for patients all tested the resilience of the nursing personnel. Assigning nursing personnel to work in unfamiliar areas created anxiety. The nurse leaders conveyed a consistent message to reflect their understanding of the uncertainty and discomfort that accompanied working in an unfamiliar area. Discomfort also was experienced by the nursing personnel on the inpatient units because of orienting multiple individuals in a short time. Concerns were raised regarding safe scope of practice and standards of care. The CNO clearly communicated that safe staffing was a priority, with the additional proviso that under pandemic surge conditions, current staffing models would no longer apply. Adapting standards of care is recognized as a necessary action under extreme circumstances such as pandemic care.13 Regardless of work area, some of the nursing personnel had personal or family member health concerns and others had childcare challenges. Such concerns were considered on an individual basis based on the belief that fair treatment did not mean treating everyone the same. Staff from the labor management and employee relations department was consulted frequently to determine appropriate actions. Chaplains were also available, as requested, to provide emotional support. The Continuing Response The expected surge in COVID-19 patients did not occur on Oahu; thus, few COVID-19 positive patients were admitted to TAMC. Possible factors playing into this lower than expected number of patients testing positive included the geographical isolation of the island, the closure of the tourist and service industries, social isolation mandates, the sense of family within the Hawaiian culture, and adequate testing and contact tracing.14 Hawaii remains among the states with the fewest COVID-19 positive cases reported. As restrictions are lifted, it remains unknown to what extent the cases will surge. Nurse leaders at TAMC are, therefore, cognizant of continued stressors such as staff concerns about bringing the virus home to their families, having personal health issues, practicing in unfamiliar work environments, curtailing previous social plans, being unable to visit extended families, and delaying expected military moves to new assignments. Even as the beds at TAMC are reduced to pre-COVID levels, the capability remains to quickly expand bed capacity. Identified nursing personnel are ready to supplement inpatient care. The patient flow would be re-established for individual patients suspected of or confirmed with COVID-19. Essential supplies, to include PPE, are being restocked with a plan for sustainment over an unknown timeframe. There is an opportunity to reexamine how to manage the impact of any pandemic as we enter a new reality of continued uncertainty. DISCUSSION In the TAMC experience, it was evident that the military context assisted in the pandemic response, although even the military training and leadership experiences did not fully prepare the nurse leaders for dealing with the uncertainty of COVID-19. As noted by Veenema et al.,1 not only do nurses need disaster preparedness training and knowledge, nurse leaders must also hone disaster-related skills through practical exercises. The nurse leaders at TAMC capitalized on their nursing expertise to lead the efforts involving bed expansion, patient flow, identifying nursing personnel to cross-train, just-in-time training, and emotional support. Perhaps because of how rank alters the power structure within the military, the nurse leaders at TAMC, all of whom were of similar rank to leaders from other disciplines, had key responsibilities during the response phase. Additionally, the collegial relationships among the interdisciplinary leaders at TAMC supported meeting demands quickly. As COVID-19 persists, and with the possibility of another pandemic from a different etiology, nurse leaders must engage in their facility’s disaster planning. Particular attention should be given to clearly identifying the nurse leaders’ expertise in areas such as the implementation of just-in-time training. Although the exact focus of the training may not be known until the event happens, nurse leaders should identify who will develop and conduct the training. In the TAMC situation, the two focus areas were ensuring that nurses familiar with inpatient care received additional critical care training and the nursing personnel who did not routinely work in inpatient areas received familiarization training. A prevalent concern noted in the literature is whether nursing personnel will be willing to work during a pandemic.15 Nurse leaders must recognize what factors influence willingness to participate in patient care during pandemics, such as perceptions of personal safety, previous training, confidence in one’s own skills and role, and knowledge of pandemic risk.15 Guidance for crisis standards of care for nursing from professional organizations may also be useful.16 Ensuring increased health risk concerns are addressed through reasonable accommodation processes can reduce inconsistencies amongst leaders and enhance the staff’s confidence in the nurse leaders’ decisions. The resiliency and mental health of nursing personnel also need close monitoring. Part of the military culture is to take care of the team. Leaders and co-workers checked on each other, with liberal time given if needed (within legal parameters) to deal with childcare, personal, or other needs. Nurse leaders must continue to monitor the emotional state of the nursing personnel and provide needed support, especially as the circumstances surrounding the COVID-19 pandemic remain uncertain. CONCLUSION Although it may be difficult to discern the exact expertise that nurse leaders contribute to disaster and/or pandemic management, the initial description in this article of applied expertise based on real-life experience provides a basis for discussion. Nurse leaders have developed this expertise over time based on their exposure to the domain of nursing that includes management of patient beds, patient flow, and competency training as well as emotional support of the staff as part of routine practice. Nurse leaders uniquely contribute this expertise for the functioning of the interdisciplinary team, regardless of the circumstances. Having nurse leaders integrated within all departments at TAMC assisted in maximizing upon their expertise and collaborative relationships to optimize the overall response to the pandemic. ACKNOWLEDGMENTS None declared. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Veenema TG , Griffin A, Gable AR, et al. : Nurses as leaders in disaster preparedness and response—a call to action . J Nurs Scholarsh 2016 ; 48 ( 2 ): 187 – 200 . Google Scholar Crossref Search ADS PubMed WorldCat 2. Labrague LJ , Hammad K, Gloe DS, et al. : Disaster preparedness among nurses: a systematic review of literature . Int Nurs Rev 2018 ; 65 ( 1 ): 41 – 53 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Knebel AR , Toomey L, Libby M: Nursing leadership in disaster preparedness and response . Annu Rev Nurs Res 2012 ; 30 ( 1 ): 21 – 45 . Google Scholar Crossref Search ADS PubMed WorldCat 4. Veenema TG , Deruggiero K, Losinski S, Barnett D: Hospital administration and nursing leadership in disasters: an exploratory study using concept mapping . Nurs Adm Q 2017 ; 41 ( 2 ): 151 – 63 . Google Scholar Crossref Search ADS PubMed WorldCat 5. World Health Organization : WHO timeline—COVID-19 . Available at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline#event-0; accessed February 11, 2021 . 6. Harapan H , Itoh N, Yufika A, et al. : Coronavirus disease 2019 (COVID-19): a literature review . J Infect Public Health 2020 ; 13 ( 5 ): 667 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Singhal T : A review of coronavirus disease-2019 (COVID-19) . Indian J Pediatr 2020 ; 87 ( 4 ): 281 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Gallagher CR : Muddling leadership and management in the United States army . APOJ 2016 ; 108 : 16 – 32 . Google Scholar OpenURL Placeholder Text WorldCat 9. Jennings BM , Scalzi CC, Rodgers JD, Keane A: Differentiating nursing leadership and management competencies . Nurs Outlook 2007 ; 55 ( 4 ): 169 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Hutchinson M , Higson M, Cleary M, Jackson D: Nursing expertise: a course of ambiguity and evolution in a concept . Nurs Inq 2016 ; 23 ( 4 ): 290 – 304 . Google Scholar Crossref Search ADS PubMed WorldCat 11. World Population Review : Hawaii population 2020 . Available at https://worldpopulationreview.com/states/hawaii-population/; accessed August 5, 2020 . 12. VITALtalk : Available at https://www.vitaltalk.org/; accessed August 5, 2020 . 13. American Nurses Association : Adapting standards of care under extreme circumstances: guidance for professionals during disasters, pandemics, and other extreme emergencies . 2008 . Available at http://www.calhospitalprepare.org/sites/main/files/file-attachments/14__adaptingstandardsofcare.pdf; accessed January 27, 2021 . 14. Warner M : How Hawaii became a rare COVID success story . Politico , 2020 . Available at https://www.politico.com/news/magazine/2020/06/19/hawaii-covid-success-story-322919; written June 19, 2020 ; accessed August 5, 2020 . 15. Aoyagi Y , Beck CR, Dingwall R, Nguyen-Van-Tam JS: Healthcare workers’ willingness to work during an influenza pandemic: a systematic review and meta-analysis . Influenza Other Respir Viruses 2015 ; 9 ( 3 ): 120 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 16. U.S. Department of Health and Human Services : Topic collection: crisis standard of care . Available at https://asprtracie.hhs.gov/technical-resources/63/crisis-standards-of-care/0; accessed August 5, 2020 . Author notes The views expressed in this abstract/manuscript are those of the author(s) and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Migliore, Laurie; Hopkins, Dawnkimberly; Jumpp, Savannah; Brackett, Ceferina; Cromheecke, Jessica

doi: 10.1093/milmed/usab190pmid: 34469529

ABSTRACT Leadership during the emergence of the novel coronavirus pandemic is complex and involves coordinated efforts between multiple levels of leadership from the medical, installation, local, state, and federal levels. Medical intelligence is critical to successful pandemic threat mitigation. We describe one of the first coronavirus (Coronavirus Disease-2019 (COVID-19)) impacted Department of Defense Medical Treatment Facility’s strategic activation of a COVID-19 Medical Intelligence Team (MIT), the products developed, and lessons learned during the pandemic onset. The MIT bridged COVID-19 knowledge and policy gaps by developing and delivering daily intelligence briefings on four domains: epidemiology and infectious disease, healthcare capabilities and infrastructure, policy and regulations, and diagnostics and therapeutic interventions. Twenty-three products were developed and delivered to aid in leadership decision-making and local policy development in the absence of higher-level policy and guidance. Employing MITs in future pandemic response strategy may more effectively mitigate pandemic threats and improve force health protection. INTRODUCTION The Problem Currently, there are over 120 million cases of diagnosed coronavirus (COVID-19) worldwide at the time of this manuscript writing.1 Over the past year, we experienced global shortages and supply chain challenges with personal protective equipment (PPE) and COVID-19 test supplies (kits and swabs) and vaccines. Healthcare systems and healthcare workers on the frontlines were stressed with providing life-saving interventions and delivering the best possible care. Amidst pandemic uncertainties and with additional pandemic duties, the Department of Defense (DoD) was relied upon to remain vigilant and fully operational, supporting Military Departments and Combatant Commands to defend and protect the USA and its allies, assets, and interests at home and throughout the world. The purpose of this manuscript is to describe a U.S. west coast Military Treatment Facility (MTF)’s early COVID-19 strategic activation of a Medical Intelligence Team (MIT), products developed, and lessons learned by the team during the pandemic onset. Background The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, in late 2019, resulting in a lockdown to mitigate its spread. On January 30, 2020, the Center for Disease Control (CDC) declared the first human-to-human transmission,2 and the U.S. Health and Human Services (HHS) declared a public health emergency on January 31, 2020.3 In early February 2020, hundreds of Americans were evacuated from Hubei province, the COVID-19 epicenter, and federally quarantined on Travis AFB, CA, for repatriation.4 On February 16, 2020, over 100 Diamond Princess Cruise patrons (21% infection rate of the 3,711 passengers) also quarantined on Travis AFB, and individuals testing positive for COVID-19 were transferred to off-base medical facilities in the local community.5 By February 21, 2020, California confirmed its first COVID-19-positive resident in Sacramento, an individual who had recently traveled from China.6 In the wake of anxiety and a mounting public health emergency, California recorded the first non-travel-related U.S. coronavirus case on February 26, 2020.7 Solano County, CA, declared a state of emergency on February 27, 2020, followed by a Travis AFB state of emergency declaration.8 The next day, a second non-travel-related COVID-19 case was diagnosed in Santa Clara, CA,9 and the first recorded U.S. COVID-19 death occurred on February 29, 2020, in Washington State.10 By March 9, 2020, Travis AFB acquired 850 more patrons for repatriation quarantine resulting from the Grand Princess Cruise line outbreak.11 Although the HHS provided all workforce and supplies for the repatriation quarantines, the Travis installation billeting (hotel and temporary lodging quarters) served as the repatriation population’s quarantine lodging from February to March. Tensions on Travis AFB and the surrounding communities regarding the COVID-19 threat escalated. The World Health Organization (WHO) declared a pandemic on March 11, 202012, and by March 15, 2020, Travis AFB reported the first COVID-19-positive active duty member.13 As California was experiencing some of the country’s earliest COVID-19 cases, David Grant USAF Medical Center (DGMC) became one of the first Air Force/DoD MTFs to develop and implement a pandemic response plan. The DGMC is a Joint Commission–accredited teaching hospital and the largest of 76 MTFs in the Air Force Medical Service. Located on Travis AFB, in Solano County, CA, and supported by over 2,400 personnel, DGMC serves an eligible beneficiary population of greater than 368,000 patients, providing care for more than 424,000 outpatients and 5,600 inpatient admissions annually. The Clinical Investigation Facility (CIF), staffed by 31 members, is responsible for leading and executing clinical research for DGMC staff and 14 graduate health education programs. The CIF maintains a vivarium in support of animal research, a $20 million infrastructure laboratory suite to facilitate laboratory research and can support a variety of human subject research. In response to the substantial disease threat, high morbidity rate, and imminent spread, a command-directed implementation of Health Protection Condition Charlie (HPCON C) was declared. Consequently, requirements for social distancing and shelter-in-place orders significantly impacted installation operations. The majority of base, Medical Group (MDG) and CIF functions transitioned to telework and telehealth. Conversely, the MDG public health, infection control (IC), and hospital contingency operations teams ramped into high gear. The MDG response planners and executive staff recognized significant gaps in COVID-19 pandemic knowledge. Requirements for information and policy soared as the MDG was responsible for providing information to aid both the hospital and Installation Commander’s decision-making in the absence of headquarters’ level policy and guidance. On March 12, 2020, the CIF Deputy volunteered to assist with hospital planning and risk management based on her past army experience with emergency response management and Biosafety Level 3 Laboratory oversight. Empowered by MDG leaders, the CIF Deputy expanded the team to include two CIF nurse scientists and a nursing readiness fellow, formally establishing the MIT to bridge COVID-19 knowledge and policy gaps and provide products to mitigate the spread of COVID-19. It is important to note that, in our circumstances, the MIT spontaneously formed based on needs and available staff familiar with rapid scientific reviews and reporting, which happened to be research staff. This is the story of our structure, functions, accomplishments, and lessons to share for future teams who may proactively and intentionally design contingency MITs from their local personnel. MEDICAL INTELLIGENCE FRAMEWORK The concept and function of medical intelligence are not new. Joint Publication 4-02 defines medical intelligence as, “The intelligence produced from the collection, evaluation, and analysis of information that includes the medical aspects of foreign areas that have an immediate or potential impact on policies, plans, and operations.”14 Medical intelligence includes information regarding threat detection and identification, the operational context and characteristics in theater, and any unique operational details that will empower the commander to successfully execute the mission. Information useful for countermeasures, threat mitigation, force health maintenance, and end strength are high intelligence priorities. Typically, medical intelligence derives information from various risk assessments (environmental, industrial, health, and infectious disease), public health centers, medical surveillance reports, and publications. Government and DoD resources such as the National Center for Medical Intelligence (NCMI), CDC, WHO, and Armed Forces Health Surveillance Branch websites, reports, and publications provide information that has been collected, analyzed, and synthesized, resulting in intelligence that contributes to strategic level decision-making and policy development. DGMC Medical Intelligence Structure and Function The structure of our MIT was composed of two dyads: Team One, the CIF Deputy (lead) and Women’s Health Nurse Scientist (associate), and Team Two, Biobehavioral Nurse Scientist (lead) and Clinical Inquiry in Nursing Readiness Fellow (associate), as illustrated in Figure 1. We reported to the Medical Command and Control (MCC) and the MDG executive staff while working in tandem with the IC and PPE working groups. The MDG leadership’s immediate pandemic response was threefold: to educate, train, and equip clinical staff to provide safe, high-quality COVID-19 patient care; anticipate and prepare for a surge; and implement the installation’s public health pandemic response plan. The majority of MDG public health and clinical manpower was consumed with clinical pandemic preparations. Therefore, a significant portion of CIF research assets shifted for 3 months to support COVID-19 MIT efforts while sustaining ongoing research and evidence-based practice initiatives. FIGURE 1. Open in new tabDownload slide David Grant USAF Medical Center’s Medical Intelligence Team (MIT) structure. Note: CIF, Clinical Investigation Facility; CINR, Clinical Inquiry in Nursing Readiness; DGMC, David Grant USAF Medical Center; IC, Infection Control; MCC, Medical Command Center; MDG, Medical Group; PPE, Personal Protective Equipment. CIF Support Staff included Doctor of Veterinary Medicine, Evidence-based Practice Facilitator, Research Nurse, Clinical Research Coordinators, Research Assistants, and Laboratory Research Technicians. The primary MIT function was to inform MDG executive staff, the MCC, Installation Commander, and Emergency Operation Center regarding four broad domains (see Fig. 2): (1) Epidemiology and Infectious Disease, (2) Healthcare Capabilities and Infrastructure, (3) Policy and Regulations, and (4) Diagnostics and Therapeutic Interventions. The primary venue for delivering MIT information was through a daily COVID-19 situation report (SITREP) briefing with leadership and over a dozen lines of effort (LOEs). Updates from all squadrons, public health, readiness, logistics, finance, public affairs, and the Public Health Emergency Officer were delivered. The MIT briefed a daily slide deck (10–25 slides) for MDG and Wing leadership utilization. Additional requests for information (RFIs) evolved during the SITREP briefings. The RFIs typically stemmed from lack of guidance, operational capability gaps for carrying out the guidance (lack of supplies, equipment, and manpower), or general guidance that delegated decision-making responsibility to the Installation Commander. The appropriate LOE, frequently the MIT, received the RFI tasker with a 24–72-hour suspense to deliver knowledge products (e.g., rapid scientific evidence summaries and policy considerations). Information shared aided decision-making to procure and distribute necessary medical resources needed to adequately prepare for, respond to, and mitigate the COVID-19 public health emergency in the hospital and on the installation. FIGURE 2. Open in new tabDownload slide COVID-19 medical intelligence reporting domains. Note: Four domains of reportable intelligence provided daily to Medical Group executive staff, Medical Command and Control, and Wing leadership by David Grant USAF Medical Center's COVID-19 Medical Intelligence Team. The CIF clinical support staff (research nurse, evidence-based practice facilitator, research coordinators, and assistants) played a critical role in contributing to the successful development and delivery of rapid evidence reviews and knowledge products for the RFIs. Likewise, the CIF veterinarian and laboratory technician conducted daily policy reviews utilizing the NCMI website providing a written summary of new policies noting any conflicting guidance or forthcoming instructions. In addition to the daily COVID-19 SITREP briefing, MIT met daily with the MCC commander, logistics flight commander, and IC and PPE working groups (bioenvironmental engineers, dentist, infection preventionist, and nurse) to synchronize activities, clarify roles and responsibilities for daily taskers, and review policy changes delegated from higher levels. Most of the RFIs required multidisciplinary engagement such as consultation with the Public Health Emergency Officer, infectious disease physician, bioenvironmental flight commander, or medical legal staff. Finally, to provide MDG leadership with vital information shared by community partners, we participated in a weekly county health department teleconference for medical facilities, emergency, and first responders, discussing local capacity, resources, and state and county policy updates. DGMC Medical Intelligence Daily Briefings Infectious Disease and Epidemiology Infectious disease epidemiology is the study of the incidence and spread of infectious disease in populations over time. The purpose of MIT’s infectious disease and epidemiology briefing was to identify the current COVID-19 threat, trends, illness clusters, and predictive models that would assist in forecasting disease spread. We presented surveillance through graphical representation for COVID-19 rates of Patients Under Investigation (PUI), persons tested, confirmed positive cases, hospitalizations, and deaths displaying installation, county, state, and U.S. data. At the outset of the pandemic, very few data dashboards were available. We tracked local installation data managed by MDG public health in an excel database listing de-identified case counts according to beneficiary categories. To target our local threat, we used county and state health department websites and Worldometer’s coronavirus website for world and U.S. data. We established clear and consistent reporting times (1,700) in accordance with daily reporting standards. As the COVID-19 case rates increased, we added a 24-hour percentage change rate to illustrate the disease trajectory, provided a standard measure to compare rates between locations, and enabled more meaningful data interpretations. Eventually, NCMI provided regional threat assessments integrating data from some, but not all the surrounding counties. Because of our installation location, many of our personnel commute from all bordering counties; therefore, we continued to provide data from local sources as well as intelligence from NCMI. Our daily epidemiologic surveillance statistics aided decision-making before higher-level policy was disseminated regarding leave and travel restrictions, elimination of cafeteria-seated dining, and closure of the hospital gym. It also informed screening processes on the installation, forecasted demand for installation isolation and quarantine lodging, and provided an overall understanding of disease impact on installation and community partner operations. Healthcare Capabilities and Infrastructure A crucial role of public health preparedness and response is understanding capacity and demand. Healthcare capability and infrastructure data enabled insight for preparation. At the onset of the pandemic, it was impossible to know if a surge in COVID-19 cases would overwhelm our healthcare system. The MDG prepared a plan that modified manpower, equipment, and supplies in anticipation of a surge. The MIT reported bed (intensive care, isolation, and medical-surgical) and ventilator utilization and availability for all county hospitals, including DGMC using the California ReddiNet web-based emergency medical communications system. ReddiNet is updated daily by county hospitals, first responders, and Emergency Medical Services (EMS) during public health emergencies for the purpose of interagency collaboration and resource sharing. It became clear early on during our meetings with the MCC and logistics leaders that supply chain issues, burn rates for PPE, supplies, equipment, and testing capability required tracking and reporting similar to ReddiNet resources. Logistics tracked numbers, and PPE and IC working groups were established to address issues with PPE utilization, conservation, and innovation (e.g., 3D printed face shields and homemade masks). To organize daily requirements, a “common operating picture” was developed, illustrating installation HPCON, CDC, and State Department threat levels, daily operations statistics by LOE (e.g., number of COVID-19 tests, point-of-entry screenings, and isolation/quarantine rooms in use), resource capacity for PPE, and a summary of critical updates and actions. Healthcare capability and infrastructure intelligence informed decision-making regarding capacity for patient transfers, collaborative resource sharing options (the county health department shared COVID-19 test supplies with our MTF), and anticipated requests for manpower assistance. Our MTF responded to a Defense Support for Civil Authorities’ tasking, providing 160 active duty medical staff in support of eight California civilian medical facilities from July to September 2020. The MIT healthcare capacity reports enabled leaders to anticipate and implement timely and effective measures to proactively address evolving issues. Policy and Regulations Owing to the nature of dealing with a novel and highly infectious zoonotic coronavirus, other than influenza pandemic preparedness guidelines, how to best handle this disease and mitigate spread was unknown. The MIT strategically combed through government regulatory agencies’ daily policy postings to provide up-to-date, relevant, and timely information to the executive staff. Trusted governmental regulatory agencies, specifically, CDC, U.S. Food and Drug Administration (FDA), and Federal Emergency Management Agency, along with NCMI were sourced daily as primary resources for the basis of policy extraction. Tracking policy in real time provided the executive team with relevant information to make informed decisions on clinical care and strategic guidance for preparedness planning. As expected, with a novel pathogen, facts were less concrete when most of the variables, transmission, infectivity, immunity, and disease outcomes, were unknown, and therefore we discovered drastic policy shifts from one day to the next as policy evolved along with new scientific evidence. Since Solano County was the first in the USA to have a detectable COVID-19 case (February 26, 2020), our MIT team often encountered issues before established policy. In these instances, the team reviewed primary literature for a full survey on what information was known, gathering evidence to assist leadership with timely decision-making. An early example was regarding face coverings and masks specifically, what material was sufficient especially with supply concerns in mind, and who should wear it? As time proceeded, COVID-19 updates began to flow down to us, similar in format to our products and NCMI provided commander policy toolkits summarizing weekly policy updates; thus, MIT members transitioned back into our full-time research positions. Diagnostics and Therapeutic Treatments The purpose of diagnostics and therapeutic treatments’ intelligence was to keep leadership abreast of innovative National Institute of Health studies, drug updates, and technique interventions from the FDA to assist clinical COVID-19 decision-making. Although MIT provided information, our Infectious Disease provider and COVID Czar operationalized the intelligence within the facility, providing implementation recommendations for PPE conservation, convalescent plasma, pooled sample testing, and other novel initiatives. Initially, in March 2020, COVID-19 diagnostic and therapeutic information was sparse. We reported the daily number of National Institute of Health COVID-19 clinical trials, which initially was zero and by mid-May totaled 1,518 clinical trials registered, with 82 completed and 17 withdrawn. Sharing clinical trial information was critical for MDG clinical decision-making regarding potential interventions, requirements for trial participation, and situational awareness. We also monitored and reported the progress of the Rapid Acceleration of Diagnostic (RADx) initiative for COVID-19, an initiative to infuse funding into early innovative technologies expediting the development of rapid and widely accessible COVID-19 testing. The RADx intelligence aided MDG laboratory considerations regarding our COVID testing options and methods. Likewise, we reviewed the FDA website daily for relevant information integral to ensuring patient safety and patient mortality regarding drug selection and shortages, informing pharmacy personnel to mitigate the impact on military beneficiaries. At times, the various organizations’ voluminous data were also conflicting, requiring large volumes of data synthesis before disseminating time-sensitive information. In cases of ambiguous or contradictory information, we referred to original sources for clear guidance to safeguard operational and clinical decision-making, patient safety practices, and fidelity of credible statistics, facts, and our MIT-developed products. As COVID-19 dashboards and dedicated COVID-19 websites evolved on government websites, the time-consuming pursuit of authority and information retrieval conducted by MIT decreased. MEDICAL INTELLIGENCE PRODUCTS Product Summary In 7 weeks, MIT developed 23 products listed in Table I. Most information requests required collaboration with the relevant clinical Subject Matter Experts (SMEs), rapid evidence reviews of scientific, peer-reviewed literature to address knowledge gaps, most commonly related to threat mitigation, specifically protecting healthcare workers, patients, and the force health protection of members on the installation. For instance, questions arose regarding developing and utilizing “do it yourself masks”; understanding crisis standards of care; how to clean residential, office, public spaces on the installation; and so on. The RFIs were tasked out at the daily COVID-19 leadership meetings. Our MIT typically provided a product back to the executive team in a 24–72-hour time frame depending on the task complexity. All MIT products preceded official government or military policies as well as published syntheses in peer-reviewed journals. TABLE I. Medical Intelligence Team (MIT) Products Evidence Review on Homemade Masks (March 18, 2020) Wing COVID-19 Reporting Guidelines (March 26, 2020) Crisis Standards of Care Evidence Summary (March 27, 2020) 24-hour Costs for Isolation Room Operations (April 6, 2020) Comprehensive Evidence-Based Cleaning Guidance (March 27, 2020) Pregnancy and COVID-19 Evidence Summary (March 27, 2020) DGMC PPE Guidance (March 26, 2020) COVID-19 Medications Evidence Summary (March 31, 2020) Guidance on Mask Wear for High-Risk Staff (March 31, 2020) 3D Printed Masks (March 31, 2020) Air Force Medical Readiness Agency (AFMRA) COVID Respiratory Protection Evidence Summary (March 31, 2020) COVID-19 Postmortem Policy Considerations (March 31, 2020) COVID-19 Respiratory Protection Evidence Summary (April 1, 2020) Nonsteroidal Anti-inflammatory Drugs (NSAID) and COVID-19 Evidence Summary (April 1, 2020) COVID-19 Reinfection Evidence Summary (April 6, 2020) Air Mobility Command (AMC)/A9 Predictive Models Summary (April 9, 2020) Multiservice Component Rules of Engagement (ROE) for 3D N95 Print Policy (April 9, 2020) COVID-19 Pre-Op Surgical Testing Evidence Summary (April 14, 2020) COVID-19 Innovation Governance Process and Policy (April 15, 2020) COVID-19 Roadmap to Recovery Evidence Summary (April 24, 2020) Travis AFB Newcomer’s COVID-19 Prevention Measures (May 4, 2020) COVID-19 Transmission Evidence Summary (May 6, 2020) COVID-19 Travis AFB Case Count Trend Tracker (May 7, 2020) Evidence Review on Homemade Masks (March 18, 2020) Wing COVID-19 Reporting Guidelines (March 26, 2020) Crisis Standards of Care Evidence Summary (March 27, 2020) 24-hour Costs for Isolation Room Operations (April 6, 2020) Comprehensive Evidence-Based Cleaning Guidance (March 27, 2020) Pregnancy and COVID-19 Evidence Summary (March 27, 2020) DGMC PPE Guidance (March 26, 2020) COVID-19 Medications Evidence Summary (March 31, 2020) Guidance on Mask Wear for High-Risk Staff (March 31, 2020) 3D Printed Masks (March 31, 2020) Air Force Medical Readiness Agency (AFMRA) COVID Respiratory Protection Evidence Summary (March 31, 2020) COVID-19 Postmortem Policy Considerations (March 31, 2020) COVID-19 Respiratory Protection Evidence Summary (April 1, 2020) Nonsteroidal Anti-inflammatory Drugs (NSAID) and COVID-19 Evidence Summary (April 1, 2020) COVID-19 Reinfection Evidence Summary (April 6, 2020) Air Mobility Command (AMC)/A9 Predictive Models Summary (April 9, 2020) Multiservice Component Rules of Engagement (ROE) for 3D N95 Print Policy (April 9, 2020) COVID-19 Pre-Op Surgical Testing Evidence Summary (April 14, 2020) COVID-19 Innovation Governance Process and Policy (April 15, 2020) COVID-19 Roadmap to Recovery Evidence Summary (April 24, 2020) Travis AFB Newcomer’s COVID-19 Prevention Measures (May 4, 2020) COVID-19 Transmission Evidence Summary (May 6, 2020) COVID-19 Travis AFB Case Count Trend Tracker (May 7, 2020) Note: The MIT products were developed in response to executive staff, Medical Command and Control (MCC) and Emergency Operations Command requests for information (RFIs). Open in new tab TABLE I. Medical Intelligence Team (MIT) Products Evidence Review on Homemade Masks (March 18, 2020) Wing COVID-19 Reporting Guidelines (March 26, 2020) Crisis Standards of Care Evidence Summary (March 27, 2020) 24-hour Costs for Isolation Room Operations (April 6, 2020) Comprehensive Evidence-Based Cleaning Guidance (March 27, 2020) Pregnancy and COVID-19 Evidence Summary (March 27, 2020) DGMC PPE Guidance (March 26, 2020) COVID-19 Medications Evidence Summary (March 31, 2020) Guidance on Mask Wear for High-Risk Staff (March 31, 2020) 3D Printed Masks (March 31, 2020) Air Force Medical Readiness Agency (AFMRA) COVID Respiratory Protection Evidence Summary (March 31, 2020) COVID-19 Postmortem Policy Considerations (March 31, 2020) COVID-19 Respiratory Protection Evidence Summary (April 1, 2020) Nonsteroidal Anti-inflammatory Drugs (NSAID) and COVID-19 Evidence Summary (April 1, 2020) COVID-19 Reinfection Evidence Summary (April 6, 2020) Air Mobility Command (AMC)/A9 Predictive Models Summary (April 9, 2020) Multiservice Component Rules of Engagement (ROE) for 3D N95 Print Policy (April 9, 2020) COVID-19 Pre-Op Surgical Testing Evidence Summary (April 14, 2020) COVID-19 Innovation Governance Process and Policy (April 15, 2020) COVID-19 Roadmap to Recovery Evidence Summary (April 24, 2020) Travis AFB Newcomer’s COVID-19 Prevention Measures (May 4, 2020) COVID-19 Transmission Evidence Summary (May 6, 2020) COVID-19 Travis AFB Case Count Trend Tracker (May 7, 2020) Evidence Review on Homemade Masks (March 18, 2020) Wing COVID-19 Reporting Guidelines (March 26, 2020) Crisis Standards of Care Evidence Summary (March 27, 2020) 24-hour Costs for Isolation Room Operations (April 6, 2020) Comprehensive Evidence-Based Cleaning Guidance (March 27, 2020) Pregnancy and COVID-19 Evidence Summary (March 27, 2020) DGMC PPE Guidance (March 26, 2020) COVID-19 Medications Evidence Summary (March 31, 2020) Guidance on Mask Wear for High-Risk Staff (March 31, 2020) 3D Printed Masks (March 31, 2020) Air Force Medical Readiness Agency (AFMRA) COVID Respiratory Protection Evidence Summary (March 31, 2020) COVID-19 Postmortem Policy Considerations (March 31, 2020) COVID-19 Respiratory Protection Evidence Summary (April 1, 2020) Nonsteroidal Anti-inflammatory Drugs (NSAID) and COVID-19 Evidence Summary (April 1, 2020) COVID-19 Reinfection Evidence Summary (April 6, 2020) Air Mobility Command (AMC)/A9 Predictive Models Summary (April 9, 2020) Multiservice Component Rules of Engagement (ROE) for 3D N95 Print Policy (April 9, 2020) COVID-19 Pre-Op Surgical Testing Evidence Summary (April 14, 2020) COVID-19 Innovation Governance Process and Policy (April 15, 2020) COVID-19 Roadmap to Recovery Evidence Summary (April 24, 2020) Travis AFB Newcomer’s COVID-19 Prevention Measures (May 4, 2020) COVID-19 Transmission Evidence Summary (May 6, 2020) COVID-19 Travis AFB Case Count Trend Tracker (May 7, 2020) Note: The MIT products were developed in response to executive staff, Medical Command and Control (MCC) and Emergency Operations Command requests for information (RFIs). Open in new tab Product Illustration The earliest MIT product (March 16, 2020) was a rapid evidence review synthesizing scientific peer-reviewed literature on homemade masks, exploring the effectiveness of different types of homemade masks (e.g., cotton t-shirts, bandanas, 2-ply, etc.) versus standard surgical masks. The evidence table (Fig. 3) lists publications retrieved between 2005 and March 2020. The request for evidence arose during COVID-19 surge preparations and before face-covering mandates or the availability of commercial face coverings. The evidence revealed that homemade masks can reduce viral transmission compared to no mask. Most importantly, the fit and the material contribute to mask effectiveness. Based on the MIT review, a resourceful provider utilized existing available medical materials (surgical drapes) to construct a mask and teamed up with our PPE working group to test the material and fit. The executive staff approved surgical drape mask mass production, resulting in over 2,000 masks protecting patients and staff and preventing PPE supply degradation. FIGURE 3. Open in new tabDownload slide Crisis management: evidence review of surgical mask material and filtration summary. Note: Four domains of reportable intelligence provided daily to Medical Group executive staff, Medical Command and Control, and Wing leadership by David Grant USAF Medical Center' COVID-19 Medical Intelligence Team. LESSONS LEARNED The MIT evolved throughout the pandemic. Review of MIT activities and ways to improve future processes resulted in five valued lessons learned noted below. Identify Critical Actors Provision of reliable and relevant intelligence relies on quickly determining the critical actors necessary for gathering quality, priority intelligence. It is vital to assure the MIT is engaged with and tasked by actors with power and authority to enact change (develop local policy/regulations) and that the appropriate stakeholders (multidisciplinary) participate in discussions. We determined our primary collaborators for this pandemic including public health, emergency operations, IC, logistics, and MDG leadership. Secondary collaborators were identified and engaged according to the tasking specialty area. Example: Our evidence-based practice facilitator alerted us that although MIT, IC, and PPE working group were providing clear guidance on PPE use and conservation methods and the inpatient nursing staff were receiving conflicting information at the unit level, we missed a key stakeholder by not including an inpatient unit leader as a primary collaborator. Roles and Responsibilities Productive and efficient functioning is highly dependent on establishing clear roles and responsibilities. The MIT functioned to facilitate critical information between the MCC and MDG leadership, and at times the Wing leaders. Clear MIT rules of engagement developed in collaboration with leadership allowed for delivery of necessary COVID-19 intelligence, specifically, explicit content for tracking and the frequency and format for reporting and establish clear expectations for other actors that engage with and collaborate with MIT and continually re-evaluate MIT roles and responsibilities to maintain relevant, productive functioning. Example: During the first few weeks, the requested information, level of detail, frequency of delivery, and format changed daily. Leaders wanted more information than was available, they wanted data trended and graphed; however, due to low case counts there was not enough data to trend until at least 3 weeks into the pandemic. Preferences for reporting varied by the requester and desire for up-to-date statistics for early morning briefs were impossible as county and state report times were typically 1,700. Eventually, dedicated content categories; report times; and slide, graph, and chart formats were established as was a tasking flow requiring all taskers to route through the MCC for triage and assignment. Use Primary Source Information The MDG Commander was dependent on the MIT for relevant and up-to-date information and ensure the use of primary sources (i.e., reporting CDC/FDA information directly from the CDC/FDA site) to decrease the potential of erroneous information dissemination. Relying on secondary sources or not verifying that data are from primary sources may lead to communicating inaccurate guidelines or policies to leadership that compromise decision-making and patient safety. Example: Open-access preprint research studies without the normal peer-review process were copious and available as were novel products, devices, and drugs. Verification of FDA Emergency Use Authorization (EUA) for COVID-19 testing equipment, supplies, and processes was vital for MTF testing strategic plans. Consistently Replicable Endpoints for Reporting Establishing a consistent close-out time for epidemiologic data (daily at 1,700 as were county and state report times) and a consistent time frame for item inventory (daily/weekly PPE inventory with prescribed close-out time) prevents undue stress on the MIT members to have necessary data ready for reports. Example: Initially, we were expected to provide as much information in real time as possible; leadership was not used to receiving day old data. It took time to establish standard reportable elements and report times, which were critical when comparing changes in data over time. Enterprise-wide Intelligence Dissemination Posting MIT products (e.g., templates, evidence reviews, and lessons learned) on an enterprise-wide central repository may reduce duplicated efforts and ensure uniformity of processes and practices utilized and information dissemination. Consider additional manpower to aid in publishing products to peer-reviewed journals during development. Due to heavy demands for guidance products and the fast pace of operations, we lost the opportunity to refine and publish. Regardless, MIT’s comprehensive daily PowerPoint slide decks and briefings served as a valuable decision aid for key MDG and Wing leadership. DISCUSSION Although the MIT provided valuable resources for leadership during the initial stages of the COVID-19 pandemic, MIT’s development and activation were not without limitations. Due to the novel role of medical intelligence in the context of COVID-19, standard operating procedures for MIT structure and function were lacking, as was staff with medical intelligence and experience. Moreover, manpower and resources constrained MIT’s capabilities and may not represent the full potential of a more robust, multidisciplinary, and experienced MIT. Core MIT members managed primary research responsibilities for funded projects in progress in addition to MIT information requests and daily briefings. In addition to operationalizing knowledge from our lessons learned, future recommendations for rapid establishment of a MIT include developing a pandemic medical intelligence toolkit or ramp-up guide containing a generic medical intelligence standard operation procedure, position descriptions for core MIT roles, briefing templates, and a trusted resource reference list. Public health pandemic response and mitigation plans should also incorporate MIT guidance. Optimally, in selecting future MIT members, consider individuals who can delegate primary job responsibilities to others while dedicating all efforts to the MIT role. If MIT members must split efforts between MIT and primary job responsibilities, we recommend including additional MIT members. Further, suppose MIT membership must be limited—in that case, we recommend utilizing individuals experienced with rapid literature reviews, analysis and synthesis of large volumes of information, and the ability to translate scientific data into actionable public health practices. Open, honest, closed-loop communication is critical for successful operations. Clear articulation of leadership priorities and daily operational, tactical needs, and limitations must flow top-down and bottom-up. Throughout the MIT journey, our experience suggests that proactive management and transparent communication are keys when navigating the fog of war during the initial stages of a pandemic. CONCLUSION The MITs incorporate multidisciplinary team members’ coordinated effort to collect, analyze, and interpret scant to overwhelming volumes of information to aid decision-making and policy development during uncertain circumstances. Employing a MIT in future pandemic response strategy may more effectively mitigate pandemic threats and improve force health protection. ACKNOWLEDGMENTS We would like to recognize the DGMC, CIF, and staff contributions to the MIT’s productivity. The success of the MIT was a unified department effort. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Worldometer : COVID-10 coronavirus pandemic . Available at https://www.worldometers.info/coronavirus/; accessed December 6, 2020 . 2. Centers for Disease Control and Prevention : CDC confirms person-to-person spread of new coronavirus in the United States . Available at https://www.cdc.gov/media/releases/2020/p0130-coronavirus-spread.html, January 30, 2020 ; accessed November 5, 2020. 3. Health and Human Services : Secretary Azar declares public health emergency for the United States for 2019 novel coronavirus . Available at https://www.hhs.gov/about/news/2020/01/31/secretary-azar-declares-public-health-emergency-us-2019-novel-coronavirus.html, January 31, 2020 ; accessed November 5, 2020. 4. Jordan M , Bosman J: Hundreds of Americans were evacuated from the coronavirus epicenter. Now comes the wait . The New York Times , 2020 . Available at https://www.nytimes.com/2020/02/05/us/coronavirus-flights-wuhan.html; accessed November 5, 2020. 5. Bay Area News : Quarantined ship passengers arrive, are sequestered at Travis AFB . Available at https://www.nbcbayarea.com/news/local/east-bay/evacuees-from-cruise-ship-with-coronavirus-outbreak-coming-to-travis-air-force-base/2235223/, February 16, 2020 ; accessed November 5, 2020. 6. Sacramento Bee : Update: coronavirus risk in Sacramento County low as first case of illness reported . Available at https://www.sacbee.com/news/local/health-and-medicine/article240516951.html, February 21, 2020 ; accessed November 5, 2020. 7. Solano County Health Department : County Public Health confirms case of COVID-19 through possible community transmission . Available at https://www.solanocounty.com/civicax/filebank/blobdload.aspx?BlobID=33236, February 27, 2020 ; accessed November 5, 2020. 8. Villalon D : Solano County declares state of emergency over coronavirus . Solano County Health Department . Available at https://www.ktvu.com/news/solano-county-declares-state-of-emergency-over-coronavirus, February 28, 2020 ; accessed November 5, 2020. 9. Santa Clara Public Health : County of Santa Clara Public Health Department reports third case of COVID-19 . Available at https://www.sccgov.org/sites/phd/news/Pages/third-novel-coronavirus-case-02-2020.aspx, February 28, 2020 ; accessed November 5, 2020. 10. Centers for Disease Control and Prevention : CDC, Washington State report first COVID-19 death . Available at https://www.cdc.gov/media/releases/2020/s0229-COVID-19-first-death.html, February 29, 2020 ; accessed November 5, 2020. 11. Travis Air Force Base : HHS completes federal quarantine efforts for Grand Princess passengers at Travis AFB . Available at https://www.travis.af.mil/News/Article/2134053/hhs-completes-federal-quarantine-efforts-for-grand-princess-passengers-at-travi/Published, April 1, 2020 ; accessed November 5, 2020 . 12. Cucinotta D , Vanelli M: WHO declares COVID-19 a pandemic . Acta Biomed 2020 ; 91 ( 1 ): 157 – 60 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 13. Solano County Public Health Department : An additional Solano County case of COVID-19 found at Travis Air Force Base due to community acquired exposure . Available at https://www.solanocounty.com/civicax/filebank/blobdload.aspx?BlobID=33234, March 15, 2020 ; accessed November 5, 2020 14. Intelligence Support to Joint Health Support : Joint Health Services: joint pub 4-02, Appendix D-1 . December 11, 2017, Incorporating Change 1, September 28, 2018 . Available at https://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp4_02ch1.pdf; accessed November 5, 2020 . Author notes The views expressed are those of the authors and do not reflect the official policy or position of the David Grant USAF Medical Center, the Department of the Air Force, the Department of Defense, or the U.S. government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Urbieta, Dehussa A; Akin, Jennifer L; Hamilton, Wendy M; Brock, Whitney W; Yablonsky, Abigail Marter

doi: 10.1093/milmed/usab213pmid: 34469531

ABSTRACT Introduction The COVID-19 pandemic has created challenges for every segment of the U.S. population, including military personnel and their families. The TriService Nursing Research Program’s Military Family Research Interest Group (FIG) formed a collaboration with Blue Star Families, a civilian non-profit organization, to identify potential issues faced by military families during the pandemic. Data Collection Methods The Pain Points Poll was introduced online by Blue Star Families, and findings were aggregated weekly between March 18 and May 26, 2020. Volunteer poll respondents were mainly recruited through social media outreach. FIG-informed questions were incorporated in week 4 of polling and focused on workplace environment, financial health, social support, physical and mental health, child behavior, utilization of family care plans, and general well-being. Data were collected to gain real-time insights into the major challenges posed by the pandemic. Findings from FIG-informed questions were collaboratively reviewed and analyzed by FIG and BSF teams. Data-driven recommendations were made to stakeholders to improve processes and reprioritize investments for services that aim to alleviate the impact of COVID-19 on military families. Findings A total of 2,895 military family units (i.e., service members and spouses) responded to the poll, a majority of which (88%) represented active duty family units. Although the majority of families (range: 59%-69%) noted no impact to their finances, approximately one in five families endorsed dipping into their savings during the pandemic. A majority of respondents (69.5%) reported taking active measures to support their mental health, endorsing various strategies. Among parents of special needs children, 45% of active duty families and 60% of single-parent service members reported the inability to maintain continued services for their children. A majority of parents with school-aged children (65%) reported child behavioral changes due to their child’s inability to socialize with peers. Among military service members, 41% were concerned about obtaining fair performance evaluations during the crisis. Conclusions The COVID-19 pandemic produced significant challenges for military families. Collaboration between military and civilian partners can inform policies and appropriate strategies to mitigate the impact of COVID-19 for military families. The findings presented here provide insight into areas where military families can be supported for optimal outcomes during unprecedented times. INTRODUCTION The novel coronavirus (COVID-19) pandemic has impacted the nation and the globe, with potentially large impacts on military families. This global health crisis may have increased the risk of financial strain, social isolation, and mental health concerns for all families but perhaps especially for military families. The necessary precautions in the wake of this pandemic, such as stay-at-home orders, school closures, and travel restrictions, have had the potential to disrupt the carefully orchestrated balance that military families create under the ordinary “extraordinary” demands of the military lifestyle. The purpose of this paper is to describe the findings and results of a recent military–civilian collaboration created to enhance the understanding of the needs of military families during the COVID-19 pandemic. According to the 2013 Institute of Medicine report, “the care and support of military families is considered a top national security policy priority in recognition of the integral role family members have in supporting service members (SMs) and, therefore, the mission of the military.”1 Military nurses are in the forefront of health care and, in all scenarios and settings, take care of active duty (AD) SMs, veterans, and their families. The TriService Nursing Research Program (TSNRP) exists in part to encourage collaboration in research and evidence-based practice among Army, Navy, and Air Force nurse scholars. The Military Family Research Interest Group (FIG) was established by TSNRP in 2016. Today, the FIG charter describes “a collaborative TriService community of diverse professionals with an interest in expanding the foundation of knowledge” upon which the health care of the military family is based (FIG Charter, January 9, 2020). The FIG has formed collaborations with various civilian partners (e.g., Johns Hopkins University, New York University, and Blue Star Families), as well as various military sister organizations (e.g., Research Facilitation Laboratory, Millennium Family Cohort Study, and Defense Health Board), which continue to inform current and future work. Blue Star Families is a 501(c)3 civilian non-profit organization, founded by military spouses in 2009 to empower military families to thrive as they serve. Blue Star Families is committed to strengthening military families by connecting them with their neighbors—individuals and organizations—to create vibrant communities of mutual support. Since its inception, Blue Star Families’ research has been raising the nation’s awareness of the unique challenges of military family life. Using the annual Military Family Lifestyle Survey2 (the largest and most comprehensive of its kind) and other data collection tools, the Blue Star Families Applied Research team listens to military and veteran families to identify emerging issues and track progress on long-standing challenges. Findings are shared with key stakeholders in government, non-profit, and the private sector to inform change at the local and national levels. By partnering with other organizations with specialized expertise (e.g., the Institute for Veterans and Military Families, the FIG, and the Sorenson Impact Center), Blue Star Families is able to integrate up-to-date expert knowledge into data gathering and research activities. The FIG and Blue Star Families were concerned that the uncertainty engendered by the pandemic in both civilian and military contexts could leave military families at increased risk for isolation and insufficient support during this critical time. Parenting during the pandemic also had the potential for significant challenges. Early anecdotal stories shed light on military families who were trying to balance competing demands in new environments, such as directly supporting their child’s education in the wake of unanticipated childcare and school closures, while also working from home using unfamiliar telework platforms. Dual-military families (i.e., where both parents serve in the military) and single-parent families may have experienced higher stress as the demands of work and family collided; these families’ attempts to fulfill their military duties while supporting their children may have led to negative work performance feedback from their respective commands. The impact of school and childcare closures on children’s behavior was also of concern. Children were suddenly thrust from socially enriched environments into physical isolation from friends and teachers, which may have led to compensatory behaviors. Areas of concern for the intersection of the pandemic’s impacts on military families also included impacts of the military work environment on health and safety. For example, there were concerns regarding the implementation of physical distancing guidelines for military work spaces and variability in command adherence to the Centers for Disease Control and Prevention guidelines to mitigate the spread of disease. Additionally, the military quickly enacted a Restriction of Movement order, which altered deployment schedules in response to the outbreak and resulted in extensions and reactivation of military SMs, including AD personnel, reservists, and National Guard members. The FIG and Blue Star Families were concerned that these unexpected modifications to deployment and permanent change of station schedules may have placed additional strain on military families. This paper describes the results of the FIG–Blue Star Families collaboration to understand these issues during the COVID-19 pandemic. DATA COLLECTION METHODS In mid-March 2020, Blue Star Families and the Association for Defense Communities created the COVID-19 Military Support Initiative (CMSI), with support from participants of the White Oak Collaborative. The purpose of the CMSI was to provide resources, support, and expertise to communities and states, as well as to military and veteran families throughout the crisis. One major objective of the CMSI was a series of information-gathering activities aimed at characterizing the experiences of military-affiliated individuals and their families during the pandemic. The CMSI disseminated a recurring series of online “pain points” polls aimed at gathering real-time insights into COVID-19-related experiences. The Pain Points Poll (PPP) was presented by Booz Allen Hamilton with additional support from the United Services Automobile Association. The PPP initially consisted of 84 questions addressing various aspects of military families’ experiences during the early days of the COVID-19 pandemic. Although the majority of Blue Star Families’ information-gathering efforts are covered under various Institutional Review Boards, it is common practice in non-profit, policy, evaluation, and marketing research to conduct polls and collect data without prior Institutional Review Board approval. Although this was not a research investigation, it provides a brief snapshot of the emerging needs of military families and lays a strong foundation for future scientific studies. All co-authors and project staff with access to the data completed The Collaborative Institutional Training Initiative (CITI) training, and all poll respondents affirmed consent electronically before answering any poll questions. Because of the immediacy of the pandemic and the urgent need to gather real-time data, the PPP was launched within 24 hours of the idea’s inception, on March 18, 2020. Simultaneously, FIG leadership was discussing the importance of understanding the experience of military families during the pandemic. The FIG leadership was aware of the broad reach of the annual Military Family Lifestyle Survey,3 and because of the broad reach of this survey, they felt that Blue Star Families would be well-positioned and well-resourced to discuss a potential information-gathering effort. FIG leaders reached out to Blue Star Families and were in touch with the project staff for the PPP. The first joint call occurred on April 1, 2020, when the PPP was in its 3rd week of fielding. After the call, FIG leadership delivered suggested edits and additional questions back to the Blue Star Families team that same day. These edits were incorporated into week 4 of the PPP, which began fielding on April 8, 2020. A collaboration between the FIG and Blue Star Families was born, with joint follow-up calls occurring every 2 to 3 weeks thereafter. Several FIG-informed questions were incorporated into the PPP on the specific topics of child behavior, well-being over time, physical and mental health, financial health, social support, workplace environment, and the utilization of family care plans (FCPs). Because there is a dearth of information on dual-military families and military single-parent families in the literature, it was deemed important to capture data on these potentially at-risk groups. As the poll was gathering one snapshot in time, the FIG suggested asking two questions which might capture the element of change across time. The specific wording for the first question was: “How are you doing right now?”. Responses ranged from “Having a really hard time” (1) to “excellent” (5). Then, “How are you doing now compared to one week ago?”. Responses ranged from “much worse than I was” (1) to “much better than I was” (5). Mean scores were calculated to assess changes over time from week 6 to week 10. The FIG suggested asking additional questions regarding physical and mental health, which were incorporated in the PPP, such as, “I am engaging in regular exercise and/or walks,” “I am getting outside daily,” “I am engaging in prayer/meditation,” and “I am connecting virtually with family and/or friends.” Because of concerns related to workplace safety, the following questions were also included: “Is your chain of command following Centers for Disease Control and Prevention (CDC) guidelines to reduce the spread of coronavirus infection?”. Questions addressing deployments and Reserve and National Guard activation were also added. As some FIG leaders are also AD members with families, the FIG leadership was aware of military FCPs and their importance to mission readiness. Military FCPs are completed by dual-military families and military single parents and codify who the military parents will name to care for their children in the case of a deployment or an extended time away from home. Because of the pandemic, there was concern that these care plans could not be utilized for a variety of reasons, such as the inability to ask a potentially high-risk family member to travel (e.g., an elderly grandparent) and CDC recommendations to adhere to social distancing guidelines by not introducing new individuals into the home. The question “I/my family is unable to use the military FCP approved by my command” was added. A panel of questions on child behavior was also included to capture any specific behavioral changes that parents were noticing during the pandemic. Findings from the PPP were aggregated by week, and response rates reflected the aggregate number of individuals who participated in the poll. The number of poll respondents varied by question according to whether or not each question was applicable to each individual (e.g., for those who noted no children, questions about childcare and children’s education were removed), and they were also able to skip any questions that they preferred not to answer. Volunteers were recruited through multiple efforts, including social media outreach, announcements at virtual Town Halls, and CMSI meetings. In order to allow poll respondents to accurately describe the complexities of their identities, they were able to select more than one military affiliation, service branch affiliation, and racial/ethnic identity. The PPP was conducted online using GetFeedback, a product of Survey Monkey. Findings discussed herein may differ slightly from other published PPP reports because of several factors: (1) this paper analyzes only data directly informed by the FIG, (2) weeks 1 through 3 of the polling period were excluded as FIG-informed questions were not asked during those time periods, (3) week 9 information was excluded from the analysis due to unusually low response rates in that time period, and (4) poll respondents who did not endorse any current connection to AD, National Guard, or Reserve service were excluded in keeping with the FIG emphasis on currently serving military members and their families. Other groups (e.g., fully transitioned veterans and DoD civilians) were excluded from this analysis, but findings pertinent to these groups can be found at https://bluestarfam.org/covid19-research/. Unless otherwise indicated, descriptive statistics included throughout this paper refer to an average across polling weeks 4-10. FINDINGS The majority of the poll respondents across all weeks (88%) were AD family units made up of spouses and AD members, and most were affiliated with the Army, Navy, or Air Force (see Table I). A minority (17%) was made up of National Guard and Reserve (NGR) family units (spouses and SMs). As the numbers in these separate groups were small, the NGR components are combined for analysis in future tables. TABLE I. Branch Affiliations in Weeks 4-10 (n = 2,762)a,b,c All active duty (AD) family units, n = 2,444 (88% of total sample) n = 1,582; 65% response rate Army 478 (30%) Navy 479 (30%) Air Force 399 (25%) Marine Corps 155 (10%) Coast Guard 86 (5%) Active duty (AD) SMs, n = 332 (12% of total sample) n = 199; 60% response rate Army 55 (28%) Navy 70 (35%) Air Force 52 (26%) Marine Corps 13 (7%) Coast Guard 11 (6%) All National Guard (NG) family units, n = 381 (14% of total sample) n = 254; 67% response rate Army 197 (78%) Air Force 57 (22%) National Guard (NG) SMs, n = 248 (9% of total sample) n = 167; 67% response rate Army 124 (74%) Air Force 43 (26%) All reserve family units, n = 70 (3% of total sample) n = 41; 59% response rate Army 12 (29%) Navy 11 (27%) Air Force 17 (41%) Marine Corps 1 (2%) Coast Guard 1 (2%) Reserve SMs, n = 31 (1% of total sample) n = 15; 48% response rate Army 2 (13%) Navy 5 (33%) Air Force 7 (47%) Marine Corps 1 (7%) Coast Guard 1 (7%) All active duty (AD) family units, n = 2,444 (88% of total sample) n = 1,582; 65% response rate Army 478 (30%) Navy 479 (30%) Air Force 399 (25%) Marine Corps 155 (10%) Coast Guard 86 (5%) Active duty (AD) SMs, n = 332 (12% of total sample) n = 199; 60% response rate Army 55 (28%) Navy 70 (35%) Air Force 52 (26%) Marine Corps 13 (7%) Coast Guard 11 (6%) All National Guard (NG) family units, n = 381 (14% of total sample) n = 254; 67% response rate Army 197 (78%) Air Force 57 (22%) National Guard (NG) SMs, n = 248 (9% of total sample) n = 167; 67% response rate Army 124 (74%) Air Force 43 (26%) All reserve family units, n = 70 (3% of total sample) n = 41; 59% response rate Army 12 (29%) Navy 11 (27%) Air Force 17 (41%) Marine Corps 1 (2%) Coast Guard 1 (2%) Reserve SMs, n = 31 (1% of total sample) n = 15; 48% response rate Army 2 (13%) Navy 5 (33%) Air Force 7 (47%) Marine Corps 1 (7%) Coast Guard 1 (7%) Abbreviation: SMs, service members. a Within family units, if an individual endorsed being both a spouse and a military service member, that demographic response was only counted once. Thus, the total number of family units within the table adds up to 2,895, but there were only 2,762 individual responses. b There is no way to know how many respondents repeated the survey more than once—these counts may be higher than the number of individual respondents. c Because of rounding, percentages may not total 100. Open in new tab TABLE I. Branch Affiliations in Weeks 4-10 (n = 2,762)a,b,c All active duty (AD) family units, n = 2,444 (88% of total sample) n = 1,582; 65% response rate Army 478 (30%) Navy 479 (30%) Air Force 399 (25%) Marine Corps 155 (10%) Coast Guard 86 (5%) Active duty (AD) SMs, n = 332 (12% of total sample) n = 199; 60% response rate Army 55 (28%) Navy 70 (35%) Air Force 52 (26%) Marine Corps 13 (7%) Coast Guard 11 (6%) All National Guard (NG) family units, n = 381 (14% of total sample) n = 254; 67% response rate Army 197 (78%) Air Force 57 (22%) National Guard (NG) SMs, n = 248 (9% of total sample) n = 167; 67% response rate Army 124 (74%) Air Force 43 (26%) All reserve family units, n = 70 (3% of total sample) n = 41; 59% response rate Army 12 (29%) Navy 11 (27%) Air Force 17 (41%) Marine Corps 1 (2%) Coast Guard 1 (2%) Reserve SMs, n = 31 (1% of total sample) n = 15; 48% response rate Army 2 (13%) Navy 5 (33%) Air Force 7 (47%) Marine Corps 1 (7%) Coast Guard 1 (7%) All active duty (AD) family units, n = 2,444 (88% of total sample) n = 1,582; 65% response rate Army 478 (30%) Navy 479 (30%) Air Force 399 (25%) Marine Corps 155 (10%) Coast Guard 86 (5%) Active duty (AD) SMs, n = 332 (12% of total sample) n = 199; 60% response rate Army 55 (28%) Navy 70 (35%) Air Force 52 (26%) Marine Corps 13 (7%) Coast Guard 11 (6%) All National Guard (NG) family units, n = 381 (14% of total sample) n = 254; 67% response rate Army 197 (78%) Air Force 57 (22%) National Guard (NG) SMs, n = 248 (9% of total sample) n = 167; 67% response rate Army 124 (74%) Air Force 43 (26%) All reserve family units, n = 70 (3% of total sample) n = 41; 59% response rate Army 12 (29%) Navy 11 (27%) Air Force 17 (41%) Marine Corps 1 (2%) Coast Guard 1 (2%) Reserve SMs, n = 31 (1% of total sample) n = 15; 48% response rate Army 2 (13%) Navy 5 (33%) Air Force 7 (47%) Marine Corps 1 (7%) Coast Guard 1 (7%) Abbreviation: SMs, service members. a Within family units, if an individual endorsed being both a spouse and a military service member, that demographic response was only counted once. Thus, the total number of family units within the table adds up to 2,895, but there were only 2,762 individual responses. b There is no way to know how many respondents repeated the survey more than once—these counts may be higher than the number of individual respondents. c Because of rounding, percentages may not total 100. Open in new tab Most of the poll respondents were female (86%), although the majority of the AD (55%) and NGR (56%) SM sub-groups were male (see Fig. 1). The race/ethnicity of the majority was White, non-Hispanic (83%), followed by Hispanic/Latinx (10%) and Black/African-American (6%), a small portion identified as dual-military (12%) and single-parent (8%) SMs (see Table II). FIGURE 1. Open in new tabDownload slide Groups by gender. TABLE II. Ethnicity and Special Populationsa,b,c All AD family units n = 1,669; 68% response rate White non-Hispanic 1,393 (83%) Black/African-American 87 (5%) Hispanic/Latino/a 166 (10%) Other 113 (7%) AD service members n = 198; 60% response rate White non-Hispanic 156 (79%) Black/African-American 12 (6%) Hispanic/Latino/a 27 (14%) Other 15 (8%) All NGR family units n = 326; 73% response rate White non-Hispanic 276 (85%) Black/African-American 33 (10%) Hispanic/Latino/a 21 (6%) Other 19 (6%) NGR service members n = 196; 70% response rate White non-Hispanic 153 (78%) Black/African-American 30 (15%) Hispanic/Latino/a 14 (7%) Other 15 (8%) Special populations ADd and NGRe service member respondents, n = 510c,d,e n = 482; 95% response rate Single-parent service members 50 (10%) AD service member, n = 255; 96% response rate 26 (10%) NGR service member, n = 249; 94% response rate 27 (11%) Dual-military service members 65 (13%) AD service member, n = 255; 96% response rate 42 (16%) NGR service member, n = 249; 94% response rate 27 (11%) All AD family units n = 1,669; 68% response rate White non-Hispanic 1,393 (83%) Black/African-American 87 (5%) Hispanic/Latino/a 166 (10%) Other 113 (7%) AD service members n = 198; 60% response rate White non-Hispanic 156 (79%) Black/African-American 12 (6%) Hispanic/Latino/a 27 (14%) Other 15 (8%) All NGR family units n = 326; 73% response rate White non-Hispanic 276 (85%) Black/African-American 33 (10%) Hispanic/Latino/a 21 (6%) Other 19 (6%) NGR service members n = 196; 70% response rate White non-Hispanic 153 (78%) Black/African-American 30 (15%) Hispanic/Latino/a 14 (7%) Other 15 (8%) Special populations ADd and NGRe service member respondents, n = 510c,d,e n = 482; 95% response rate Single-parent service members 50 (10%) AD service member, n = 255; 96% response rate 26 (10%) NGR service member, n = 249; 94% response rate 27 (11%) Dual-military service members 65 (13%) AD service member, n = 255; 96% response rate 42 (16%) NGR service member, n = 249; 94% response rate 27 (11%) Abbreviations: AD, active duty; NGR, National Guard and Reserve. a Respondents could have chosen more than one category. b Other includes Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Asian American, and Other. c Some respondents reported multiple affiliations (e.g., National Guard and Reserve). d AD respondents = 255. e NGR respondents = 249. Open in new tab TABLE II. Ethnicity and Special Populationsa,b,c All AD family units n = 1,669; 68% response rate White non-Hispanic 1,393 (83%) Black/African-American 87 (5%) Hispanic/Latino/a 166 (10%) Other 113 (7%) AD service members n = 198; 60% response rate White non-Hispanic 156 (79%) Black/African-American 12 (6%) Hispanic/Latino/a 27 (14%) Other 15 (8%) All NGR family units n = 326; 73% response rate White non-Hispanic 276 (85%) Black/African-American 33 (10%) Hispanic/Latino/a 21 (6%) Other 19 (6%) NGR service members n = 196; 70% response rate White non-Hispanic 153 (78%) Black/African-American 30 (15%) Hispanic/Latino/a 14 (7%) Other 15 (8%) Special populations ADd and NGRe service member respondents, n = 510c,d,e n = 482; 95% response rate Single-parent service members 50 (10%) AD service member, n = 255; 96% response rate 26 (10%) NGR service member, n = 249; 94% response rate 27 (11%) Dual-military service members 65 (13%) AD service member, n = 255; 96% response rate 42 (16%) NGR service member, n = 249; 94% response rate 27 (11%) All AD family units n = 1,669; 68% response rate White non-Hispanic 1,393 (83%) Black/African-American 87 (5%) Hispanic/Latino/a 166 (10%) Other 113 (7%) AD service members n = 198; 60% response rate White non-Hispanic 156 (79%) Black/African-American 12 (6%) Hispanic/Latino/a 27 (14%) Other 15 (8%) All NGR family units n = 326; 73% response rate White non-Hispanic 276 (85%) Black/African-American 33 (10%) Hispanic/Latino/a 21 (6%) Other 19 (6%) NGR service members n = 196; 70% response rate White non-Hispanic 153 (78%) Black/African-American 30 (15%) Hispanic/Latino/a 14 (7%) Other 15 (8%) Special populations ADd and NGRe service member respondents, n = 510c,d,e n = 482; 95% response rate Single-parent service members 50 (10%) AD service member, n = 255; 96% response rate 26 (10%) NGR service member, n = 249; 94% response rate 27 (11%) Dual-military service members 65 (13%) AD service member, n = 255; 96% response rate 42 (16%) NGR service member, n = 249; 94% response rate 27 (11%) Abbreviations: AD, active duty; NGR, National Guard and Reserve. a Respondents could have chosen more than one category. b Other includes Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Asian American, and Other. c Some respondents reported multiple affiliations (e.g., National Guard and Reserve). d AD respondents = 255. e NGR respondents = 249. Open in new tab The poll data were analyzed by groups, starting with AD family units, AD SMs, NGR family units, and NGR SMs. As there is very little information on single-parent and dual-military SMs, we analyzed these sub-groups where appropriate. For questions about family circumstances, data were analyzed by family units, and if a question referenced individual perceptions, AD and NGR SM data were also included in the analysis. Military Personnel and Readiness Across the time period of this poll, most respondents reported that their workplaces were following CDC guidelines (range: 63%-80%), although the percentages were lower for both AD family units and AD SMs when contrasted with their respective peer groups in the NGR (see Table III). Less than 10% of poll respondents noted that a SM had been activated or had been unable to return from deployment. However, of families who endorsed a recent transition, 23% of AD family units and 18% of NGR family units noted that their transition from one duty station to another had been disrupted by the pandemic (not shown in the table). The proportion of male poll respondents reporting no impact to their work was 14-23 percentage points higher (range: 29%-46%) than female poll respondents (range: 15%-23%). Obtaining fair work evaluations ranged from “somewhat” to “extremely” concerning for 47% of AD SMs (out of 128 who answered this question; 48% response rate) and 36% of NGR SMs (out of 150 who answered this question; 56% response rate). TABLE III. Military Personnel and Readiness (Weeks 4-10) . AD family units, n = 1,812 . AD SMs, n = 216 . NGR family units, n = 345 . NGR SMs, n = 202 . Command is following CDC guidelines 1,141 (63%) 150 (69%) 253 (73%) 162 (80%) SM has been activated 41 (2%) 8 (4%) 26 (8%) 8 (4%) SM is unable to return from deployment 177 (10%) 11 (5%) 17 (5%) 3 (1%) Work has not been impacted (separated by gender) F: 124/826 (15%) M: 30/102 (29%) F: 10/67 (15%) M: 24/74 (32%) F: 37/165 (22%) M: 47/104 (45%) F: 17/73 (23%) M: 47/102 (46%) . AD family units, n = 1,812 . AD SMs, n = 216 . NGR family units, n = 345 . NGR SMs, n = 202 . Command is following CDC guidelines 1,141 (63%) 150 (69%) 253 (73%) 162 (80%) SM has been activated 41 (2%) 8 (4%) 26 (8%) 8 (4%) SM is unable to return from deployment 177 (10%) 11 (5%) 17 (5%) 3 (1%) Work has not been impacted (separated by gender) F: 124/826 (15%) M: 30/102 (29%) F: 10/67 (15%) M: 24/74 (32%) F: 37/165 (22%) M: 47/104 (45%) F: 17/73 (23%) M: 47/102 (46%) Abbreviations: AD, active duty; F, female; M, male; NGR, National Guard and Reserve; SM, service member. Open in new tab TABLE III. Military Personnel and Readiness (Weeks 4-10) . AD family units, n = 1,812 . AD SMs, n = 216 . NGR family units, n = 345 . NGR SMs, n = 202 . Command is following CDC guidelines 1,141 (63%) 150 (69%) 253 (73%) 162 (80%) SM has been activated 41 (2%) 8 (4%) 26 (8%) 8 (4%) SM is unable to return from deployment 177 (10%) 11 (5%) 17 (5%) 3 (1%) Work has not been impacted (separated by gender) F: 124/826 (15%) M: 30/102 (29%) F: 10/67 (15%) M: 24/74 (32%) F: 37/165 (22%) M: 47/104 (45%) F: 17/73 (23%) M: 47/102 (46%) . AD family units, n = 1,812 . AD SMs, n = 216 . NGR family units, n = 345 . NGR SMs, n = 202 . Command is following CDC guidelines 1,141 (63%) 150 (69%) 253 (73%) 162 (80%) SM has been activated 41 (2%) 8 (4%) 26 (8%) 8 (4%) SM is unable to return from deployment 177 (10%) 11 (5%) 17 (5%) 3 (1%) Work has not been impacted (separated by gender) F: 124/826 (15%) M: 30/102 (29%) F: 10/67 (15%) M: 24/74 (32%) F: 37/165 (22%) M: 47/104 (45%) F: 17/73 (23%) M: 47/102 (46%) Abbreviations: AD, active duty; F, female; M, male; NGR, National Guard and Reserve; SM, service member. Open in new tab Financial Security The majority of families (range: 59%-69%) noted that family finances had not been impacted by the COVID-19 pandemic, leaving at least one-third of families whose finances were impacted (data not shown). As can be seen in Figure 2, only 9% of dual-military SMs reported dipping into family savings, but among the other family units, the range of reporting this circumstance was much higher (range: 13%-23%). Although many poll respondents reported reduced working hours, in general, many also reported reduced working hours as a function of needing to provide educational support from home or due to the inability to obtain or use child care. A greater proportion of AD SMs (26%) reported increased work hours compared to other groups. FIGURE 2. Open in new tabDownload slide Financial security of military family units and service members. Social Support Systems and Physical Health Several questions assessed various aspects of social support (see Table IV). A minority of poll respondents reported receiving tangible support from others during the pandemic (range: 7%-12%), and with the exception of single military parents, twice as many reported receiving emotional support from others (range: 17%-23%). A majority of poll respondents with children reported concerns about their children’s welfare as a function of being unable to socialize with peers (range: 51%-65%). These families were asked additional questions regarding specific child behaviors that they had observed, and these findings are noted in the next section and in Table V. TABLE IV. Social Support Systems (Weeks 4-10) . AD family units . NGR family units . Single-parent SMs . Dual-military SMs . We received tangible support 225/1,908 (12%) 28/383 (7%) 3/41 (7%) 5/59 (8%) We received emotional support 441/1,908 (23%) 70/383 (18%) 3/41 (7%) 10/59 (17%) Behavioral changes noted in children with inability to socialize 883/1,358 (65%) 113/203 (56%) 23/37 (62%) 20/39 (51%) . AD family units . NGR family units . Single-parent SMs . Dual-military SMs . We received tangible support 225/1,908 (12%) 28/383 (7%) 3/41 (7%) 5/59 (8%) We received emotional support 441/1,908 (23%) 70/383 (18%) 3/41 (7%) 10/59 (17%) Behavioral changes noted in children with inability to socialize 883/1,358 (65%) 113/203 (56%) 23/37 (62%) 20/39 (51%) Abbreviations: AD, active duty; NGR, National Guard and Reserve; SM, service member. Open in new tab TABLE IV. Social Support Systems (Weeks 4-10) . AD family units . NGR family units . Single-parent SMs . Dual-military SMs . We received tangible support 225/1,908 (12%) 28/383 (7%) 3/41 (7%) 5/59 (8%) We received emotional support 441/1,908 (23%) 70/383 (18%) 3/41 (7%) 10/59 (17%) Behavioral changes noted in children with inability to socialize 883/1,358 (65%) 113/203 (56%) 23/37 (62%) 20/39 (51%) . AD family units . NGR family units . Single-parent SMs . Dual-military SMs . We received tangible support 225/1,908 (12%) 28/383 (7%) 3/41 (7%) 5/59 (8%) We received emotional support 441/1,908 (23%) 70/383 (18%) 3/41 (7%) 10/59 (17%) Behavioral changes noted in children with inability to socialize 883/1,358 (65%) 113/203 (56%) 23/37 (62%) 20/39 (51%) Abbreviations: AD, active duty; NGR, National Guard and Reserve; SM, service member. Open in new tab TABLE V. Child Behavior and Child Care (Weeks 4-10) Child behavior . AD family units, n = 966 . NGR family units, n = 119 . Single-parent SMs, n = 23 . Dual-military SMs, n = 23 . Acting out more 572 (59%) 78 (66%) 15 (65%) 15 (65%) More withdrawn 292 (30%) 31 (26%) 5 (22%) 3 (13%) Sadder than usual 516 (53%) 55 (46%) 11 (48%) 11 (48%) Angier than usual 411 (43%) 45 (38%) 8 (35%) 8 (35%) More affectionate than usual 206 (21%) 25 (21%) 4 (17%) 5 (22%) More anxious than usual 486 (50%) 63 (53%) 10 (43%) 11 (48%) Happier than usual 42/743 (6%) 6/103 (6%) 3/20 (15%) 3/20 (15%) Child care Special needs child unable to maintain continuity of care 207/461 (45%) 19/64 (30%) 6/10 (60%) 2/11 (18%) Incurring additional childcare costs 50/1,583 (4%) 5/371 (1%) 3/46 (7%) 7/67 (10%) Unable to provide adult supervision 67/1,358 (5%) 12/203 (6%) 4/37 (11%) 3/39 (8%) Unable to use command-approved family care plan 48/870 (6%) 5/133 (4%) 2/21 (10%) 13/38 (34%) Child behavior . AD family units, n = 966 . NGR family units, n = 119 . Single-parent SMs, n = 23 . Dual-military SMs, n = 23 . Acting out more 572 (59%) 78 (66%) 15 (65%) 15 (65%) More withdrawn 292 (30%) 31 (26%) 5 (22%) 3 (13%) Sadder than usual 516 (53%) 55 (46%) 11 (48%) 11 (48%) Angier than usual 411 (43%) 45 (38%) 8 (35%) 8 (35%) More affectionate than usual 206 (21%) 25 (21%) 4 (17%) 5 (22%) More anxious than usual 486 (50%) 63 (53%) 10 (43%) 11 (48%) Happier than usual 42/743 (6%) 6/103 (6%) 3/20 (15%) 3/20 (15%) Child care Special needs child unable to maintain continuity of care 207/461 (45%) 19/64 (30%) 6/10 (60%) 2/11 (18%) Incurring additional childcare costs 50/1,583 (4%) 5/371 (1%) 3/46 (7%) 7/67 (10%) Unable to provide adult supervision 67/1,358 (5%) 12/203 (6%) 4/37 (11%) 3/39 (8%) Unable to use command-approved family care plan 48/870 (6%) 5/133 (4%) 2/21 (10%) 13/38 (34%) Abbreviations: AD, active duty; NGR, National Guard and Reserve; SM, service member. Open in new tab TABLE V. Child Behavior and Child Care (Weeks 4-10) Child behavior . AD family units, n = 966 . NGR family units, n = 119 . Single-parent SMs, n = 23 . Dual-military SMs, n = 23 . Acting out more 572 (59%) 78 (66%) 15 (65%) 15 (65%) More withdrawn 292 (30%) 31 (26%) 5 (22%) 3 (13%) Sadder than usual 516 (53%) 55 (46%) 11 (48%) 11 (48%) Angier than usual 411 (43%) 45 (38%) 8 (35%) 8 (35%) More affectionate than usual 206 (21%) 25 (21%) 4 (17%) 5 (22%) More anxious than usual 486 (50%) 63 (53%) 10 (43%) 11 (48%) Happier than usual 42/743 (6%) 6/103 (6%) 3/20 (15%) 3/20 (15%) Child care Special needs child unable to maintain continuity of care 207/461 (45%) 19/64 (30%) 6/10 (60%) 2/11 (18%) Incurring additional childcare costs 50/1,583 (4%) 5/371 (1%) 3/46 (7%) 7/67 (10%) Unable to provide adult supervision 67/1,358 (5%) 12/203 (6%) 4/37 (11%) 3/39 (8%) Unable to use command-approved family care plan 48/870 (6%) 5/133 (4%) 2/21 (10%) 13/38 (34%) Child behavior . AD family units, n = 966 . NGR family units, n = 119 . Single-parent SMs, n = 23 . Dual-military SMs, n = 23 . Acting out more 572 (59%) 78 (66%) 15 (65%) 15 (65%) More withdrawn 292 (30%) 31 (26%) 5 (22%) 3 (13%) Sadder than usual 516 (53%) 55 (46%) 11 (48%) 11 (48%) Angier than usual 411 (43%) 45 (38%) 8 (35%) 8 (35%) More affectionate than usual 206 (21%) 25 (21%) 4 (17%) 5 (22%) More anxious than usual 486 (50%) 63 (53%) 10 (43%) 11 (48%) Happier than usual 42/743 (6%) 6/103 (6%) 3/20 (15%) 3/20 (15%) Child care Special needs child unable to maintain continuity of care 207/461 (45%) 19/64 (30%) 6/10 (60%) 2/11 (18%) Incurring additional childcare costs 50/1,583 (4%) 5/371 (1%) 3/46 (7%) 7/67 (10%) Unable to provide adult supervision 67/1,358 (5%) 12/203 (6%) 4/37 (11%) 3/39 (8%) Unable to use command-approved family care plan 48/870 (6%) 5/133 (4%) 2/21 (10%) 13/38 (34%) Abbreviations: AD, active duty; NGR, National Guard and Reserve; SM, service member. Open in new tab For those poll respondents who endorsed taking active measures to support their mental health (see Fig. 3), social support strategies and physical health strategies were endorsed. Many reported engaging with friends and family during the pandemic (range: 60%-72%), and smaller numbers reported participating in virtual social events (range: 21%-29%). A substantial majority also reported keeping up with physical health by regular exercise and/or walks (range: 66%-77%). However, fewer poll respondents reported maintaining a nutritious diet (range: 42%-50%) and getting quality sleep (range: 42%-46%) across AD SM, NGR SM, AD family unit, and NGR family unit groups. FIGURE 3. Open in new tabDownload slide Strategies used by military families to support their mental health (weeks 6-10). Child Behavior and Child Care Among the majority of poll respondents who reported concerns regarding behavioral changes in their children, the most commonly endorsed behaviors were “acting out more than usual,” being “sadder than usual,” or being “more anxious than usual,” across family groups and among single-parent and dual-military SMs (range: 43%-66%; see Table V, child behavior). In week 5, a question asking if children were “happier than usual” was added, and 6% each of AD and NGR family units and 15% each of single-parent and dual-military SMs reported that their child was “happier than usual.” AD families (45%) and single-parent SMs (60%) noted that their special needs children were unable to maintain continuity of care for services (e.g., occupational therapy and speech therapy; see Table V, child care), while NGR families and dual-military SMs reported this less frequently (30%, 18% respectively). All family units reported low rates (11% or below) of incurring additional child care costs and of inability to provide adult supervision for children at home. However, 34% of dual-military SMs reported being unable to utilize their FCPs, but all other family units endorsed this at rates of 10% or less. Adult Mental Health Across all groups of SMs and family units, a majority endorsed taking active measures to support their mental health (range: 59-70%). Except for NGR SMs (58%), a minority of poll respondents across all other groups noted that their mental health had not been impacted during the pandemic (range: 22%-46%; data not shown). As reported previously, among poll respondents who endorsed proactively caring for their mental health, many noted using social support and physical health strategies (see Fig. 3). Self-care activities were also commonly endorsed, including “spending time outside each day” (range: 65%-74%), “spending time doing hobbies or other enjoyable activities” (range: 58%-63%), and “finding time to be alone” (range: 37%-44%). The use of meditation or prayer was commonly cited (range: 44%-53%), and the use of formal spiritual supports was endorsed by a significant minority (range: 14%-19%). The use of medication to support mental health (range: 4%-17%) and the use of formal mental health care (range: 2%-15%) were less commonly reported across groups. General Well-Being In week 6 of the PPP (April 22-28), AD family units, AD SMs, and NGR family units reported they were doing less well than average (data not shown). Throughout each week of the polling period, most respondents reported an average overall status, with not much change from the week prior. The only departure from this pattern was among single-parent SMs, who reported doing somewhat less well than average in week 10. Due to the complexity of the data, Figure 4 shows average aggregated scores over the time period from week 6 to week 10 for each group. NGR SMs and family units, as well as single-parent SMs, showed the most variation in well-being between current status and status 1 week prior. FIGURE 4. Open in new tabDownload slide General well-being aggregated (weeks 6-10). DISCUSSION This paper presents the results of a partnership between Blue Star Families and the FIG to better understand the needs of military families during COVID-19. The complete PPP encompassed many more questions than are included here; overall findings have been published elsewhere and can be explored at https://bluestarfam.org/covid19-research/. This manuscript specifically focuses on the findings and outcomes from FIG-informed PPP questions, which were incorporated starting in week 4. Military Personnel and Readiness Guidance was issued on April 5, 2020 (week 3 of polling) from the Office of the Secretary of Defense to adhere to CDC recommendations,3 but behavioral changes at the local level were slow to take hold and did not greatly improve over the course of the polling period. Just over half (55%) of AD family poll respondents reported that their SM’s unit was “following CDC guidelines to reduce the spread of the COVID infection” in week 4 of polling (April 8-14); 6 weeks later, that number had barely increased to 65%. Furthermore, CMSI working group participants found inconsistencies in following CDC guidelines between the service branches and sometimes even within individual service branch installations. These findings reinforce the need for better communication about, and stronger enforcement of, health policy directives to mitigate the spread of COVID-19 within the military force. On March 11, 2020, the DoD announced a Restriction of Movement order limiting all forms of travel including change of duty station, temporary duty, and leave/vacation.4 In the PPP, one in five AD and NGR family units reported having their transfers disrupted, and 9% of these poll respondents noted that the military SM was unable to return from deployment during the pandemic. In a separate CMSI report, disruption of family transfers was found to be a major source of emotional and financial distress for military families.5 Attaining fair performance evaluations during the crisis was of concern for 41% of AD and NGR SMs. This high level of concern is startling; it is incumbent on military leadership to reassure military SMs that they will receive appropriate and unbiased evaluations in this unusual time. These concerns may have been related to family upheaval, changes in working hours and working locations (e.g., teleworking from home), alterations in deployment/training schedules, and the stress of the pandemic. The military has given some guidance on evaluations during the pandemic,6 but based on the PPP findings, it appears that more information needs to be communicated to military personnel. Of interest, across all AD and NGR family units and SMs, males reported that their work had not been impacted by the pandemic more often than females. These findings suggest that female SMs may have experienced the effects of the pandemic differently, perhaps shouldering the majority of child care responsibilities while working, whereas males may have been able to fully concentrate on work responsibilities. Although these PPP findings cannot bolster or refute this idea, previous research on gender in the workplace supports this interpretation,7,8 and a CMSI report affirmed that women in uniform reported more difficulty related to child care concerns.9 Financial Security Financial security has a direct impact on the health and functioning of the family unit. It was anticipated that military families would be at risk for financial strain as a result of the economic crisis and increasing unemployment rates; Park and colleagues10 found that financial concerns were rated as the most stressful for Americans during this pandemic. The financial picture for military families as seen from the PPP was more complex. Although a majority of PPP respondents (range: 59%-69%) reported that their finances had not been impacted by the pandemic, 22% of AD and NGR family units reported that the pandemic had forced them to dip into their savings to cover necessary expenses. These findings may reflect the complexities of many military families: while military SMs earn a consistent income no matter the prevailing economy, spouses employed in the civilian sector are more vulnerable to economic downturns. A recent report confirmed that an additional compounding factor in the current pandemic was the impact of school closures and lack of child care options on the financial security of spouses working in the civilian sector.11 The COVID-19 pandemic had distinct effects on the working hours of military personnel and their families. While 16% of all families in the PPP reported reducing working hours related to providing educational support from home or the inability to find child care, 26% of AD SMs reported increased working hours during the pandemic. Several reports note that military productivity remained high during the pandemic,9,12 and the increased working hours noted in the PPP may help explain this. However, increased working hours for military personnel does not equate to increased earnings, and it may be that some family units that had to dip into savings to cover necessary expenses needed additional funds for child care. The PPP findings also noted decreased working hours for many families; it has been reported elsewhere that some of the most severe COVID-19 financial impacts were to civilian spouses who experienced reduced hours or wages, as well as military families with special needs children.11 Social Support Systems and Physical Health Grey and colleagues13 found that perceived social support during the pandemic was associated with lower levels of depression and anxiety. The PPP assessed perceived social support in the forms of tangible support (e.g., delivering groceries and running an errand) and emotional support (e.g., being available to talk about worries). On average, 11% of AD and NGR families reported being provided with tangible support, and 22% reported being provided with emotional support. Although 7% of single parents reported receiving tangible support, this group seemed to be at a deficit when reporting emotional support (still at 7%). Single parents may have decreased social support networks, making them more at risk for a deficit in this area.14,15 Despite enforced physical distancing measures, the PPP revealed that social connections were still happening, albeit in different ways. Approximately one half of the poll respondents reported talking to friends and family, while close to a quarter endorsed participating in virtual social events. Worldwide, there has been a substantial decline in physical activity levels in addition to an increase in poor eating behaviors during the pandemic.16,17 However, as part of their military requirements, SMs are charged to maintain physical fitness and strict body composition standards.18 Research has shown that there is a link between physical activity and positive mental health outcomes.19–21 Of those who reported actively using strategies to support their mental health, 70% reported participating in regular exercise. Even though physical fitness testing has been suspended throughout all branches of the military due to the ongoing pandemic,22 SMs are still maintaining their physical health. However, closer to 50% of poll respondents reported maintaining a nutritious diet, and about 40% reported getting adequate sleep. These are two areas where interventions could be developed to support the health of military families. Child Care and Child Behavior While adults were socializing in non-physical ways, parents endorsed that their children were missing physical interaction. Almost 65% of families with children reported child behavioral changes due to their child’s inability to socialize with peers. Among parents who reported behavioral alterations in their children, 60% of AD and NGR families reported that their child was acting out more than usual, while 53% reported they were sadder than usual, and 51% reported they were more anxious than usual. This highlights the importance of focusing resources toward child and adolescent mental health; a recent review found strong positive associations between loneliness and mental health disorders in this population.23–25 Screening and timely recognition of psychological disorders is imperative. In contrast, of those single-parent and dual-military SMs who noted child behavioral changes due to their child’s inability to socialize with peers, 15% reported that their children were happier than usual. Idoiaga and colleagues26 noted that some children felt happy to spend more time with their families and felt safer at home during the pandemic. Child care costs were a serious concern before the pandemic.2 Single-parent and dual-military SMs in the PPP reported incurring additional child care costs during the pandemic at higher rates than AD and NGR families. Decreased accessibility to affordable child care among military families during the pandemic prompted the National Military Family Association (NMFA) to launch a temporary child care financial assistance program targeting junior enlisted personnel. NMFA received close to 7,000 applications within 10 days of their 2-week application window, with dual-military and single-parent military families representing almost half of the applicants.27 The FIG postulated that the pandemic may have rendered many military FCPs unusable in light of pandemic restrictions regarding travel and physical distancing. Findings from the PPP confirmed this concern; 34% of dual-military SMs endorsed an inability to utilize their previously approved FCPs. Data-driven recommendations were made to the DoD by the CMSI Policy Committee and separately by Blue Star Families. These groups requested temporary changes to FCP requirements and implementation of flexible policies to decrease punitive action against SMs who were unable to execute their established FCPs.28 CMSI and Blue Star Families have also advocated for shortening the application timeline to participate in the Career Intermission Program; currently, participants must apply 10-12 months ahead of time in order to take advantage of this program when facing unanticipated family burdens such as those imposed during the COVID-19 pandemic. Findings from the PPP demonstrated that children with pre-existing chronic health conditions and special needs were at an exponentially greater risk for adverse health outcomes during the pandemic, particularly in light of school closures, which cut off access to specialized school-provided services (e.g., occupational therapy and speech therapy). Two out of every five poll respondents indicated that they were unable to maintain continuity of care for their special needs children. Blue Star Families shared these findings through numerous channels and gained traction on the issue with the Defense Health Agency. On March 31, 2020, it was announced that TRICARE would extend temporary telehealth support for Applied Behavior Analysis during the pandemic.29 Despite ongoing efforts to bridge gaps in care, parents continue to struggle with the significant reduction of therapy hours provided through telehealth modalities, as well as the deficit in human interaction for their children. Adult Mental Health Findings from the PPP showed that 69% of poll respondents reported taking active measures to support their mental health. Among this group, about 70% reported that these active measures included spending time outside each day and about 60% spending time doing hobbies. A recent study conducted in Spain assessed coping behaviors in the context of the COVID-19 pandemic and found that spending time outdoors and pursuing hobbies were the best predictors for lower levels of depressive symptoms.30 Almost 50% of PPP respondents utilized meditation or prayer as a positive mental health strategy and closer to 20% sought spiritual or religious support. Research suggests that higher levels of religiosity and spirituality may be linked with lower mental health symptoms.31,32 Clearly, many poll respondents understood the importance of maintaining their mental health, were aware of strategies to support their well-being, and preferred informal, self-directed strategies to formal strategies (such as mental health counseling or medication use). This poll also sought to evaluate the overall well-being of military families at separate points in time. A recent nationwide survey conducted in China immediately before and at the onset of the COVID-19 pandemic found a 74% decline in overall emotional well-being.33 However, a similar study in Denmark compared psychological well-being during the first two waves of the pandemic and found that overall scores increased from the first wave (March 31 toApril 6, 2020) to the second wave (April 22-30, 2020).34 Findings from the PPP demonstrated the lowest mean scores in week 6, with modest increases in perception of well-being among almost all groups from week 6 to week 10. The only variation from this trend was among single parents in week 10 who reported doing somewhat less well than average. Although these findings cannot explain the trend for lower scores in week 6 of polling, it is worth noting that U.S. Secretary of Defense Mark Esper announced an extension to the Restriction of Movement order in week 5 of polling, which may have had a negative impact on the overall morale during week 6. Limitations Although these findings are illuminating, several limitations to this information must be considered. First, AD personnel, male poll respondents, and minority subpopulations (racial/ethnic minorities and LGBTQ) were not well-represented in the poll respondent pool. Second, poll respondents were encouraged to complete the poll weekly, but it was not possible to follow them longitudinally (no matched panel), nor was there a way to restrict them from taking the poll multiple times in the same week, which may have skewed the findings. Third, demographic information did not capture rank, which is an important socioeconomic marker of income. Respondents from the Blue Star Families’ annual surveys tend to over-represent White, non-Hispanic, officer, and senior enlisted spouses, which could explain the majority of PPP respondents who reported no economic impact during the pandemic. Although the findings discussed here offer important insights into the unique circumstances experienced by military families during the early days of the COVID-19 pandemic, they are only a snapshot. Not much is known about the long-term physical and psychological sequelae of COVID-19 on military families; there is a need for longitudinal data. Despite these limitations, this poll represents a huge step in understanding the effects of COVID-19 in the military family population. The overall findings provide a general sense of how the military community is coping during COVID-19, which can inform future strategies to mitigate these issues. Future Directions There were several broad areas where more work can be done to illuminate issues of concern noted in the PPP findings. These areas include the military workplace, financial and social health of junior personnel, mental health strategies for adults, and support for military-connected children. Future directions in these areas are discussed below. Now that the pandemic has been going on for almost a year, military leadership should be acutely aware of all CDC and public health guidelines to protect the safety of their SMs. For the future, partnering with community health experts and sending clear messaging to military supervisors on safety measures for their personnel are steps that can be taken early on during the next public health emergency. In addition, SMs’ concerns with regard to the fairness in military ratings during the pandemic is a wake-up call to leadership—the military performance evaluation system must be flexible, timely, and responsive to feedback. Blue Star Families sought to make the PPP responsive to feedback, such that when findings showed problems for dual-military families in utilizing FCPs, these findings were communicated to the DoD leadership for action. Although the PPP explored the financial health of military families, more work should occur in exploring and addressing the financial security of junior enlisted personnel. In particular, exploring the importance and impact of childcare costs on family income for junior enlisted families (including single parents and dual-military families) is necessary. The role of gender in the military as it relates to child care, employment, and retention is also worthy of further investigation. The PPP findings indicated that social supports for single military parents may be lacking—this may be an area where appropriate interventions may prove very useful. The wide range of noted child behavior changes as a result of pandemic public health measures was concerning. Many parents noted acting out behaviors, anxiety, and sadness in their children. More work needs to be done observing the emotional patterns of children over time, in order to inform support services and techniques to strengthen resilience during times of stress.35,36 More attention needs to be directed to military families caring for children with special needs37,38; the PPP findings showed an alarming pattern of risk for these children during the early stages of the pandemic. The PPP also revealed encouraging trends in military families who reported widespread use of many positive strategies to support their mental health, including the use of social connection, time outside, hobbies, and physical exercise. Poll respondents were more likely to utilize self-directed strategies to maintain their mental health. This finding could be incorporated into future mental health clinical messaging. In addition, interventions to support optimal health for military families could include ones targeted to encourage well-balanced nutrition and quality sleep. This collaboration between the FIG and Blue Star Families shows what can be accomplished when diverse teams work together. For example, the FIG leadership initially raised a concern related to FCPs, and Blue Star Families added a question on this topic into the PPP. When findings showed that the use of FCPs was not working well for dual-military families, Blue Star Families and CMSI were able to bring this information to the DoD leadership for action. The FIG leadership does not have this level of accessibility to policymakers, so this partnership made use of the expertise and strengths of both teams. CONCLUSION There is a paucity of real-time information on the experiences of military families during COVID-19. As the pandemic evolves, it is critical to continue to engage government policymakers to reprioritize investments that aim to alleviate adult mental distress, child behavioral concerns, and financial burden among military families. The FIG leadership sought to engage in a collaborative and timely partnership that would be relevant to military families going through the pandemic. Similarly, Blue Star Families sought to incorporate the insights of uniformed subject matter experts. Their unified efforts functioned as a catalyst for change and resulted in a successful collaboration. This interdisciplinary collaboration between the FIG and Blue Star Families constitutes an important means for conducting time-sensitive data collection, increasing political support, providing important context on emerging issues, and disseminating findings widely. ACKNOWLEDGMENTS The authors gratefully acknowledge Dr. Kristal Melvin, Dr. Heather King, and the TriService Nursing Research Program, as well as Dr. Jessica Strong, Dr. Kim Hunt, Drew Brazer, and Carrie Carter for their insights and support of this project. FUNDING Funding was provided by Booz Allen Hamilton and the United Services Automobile Association (USAA). 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Google Scholar Crossref Search ADS PubMed WorldCat 21. White RL , Babic MJ, Parker PD, Lubans DR, Astell-Burt T, Lonsdale C: Domain-specific physical activity and mental health: a meta-analysis . Am J Prev Med 2017 ; 52 ( 5 ): 653 – 66 . Google Scholar Crossref Search ADS PubMed WorldCat 22. Navy Administrative Message 193/20, Chief, Naval Operations : Physical readiness program policy update for physical fitness assessment cycle two due to COVID 19 mitigation . Available at https://www.public.navy.mil/bupers-npc/reference/messages/Documents/NAVADMINS/NAV2020/NAV20193.txt; published July 16 , 2020 ; accessed November 16, 2020 . 23. Loades ME , Chatburn E, Higson-Sweeney N, et al. : Rapid systematic review: the impact of social isolation and loneliness on the mental health of children and adolescents in the context of COVID-19 . J Am Acad Child Adolesc Psychiatry 2020 ; 59 ( 11 ): 1218 – 1239 . Google Scholar Crossref Search ADS PubMed WorldCat 24. Matthews T , Danese A, Wertz J, et al. : Social isolation and mental health at primary and secondary school entry: a longitudinal cohort study . J Am Acad Child Adolesc Psychiatry 2015 ; 54 ( 3 ): 225 – 32 . Google Scholar Crossref Search ADS PubMed WorldCat 25. Stickley A , Koyanagi A, Koposov R, et al. : Loneliness and its association with psychological and somatic health problems among Czech, Russian and U.S. adolescents . BMC Psychiatry 2016 ; 16 : 128.doi: 10.1186/s12888-016-0829-2 Google Scholar OpenURL Placeholder Text WorldCat Crossref 26. Idoiaga N , Berasategi N, Eiguren A, Picaza M: Exploring children’s social and emotional representations of the COVID-19 pandemic . Front Psychol 2020 ; 11 : 1952.doi: 10.3389/fpsyg.2020.01952 Google Scholar OpenURL Placeholder Text WorldCat Crossref 27. Jowers K : Junior military families ‘inundating’ nonprofit with requests for care cost help during pandemic . Military Times . Available at http://www.militarytimes.com/pay-benefits/2020/10/09/junior-military-families-inundating-nonprofit-with-requests-for-care-cost-help-during-pandemic/; published October 9 , 2020 ; accessed November 9, 2020 . 28. Albrycht S , Grogan N: Into the unknown: military families struggle with family care plans . Military Times . Available at http://www.militarytimes.com/opinion/commentary/2020/04/23/into-the-unknown-military-families-struggle-with-family-care-plans/; published April 23 , 2020 ; accessed October 21, 2020 . 29. Roth-Douquet K : Supporting military children with the services they need, but lost in the pandemic . Military Times . Available at http://www.militarytimes.com/opinion/commentary/2020/06/18/supporting-military-children-with-the-services-they-need-but-lost-in-the-pandemic/; published June 25 , 2020 ; accessed October 21, 2020 . 30. Fullana MA , Hidalgo-Mazzei D, Vieta E, Radua J: Coping behaviors associated with decreased anxiety and depressive symptoms during the COVID-19 pandemic and lockdown . J Affect Disord 2020 ; 275 : 80 – 1 . Google Scholar Crossref Search ADS PubMed WorldCat 31. Brown DR , Carney JS, Parrish MS, Klem JL: Assessing spirituality: the relationship between spirituality and mental health . J Spiritual Ment Health 2013 ; 15 ( 2 ): 107 – 22 . Google Scholar Crossref Search ADS WorldCat 32. Sharma V , Marin DB, Koenig HK, et al. : Religion, spirituality, and mental health of U.S. military veterans: results from the national health and resilience in veterans survey . J Affect Disord 2017 ; 217 : 197 – 204 . Google Scholar Crossref Search ADS PubMed WorldCat 33. Yang H , Ma J: How an epidemic outbreak impacts happiness: factors that worsen (vs. protect) emotional well-being during the coronavirus pandemic . Psychiatry Res 2020 ; 289 : 113045.doi: 10.1016/j.psychres.2020.113045 Google Scholar OpenURL Placeholder Text WorldCat Crossref 34. Sønderskov KM , Dinesen PT, Santini ZI, Østergaard SD: Increased psychological well-being after the apex of the COVID-19 pandemic . Acta Neuropsychiatrica 2020 ; 32 ( 5 ): 277 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 35. Aptekar L , Boore JA: The emotional effects of disaster on children: a review of the literature . Int J Ment Health 1990 ; 19 ( 2 ): 77 – 90 . Google Scholar Crossref Search ADS WorldCat 36. Jiao WY , Wang LN, Liu J, et al. : Behavioral and emotional disorders in children during the COVID-19 epidemic . J Pediatr 2020 ; 221 : 264 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 37. Huebner CR : Health and mental health needs of children in US military families . J Pediatr 2019 ; 143 ( 1 ): e20183258.doi: 10.1542/peds.2018-3258 Google Scholar OpenURL Placeholder Text WorldCat Crossref 38. Yablonsky AM , Brock WW, Whalen AE, Melvin KC, Agazio J: Finding the evidence: screening of military family research . J Am Assoc Nurse Pract 2019 ; 13 ( 10 ): 551 – 4 . Google Scholar Crossref Search ADS WorldCat Author notes The views expressed in this article are solely those of the authors and do not necessarily reflect the official policy or position of the Departments of the Navy, the Army, the Air Force, or the U.S. Government. I am a military service member or federal/contracted employee of the U.S. Government. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a U.S. Government work as work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Bradley, David F; Romito, Kenneth; Dockery, James; Taylor, Lance; ONeel, Nicholas; Rodriguez, Jose; Talbot, Laura A

doi: 10.1093/milmed/usab214pmid: 34469530

ABSTRACT Introduction The global 2019 coronavirus pandemic (COVID-19) is setting unprecedented demands on the nation and the military and surgical services. Surgical demands include a large backlog of surgical cases, strain on available resources, and the need for additional measures to prevent exposure. The purpose of this project was to evaluate the feasibility, duration, adverse events, and potential gains associated with using a Turbett Sterilization Pod (TSP) for total joint replacements. Materials and Methods A multidisciplinary team used the Plan–Do–Study–Act model to guide this project. A time–motion study was completed in the operating room (OR) to measure the average time required to set up surgical instrumentation for total joint replacement cases that required 12 or more instrument trays. We compared the amount of time it took to complete the setting up of instrumentation using the traditional method versus the TSP method. The traditional method consisted of unwrapping each surgical tray, checking for holes in the blue wrapper, and placing the tray on the back table. In the case of the TSP, the door of the pod was opened, and the instrument trays were transferred directly to the back table. We measured the time the staff took to perform the task using each of these methods. Results When compared to the traditional method, the use of the TSP resulted in improved turnover time, decreased room setup time, reduced environmental waste, and eliminated both the effect of damage to wrappers and the time previously spent wrapping surgical trays. Conclusion The TSP minimizes the time needed by the staff to set up an OR suite for a total joint replacement, therefore permitting them to focus more on direct patient care. This time improvement suggests that all surgical specialties, including those requiring greater than 12 traditional instrument sets, may experience reduced turnover time between cases. The use of the TSP is one means to help rectify the OR backlog brought on by COVID-19. INTRODUCTION The United States is in the midst of a global 2019 coronavirus pandemic (COVID-19), which is putting unprecedented demands on the nation and the military. The best practice models in the operating room (OR) are continuously evolving as COVID-19 develops.1 As the pandemic continues, the ability to predict the progression of COVID-19 cases remains uncertain. The initial recommendation by the DoD on surgical services was to operate only on urgent cases and delay elective surgeries, such as orthopedics, matching Centers for Disease Control and Prevention recommendations.2 This created many challenges in the perioperative arena, including a large backlog of surgical cases, causing a strain on available resources and requiring staff to take extra steps to prevent exposure to the virus. This backlog was not unique to the military. According to a global assessment, 73% of surgical procedures would be canceled or postponed.3 It was also estimated that if countries increased their normal case load by 20%, it would take approximately 45 weeks to reach pre-COVID-19 workloads and clear backlogs.3 Another study projected pre-pandemic caseloads levels would not be enough to clear the newly formed backlog, and if an increase in productivity is not achieved, the backlog will never clear.4 As military treatment facilities (MTFs) began to reopen, the realization dawned that mechanisms must be developed to address the overflowing case demand and backlog of surgeries and procedures while maintaining the focus on safety for both patients and staff. In contemplating the clearing of the surgical backlog, the element of time becomes a key factor. While the surgical procedures themselves cannot be rushed, perhaps the preparation time could be optimized to shorten the length of OR room turnovers. Reprocessing and preparation of surgical instruments is a bottleneck for OR efficiency.5 We reasoned that improved OR sterilization methods such as the use of sterilization pods would reduce the turnover time between surgical procedures. Complex surgical cases such as total joint replacements require three or more OR staff members to open 12 or more sets of surgical instruments for each procedure and to place them on a table in the OR for easy access during the procedure. Quality inspection processes for this number of sets often require multiple staff members to streamline the process and prevent delays in first case start times and room turnovers. The goal of this project was to evaluate the use of an instrument sterilization pod, specifically the Turbett Sterilization Pod (TSP; Turbett Surgical, Rochester, NY), in reducing the amount of time required to open total joint surgical sets and place them on the back table, as compared to the traditional unwrapping method. This project further aimed to reduce turnover times between surgical cases and decrease environmental burden through waste reduction, thus allowing for increased case volume per room per day. The purpose of this project was to evaluate the feasibility, duration, adverse events, and potential gains associated with using a TSP for total joint replacements and to consider the potential impact on these and other surgical procedures during the current COVID-19 pandemic and thereafter. METHODS A multidisciplinary team used the Plan–Do–Study–Act model to guide this project.6 A time–motion evaluation was used in the OR to assess the average time to open 12 or more sets for total joint cases. The project was categorized as process improvement by the Brooke Army Medical Center (BAMC) Center for Nursing Science & Clinical Inquiry and the Standardization Committee and determined to not constitute human research. Setting This project was performed at BAMC, a joint military medical center in San Antonio, TX, which is staffed by the military, government civilians, and contract company workers. The facility is the only multidisciplinary military Level 1 trauma center in the country and the largest medical center in the DoD enterprise, averaging 65-70 cases per day. The Department of Operative Services is made up of the OR and the Sterile Processing & Distribution (SPD) section. The OR has 28 rooms spread between two buildings, the main nursing tower (main side, 15 rooms), and a consolidated trauma tower (COTO, 13 rooms). All the total joint procedures were performed on the COTO side with three ORs set aside for the service on each of 3 days per week. The orthopedic service averages two to three cases per day in each of those rooms, with the total averaging 32-34 cases per month. When the staff gather the instrumentation for total joint procedures, an average of 10/15 sets are from vendor companies. Case carts for the total joint procedures are transported via robot to the COTO side. A second MTF was evaluated for comparison, Tripler Army Medical Center (TAMC). Initial Planning Phase The initial phase of preparation and planning was developed by the deputy chief of SPD to decrease room turnover times, increase daily first-case on-time starts, and reduce instrument set defects using a sterilization container in place of traditional wrapping for the instrument sets before autoclaving. The plan was to pilot the use of the container in a specific surgical service and type of surgery, in this case orthopedic service total joint replacement surgery, and determine whether the container could achieve these goals. To simplify the interpretation of the data, the total joint surgery was selected on the basis of its low variability of required instrument sets. The TSP was chosen as a test system based on the ability of its manufacturer to list its consumable filters under the defense agency pricing agreement, thereby enabling the investigators to evaluate its use in a military medical facility. The TSP was also evaluated against the Association of periOperative Registered Nurses (AORN)’s Guidelines for Sterilization Packing Systems as being able to safely store and transport surgical instruments during reprocessing.7 The evaluation team was assembled from orthopedic total joint program staff surgeons, clinical nurse specialists, representatives from SPD and OR department leadership, and an infection control specialist recruited to provide tracing support for any potential post-op surgical site infections arising during the study duration. The project was submitted to the hospital standardization committee for approval before starting the evaluation. Pre-implementation Phase With the known parameters for weight (375 pounds) and number of instrument sets (15 sets), the surgical team, vendors, and SPD department staff standardized the sets to be supported by each pod. These sets include all of the standard items necessary to complete a primary total joint replacement procedure. Any items not consistent with the pod’s capacity parameters would be processed in the traditional manner with either sterilization pan or wrapping. Sterilizers were evaluated as being compatible with the TSP as recommended by the AORN.8 The proper loading of the pods with instrument sets was checked by both the vendor and SPD department staff before sealing and locking the unit. The pod was sterilized in the SPD facility, and SPD personnel transported the loaded and sterilized pod to the OR. Implementation The 30-day evaluation of the surgical pod at BAMC involved three orthopedic surgeons assigned to the total joint service for total knee and total hip procedures (June 11, 2019, to July 9, 2019). Three registered nurses, five OR surgical technicians, and the SPD staff received individual training on the surgical sterilization pod before the start of the trial. To ensure that the surgical pod and its contents would meet all of the Association for the Advancement of Medical Instrumentation ST 79 guidelines for sterilization within our facility,9 a trial of six test loads were sterilized as per the manufacturer’s instructions, while varying the time and temperature within accepted parameters. A workflow analyst monitored each step of the process to track processing times of both the current procedure and the pod method (Fig. 1). The evaluation was initially projected to include at least 72 total joint surgical procedures, based on historical scheduling data within the facility. Due to electrical issues that resulted in the closure of half of the ORs within the facility and consequently a decrease in scheduled total joint cases, the inclusion criteria were modified to include other orthopedic cases. The final count of surgical procedures using the sterilization pod in the trial was eight cases. For the traditional method, similar OR cases were selected using the Surgery Scheduling System (S3) from September 3, 2019, to October 8, 2019. A total of 10 traditional orthopedic cases were selected. FIGURE 1. Open in new tabDownload slide BAMC SPD instrument sterilization process time reduction using Turbett sterilization process. BAMC, Brooke Army Medical Center; SPD, Sterile Processing & Distribution. FIGURE 1. Open in new tabDownload slide BAMC SPD instrument sterilization process time reduction using Turbett sterilization process. BAMC, Brooke Army Medical Center; SPD, Sterile Processing & Distribution. Traditional Method In the SPD, instrument sets were assembled, placed into a metal pan or wrapped in blue wrap and secured with a heat-sensitive tape, loaded into a sterilization rack, and placed into the sterilizer. After the sterilizer had completed its cycle, it was opened, and the racks and instruments were allowed to cool. The sets were then placed in their proper storage areas until use. For the total joint procedure, the instrument sets specified by the surgeon’s preference card were retrieved by SPD staff, placed on a case cart, and transported to the OR by a robotic system. The transportation process was timed to take 18 minutes. Once the sets arrived in the OR, they were opened, inspected by the circulator nurse, and placed onto the back table by the surgical technician. A typical total joint case uses 12 or more sets of instruments. The traditional method involves unwrapping each set, checking for holes in the blue wrapper, and placing intact sets on the back table. If holes are found, the set is taken out of circulation until it can be re-sterilized for use another time. If enough sets have holes, the procedure may be delayed until sufficient replacement sets have been delivered or cancelled altogether. Holes and waste data were derived from the OR Debrief Tracking Tool. Sterilization Container (Pod) Method The pod sterilization method also began in the SPD. The instrument sets specified by the surgeon’s preference card were assembled, placed into a metal pan, and loaded into the pod. The pod was sealed with one filter sheet in place of traditional surgical wrap and placed into the sterilizer. After the sterilizer completed its cycle, the pod and the enclosed instruments were allowed to cool. The pod and its contents were then transported to the OR by SPD staff, which took 4 minutes. When the pod arrived in the OR, its door was opened, the filter was inspected for the presence of pinholes by the circulator nurse, and the instruments were placed onto the back table by the surgical technician. The 12 or more sets used by a typical total joint case fit into a single pod. Outcome Measures A workflow analyst collected data to evaluate several parameters in the SPD and the OR (Fig. 1). The amount of time SPD staff needed to perform quality checks and prepare instruments (wrapping instrument sets or placing them into the sterilization pod) was measured. Turnover time was measured from the time one patient left the OR until the next patient arrived using timed measurements (traditional method, n = 10; pod, n = 8). Also assessed were the number of staff members needed to set up the back table and the time it took them to move the instrument sets from the case cart or pod to the back table (Room Setup Time), utilizing the work analyst time (n = 1) and the Surgery Scheduling System (S3) data (n = 16). Room Setup Time was measured at TAMC comprising six total joint cases per group. Statistical Analyses Descriptive statistics were calculated including frequencies, means, SDs and percentages. T-test statistics were used to determine differences between the traditional method and the pod method. A two-tailed P-value of ≤.05 established statistical significance. For the outcome measure of OR setup time in which the sample size was one, the calculation was based on 16 Pod cases with a t-score of 29.5 for the traditional method. RESULTS Turnover times using the traditional method (before implementation) averaged 48 minutes (SD = 11). After implementation of the pod method, the turnover time decreased by nearly a third, to 33 minutes (SD = 7; t = 3.54; df = 15.45; P = .003, Welch two-sample t-test). OR setup time improved 94% from 24 minutes to 1 minute 51 seconds (SD = 45 seconds; t = 29.5, df = 15, P = <.0001). At TAMC, the POD averaged 95 seconds (SD = 25) for room setup, whereas the traditional was 550 seconds (SD = 128) (t = −8.5, SD = 5.4, P = .0002, t-test). The number of man-hours required for SPD personnel to prepare surgical instrument trays for sterilization improved 51% from the traditional method’s 72 minutes to 35 minutes with the pod method. The “show-stopping” adverse event of finding holes in sterilization wrappers, which often led to surgery cancellations, was eliminated with the use of the TSP. The monthly 12 holes-in-wrappers events previously observed with the traditional method were cut to virtually no pinholes seen with the pod method. The use of the TSP reduced delays in first case start times by approximately 15 minutes and reduced the amount of surgical waste from four to five bags to two, a 50%-60% reduction. Figure 1 illustrates the reduction in steps and time from the traditional method to the pod method. To date, zero surgical site infections have been reported when the TSP was used during instrument sterilization. The ability to customize every surgical pod to each surgeon’s request to ensure that all requested instrumentation was provided to the OR resulted in improved communication between the vendor teams and SPD staff. The removal of excess surgical instrumentation decreased the workload and costs involved in processing and sterilization. The sterilization pod was also effective in support of emergent trauma surgical cases. Its utilization decreased delays associated with the assembly and processing of requested vendor sets, which were processed with minimal impact on current workload. DISCUSSION This time–motion study, which evaluated its impact pre-operatively, showed a significant decrease in turnover time and setup time between surgical cases with the pod when compared to the traditional method. The outcomes obtained from this initiative support several key concerns impacting surgery during a global pandemic and possibly future crisis. Due to COVID-19, elective surgery backlogs are increasing, and measures must be taken to address access to surgical care. The time saved during OR turnover and back table setup using the TSP maximizes OR utilization and increases access to care (the possibility that OR leadership may be able to add an extra case at the end of the day). In addition, shortages of nursing staff in the United States have resulted in limited human resources to sustain OR operations safely and efficiently. By introducing the TSP to the OR workflow, fewer manpower hours are needed for completing tasks while setting up the back table, which enables better utilization of human resources during this pandemic. Because OR clinical labor represent a significant portion of the surgical services budget, the overall costs would be reduced.10 Finally, the integration of new technology, such as the TSP, contributes to productivity and efficiency in the OR. We observed that the use of the TSP resulted in decreased OR setup time, reduced surgical waste, and eliminated both the effect of damage to wrappers and the time previously spent wrapping surgical instrument sets. The disposal of medical waste can account for up to 20% of a hospital’s environmental services budget.11 An average of 15 instrument wraps and no-drip padding per case was replaced by 1 filter and 6 plastic locks, further promoting the facility’s Go-Green initiatives and smaller footprint. A nationwide shortage of sterilization wrap has prompted the AORN to issue a safety statement with alternative sterilization approaches such as the POD.12 Limitations of the POD One limitation of the use of the sterilization pod was its large size, which caused a storage issue. Additionally, because the pods did not fit in the robotic case cart transport system at BAMC, extra SPD staff members were required to manually transport the sterilized pods from the SPD to the COTO ORs. Extra tasking and deployments of military staff members can affect the number of individuals at any given time who are available to transport the pods. Finally, the cost and procurement process involved in purchasing the TSP can be daunting. The military purchasing process can take up to a year on high dollar items and justifications, and data must show a significant return on investment or an improvement in quality and safety before the purchase will be approved. Study Limitations This quality improvement project evaluated orthopedic total joint replacement surgical cases in two large MTFs. The amount of time improvements may not be applicable to other MTFs or surgical procedures. This project focused on only one orthopedic procedure. This preliminary work consisted of combining several data sets, including the data from an independent analyst. Future research is needed using other surgical procedures, a larger sample size, additional MTFs, and measuring cost savings related to decreased workload in processing and sterilization. CONCLUSIONS The backlog of elective surgeries associated with COVID-19 in MTFs is unprecedented.13 Consideration must be given to the possibility of viral contamination to staff during surgery. The TSP can be used for any surgical specialty that requires many sets and reduces the exposure time and staff. The TSP minimizes the time spent on OR setup and enables the OR staff to focus more on direct patient care (for example, assisting anesthesia during induction or providing patient comfort measures). Fewer nurses or techs are needed for case setup, thereby reducing exposure to COVID-positive patients. The faster setup of the room translates to reduced time patients must remain under anesthesia. The time saved by using the TSP can also be used to add backlog cases to the surgical schedule for the day. Because the need to wrap surgical instruments is eliminated with the TSP, SPD staff have more time to check for bioburden and perform quality checks on instrument sets and less surgical waste is produced, which in turn decreased the need for its removal. The pod can also house (in one place) the instruments needed for COVID-19 patient emergencies, potentially allowing damage control surgery to be started faster. ACKNOWLEDGMENTS None declared. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Al-Jabir A , et al. : Impact of the coronavirus (COVID-19) pandemic on surgical practice - part 1 . Int J Surg (London, England) 2020 ; 79 : 168 – 79 . Google Scholar Crossref Search ADS WorldCat 2. Centers for Medicare & Medicaid Services : Centers for Medicare and Medicaid Services (CMS) recommendations: re-opening facilities to provide non-emergent non-COVID-19 healthcare: phase 1 . Available at https://www.cms.gov/files/documents/covidflexibility-reopen-essential-non-covid-services.pdf; accessed October 23, 2020 . 3. COVIDSurg Collaborative : Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans . Br J Surg 2020 ; 107 ( 11 ): 1440 – 1449 .doi: 10.1002/bjs.11746 Crossref Search ADS PubMed WorldCat 4. Salenger R , et al. : The surge after the surge: cardiac surgery post-COVID-19 . Ann Thorac Surg 2020 ; 110 ( 6 ): 2020 – 2025 .doi: 10.1016/j.athoracsur.2020.04.018 Google Scholar Crossref Search ADS PubMed WorldCat 5. Coban E : The effect of multiple operating room scheduling on the sterilization schedule of reusable medical devices . Comput Ind Eng 2020 ; 147 .doi: 10.1016/j.cie.2020.106618 Google Scholar OpenURL Placeholder Text WorldCat Crossref 6. Silver SA , et al. : How to begin a quality improvement project . CJASN 2016 ; 11 (5): 893 – 900 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Association of periOperative Registered Nurses(AORN) :Guidelines for sterilization packaging systems. Guidelines for Perioperative Practice . AORN ; 2021 : 985 – 1013 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 8. Croke L : Guideline for sterilization packing systems . Vol 110 . AORN Periop Briefing , 2019 ; 110(3): P8 – 10 . 9. Association for the Advancement of Medical Instrumentation . ST 79 . AAMI ; 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10. Biala GE , Fitzpatrick TA: Healthcare Executive’s Guide to Navigating the Surgical Suite . Sigma Theta Tau International ; 2019 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 11. Conrardy J , et al. : Reducing medical waste . AORN J 2010 ; 91 ( 6 ): 711 – 21 . Google Scholar Crossref Search ADS PubMed WorldCat 12. Association of periOperative Registered Nurses (AORN) : Safety statement from AORN . Available at https://www.aorn.org/about-aorn/aorn-newsroom/sterilization-wrap; accessed April 28, 2021 . 13. Brandman DM , et al. : Modelling the backlog of COVID-19 cases for a surgical group . Can J Surg 2020 ; 63 ( 5 ): E391 – 2 . Google Scholar Crossref Search ADS PubMed WorldCat Author notes The content of this manuscript was accepted for poster presentation at the TSNRP Research and Evidence-based Practice Dissemination Course, October 16, 2020. A copy of the poster is available at the Turbett Surgical website (https://s81.3ac.myftpupload.com/wp-content/uploads/2020/08/Fina-lTurbett-Poster.pdf). The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, Defense Health Agency, Tripler Army Medical Center, University of Tennessee Health Science Center, Uniformed Services University of the Health Sciences, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, or the Department of Defense or the U.S. Government. Mention of trade names, commercial products, or organizations does not imply endorsements by the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Duffy, Julie R; Vergara, Mario A

doi: 10.1093/milmed/usab195pmid: 34469525

ABSTRACT Landstuhl Regional Medical Center’s response to the coronavirus disease 2019 pandemic included a plan to provide just-in-time training for nursing staff and paraprofessionals from throughout the organization in the event that it became overwhelmed with more critically ill patients than the facility was staffed to manage. Training conducted was a combination of online learning from the Society of Critical Care Medicine and the Association of Critical Care Nurses as well as a 2-hour block of hands-on skills. The three competencies for floating staff from Wright’s Method for Competency Assessment were utilized in the training process, allowing trainees to (1) learn to fly, (2) market themselves in a positive way, and (3) understand crisis management options. Quick implementation of the plan led to over 125 nurses and paraprofessionals receiving the education and training in preparation for the pandemic response. The article further discusses training topics covered and the competency expectations for non-critical care nurses trained. In March 2020, the WHO declared a global pandemic due to the novel coronavirus (severe acute respiratory syndrome coronavirus 2). Initial news reports from China and Italy highlighted healthcare systems overwhelmed and struggling to care for patients requiring ventilator support, as well as shortcomings in supplies, equipment, staff, and space for the critically ill.1–4 Early models for Germany predicted 550,000 cases and 14,000 deaths,5 suggesting that 16,500 patients would require a higher level of care based on early reports from Italy, where approximately 20% of cases required hospitalization and 3% required intensive care.5 This led many healthcare organizations, including military treatment facilities like Landstuhl Regional Medical Center (LRMC) in Germany, to begin planning for the implementation of the tiered intensive care unit (ICU) staffing model recommended by the Society of Critical Care Medicine (SCCM)’s Fundamental Disaster Management Plan.6 The SCCM’s tiered staffing model joins non-intensive care providers and nurses with critical care staff to help manage and care for critically ill patients. The model joins four ICU nurses with 12 non-ICU nurses to provide bedside care for a surge of up to 24 critically ill patients as one team. Using this model as a framework, healthcare facilities raced to provide just-in-time staff training to ensure a safe and effective care environment if the tiered staffing model needed implementation. This article focuses on the considerations for just-in-time training and its implementation for nursing staff at LRMC in response to the coronavirus disease 2019 (COVID-19) pandemic. JUST-IN-TIME NURSE TRAINING As it became clear that Italy was a pandemic hot spot, LRMC began to anticipate a potential increase in COVID-19 patients. Landstuhl Regional Medical Center’s beneficiary population of 205,000 spans throughout the European region, the Middle East, and Africa. The facility immediately revisited its expansion plan for critical care capabilities that included nurses from across the medical center. Nurses that could be utilized would be coming from various care environments throughout the 14 specialty clinics in LRMC’s organizational footprint, including Red Cross volunteers. Acquisition of additional staff members usually requires multiple months due to the facilities overseas location. Acquisition of additional staff members usually requires multiple months due to its overseas location. The on-boarding process of any newly hired staff would take longer than usual due to the restraints of the pandemic; therefore, preparing the staff on hand became a priority. To ensure the availability of resources and capacity, outpatient clinics ceased operations, and elective procedures were canceled in anticipation of the surge of COVID-19 patients. Reducing the virus’s transmission was a priority, leading to significant changes including social distancing and reducing the total number of staff within the facility. Given these working condition limitations, the utilization of free online resources became the timeliest and most efficient way to provide staff with foundational information related to the care of critically ill patients with respiratory disease. The SCCM’s Critical Care for Non-ICU Clinician7 modules and the American Association of Critical Care Nurses (AACN)’s8 online COVID training resources were selected. These modules were assigned to nurses working outside of the ICU for baseline knowledge expectations if used as ICU nursing staff extenders under the SCCM staffing model. The utilization of online modules allows staff to complete training while maintaining social distancing versus training in a traditional classroom setting. Additionally, online training provided flexibility to allow teleworking staff and staff working outside traditional day shift hours to complete this required training. Nursing leadership and clinical nurse specialists (CNSs) completed an assessment of an individual nurse’s experience and assigned appropriate modules based upon their clinical background. Each non-ICU nurse completed approximately 6 hours of online educational modules. Learning modules highlighted the basics of respiratory assessment, ventilator management of the critically ill patient, and the treatment of acute respiratory distress syndrome (ARDS). In 5 weeks, 126 non-ICU trained nurses and paraprofessionals from areas such as the Medical/Surgical/Pediatrics Unit, Mother/Baby Unit, and Labor and Delivery completed the online learning in conjunction with a 2-hour hands-on skills session. Those trained included 75 registered nurses, 32 licensed practical nurses, and 19 paraprofessionals. In a 2-week period, 35 ICU nurses also completed training through the AACN as a refresher on respiratory management principles for patients in ARDS. The decision to require this refresher training for ICU nurses was because the majority of LRMC’s critical care patient population consisted of patients with trauma and surgical issues rather than medical ICU patients. HANDS-ON SKILLS After completing the online training modules, staff attended a 2-hour hands-on skills session at the hospital. The healthcare staff trained to assist the critical care team with ICU and COVID patients included registered nurses, licensed practical nurses, army medics, and air force technicians. Initial skills covered in the session included items related to the management of mechanically ventilated patients (e.g., oral care, in-line suction, and alarm management), hemodynamic monitoring (e.g., arterial line management, assessment related to vasoactive medications, and effects of sedation), and manual prone positioning. Army medics and Air Force technicians were trained on the skills to their full scope of practice as outlined in the Army’s Individual Critical Task Lists and Air Force’s Comprehensive Medical Readiness Program. Additionally, trainees had the opportunity to spend a shift precepting with an ICU nurse caring for the first critically ill COVID-19 patient admitted. After a non-ICU member’s shift, the CNSs would solicit feedback to adapt the hands-on skills training based on staff responses. The staff feedback aligned with the hands-on training program objectives; therefore, the skills session components remained consistent for the training duration. Although hosting in-person hands-on skills sessions was a risk during the pandemic, the difference in learning styles preferred by nurses and the positive impact that tactile learning can have on some learners’ retention were considered.9 Leadership and CNSs determined that with appropriate mitigation strategies, the benefit of a ready healthcare team outweighed the risk. Several measures were taken to decrease the risk of staff exposure during the hands-on skills sessions, such as limiting the group size to six trainees per session, maintaining hand hygiene, and wearing masks as per the Command Team’s implemented facility policy. PERSONAL PROTECTIVE EQUIPMENT CONSIDERATIONS Additional staff training took place regularly in the form of hands-on personal protective equipment (PPE) donning and doffing adapted to the on-hand PPE supply. Additionally, PPE observers were trained to ensure staff maintained safe donning and doffing practices while working with COVID-19-positive patients. The CNSs immediately began to assist in staff training to include the development of a learning video for staff to watch, which outlines the various pieces of PPE available to staff and their safe utilization. A system to closely monitor PPE usage rates was also implemented and managed by a facility CNS to ensure the ordering of adequate supplies for the immediate time frame and predictive values based on potential caseloads. Pertinent information regarding PPE use was continuously emphasized with staff during a hands-on skills station. NOVICE VERSUS COMPETENT Training was only designed to orient non-critical care staff to the extender role. These individuals would not be assigned primary care roles of ICU patients. This approach was adopted from Wright’s Method for Competency Assessment.10 According to Wright, there are three competencies for floating staff to unfamiliar areas within a medical facility: (1) learning to fly, (2) marketing yourself in a positive way, and (3) understanding crisis management options. The training provided hands-on experience to simulate the clinical cases emerging in the literature that would help determine the care required for COVID-19 patients and to encourage mastery of the three floating competencies.10 A description of the impact and utilization of the three float competencies during hands-on training can be found in Table I. TABLE I. Utilization of Wright’s Float Competencies in LRMC’s Just-in-Time Hands-on Training Wright’s method for competency assessment float competencies10 . Learning to fly . Marketing yourself in a positive way . Understanding crisis management options . Attendees were able to identify knowledge deficits and ask questions Attendees were able to share clinical strengths with critical care team Facilitated attendee’s understanding of the proposed staffing model Provided opportunity to practice unfamiliar hands-on skills Attendees had the opportunity to demonstrate skill Facilitated attendee’s understanding of their role in the pandemic response Training in environment allowed attendees to identify available resources Attendees had opportunity to share experience and begin building relationships Attendees were able to make recommendations for workable solutions in crisis management Wright’s method for competency assessment float competencies10 . Learning to fly . Marketing yourself in a positive way . Understanding crisis management options . Attendees were able to identify knowledge deficits and ask questions Attendees were able to share clinical strengths with critical care team Facilitated attendee’s understanding of the proposed staffing model Provided opportunity to practice unfamiliar hands-on skills Attendees had the opportunity to demonstrate skill Facilitated attendee’s understanding of their role in the pandemic response Training in environment allowed attendees to identify available resources Attendees had opportunity to share experience and begin building relationships Attendees were able to make recommendations for workable solutions in crisis management Open in new tab TABLE I. Utilization of Wright’s Float Competencies in LRMC’s Just-in-Time Hands-on Training Wright’s method for competency assessment float competencies10 . Learning to fly . Marketing yourself in a positive way . Understanding crisis management options . Attendees were able to identify knowledge deficits and ask questions Attendees were able to share clinical strengths with critical care team Facilitated attendee’s understanding of the proposed staffing model Provided opportunity to practice unfamiliar hands-on skills Attendees had the opportunity to demonstrate skill Facilitated attendee’s understanding of their role in the pandemic response Training in environment allowed attendees to identify available resources Attendees had opportunity to share experience and begin building relationships Attendees were able to make recommendations for workable solutions in crisis management Wright’s method for competency assessment float competencies10 . Learning to fly . Marketing yourself in a positive way . Understanding crisis management options . Attendees were able to identify knowledge deficits and ask questions Attendees were able to share clinical strengths with critical care team Facilitated attendee’s understanding of the proposed staffing model Provided opportunity to practice unfamiliar hands-on skills Attendees had the opportunity to demonstrate skill Facilitated attendee’s understanding of their role in the pandemic response Training in environment allowed attendees to identify available resources Attendees had opportunity to share experience and begin building relationships Attendees were able to make recommendations for workable solutions in crisis management Open in new tab Hands-on skills training for ICU skills offered nurses the opportunity to embrace the first float competency of learning to fly. The staff recognized their knowledge and competency level for each skill. They were encouraged to ask questions that would assist in the comprehension of the education provided. They experienced the process of tactile learning as they physically performed the skill. Resources for future use were made available at this time, such as quick reference guides for common ICU medications and documentation requirements, as well as a prone positioning checklist. Non-ICU staff were reassured during the training that they would be working in a team environment when supporting the ICU nurses and that resources were available. Staff were also encouraged to market themselves positively when operating as an extender. Staff acting as extenders in unfamiliar environments who verbalize their skills and competencies upfront can be utilized more effectively, leading to a fulfilling and productive experience for all involved.10 This goes hand-in-hand with the third competency of understanding crisis management options. Activation of the SCCM’s staffing model for pandemic response means the facility is truly operating in a crisis mode. Critical care nurses are aware that their nurse extender counterparts may have no critical care background and expect an initial period of added support for extenders to become competent in critical care nursing skills. Staff extenders must exhibit a positive attitude and confidence in what skills they do possess. This allows critical care staff to utilize the extenders for their strengths and focus any orientation time on known areas of knowledge or skill gaps. During the period of just-in-time training, teamwork and communication of extenders with the ICU staff were critical for maximizing their skills while building working relationships that ultimately benefit the patient. OPPORTUNITIES FOR IMPROVEMENT AND SUSTAINMENT Initial information about COVID-19 evolved as the scientific community learned more about the virus and how it impacted patients. The rapid guidance changes were a source of anxiety among the nurses within the facility. The SCCM online modules provided baseline information on the pandemic staffing model to be utilized, but it was critical for leadership to communicate the expectations of their role in the pandemic response. The development of facility-specific Clinical Practice Guidelines for pandemic response included considerations specific to the care of COVID-19 patients, with the resources available in LRMC’s overseas location. One example of the facility-specific guidelines is the utilization of manual patient proning as Rotoprone beds (mechanical beds designed for the proning of patients) are not available in Germany. Another example relates to patients from areas of operation outside the LRMC footprint, making distance and time differences challenging for loved ones. Telehealth was included in the plan to encourage patients to connect with loved ones, as they were hundreds of miles apart. A third example is the utilization of continuous glucose monitors for the COVID-19 patients to allow nurses to decrease exposure time and PPE use while continuously monitoring the critically ill patients’ blood glucose levels. Updates made to the existing emergency operation plans related to the tiered response plan for the expansion of beds. Guidance was also developed to use critical resources and how staff would be utilized as extenders at all levels of care (nurses, providers, and mid-level providers). These updates will help guide future responses based on lessons learned during this current pandemic. Fortunately, to date, there has been no need for LRMC to implement the SCCM staffing model. However, in anticipation of a second wave of COVID-19 patients, the facility performs regular monthly simulation sessions to validate skills. These monthly sessions were originally designed to validate the Army Nurses Individual Critical Task Lists (ICTL). The Army Nurse ICTL list for preparedness of critical care nurses for wartime missions encompasses many of the skills required for the care of the COVID-19 patient So the monthly training was utilized as refresher training available to all nurses (military and civilian), medics, and technicians within the facility. Additional follow-up training for nursing staff consisted of two skills fairs that focus on skills commonly required for the critically ill COVID-19 patient. Non-ICU nurses also continue to float shifts into the ICU to work with experienced ICU nurses caring for critically ill patients. This allows nurses to gain competency in critical care without the fear/risk of exposure to COVID and the added complexity of caring for ICU patients while wearing PPE. Finally, in preparing to shift additional staff from units to support the critical care team, nurses in administrative roles were trained using similar methods, increasing the total number of bedside staff available for units other than ICU. CONCLUSION During the pandemic’s rapid escalation, nursing leadership and CNSs within LRMC quickly identified and responded to issues that arose during the pandemic. The early identification of possible staffing and clinical skills issues allowed for quick implementation of a training program for critical care nurse extenders as necessary. CNSs were indispensable in evaluating staff skill, experience, and training, ensuring that hospital leadership’s pandemic expansion plan could be implemented safely and efficiently. Staff utilization of the free online learning modules offered by professional organizations and the hands-on skills sessions allowed 126 staff members’ expeditious training. The measures incorporated to maintain safe practices helped mitigate the spread of the virus among the healthcare staff. With the pandemic ongoing, the facility’s leadership focus for the facility is now on sustainment of the education and skills gained by staff related to the care of the COVID-19 patients to ensure preparedness for future waves. ACKNOWLEDGMENTS None declared. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Bloomberg : As coronavirus cases overwhelm China’s hospitals, those with other problems are told to leave . Fortune . Available at https://fortune.com/2020/02/21/coronavirus-cases-china-hospitals-turn-away-patients/; published February 21, 2020 ; accessed December 28, 2020. 2. Deng C , Woo S: Hospitals pushed to the brink in Wuhan: ‘I just want to save his life’ . The Wall Street Journal . Available at https://www.wsj.com/articles/coronavirus-patients-in-wuhan-face-a-health-system-past-the-brink-11581084599; published February 7, 2020 ; accessed December 28, 2020. 3. Horowitz J : Italy’s healthcare system groans under coronavirus – a warning to the world . The New York Times . Available at https://www.nytimes.com/2020/03/12/world/europe/12italy-coronavirus-health-care.html; published March 17, 2020 ; accessed December 28, 2020. 4. van Beusekom M : Doctors: COVID-19 pushing Italian ICUs toward collapse . Center for Infectious Disease Research and Policy . Available at https://www.cidrap.umn.edu/news-perspective/2020/03/doctors-covid-19-pushing-italian-icus-toward-collapse; published March 16, 2020 ; accessed December 28, 2020 . 5. Barbarossa MV , Fuhrmann J, Meinke JH, et al. : Modeling the spread of COVID-19 in Germany: early assessment and possible scenarios . PLoS One 2020 ; 15 ( 9 ): e0238559.doi: 10.1371/journal.pone.0238559 Google Scholar OpenURL Placeholder Text WorldCat Crossref 6. Society of Critical Care Medicine : Augmenting critical care capacity during a disaster . Available at https://covid19.sccm.org/Presentations/Augmenting-Critical-Care-Capacity-During-Disaster/story_html5.html?lms=1, 2020; accessed July 2020. 7. Society of Critical Care Medicine : COVID-19 resources for non-ICU clinicians . Available at https://covid19.sccm.org/nonicu/, 2020; accessed July 2020. 8. American Association of Critical Care Nurses : Coronavirus (COVID-19) resources . Available at https://aacn.org/clinical-resources/covid-19, 2020; accessed July 2020. 9. Mangold K , Kunze KL, Quinonez MM, Taylor LM, Tenison AJ: Learning style preferences of practicing nurses . J Nurses Prof Dev 2018 ; 34 ( 4 ): 212 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 10. Wright D : Competency Assessment Field Guide: A Real World Guide for Implementation and Application . Creative Health Care Systems ; 2015 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Navy, U.S. Air Force, the Department of Defense, or the U.S. government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Gillis, Breslin T; Murray, William O; Brown, William J

doi: 10.1093/milmed/usab105pmid: 34469526

ABSTRACT The coronavirus disease-2019 (COVID-19) pandemic remains an extraordinary event that continues to strain healthcare systems worldwide. Unlike the military treatment facilities (MTFs) in the USA, which have ready access to tertiary care facilities, those MTFs in foreign countries confront a host of challenges in meeting mission requirements. In this article, we discuss the MTFs’ COVID-19 response in the rural environment of Bavaria, Germany. Relevant factors including regional and clinic response, force health protection, and contingency planning, which influenced the MTFs response, are identified. These factors are further analyzed from a “lessons learned” perspective, and recommendations to shape the future response to a pandemic are provided. This current crisis portends a future where pandemics may remain an omnipresent threat. INTRODUCTION Pandemic is defined as “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting a large number of people.”1 This effect was quite evident as the coronavirus disease, coronavirus disease-2019 (COVID-19), swept through Europe and the USA,2 placing an incredible strain on the healthcare system as it responded to this novel infectious disease. Within the USA, large metropolitan areas such as New York City and Seattle were the hardest hit.3 Despite their robust healthcare systems, the surge in infections severely strained healthcare resources and capabilities. If large and complex healthcare systems were overwhelmed by the pandemic, what would happen to those regions with limited healthcare resources? How could they best prepare? To that end, this commentary will briefly examine the challenges and lessons learned from a small U.S. army medical treatment facility (MTF)’s response to the COVID-19 pandemic. We discuss the regional and clinic level response, force health protection, contingency planning, and review lessons learned. BACKGROUND The Medical Department Activity Bavaria (MEDDAC-B) is located on Rose Barracks, a U.S. military post in the rural village of Vilseck in the German state of Bavaria. The MEDDAC-B headquarters commands five MTFs positioned from east to south and across two German states of Bavaria and Baden-Württemberg (see Fig. 1).4 These MTFs provide essential outpatient services to the beneficiary population of active duty service members (SMs) and their family members. However, for medical emergencies and specialty care requiring inpatient services, the host nation (HN) hospitals are utilized, as these services are not available in MEDDAC-B MTFs. In total, these five MTFs provide health care for a beneficiary population of over 34,000 personnel. FIGURE 1. Open in new tabDownload slide U.S. Army medical assets Germany. FIGURE 1. Open in new tabDownload slide U.S. Army medical assets Germany. Germany’s cases quickly rose, with Bavaria and Baden-Württemberg being two of the hardest-hit states with over 5,000 cases reported (or 44–48/100,000/population) as of March 24, 2020.5 There was great concern that the HN nation facilities could not support their beneficiaries plus the local U.S. military population. Once HN facilities reached 90% patient occupancy, U.S. Army Health Clinic-Vilseck (USAHC-Vilseck) would need to treat and hold patients for up to 72 h before transport to the Landstuhl Regional Medical Center (LRMC). This potential requirement created logistical challenges as the five MEDDAC-B MTFs located at Grafenwoehr, Vilseck, and Hohenfels are between 358 km and 378 km away from LRMC, while the MTFs at Ansbach and Stuttgart are 246 km and 197 km away. REGIONAL RESPONSE TO COVID-19 Communication An effective response to the pandemic required military and civilian medical personnel’s coordinated efforts. The HN’s and USAHC-Vilseck’s primary goal was to slow the disease spread by “flattening the curve,” i.e., implementing public health measures to reduce the infection rate over a longer period so as to not overwhelm the healthcare system capacity.6,7 To that end, the seventh Army Training Command (ATC) commander established a public health response that implemented robust quarantine rules. The seventh ATC commander established this guidance based on the U.S. Centers for Disease Control (CDC) guidance8 and the German Government’s Bavarian Ordinances.9 These measures included travel restrictions for essential activity only, i.e., work, food, and medical care. Additionally, to establish and enforce the extensive public health measures, the seventh ATC commander asserted command-and-control of all posts and communicated specific guidance to be followed. This guidance included 14-day quarantine rules, screening procedures, testing criteria, and access criteria for entrance onto the post. All personnel attempting access to the base were screened with the following questions: “Have you left the country in the last two weeks,” “Do you have any symptoms,” and “Are you on quarantine.” Other efforts included community messaging via Facebook Live town hall meetings, which were conducted weekly with key leaders providing the most up-to-date information to soldiers and their families. The second Cavalry Regiment (2CR) is the primary unit in Rose Barracks and its soldiers receive most of their care at USAHC-Vilseck. The 2CR commander established screening measures, quarantine rules, lockdown guidelines, and testing procedures based on the seventh ATC commander’s guidance. The main difference was the lockdown measures in Rose Barracks. Those living in the base were prohibited from leaving it unless there was an emergency, and those living off-post were required to have a yellow exit pass. These efforts enabled standardization and enforcement of public health measures through USAHC-Vilseck using garrison-level assets. Second Cavalry Regiment and USAHC-Vilseck had weekly meetings to discuss the implementations and how they could be improved. The MEDDAC-B prepared the healthcare staff for a worst-case scenario and established surveillance testing to randomly test SMs to identify potential asymptomatic but COVID-19-positive cases to decrease disease spread. This coordinated effort provided continuity between command groups and built trust with medical staff tasked to manage this pandemic. When increased numbers of positive cases threatened the HN’s inpatient and emergency services, capability limits were placed on the type of care they could provide to SMs and their families. Emergency rooms had limited treatment to emergent care only for patients presenting with a stroke or heart attack. Many outpatient specialty services, including elective surgeries, were canceled to conserve resources and capabilities such as personnel, personal protective equipment (PPE), and hospital beds. Due to the closure of HN specialty services and non-emergent care, SMs and beneficiaries could only receive care at USAHC-Vilseck. Commanders quickly realized that with increased patient volume at these clinics, the risk of staff exposure to COVID-19 increased. The potential increase in COVID-19-positive patients coming through the clinic created a readiness threat to the USAHC-Vilseck and medics assigned to 2CR who work in the clinic. The 2CR commander’s solution was to create a dedicated area for patients presenting with COVID-19 symptoms to be screened and tested in a separate location from the clinic. This effort resulted in establishing the acute respiratory center (ARC) located on the Vilseck airfield, roughly 1.5 miles away. The ARC was staffed 24 h, 7 days per week (24/7) by a provider, nurse, non-commissioned officer, and 7–10 medics. The ARC provided rapid screening for all personnel entering the base or presenting to the clinic with COVID-19-like symptoms. Locating the ARC on the Vilseck airfield prevented high-volume traffic through the clinic that could expose patients and staff to the COVID-19 virus and isolated the cases of COVID-19 from spreading within the post. Also, it allowed the clinic to focus on caring for patients with non-COVID-19-related chronic and acute healthcare needs. CLINIC RESPONSE TO COVID-19 The ARC providers followed a triage and treatment algorithm (see Fig. 2). Patients were screened for pertinent travel history to high-risk locations and COVID-19 symptoms and had their temperature taken. Patients who were febrile (temperature > 99.5°F) were presumed to be COVID-19 positive and were moved to an isolation tent outside the hanger to reduce the potential spread to other patients and staff. The provider’s clinical judgment and laboratory results determined whether a patient should self-isolate, be quarantined, or return to work. According to the CDC, self-isolation is separating sick people with a contagious disease from healthy people. In contrast, quarantine separates and restricts the movement of people exposed to a contagious disease to see if they become sick.10 Therefore, patients with a COVID-19 diagnosis were ordered to self-isolate in their home and avoid contact with all family members for 14 days or until symptoms subsided for 72 h without medication intervention. FIGURE 2. Open in new tabDownload slide Acute respiratory clinic screening algorithm. FIGURE 2. Open in new tabDownload slide Acute respiratory clinic screening algorithm. FORCE HEALTH PROTECTION Personal Protective Equipment At the beginning of the pandemic, stores of PPE and other critical supplies were limited, as shipments had not arrived from the U.S. Army Medical Material Center, Europe. Due to the highly infectious nature of COVID-19, there was a critical need for PPE and requisite training in its use to reduce the risk of transmission between infected patients and medical staff. The USAHC-Vilseck initially had no N95 masks in stock when the pandemic began. Items like gowns and face shields were in stock, but the amount available would have lasted 2 days if not reused. A subject matter expert (SME) from the USAHC-Vilseck provided PPE education on proper donning and doffing of gowns, gloves, N95 masks, and face shields. The SME was also responsible for fit testing personnel for N95 masks. However, there was only one N95 fit testing kit and two SMEs between Rose and Tower Barracks, which delayed the process of fitting over 200 military and civilian personnel in Rose Barracks. The fit test kit would be handed off 2–3 times a week between the USAHC-Vilseck SME and the USAHC-Grafenwoehr SME once all schedules with 2CR medic personnel and clinic staff were finalized. Testing Challenges The need for increased testing created additional challenges. The highly infectious nature of COVID-19 and the fact that its symptoms could mimic other infections such as influenza prompted an increase in testing prevalence. At the beginning of the pandemic, providers thought it was better to test for COVID-19 than not. However, as testing requirements increased, so did the workforce needed to collect, package, and ship the tests more frequently to LRMC for processing. The USAHC-Vilseck laboratory department provided the swabs and prepared the shipments of specimens for transport to LRMC. Collection of COVID-19 and influenza samples occurred 24/7 at the ARC. Medics were properly trained on the swabbing technique through the nares before they arrived at the ARC. These medics later provided education and training to 2CR medics on properly collecting and packaging the specimens for transport to the laboratory without contamination. Contact Tracing Identifying, assessing, and managing SMs with a potential COVID-19 exposure was critical to prevent the disease’s further spread. As the public health nurses assigned to USAHC-Vilseck and contact trace teams in 2CR completed contact traces, over 50 close contacts needed testing. An example of a significant trace was during a large training event soldiers were conducting. A mass trace was a result of one positive patient that would lead to over 75 close contacts. There was a noticeable need for additional assistance at the ARC to process all the patients. Nurses were responsible for crowd control, swabbing patients, and providing discharge education while the providers assessed and diagnosed the contacts. Effective contact tracing required leadership communication at all levels to ensure proper coverage at the ARC and USAHC-Vilseck. Therefore, biweekly meetings were established between the 2CR and USAHC-Vilseck to ensure accurate and timely information dissemination. CONTINGENCY PLANNING Just in Time Training Experience and competency levels of the USAHC-Vilseck’s nurses and medics were not adequate for critically ill patients requiring modalities beyond those encountered in routine outpatient care. In the outpatient setting, nurses are responsible for screening patients for the concern, bringing them in, performing and identifying abnormal vital signs, administering immunizations, replying to telephone consults, providing wound care, and responding to cardiac or respiratory distress in a Basic Life Support capability only. However, COVID-19 abruptly changed this situation and forced new critical nursing requirements for the staff. To address this gap, the clinic and education department at MEDDAC-B, while working with Regional Health Command-Europe and LRMC, provided “just in time training.” These classes focused on nursing care and management of patients with acute respiratory symptoms. Staffs were required to take online classes via Elsevier and then attend in-person skills validation. Stations were set up with mannequins, ventilators, and essential supplies needed to manage acute respiratory symptoms. The instructors provided education on the proper use of portable ventilators and the management of endotracheal and nasogastric tubes. Nurses then performed hands-on simulations for further familiarization. A final test-out scenario enabled nurses to apply their knowledge on primary assessments and interventions requiring oxygen or an advanced airway. The staff consensus was to incorporate these skills into the initial staff orientation and conduct yearly skills validation as required by Competency Assessment Folders. These changes would help maintain those critical skills should a second wave occur or if a new pandemic arises in the future. LESSONS LEARNED This pandemic was a first for every nurse, medic, and healthcare provider. There was little or no experience or institutional knowledge to draw from, which resulted in a great deal of uncertainty in managing the crisis. The following section will discuss important lessons learned from the regional and clinic level response, force health protection, contingency planning, and returning to normal operations. These matters are likely similar to what other military MTFs faced. They are also unique due to the geography and locations of these Bavarian MTFs. Importantly, this knowledge may benefit those small civilian healthcare facilities located throughout rural America. Regional and Clinic Level Response Leveraging garrison- and brigade-level command teams to manage the pandemic response was essential for mission success. This was similar to the way governments collaborated with healthcare systems to respond to the pandemic worldwide. The public health initiatives implemented to control the pandemic’s spread were crucial. They would have been impossible to initiate and enforce from a clinic or even the larger medical component because the measures required abrupt changes in people’s lifestyles and behaviors. Brigade- and garrison-level commanders can enforce adherence to behavior change due to the assets at their disposal, such as law enforcement and gate control; the ability to shut down and open commercial sectors on bases; and stop movements, leaves, and passes. Keeping the clinic staff involved in communication was vital to overcoming the frequent changes in standard operating procedures. Team huddles were established to improve group communication, address daily concerns covering COVID-19 testing criteria, logistical or personnel issues, and provide local and regional updates. Force Health Protection The Defense Health Agency’s primary mission is to maintain military readiness, i.e., preserve the fighting strength. To achieve those ends, keeping the staff healthy and able to perform their mission was vital. As the transmission of COVID-19 results from close contact and respiratory droplets,11 having sufficient PPE stores was critical. Therefore, all clinics should consider increasing their storage of PPE for future contingencies. Pandemic control through testing and contact tracing was another essential force protection measure. This effort was necessary because of the coronavirus’s virulence and the fact that infected patients could be asymptomatic. Having a MEDDAC-B or USAHC-Vilseck staff member unknowingly infecting nursing and medical staff posed a significant risk and could compromise their ability to perform their mission. Another vulnerable population was the soldiers because of barracks living and the fact that the units in Bavaria conduct many field-training exercises, requiring soldiers to quarter in field tents that increase exposure risk. As in the past, disease non-battle injury represents the most significant risk of morbidity to military personnel.12 The testing of personnel was a vital mission, including surveillance testing to identify asymptomatic carriers. However, it required additional manpower to staff the testing sites, process the specimens, and perform contact tracing, which could be time and labor-intensive. Therefore, cross-training of medics or other staff members is a crucial contingency consideration for a future pandemic. Contingency Planning The majority of Army Nurse Corps Officers start their military career as inpatient medical–surgical nurses. Training is conducted for mass casualties but not pandemics. The current COVID-19 pandemic provides important lessons learned that could be incorporated in Army Nurse Corps Officers training to improve readiness. It has forced nurses to respond to a whole new set of challenges that a pandemic brings. This pandemic also illustrated that nurses in various roles utilize different skill sets. However, no matter where they work, military nurses must be able and ready to respond to all types of emergencies. The skills learned from mass casualties and triaging patients are essential for staff to maintain their competencies. However, a new requirement has emerged, and that is how to respond to a pandemic. Since militaries can weaponize biological diseases and viruses, our capability to respond to these threats must remain high. Current training and validation of skills will need to be flexible to the ever-changing threat environment. Validating Individual Critical Task List or Mission Essential Task List competencies will remain at the forefront of training. However, new scenarios must implement training that enables the effective response of all staff to a pandemic. Finding time for staff training remains a challenge for all disciplines actively engaged in healthcare operations. However, skills not practiced are skills that will be lost. Therefore, command support and innovation that enhance skills development in the current time-constrained environment remains critical. CONCLUSION This pandemic highlighted gaps in the military healthcare system on how to best respond to a pandemic. However, important lessons learned have improved our capabilities. A critical component identified was the need to swiftly establish a single point of communication to ensure rapid, decisive, and precise messaging. As healthcare workers are at the “tip of the spear,” ensuring their health and safety to execute the mission is paramount. Screening remains a central component to stop the spread of a pandemic. Understanding the need for a borrowed workforce and cross-training enabled faster processing and quicker test results. The variability in staff training and experience between inpatient and outpatient underscores the importance of readiness and skills training, no matter where we practice. In a future pandemic, access to a medical center’s capabilities may not be readily available. Staff in outpatient environments may need to hold and treat very sick patients for extended periods. Therefore, their training must align with these requirements to ensure the best patient outcomes. As of this writing, the USA and Europe are amidst another surge in infection rates, with multiple countries enacting severe restrictions and lockdowns. Fortunately, the military has learned important lessons and is better prepared to respond to what is likely to be an omnipresent threat both now and in the future. ACKNOWLEDGMENTS We want to thank TSNRP for championing this writing effort, providing continued support and education, and importantly giving novice nurses the opportunity to publish. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Dicker RC , Coronado F, Koo D, Parrish RG: Principles of Epidemiology in Public Health Practice; an Introduction to Applied Epidemiology and Biostatistics . Department of Health and Human Services, 2006 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 2. Worldometers.info. Coronavirus worldwide graphs . Worldometer.com , 2020 . Available at https://www.worldometers.info/coronavirus/worldwide-graphs/#countries-cases; accessed November 10, 2020. 3. Centers for Disease Control and Prevention : COVID-19 stats: COVID-19 incidence, by urban-rural classification — United States, January 22–October 31, 2020 . MMWR Morb Mortal Wkly Rep 2020 ; 69 ( 46 ): 1753. OpenURL Placeholder Text WorldCat 4. Hudson AL , Reynolds TL: Sole Medical Center in Europe for Service Members, Families, and Other Beneficiaries . Regional Health Command Europe ; 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 5. Robert Koch Institute : COVID-19 Situation Report 24/03/2020 . The Robert Koch Institute ; 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 6. Qualls N , Levitt A, Kanade N, et al. : Community mitigation guidelines to prevent pandemic influenza—United States, 2017 . MMWR Recomm Rep 2017 ; 66 ( 1 ): 1. Google Scholar OpenURL Placeholder Text WorldCat 7. Centers for Disease Control and Prevention : Interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the United States-early, targeted, layered use of nonpharmaceutical interventions . Available at http://www.pandemicflu.gov/plan/community/community_mitigation.pdf; accessed date November 5, 2020. 8. Centers for Disease Control and Prevention : When to quarantine . Available at https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html, 2020 ; accessed December 5, 2020. 9. Huml M : Bavarian Ordinances on Protective Measures against Infectious Diseases in Response to the Corona Pandemic . Vol 158 , pp 1 – 4 . Bavarian State Ministry for Health and Care ; 2020 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 10. Centers for Disease Control and Prevention : Quarantine and isolation . Available at https://www.cdc.gov/quarantine/index.html, 2020 ; accessed November 15, 2020. 11. Centers for Disease Control and Prevention : How COVID-19 spreads . Available at https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covid-spreads.html, 2020 ; accessed December 10, 2020. 12. Hauret KG , Pacha L, Taylor BJ, Jones BH: Surveillance of disease and nonbattle injuries during US Army operations in Afghanistan and Iraq . US Army Med Dep J 2016 ; 2–16 ( 2016 ): 15 – 23 . Google Scholar OpenURL Placeholder Text WorldCat Author notes The views expressed are those of the authors and do not reflect the official policy or position of the TriService Nursing Research Program, USUHS (University of the Health Sciences), the Department of Defense, or the U.S. government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Akpan, Ekerette U; Murray, William O; Vergara, Mario A; Murray, Sarah J; Stucky, Christopher H; De Jong, Marla J; Villacorta, Elba

doi: 10.1093/milmed/usab179pmid: 34469527

ABSTRACT The coronavirus disease 2019 pandemic stressed healthcare systems worldwide and exposed major flaws in military and civilian healthcare systems. Landstuhl Regional Medical Center (LRMC) serves as the only military medical center for over 205,000 U.S. service members, beneficiaries, and coalition partners stationed throughout Europe, Africa, and the Middle East. The pandemic response required LRMC leaders to reconfigure services to meet pandemic concerns while providing lifesaving care to injured service members from combatant commands. The quickly evolving pandemic challenged leaders to ensure healthcare delivery amid constant change and imperfect information. While LRMC senior leaders developed a strategic pandemic response plan, a multidisciplinary team of nurses, doctors, and technicians collaborated to create an inpatient team to support the dual mission of coronavirus disease 2019 response and casualty care for the warfighter. In this manuscript, we discuss how a multidisciplinary clinical working group at a regional medical center prepared and responded to the pandemic, strategically planned patient care, and ensured support to combatant commands for ongoing forward military operations. Additionally, we share our experiences and lessons learned to inform other military facilities across the medical community and global healthcare systems. INTRODUCTION The coronavirus disease 2019 (COVID-19) first emerged in China and quickly spread to cause a worldwide pandemic, resulting in 124 million global cases and over 2.7 million deaths.1 The severity of the disease varies from flu-like symptoms to severe acute respiratory syndrome.2 The disease spreads among people in close contact through respiratory droplets or small particles, such as those in aerosols produced during coughing, sneezing, talking, or medical procedures. The European Centre for Disease Prevention and Control reported the first case of COVID-19 on January 27, 2020, near Munich, Bavaria.3 All European Union countries soon reported COVID-19 cases by March 25, 2020,3 and Germany imposed a nationwide state of emergency for the first time in its postwar history.4 Landstuhl Regional Medical Center (LRMC) leaders reported their first COVID-19-positive patient in March 2020, and they developed strategies to prepare for a potential rapid influx of patients. The pandemic stressed healthcare systems worldwide and exposed major weaknesses, including severe shortages of personal protective equipment (PPE), hospital beds, medication, and supplies.5,6 COVID-19 also challenged the vitality of the healthcare workforce, as the disease infected thousands of U.S. healthcare workers, resulting in the mortality of over 3600 frontline clinicians.7 The pandemic likewise affected military healthcare, as military leaders enacted measures to ensure safe and effective care to their beneficiaries.8 LRMC is a forward stationed U.S. military medical center located in western Germany, where over 205,000 beneficiaries, including U.S. and coalition forces, Department of State personnel, repatriated U.S. citizens, and dependents receive care.9 LRMC is the largest American hospital outside the continental US. Its inpatient capability includes a combined intensive care unit (ICU), medical–surgical pediatric ward, labor and delivery ward, mother–baby unit, and neonatal ICU. LRMC has a unique mission as an evacuation and treatment center for all injured U.S. service members and civilians, including coalition forces supporting the Africa Command, Central Command, and European Command. COVID-19 created a heightened sense of urgency, as a neighboring country, Italy, was a pandemic hotspot inundated with critically ill patients that threatened to overwhelm their healthcare system.10 The risk to LRMC beneficiaries was elevated due to the infectiousness of the virus, mortality rate, and potential impact of diverting efforts away from the primary mission. Furthermore, the German healthcare system did not have the capacity to assume medical care for U.S. service members and their dependents if their hospitals became overwhelmed. In this manuscript, we discuss how a multidisciplinary (Multi-D) inpatient team at a regional medical center prepared and responded to the pandemic while continuing to manage combat casualty care. Additionally, we share our experiences and lessons learned to inform other military facilities across the medical community and global healthcare systems. BUILDING THE TEAM Nursing leaders from inpatient wards collaborated with infectious disease, pulmonary, and critical care medicine teams, and created an ad-hoc COVID-19 Inpatient Working Group (CIWG) to leverage all available expertise for a coordinated pandemic response. Comprising the CIWG were bedside clinical staff, clinical leaders, and ancillary staff. Key CIWG leaders and members were the Deputy Commander for Inpatient Services (DCIS) and leadership from inpatient nursing services, critical care, pulmonology medicine, women’s health, operating room, nursing education, nursing supervisors, radiology, infection control, nutrition care, case management, information management division, logistics, environmental services, and clinical nurse specialists (CNS) from the center for nursing science and clinical inquiry. The CIWG commenced in early March 2020 and was a crucial first step to help the organization adapt to a changing environment and requirements. The team met daily before the first patient’s arrival to discuss recent developments, requirements, training needs, pending admissions or inbound aeromedical evacuations, and plan patient care. Regular meetings allowed team members to review the latest COVID-19 guidance and adjust plans and procedures based on evolving evidence. The team developed organizational standard operating procedures (SOPs) that guided all COVID-19 activities related to patient care, workflow, and training. The COVID-19 SOP’s purpose was to guide the diagnosis, disposition, and treatment of either COVID-19 positive patients or those suspected of having the disease. The COVID-19 SOP is a living document that is updated regularly to reflect the pandemic’s rapidly changing nature. The SOP outlines the procedures for hospital and inpatient staff to provide optimal patient care while minimizing the risk of transmission. We designed the SOP to serve as a “quick reference” to on-call personnel at the point-of-care. The SOP is not a comprehensive policy and is not a substitute for clinical judgment. BED EXPANSION PLAN Caring for COVID-19 positive and negative patients created workflow, space, and safety problems, as leaders enacted measures to decrease the spread of the disease to uninfected patients. First, nursing leadership and section leaders completed a thorough facility assessment, including inpatient and outpatient areas, verified current capabilities, and identified expansion contingency wards and equipment needs. As a result of the walkthrough, a seven-tiered bed expansion plan containing distinct COVID units was developed to actively manage inpatient beds for positive and suspected COVID-19 patients. The inpatient leadership team developed the bed expansion plan as the way forward after working through multiple courses of actions with the command team. The first unit developed in the tiered expansion plan was an 11-bed COVID-19 Unit (CVU) with critical care capabilities. To ensure adequate critical care support and close proximity to the emergency department, the hospital commander directed the ambulatory procedure unit’s repurposing into the CVU, serving as the central hub for all COVID-19 patient admissions in Tier-1. As the number of patients increased, the next unit’s activation would occur once the current unit reached a 75% occupancy rate. To date, inpatient COVID-19 support operation continues in CVU, and the hospital remains in the Tier-1 of the bed expansion plan. In preparation for the COVID-19 response and bed expansion plan, the hospital commander reduced outpatient clinical face-to-face appointments by 80%. Thus, to limit the spread of the disease, most patients received healthcare from their providers via a virtual platform. The move to a virtual format mitigated disease transmission risk while still enabling face-to-face appointments for patients requiring high-risk screenings. To date, clinical operations have returned to 60% face-to-face with COVID-19 precautions, with the remainder occurring via the virtual platform. The department of surgery reduced operations by 80% to strictly emergent and urgent procedures, enabling the conversion of the ambulatory procedure (APU) and same day surgery (SDS) units to the specialized CVU that is still in current operation. The administrative offices, including support for critical care CNS, were also relocated. To date, surgeons are operating at nearly 70% of the pre-COVID-19 capacity, with the SDS and APU continuing to occur in their new locations. The change in the COVID-19 operational tempo allowed the CIWG to reduce team administrative huddles to monthly, with clinical leader consultation as needed. The daily Multi-D clinical rounds continue when there are patients on the CVU. WORKFLOW The CIWG made changes to the workflow for each unit to ensure safety, limit traffic in and out of the unit, and decrease the disease’s spread. The CIWG developed workflow diagrams that established entry and exit points for staffing and patient transport, a donning and doffing area, and a dedicated team locker room and rest area. One elevator was designated as the transport for COVID-19 patient movement. Access points to the unit were restricted to only CVU and CIWG team members to reduce traffic entering the unit. To manage patient flow, the CIWG developed three categories of COVID-19 patient admission criteria: positive, probable, and unlikely. Confirmed symptomatic positive and probable patients were admitted to the CVU. Patients with an atypical clinical presentation were admitted to an isolation or private room in the medical-surgical (MEDSURG) ward, pending COVID-19 test results. RESOURCE MANAGEMENT Supplies and Equipment The ongoing wartime mission and readiness posture for contingency operations placed LRMC at an advantage for the COVID-19 response compared with other facilities concerning supply chain management. However, effective collaboration with hospital logistics and facilities was paramount to acquire the equipment (ventilators, monitors, and UV sterilization) and the renovation of ventilation systems necessary to support the mission. The logistics division maintains mass casualty supplies and equipment for contingency operations and collaborates with the regional strategic supply chain to ensure the availability of expansion equipment, including ventilators, monitors, and PPE. On short notice, the team acquired additional transport monitors, beds, and ventilators to nearly double pre-COVID-19 operational bed capacity. To date, the LRMC COVID-19 response has not exceeded the Tier-1 bed capacity, and we have had an excess of hospital beds and ventilators. The one item that we certainly maximized from the contingency stocks was PPEs. A clear reporting process and open lines of communication between unit leaders and logistics ensured that the CVU had the necessary supplies and equipment to provide safe patient care. Personal Protective Equipment In the early phases of the pandemic, PPE projection, availability, timely acquisition, and resupply were top priorities. Operational plans guided PPE requirements by estimating the number of personnel per shift, the number of shifts, and work/rest cycle. PPE burn rates depended on multiple variables, including PPE protocols (Fig. 1) and the number of staff-to-patient encounters. We adapted the Centers for Disease Control and Prevention (CDC) PPE burn rate calculator11 as a template to provide a foundation for establishing requirements. The original CDC calculator helped track how quickly PPE was being used, rather than PPE demand projections. The CDC calculator was modified to include the staff roles, number of staff per shift, number of shifts, number of patients, and number of potential staff to patient encounters based on patient acuity. FIGURE 1. Open in new tabDownload slide Landstuhl Regional Medical Center personal protective equipment (PPE) guidance. COVID-19 Inpatient Working Group developed this PPE worksheet as a guide for donning and doffing PPEs by nursing personnel. The standard was utilized as a checklist for donning and doffing protective equipment and was strictly enforced. FIGURE 1. Open in new tabDownload slide Landstuhl Regional Medical Center personal protective equipment (PPE) guidance. COVID-19 Inpatient Working Group developed this PPE worksheet as a guide for donning and doffing PPEs by nursing personnel. The standard was utilized as a checklist for donning and doffing protective equipment and was strictly enforced. We validated the PPE calculator after caring for the first COVID patient. The CNS tracked the number of staff to patient encounters, and the number of each PPE items was logged. Hospital leaders used the data for decision support to decide if clinicians should reuse PPE when faced with 10+ patients. The team compared the initial burn rate projection with actual burn rate data for a given patient over 10 days. The amount of PPE used throughout the patient’s stay remained consistent even as the patient converted from an ICU patient to a MEDSURG patient. The type of events that drastically increased the PPE usage were new patient admissions, proning procedures, intubating, and patient extubation. To date, clinical staff members have not reused PPE due to shortages. STAFFING PLAN Early in the operation’s planning phase, clinical leaders determined that staffing was a major limiting factor in the response plan. Nurse staffing for critical care support represented the largest projected manpower deficit. The team calculated the staffing deficit based on the DoD COVID-19 Practice Management Guide (PMG), which estimated that 80% of COVID-19 projected cases would be mild, 15% severely ill, and 5% would require critical care support and interventions, including mechanical ventilation.12 Other issues that further complicated staffing challenges were routine patient care operations, including combat casualty care and the level of turbulence associated with the air evacuation and critical care transport mission. The average daily census for routine patients and battle injuries in the ICU and MEDSURG unit varied daily. The patient load from inbound aeromedical flights was unpredictable; however, the number of weekly outbound fights was consistent. To mitigate staffing challenges, the hospital commander temporarily closed clinic operations, enabling clinic nursing personnel to train and support the inpatient mission. As a result, frontline nursing leaders developed a dedicated team of nurses and technicians from the ICU and MEDSURG wards to provide direct patient care in the CVU. The rest of the nursing staff from both units, supported the non-COVID-19 MEDSURG and critical care operations with augmentation from sister services and clinics to include labor and delivery, mother-baby unit, outpatient clinics, and the department of surgery. Nursing leaders developed a team nursing staffing plan based on the PMG crisis staffing model to support direct patient care. A care team included an ICU Registered Nurse (RN), a MEDSURG RN, a Licensed Practical Nurse, and a technician. Initially, another technician was posted at the entrance and exit of the ward to assist and monitor the donning and doffing of PPE, respectively. The CVU implemented a buddy system for donning and doffing of PPE. We grouped care to conserve PPE and reduce the number of times the staff entered the room. As census, acuity and/or workload increased, the team adjusted the staffing plan. This staffing mix allowed care-teams to manage multiple patients with work–rest cycles and ultimately became the standard of care, which continues to be utilized today. JUST-IN-TIME TRAINING The CIWG education team planned and implemented just-in-time training (JTT) for inpatient and outpatient clinical nurses to learn the requisite skills necessary to augment critical care nursing areas. The staff were able to be cross-leveled after receiving the JTT for the personnel assigned to inpatient services, the primary care clinics, and other departments. The education team consisted of senior critical care nurses, respiratory therapy technicians, critical care, and MEDSURG CNSs. The team used online modules from the Society of Critical Care Medicine 13 to provide non-ICU clinicians with baseline education on COVID-19 critical care treatment. The team also provided a 2-hour simulation-based training session in the ICU with a high-fidelity mannequin. The topics covered in the hands-on training were crucial elements of ICU care, including ventilator, hemodynamics, telemetry basics, and proning procedures (Fig. 2). In addition to the learning modules and hands-on ICU training, the education team provided PPE training for nursing personnel to prevent cross-contamination and potential exposure to the disease. Last, the non-critical care nurses went through a short orientation and preceptorship with an ICU nurse and fellow teammates already working on the COVID-19 units. FIGURE 2. Open in new tabDownload slide Just-in-time training modules and topics from society of critical care medicine. Clinical staff were assigned modules online to complete as a prerequisite. They would then schedule to attend a simulation-based familiarization training with basic ICU equipment and patient management skills. As stated above the training team made sure to address topics treatment protocols that were related to managing a COVID-19 patient. FIGURE 2. Open in new tabDownload slide Just-in-time training modules and topics from society of critical care medicine. Clinical staff were assigned modules online to complete as a prerequisite. They would then schedule to attend a simulation-based familiarization training with basic ICU equipment and patient management skills. As stated above the training team made sure to address topics treatment protocols that were related to managing a COVID-19 patient. COMMUNICATION Team Huddles The CIWG met daily to plan operational activities, discuss real-time issues and challenges, and develop real-time Multi-D solutions. Starting in the early phase of COVID-19, the CIWG meetings were held in-person with social distancing and mask, and then virtually. The meeting promoted robust discussions, brainstorming of ideas, and open expression of views without fear of reprisal or discipline. The CIWG continually adapted patient care, processes, and safety measures to new guidance from the DoD, CDC, LRMC infectious diseases, and current clinical activities. The forum allowed for decision-making at the tactical level. However, senior hospital leadership made final decisions on operational plans that impacted the larger organizational mission. A decision to create a COVID-19 specific code team using Vocera, a handheld communication system staff wore on their uniform. This method of communication ensured an efficient and safe emergency response to a COVID-19 patient in crisis. Multidisciplinary Rounds The CIWG conducted daily Multi-D rounds in the CVU. The purpose of the dedicated rounds was to discuss the status of each COVID-19 patient, care plan, and care coordination issues, and, to provide any updates on guidelines or standards to the team. The team also discussed projected inbound patients to LRMC from deployed or remote areas in the LRMC area of responsibility, including Europe, Southeast Asia, and Africa. The team conserved inpatient beds, supplies, and resources by isolating the COVID-19 patients coming from downrange that did not meet the criteria for hospitalization in isolation lodging on the LRMC instillation. Key factors that enabled positive patient outcomes in the COVID-19 ICU were nutrition care and early rehabilitation. Physical therapists (PT) and PT technicians often performed therapy, such as walking with critically ill patients, inside the hospital to facilitate recovery. The team recognized this could increase the potential for exposure to the disease between patients and staff. To maintain standard of care and optimize recovery for this population, PT conducted exercise outside while following established PPE protocols. The nutrition care division delivered meals at the CVU entrance in disposable containers. Unit-Level Communication with Frontline Staff Leadership engagement and open lines of communication between LRMC leaders and frontline staff promoted a healthy work environment and enabled safe and efficient clinical operations. Unit-level leaders conducted daily staff safety huddles to provide assurances about operational safety, encouraged self-care, and provide resources. One of the first things that instilled a sense of ownership and support from the command team was when the Chief Nursing Officer provided direct patient care to the first intubated critically ill COVID-19 patient. This action communicated to the unit leaders and the staff that the hospital leaders would not put their health at risk. Unit leaders paid special attention to signs of complacency with safety protocols and any mental health issues related to feelings of isolation from other team members not involved in caring for COVID-19 patients. Early intervention through leadership engagement, resource management, training, and leveraging existing programs such as pastoral care and clinical psychology to support self-care were critical for staff resilience. LESSONS LEARNED The LRMC clinical leader initiative to develop the CIWG led to a coordinated pandemic response while maintaining routine combat casualty care support. In developing and executing a response plan, some key lessons learned centered on teamwork, communication, adapting to change, and leadership. Teamwork Key to the success of CIWG was an intentional effort in the early phase of the pandemic to bring a Multi-D team together to work toward a common goal through knowledge sharing and collaboration. In so doing, we executed a coordinated response to the pandemic, members of the team learned capabilities and limitations of the facility, relationships were built, partnerships were forged, and issues were addressed in a timely manner. Communication Inpatient operations were heavily staffed by a novice nursing team, JTT, and staying vigilant with closed-loop communication within the team and frontline staff was important for success. In addition to communicating new information to the staff during team huddles, leaders helped subordinates understand the rationale behind changes and new guidance. Face to Face (F2F) or Virtual Telehealth (VTH) and Multi-D rounds kept everyone on the same page, and issues were addressed early. Open lines of communication with the hospital commander through the Deputy Commander for Inpatient Services level of leadership created a quicker channel for making decisions that impacted the organization. Also vital to operation were open lines of communication with nursing supervision. We noted confusions between clinical staff and nursing supervisors in the early phases of inpatient care that were not in sync. The fact that this team did not play a very active role in the planning phase for the pandemic response resulted in confusion with bed management and compliance with established admission processes. Thus, these issues had to be resolved in the middle of a real pandemic response. Adapting to Change Quickly adapting to an evolving situation was important for the success of the response plan and the team. This operation evolved overtime with changing information, practices, and guidelines from multiple avenues to include the CDC and World Health Organization. The policies and plans developed were kept fluid and updated almost daily. The updated policies were stored on the hospital intranet, enabling easy access by leaders and clinicians facility-wide. Within the CIWG, LRMC had a core group of expert decision-makers who oversaw the ground-level response and quickly adapted policies and staffing to meet standards. Leadership Inpatient services also succeeded in responding to the pandemic because we largely abandoned the more rigid leadership framework and traditional approval process for decision-making in exchange for speed. CIWG leaders were empowered to make decisions using the best evidence available without lengthy bureaucratic approval processes. The team had open lines of communication with senior leaders, and they were engaged as needed. Department chiefs empowered their junior leaders and staff to be creative and offer novel solutions to address identified problems. Leaders assigned tasks to team members regardless of rank because they showed initiative and follow-through. CONCLUSIONS The LRMC mission statement is: “LRMC, with partners, elevates the readiness and healthcare support of our joint warfighters and their families, by maximizing the quality and safety of our Role-4 Theater Hospital across the continuum of care in support of the Combatant Commanders.” The assumption as an MTF is that the hospital and team are trained and ready to respond to this call and to any crisis, if and when overwhelmed, the host nation will be able to support. This pandemic and its impact on healthcare systems across the globe challenged these assumptions. The constant preparation and training for contingency operations and, most importantly, the development of the CIWG working toward a common goal led to a successful LRMC readiness and response to the COVID-19 pandemic while continuing to support the joint warfighter. The CIWG was not only able to develop and execute an inpatient response to the pandemic, but it was also able to assess, analyze, and adapt to internal challenges and new guidelines along the way. Future and current leaders can use our implementation strategies and lessons learned to prepare for the next pandemic response. Many lessons were learned in teamwork, communication, adapting to change, and leadership applied in real time to operation with quality and safety as our center of gravity. ACKNOWLEDGMENTS On behalf of my teammates on this journey, I want to take this opportunity to thank Dr. Brian Cohee, LRMC Command Staff, members of the LRMC COVID-19 Inpatient Working Group and the frontline clinical personnel for their hard work and dedication to this mission. LTC Ekerette Akpan. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. Johns Hopkins University & Medicine : COVID-19 dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU) . Available at https://coronavirus.jhu.edu/; accessed March 24, 2021. 2. Centers for Disease Control and Prevention : Coronavirus (COVID-19) . Available at https://www.cdc.gov/coronavirus/2019-nCoV/index.html; accessed March 24, 2021. 3. European Centre for Disease Prevention and Control : Timeline of ECDC’s response to COVID-19 . Available at https://www.ecdc.europa.eu/en/covid-19/timeline-ecdc-response, published 2020 ; accessed March 24, 2021. 4. Bloomberg LP : Germany declares emergency to unleash historic virus bailout . Available at https://www.bloomberg.com/news/articles/2020-03-25/germany-approves-emergency-borrowing-for-historic-virus-bailout-k87ephwe, published 2020 ; accessed March 24, 2021. 5. Bloom JA , Foroutanjazi S, Chatterjee A: The impact of hospital bed density on the COVID-19 case fatality rate in the United States . Am Surg 2020 ; 86 ( 7 ): 746 – 7 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Ranney ML , Griffeth V, Jha AK: Critical supply shortages—the need for ventilators and personal protective equipment during the Covid-19 pandemic . N Engl J Med 2020 ; 382 ( 18 ): e41. Google Scholar OpenURL Placeholder Text WorldCat 7. The Guardian : Covid-19 healthcare worker death toll: 821 deaths under investigation . Available at https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database, published 2020 ; accessed March 24, 2021. 8. Stucky CH , De Jong MJ, Lowe AW, Mathews B: COVID-19: initial perioperative and perianesthesia nursing response in a military medical center . J Perianesth Nurs 2020 ; 35 ( 4 ): 353 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat 9. Regional Health Command Europe : Landstuhl Regional Medical Center . Available at https://rhce.amedd.army.mil/landstuhl/, published 2021 ; accessed March 24, 2021 . 10. Center for Infectious Disease Research and Policy : ECDC warns of overwhelmed hospitals, Italy-type COVID-19 pattern . Available at https://www.cidrap.umn.edu/news-perspective/2020/03/ecdc-warns-overwhelmed-hospitals-italy-type-covid-19-pattern, published 2020 ; accessed March 24, 2021. 11. Centers for Disease Control and Prevention : Personal protective equipment (PPE) burn rate calculator . 2020 . Available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html; accessed March 24, 2021. 12. Matos RI , Chung KK: DoD COVID-19 practice management guide version 7.0 . DoD COVID-19 resources . Available at https://jts.amedd.army.mil/index.cfm/PI_CPGs/COVID-19, published 2021 ; accessed March 24, 2021. 13. Society of Critical Care Medicine (SCCM) : Education center . Available at https://www.sccm.org/Education-Center, published 2020 ; accessed March 24 , 2021. Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Army, U.S. Air Force, Department of Defense, or U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2021. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Hernandez, Stephen

doi: 10.1093/milmed/usab090pmid: 34468002

ABSTRACT Initial DoD support of Federal Emergency Management Agency (FEMA) operations for New York City (NYC) coronavirus disease 2019 (COVID-19) relief included the deployment of military medics to the Javits New York Medical Station and USNS Comfort. When Air Force (AF) Reservists arrived in NYC, 64th Air Expeditionary Group leaders worked with FEMA, Task Force New York/New Jersey, and NYC chains of command to send Airmen to NYC hospitals, including Lincoln Medical Center (LMC). Within 72 hours of arrival, 60 AF Reservists, including 30 registered nurses and 3 medical technicians, integrated into LMC to provide support during April and May 2020. This assistance began during the peak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. Air Force nurses provided over 6,000 hours of care to over 800 patients in the emergency department and ad hoc intensive care and medical-surgical units. As infections declined, AF nurses shifted to providing care in established units. In these units, AF nurses provided patient care and worked directly with LMC nurses to provide directed teaching experiences to improve their comfort and competency with caring for acutely ill COVID-19 patients. The deployment of AF Reservists into civilian facilities was a success and bolstered the capability of three facilities struggling to care for SARS-CoV-2 patients. This effort was recognized by military and civilian healthcare leaders and resulted in over 600 military medical personnel being sent to support 11 NYC public hospitals. INTRODUCTION The first case of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in New York City (NYC) was reported on February 29, 2020.1 The DoD began its support of Federal Emergency Management Agency (FEMA) operations for NYC coronavirus disease 2019 (COVID-19) relief efforts with the deployment of military medics/corpsmen to the Javits Medical Station and USNS Comfort. New York City public hospitals were being overwhelmed as the city reached its peak of SARS-CoV-2 infections when Air Force (AF) Reservists began arriving on April 6, 2020. As the first group of AF Reservists began in-processing into NYC, 6,045 new cases of SARS-CoV-2 infections, with a 7-day average of 5,274, were recorded.1 After our arrival, 64th Air Expeditionary Group (AEG) leaders worked with FEMA, Task Force New York/New Jersey, and NYC civilian chains of command to send 275 Airmen into three NYC hospitals, the Jacobi, Lincoln, and Queens Medical Centers. In time, the success of this effort was recognized by civilian leaders and resulted in over 600 military medical personnel being sent to support 11 NYC public hospitals. In this case study, an overview of the accomplishments of AF registered nurses (RNs) and medical technicians supporting one NYC hospital during the initial surge of SARS-CoV-2 infections will be provided and lessons learned from the deployment will be discussed. Our team shared many common experiences with other healthcare professionals providing care to COVID-19-positive patients throughout the country. The efforts of our full team of providers—nurses, respiratory therapists, pharmacy staff, and a radiologic technician—deserve a larger discussion beyond the scope of this article. However, AF nurses made unique contributions, which merits a focused examination in this case study. CASE REPORT Air Force Reserve deployments over the past 19 years of conflict have routinely been planned events with opportunities for deployers to receive required preparation, training, and equipment. In the current case, the initial group of AF Reserve healthcare personnel was deployed within 24 hours of notice with no advanced preparation. Deploying a relatively large group of reservists in this short time frame was an extraordinary accomplishment. Minor shortfalls in the deployment process (e.g. no deployment orders prior to departure from home) were quickly corrected, and the overall sentiment of the Airmen was the overall deployment process was efficiently executed. Within 72 hours of deployment, 60 AF Reservists, including 30 RNs and 3 medical technicians, rapidly integrated into Lincoln Medical Center (LMC) acute care units to provide staffing support during April and May 2020. Approximately 12 hours of orientation were provided by LMC staff to familiarize our team with LMC policies, the electronic charting system, and their equipment. Although the orientation was brief, it was adequate to integrate our team into the hospital. As the senior ranking nurse, the author took on the role of the Chief Nurse for the team. There was a constant requirement for senior officers to liaise with the LMC Chief Medical Officer and Chief Nursing Officer. It was an unprecedented situation, and our civilian colleagues were not accustomed to working with the military. We had to ensure clear communication at all times. Lincoln Medical Center is a 362-bed hospital located in the borough of the Bronx.2 Of the five NYC boroughs, the Bronx has the lowest socioeconomic status, including household income, poverty level, and education level, as well as the highest percentage of Black or African American and Hispanic residents.3 In data collected through April 25, 2020, Wadhera et al.3 reported that the Bronx saw the highest number of SARS-CoV-2 infections resulting in hospitalization (634 per 100,000) and deaths (173 per 100,000) compared with the other NYC boroughs. A typical day for the team began with boarding buses at the Javits Center in Manhattan for a 30- to 45-minute ride to the Bronx to begin a 12-hour shift, with each nurse working three to four shifts per week. For much of our time in NYC, the streets were empty, but gradually increasing activity was seen as time passed. Unlike many hospitals that have designated COVID-19 units, LMC was presumed to be 100% COVID-19 positive, and an N-95 mask was donned before personnel entered the hospital. We found that the LMC employees’ morale was low when our team arrived. Several of their coworkers and friends had died from COVID-19, one just days before our arrival. However, the LMC staff continued to proudly serve their community. Initial Efforts Air Force nurses and medical technicians at LMC were initially focused on supporting the emergency department (ED) and ad hoc intensive care and medical-surgical units. The newly opened intensive care unit (ICU) was a converted mother–baby unit, and the medical-surgical unit had been the employee health clinic. Both converted units were needed because of the overwhelming number of COVID-19-positive patients LMC was treating. Staffing for these units was predominantly supported by the AF Reserve and travel nurses who had been contracted to supplement the LMC staff. The AF nurses were current with their expeditionary skills training, but LMC staff helped AF nurses adapt to the new setting and understand and comply with local policies. The ICU was especially difficult for our nurses. A team nursing model was used to increase the number of critically ill patients assigned to each ICU nurse. With a team model, ICU nurses were typically augmented by two civilian or AF medical-surgical nurses. The ICU RN would oversee complex nursing care for up to four patients, while medical-surgical nurses provided more routine patient care. Although the ad hoc ICU was not ideal, the team was able to work together to ensure that the highest possible level of care was achieved. Nearly all patients in the ad hoc ICU were mechanically ventilated. At the time, internal data showed that the estimated mortality was ∼80% for mechanically ventilated patients and mortality increased to over 90% if a mechanically ventilated patient developed renal failure (S. Hernandez, written communication, April and May 2020). Air Force nurses augmenting the ED and ad hoc medical-surgical unit were challenged with high acuity and high volume of COVID-19-positive patients. Many COVID-19-positive patients in the ED quickly decompensated and required intubation. Although many of the patients with COVID-19 were stable in the ad hoc medical-surgical unit, it was not uncommon for one to two patients per shift to progress into respiratory failure and require intubation and transfer to an ICU. A pulmonary critical care physician and certified RN anesthetist from our team worked with LMC leadership to establish a prone repositioning team in an effort to improve the oxygenation and survival of mechanically ventilated patients.4 In mid-April, five AF nurses joined providers and respiratory therapists to fully staff the prone team. Before our arrival, LMC did not have the staffing to dedicate to this effort. An analysis of the team’s efforts indicated that mechanically ventilated patients’ oxygenation saturation index and partial pressure of arterial oxygen significantly improved in patients who were proned and estimated that one in eight deaths could be prevented with proning.4 Despite the high mortality rates, AF nurses provided relief to the LMC staff and a level of care for patients that may not have been otherwise possible. During the first month of supporting LMC, the hospital had a daily average of 145 COVID-19-positive patients (peak n = 177) in the inpatient setting, 96 of whom were mechanically ventilated (peak n = 112), and an average daily census of 235 patients (peak n = 298; S. Hernandez, written communication, April and May 2020). By May 7, SARS-CoV-2 infections in NYC had decreased to 1,237 new daily cases, with a 7-day average of 1,347.1 The census at LMC had likewise decreased, and the hospital was providing care for fewer than 100 COVID-19-positive patients for the first time since we had arrived. In less than a month, AF nurses provided over 6,000 hours of care to more than 800 patients, of which over 380 were mechanically ventilated. Later Efforts As infections declined, the team’s Chief Nurse, other military nurse leaders, and our LMC counterparts met to explore options to ensure that the LMC nursing staff could better meet the challenges of a future COVID-19 surge. The civilian and military nursing leadership agreed that AF nurses would shift to providing care in the hospital’s permanent in-patient medical units. In these units, AF nurses continued to provide patient care and worked directly with the LMC mental health and outpatient clinic nurses to provide directed teaching experiences to improve their comfort and competency with caring for COVID-19-positive patients. The hospital had made previous attempts to utilize inpatient mental health and outpatient clinic nurses in inpatient care settings during the surge of COVID-19-positive patients to assist with providing patient care, but most needed more training than was possible at the time. The clinical background of these RNs varied greatly, and some of the inpatient mental health and outpatient clinic nurses had not worked with acutely ill patients since completing their nursing degree program. As part of this initiative, the LMC nurses were initially provided focused refresher training in didactic and simulation settings focused on caring for acutely ill patients. Then, a rotating schedule was developed for each AF nurse to be paired up with two LMC RNs for up to four, 12-hour shifts. The LMC nurses were initially assigned one patient and progressed to taking additional patients as they completed more shifts and as the units’ patient census allowed. We recognized that many of the LMC nurses were initially skeptical of the training, but most were grateful for the experience after working a few shifts with us. Before our redeployment, AF nurses provided a total of 119 training days to ∼30 LMC RNs. DISCUSSION Air Force nurses at LMC provided excellent care for our patients and essential assistance to support the hospital staff. However, it is necessary to engage in critical reflection to ensure that lessons learned are codified. These lessons are distinct from operational lessons, which were discussed during several after-action reporting sessions. Although the identified lessons are focused on our team’s experience, they are likely transferrable to a broader audience. Improving Competency With Crisis Standards of Care The Institute of Medicine5 defines crisis standards of care as follows: A substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. Generally speaking, the USA is capable of providing a high level of quality health care to its citizens, and the U.S. Military has provided a high standard of care to wounded service members in austere conditions for almost two decades. In the first days of our deployment, many of us struggled to adjust to the reality of the pandemic, including the need to adapt from our normal, expected level of patient care to crisis standards of care. Although many of us had experienced mass casualty events, we were used to these resolving in time and returning to normal operations. In contrast, our experience could be likened to a mass casualty event that improved slowly over a month’s time. We were successful in adapting and excelling in a short period of time, but the delay in adaptation could be greatly shortened by improving competency and training for military healthcare personnel with crisis standards of care. This training is essential to prepare military nurses for a future near-peer/peer advisory conflict, where military nurses will be more likely to be required to provide care in austere or modified environments with limited and constrained resources. Training could be accomplished at the unit level as part of recurring readiness training. As healthcare professionals, we must be ready to adjust to the realities of caring for wounded service members without having a grace period of adapting to such an environment. Resilience and Moral Distress Resilience consists of “assets and resources within the individual, their life and environment”6 that promote a “capacity for adaptation and ‘bouncing back’ in the face of adversity.”6 Moral distress may be defined as the “experience of knowing the right thing to do while being in a situation in which it is nearly impossible to do it.”7 The high mortality of critically ill patients and crisis standards of care caused moral distress for AF nursing personnel throughout our time at LMC. This distress was somewhat eased by frank and open discussions that allowed team members to express feelings about their moral distress, the importance of the mission, and ethical and legal considerations caused by the pandemic conditions. The 64th AEG leadership also obtained increased military chaplain and mental health professional support during our deployment. The American Association of Critical Care Nurses has stated that healthcare personnel will experience an increase in moral challenges while providing patient care during a crisis response.8 In one study with civilian nurses working in high-stress acute care settings, researchers found that resilience did not independently prevent the experience of moral distress.9 However, moral distress was correlated with emotional exhaustion (r = 0.49; P < .01) and depersonalization (r = 0.42; P < .01), whereas resilience was negatively correlated with emotional exhaustion (r = −0.31; P < .01) and positively correlated with personal accomplishment (r = 0.59; P < .01).9 Finding ways to assist service members to develop a higher level of resilience and mitigate moral distress is necessary to maintain a fit and ready force in preparation for a response to future crises. Although the DoD and AF have made substantial efforts to increase service member resilience, there is limited published evidence that these efforts have been successful. The RAND Center for Military Health Policy Research assessed resilience programs in 2011 and found “generally very little rigorous research […] across the different resilience factors.”10 Across the reviewed programs, RAND found a lack of consistency in definitions of resilience, outcomes, and evaluation measures; they also reported that inadequate buy-in and logistical support from military leadership were barriers to program implementation.10 Subsequent literature reviews have identified a continued lack of resilience program evaluation or evidence for the efficacy of military resilience programs.11,12 Therefore, it is essential efforts continue to research and develop evidence-based and focused efforts to enhance resiliency into military nursing competencies. Continuous Training When we initially arrived at LMC, we found that several of the RNs on our team had not worked with acutely ill patients in some time. This was an understandable side effect of Reserve members seeking opportunities to grow into new areas of nursing practice, such as advanced practice, management, and education, as part of their civilian employment. Although these nurses were initially uncomfortable working with high-acuity COVID-19-positive patients, we needed to maximize our support for the Lincoln staff. To ensure their comfort with working critically ill patients with COVID-19, AF nurses were identified to serve as ICU and medical-surgical subject matter experts to provide these nurses just-in-time training and consultation, when needed, for caring for high-acuity patients with COVID-19. With the assistance of our subject matter experts, we found that these nurses were able to rapidly regain underutilized skills, and they eventually became subject matter experts who were able to train LMC RNs. As we continued to work in LMC units, the team’s Chief Nurse ensured all RNs and medical technicians had their comprehensive medical readiness tasks and required clinical competencies validated by the team’s subject matter experts. As the number of patients with COVID-19 declined, we sought additional opportunities for training. For example, we were able to provide American Heart Association–approved basic, advanced, and pediatric life support courses to recertify team members on days they were not staffing in units. As the hospital’s patient census decreased, a few of the nurses on our team were able to complete cross-training in the ICU or ED. The Reserve component will always need to seek a balance between filling open positions and ensuring individual reservists maintain a balance of clinical currency needed in the case of short-notice deployments. Reserve leaders can mitigate shortfalls of civilian clinical experience by working with their subordinates to engage in and evaluate the effectiveness of their training. Reserve Chief Nurses and nursing leaders should continue to seek opportunities to provide meaningful training to enhance their Airmen’s proficiency in their respective readiness skills requirements based upon their assigned AF Specialty Codes and Unit Training Codes. Finally, as Reserve nurses pursue less clinically involved positions in their civilian careers, Reserve nurse leaders must work to assist these personnel to remain clinically prepared and competent in their assigned military. CONCLUSION In this case study, the author has provided a report of AF Reserve nursing personnel deploying into a civilian hospital to bolster their capability to care for COVID-19-positive patients. These courageous citizen Airmen answered their nation’s call to deploy on short notice into an uncertain environment and accepted the risk of contracting SARS-CoV-2. Despite this risk, they succeeded in providing essential assistance at the height of SARS-CoV-2 infections in NYC to over 800 COVID-19-positive patients. The team also ensured the transfer of knowledge to LMC RNs who received focused training to help them be better prepared to provide effective nursing care for a future surge of COVID-19-positive patients. The team was also able to seek additional opportunities to enhance our own clinical skills to better prepare ourselves for future missions. Civilian healthcare leaders recognized the high value and quality of care provided by AF military healthcare personnel. After the USNS Comfort redeployed and the Javits Medical Station closed, AF, Army, and Navy medics/corpsmen supplemented patient care capacity at eight additional NYC public hospitals. During future surges of COVID-19 or another crisis, similar deployments are likely to provide the best outcomes for relief efforts. Furthermore, the successful short-notice deployment of a relatively large number of reservists demonstrated the value of the reserve component and can be used by military planners as a model to rapidly integrate reservists into future conflicts. ACKNOWLEDGMENTS The author would like to acknowledge the heroic efforts made by the team of Air Force Reservists who tirelessly worked to support COVID-19 relief efforts at Lincoln Medical Center and other New York public hospitals. The author would like to thank Ann Mattarella, MA, ELS, for her editorial assistance. DISCLAIMER The views expressed in this supplement do not necessarily represent the official policy or position of the TriService Nursing Research Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government. CONFLICT OF INTEREST STATEMENT The authors have no known conflicts of interest of financial or material support disclosures. REFERENCES 1. NYC Health : COVID-19: data . Available at https://www1.nyc.gov/site/doh/covid/covid-19-data.page; accessed November 10, 2020. 2. NYC Health and Hospitals : About Lincoln . Available at https://www.nychealthandhospitals.org/lincoln/about-lincoln-hospital/; accessed November 10, 2020. 3. Wadhera RK , Wadhera P, Gaba P, et al. : Variation in COVID-19 hospitalizations and deaths across New York City boroughs . JAMA 2020 ; 323 ( 21 ): 2192 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 4. 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Rocklein Kemplin K , Paun O, Godbee DC, Brandon JW: Resilience and suicide in special operations forces: state of the science via integrative review . J Spec Oper Med 2019 ; 19 ( 2 ): 57 – 66 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Author notes The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of the Air Force, Department of Defense, U.S. Government, or TriService Nursing Research Program. © The Association of Military Surgeons of the United States 2021. All rights reserved. For permissions, please e-mail: [email protected]. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)