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Melanie Cole, MS (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And please join us as we discuss the ongoing impact of COVID-19 in ambulatory care settings. Joining me in this panel is Jennifer Rosales, Antoinette Shedlarski and Alyse Hicks. They're all registered nurses at UAB Medicine. Ladies, I'm so glad to have you with us today. As I was telling you a little bit about this off the air, you all have been the backbone of everything in the last few years and beyond. And so I would like this to really be your chance to shine. Jennifer, I'd like to start with you. Tell us a little bit about the role of nurses in primary care clinic.

Jennifer Rosales, RN (Guest): Hi, Melanie, thank you for having us on today. So our job title is care transition nurse, and we are responsible for the provision and management of our adult patients in primary care. We utilize the nursing process, of course of assessment, nursing diagnosis, planning, implementation, and evaluation while providing care to our patients. We are responsible for accurately and efficiently triaging telephone calls and portal messages that we receive from patients, their significant others, other healthcare team members, such as home health agencies, and then we have to prioritize our patients' needs based on their urgency. A great care transition nurse has to have excellent communication skills, be very well organized and know where to locate important information in the patient's chart.

Triaging patients can be challenging, however, because we can't perform a visual assessment. So to evaluate the patient properly, we need to know which questions to ask. And then once we sort through the information that we collect and determine the appropriate disposition for each patient, whether we schedule an in-office visit, Telehealth video visit, or if they're having an emergency symptoms, of course, send them to the ER and we advise and educate patients and make safe, effective decisions under direction of the patient's physician.

Host: Well, it certainly has been a comprehensive role. And Annie, how did COVID impact nursing in the ambulatory primary care clinic? Tell us a little bit about what was going on in your minds, in the clinic. What was it like for you all?

Antoinette Shedlarski, RN (Guest): A start by saying nursing's always been a very, very dynamic profession. Nurses are excellent at problem solving. We do a great job of assessment and we try to you know, find a solution right away. With the COVID pandemic, we were faced with a rapid skyrocketing increase in demand for our services. Patients wanting to come in and receive treatment. And yet our supply of providers did not grow with that demand. So we had to become very, very proficient and very expert on managing these patients and finding a way for them to receive the care that they really needed at the same time not sending them into our emergency rooms, and our urgent care clinics. And as nurses, we do, we analyze everything. So if we've done a lot of graphics and we've created a lot of different improved workflows. We found different strategies to decompress this, you know, onslaught of demand.

I would like to hear a little bit from Jennifer and Alyse because we work as a team. So I thought maybe they might have something they want to add to that.

Jennifer: Yes. I would like to add so the COVID pandemic, it definitely changed how patient care was delivered in the ambulatory clinics. Anyone who called in with any kind of COVID symptoms, they were automatically scheduled as a Tele-health video visit. many of our inpatient visits, they were converted to Telehealth as well to decrease the risk of transmitting the virus to patients and healthcare workers within our clinics and patients were screened at the front entrance for symptoms and recent exposure. We also required face masks coverings, and then we also implemented as visitor restrictions and cutting down on the amount of people that were in the clinic and then instituting more rigorous use of our personal protective equipment when in contact with our patients. And then we also, you know, as nurses we had to bridge the gap between our patients and providers and many patients wrote in inquiring about COVID, you know, how long to quarantine, where can they get tested? So we provided that information to the patients as long as like where to get COVID vaccines and then treatment options to cut down on the amount of messages that our providers were receiving.

Alyse: And I will also like to mention to what Jennifer just said. Our nurse practitioners were very accommodating in their schedules. I know in their schedules where they were flexible and seeing patients through Telehealth and also as our role, we made sure that anybody that could manage their symptoms at home, that we provided that education to, to manage at home at the end, those cases that were a little bit more severe, we either directed them to the emergency room if they absolutely needed that emergent care, or we were able to schedule them with, with a nurse practitioner. So the nurse practitioners were very accommodating and they worked very hard in, in making sure that patients were seen in a timely manner.

Host: Well, Alyse, I'd like to speak about how you all adapted just a bit. We've mentioned a few process changes that were implemented in the clinic to manage the surges. And as we've been saying, the pandemic really encouraged healthcare systems to be more creative and innovative in their ability to deliver essential care whether it was for COVID or non COVID. Tell us a little bit about what that adaptation was like, because as Annie said, this is a dynamic profession that you're in. So how did it all come cohesively together?

Alyse: Well, I would say first and foremost, communication. Annie being our supervisor, was really great at bringing us together, providing us the information that we needed especially with other referring clinics as well when it came to caring for COVID patients. So communication was definitely key and the priority. And once we got that communication, we as the care transition nurses just talked amongst ourselves as far as making sure that patients were seen via Telehealth, also communicating with the the medical assistants that work directly with the providers, making sure you know, which patients can come into the office, which was needed a Tele-health and just kind of how to manipulate some of the provider's schedule as well. So communication was key. And Jennifer touched on this earlier, as far as triaging patients based on the severity of the COVID case and all hands were on deck with our patient portal because we have seen such an influx of portal messages during the surge and as well as, as education providing that education was a big implementation, cause a lot of our patients, if we provided that information to them, as far as managing symptoms at home or, or how to be treated or, or where to go for the monoclonal antibody infusion, that also gave them a little bit more confidence and trust in us to care for them. So I think all of those changes that were implemented just helped us adapt it well to the surges.

Host: Jennifer, do you still have COVID patients and how are you keeping them separate? What's going on right now? And how are you pre-planning for future surges?

Jennifer: Right now we don't have as many COVID patients. There is one that tests positive. We do still schedule them as a Tele-health video visit. And then, you know, the provider can call in new medication for them. And then, you know, if they, if their symptoms don't improve, they reach back out to us. And then we do further workup. You know, there is going to come a time where we won't have the restrictions. Once we get back out. You know, it'll be like a regular flu season. So we're still trying to work through how we're going to manage those patients. You know, still requiring them to have a mask, getting them in and out of the building, you know, as quickly as possible and not have them, you know, lingering around.

Annie: I would like to just add to that UABs response to the COVID pandemic has been phenomenal. The University of Alabama has just developed COVID clinics. Post COVID clinics, long COVID clinics, Infusion centers. I mean, the resources were absolutely mobilized and put together to manage each phase of the pandemic because the pandemic did have many phases, you know, in the beginning we just didn't know how to respond to those patients.

And our infectious disease team was right, right on it. I mean, they started immediately trying to come up with treatments, putting together protocols. And as we got more knowledge, we realized what treatments were working with COVID. UAB, absolutely you know, changed and grew and adapted everyone of those support systems.

So we had those resources at our finger tips to take care of those patients. And we're still doing. UAB is still continuing to research on COVID. We're still continuing to you know, fine tune our protocols and our treatment plans. They've been, it's been a phenomenal.

Host: I imagine it has, as UAB is an incredible medical center. And I know this because I host their podcasts and Annie sticking with you for a second, tell us, are you still going to be using those Televisits? Is the portal still as busy? Are you going to continue to use some of the things that we've learned going forward in the future? Because they've shown to be pretty efficient.

Annie: Absolutely. Not only are we going to continue to use those protocols and new practices, but we're going to continue to fine tune them and make them even more efficient so we can reach the greatest percentage of our population because access to care in Alabama has always been a challenge and it continues to be a challenge. The demand for our services is so far in excess of the supply that we have to think of very, very efficient and proficient way to treat these patients. We're going to continue with Tele-health, although I don't think it will continue to be as large as a percentage of our care as we did during the pandemic, but we're definitely going, it is, it is here to stay.

It is part of our everyday life here and UAB, which is always ahead of everybody in Alabama, is already putting together, our e-medicine coordinating centers, which deal strictly with Telehealth and remote patient monitoring, which also helps us. So patients who have long COVID, those patients who continue to have symptoms after the initial phase of the disease, they are now being managed in our remote patient monitoring system.

So we're, we're still providing ongoing care. We will continue to do that. And we will continue to come up with new therapies and new treatments and new protocols.

Host: And you could just go ahead and say it ,because it is really across the country, UAB is truly leading the pack and I'd like to give you each a chance for a final thought. And I love that point, Annie, that you made about rural areas and Telemedicine and long COVID that it's really a great way to get specialists and visits through that way. So, Alyse, how do you feel nursing will change to help your providers meet the increasing demand for services? Where do you see nursing going in the future?

Alyse: That's a great question. I think our nurses will continue to be advocates for their patients as far as making sure they receive the best care possible. I think also too, the doctors will of course continued to do Tele-health medicine, just so everybody does have access to some type of healthcare. So I hope that nursing will continue to be the best profession. And then we'll just all work together, no matter what type of unprecedented challenge comes our way.

Host: Well, you have all faced it so bravely. And so my next question, Jennifer, how are you all, how have you been, how have you been holding up, making it through day to day? Families, kids, very sick people. You literally all I'll get choked up even when I say this, you literally all saved the country. You're the very foundation of medicine. How did you, how did you hold up how are you all now..

Jennifer: Right. We are all hanging in there. I mean, there were many nights that, you know, we stayed late, I'm waiting to hear back from the providers, you know, about what a patient should do. And you know, I would always tell patients, you know, I'll follow up with you today. And so, I mean, sometimes it meant staying, you know, 30 minutes or an hour afterwards, just to, you know, hear back from the doctor or talk to the physician and then talk tell the patient and answer and, you know, relieve some of that stress of just worrying, you know, wait until the next day for a phone call.

We are, you know, closer to our patients and primary care, and some of them have been patients with us for many years. And so, you know, you go through so much with them and you just want the best outcomes for them. So, another thing I will say is it's important for self-care and take in time. To realize that there is a work-life balance, spend time with our families exercise, eating, healthy balanced meals, and taking breaks frequently. That all helps as well.

Host: It sure does and Annie, last word to you. What would you like to tell other providers, around the country, about the job that nurses do and the ongoing impact of COVID-19 in the ambulatory care setting?

Annie: Nurses have been foundational during this pandemic in my opinion. Okay. And nurses have always used application knowledge to provide the best care to our patients. We've always been a resource to other members of the team. We are proficient at protocols and practices and nurses have always been resilient.

We've always adapted very quickly to change. And at UAB, we get to function at the very top of our scope of practice and UAB encourages us to grow our knowledge base and our skills. And and in return, UAB relies on us to provide the very best care we can to our patients and to our team because we, we not only support our patients, we sorta, we also support our physicians.

Okay. We partner with them. We are very close in working with them. We, we see what's going on with them as well. I'm going to say that as a nurse, if a nurse is looking for a job that, you know, you want a job that grows with you, UAB is the place to be. It is dynamic. Our, our roles change, our skills change. And we have a say in that, and it's, it's a great place. It is a great place to work. All right. And, and we, we really provide excellent care. And these nurses who you've been listening to on this Med Cast, they are very humble. But they, you really need to know that they all function at the very, very top of their scope.

They have a great knowledge base and they keep themselves abreast on what's new and trending. So it's it's just a great team.

Host: Bless your hearts, all of you. And thank you so much for everything that you've done throughout the, the profession that you're in and certainly for the last two years, just really you are the heroes that everybody's been talking about. And thank you again for joining us on the Med Cast today. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or by visiting our website ay uabmedicine.org/physician.

This concludes this episode of UAB Med Cast. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole.