Patients come in with fevers, coughing. Some develop acute respiratory distress syndrome, fluid in their lungs causing them to gasp for air. For many, ventilators are needed. Some can be saved, but others are lost to this mysterious illness. For Marie Beck-Dougherty, RN, a 22-year-old nurse supervisor of a respiratory unit, and her colleagues at Pennsylvania Hospital it’s something they’ve never seen before. It’s something no one has ever seen before.

It takes a year, but scientists eventually determine what it is: Legionnaire’s Disease.

“We got hit very hard,” Beck-Dougherty recalls now, almost 45 years later. “We didn’t know what it was, but this situation we’re dealing with now is very familiar to me. The lung conditions and pneumonias we saw then and the ones we see now in COVID patients are really similar in management.”

The Challenge Today

In facing COVID-19, clinicians at least have the benefit of knowing the identity of the enemy they face, but the unknowns — a lack of a cure, what the best treatment course is, how much worse things can get — are similar to those Beck-Dougherty encountered in 1976. Now a clinical nurse liaison for Good Shepherd Penn Partners, Beck-Dougherty was pulled back to the front lines of an emerging respiratory disease, albeit telephonically, when she was recruited for Penn Medicine’s COVID Hotline this year.

The hotline was designed to handle a major challenge of the outbreak facing the community at large — far beyond the population who needed to be admitted to the hospital, as in Beck-Dougherty’s earlier experience. The COVID hotline was active from mid-March until early June in order to take inquiries from all comers — patients, caregivers, concerned family members, even doctors and nurses — and direct them to the help they needed.

The initiative, like most responses to COVID-19 across the country, needed to come together quickly. The idea was to reassign nurses from their typical duties in specialties not hard-hit by the virus to answer phones out of two different locations, one in Center City Philadelphia and the other at Chester County Hospital. Before the outbreak, most members of the hotline teams didn’t know each other. Nurses were pulled from 36 different areas across four different hospitals, but in spite of that, there was an almost immediate fellowship.

“In a matter of days, I received a list of over 100 RNs from the chief nursing officers (CNOs) across the health system,” said Ann Huffenberger, DBA, RN, NEA-BC, director of the Center for Connected Care, a hub for many of Penn Medicine’s telemedicine efforts. “This was an across-the-board CNO-sponsored response and every Penn Medicine entity contributed to the enterprise RN workforce. The team-building was like nothing I’ve ever experienced before.”

Huffenberger chose Nancy Bonalumi, RN, to head the operation as interim nurse manager. The initial job offer came at 7 pm on a Wednesday, and by the next Monday, they were going live. It was a whirlwind, to say the least.

The Calls

Mary Louise Dempsey, RN, served as a supervisor on the hotline team alongside Beck-Dougherty at Chester County. She said “no call was the same.” At the beginning, almost all them came in from symptomatic patients looking for guidance. But as time went on, they got calls from people who were recovering and looking for next steps. They also heard from patients who needed help with anxiety resulting from the virus.

“I have a critical care background and this was like critical care at home,” said Dempsey, who already had telemedicine experience as the lead telehealth nurse at Connected Care. “You have to ask the right questions to take care of a patient that you can’t see. We had a process to make sure we were sending them the right way.”

That could include calling 911 for the patient if the answering nurse thought they needed it or scheduling an appointment for less critical needs with Penn Medicine OnDemand, the health system’s virtual visit service. The hotline team also responded to patients in the COVID Watch program recovering at home. If COVID Watch’s text message system flagged a patient’s condition as worsening overnight, they were called by a member of the hotline team.

“Some calls could be five minutes, some were 30,” Dempsey said. “Some patients called back multiple times. We even had some call back and ask for the specific person who answered the first time because they felt comfortable with them, especially at a time when people can be so alone.”

Beck-Dougherty recalled a patient who made sure to tell the answering nurse that he’d never felt so taken care of by a health system as he did by the hotline’s efforts.

Alleviating the System

Establishing the COVID Hotline, in conjunction with at-home monitoring services like COVID Watch, not only helped patients, but helped alleviate the potential strain on the entire health system created by the COVID outbreak. To maintain capacity in hospital facilities at the initial peak of the Philadelphia area’s outbreak, patients who didn’t need hospitalization were encouraged to call virtual services like Penn Medicine OnDemand, which conducted appointments over the phone or video chat.

That service increased its staff exponentially, taking five times as many daily calls as pre-outbreak peaks. Days before the hotline became operational at Chester County, calls to OnDemand peaked at 585 in one day.

“For OnDemand's virtual providers, the hotline’s nurses helped offload our patients’ understandable need for information and allowed OnDemand’s team of clinicians to focus in on those with symptoms,” said Krisda Chaiyachati, MD, the medical director of OnDemand and an assistant professor of Medicine. “We couldn't have gotten through the first few months of this pandemic without this invaluable team."

By the end of March, OnDemand call volume dropped into the 100 range, a much more manageable load.

During its operation, the hotline team handled almost 20,000 calls. There was a peak of nearly 400 calls on March 23, the day after the Chester County site was opened, and the team regularly handled well over 300 calls daily.

A Return?

The hotline was wound down at the start of June as the initial wave of new COVID-19 hospitalizations and cases began to wane. Patients who have questions can now easily access answers via a chatbot symptom checker, the FAQ posted to the health system’s site, or Penn Medicine OnDemand.

But if a larger response is needed again in the future, the hotline team feels confident they can apply the lessons they learned this spring.

“I'm confident that if a second wave of patients occurs related to the pandemic, this team stands ready for the challenge,” said Bonalumi. “We developed a highly skilled and agile RN workforce. As the nurse leaders of this effort, Ann Huffenberger and I have gained insights and experiences that will guide us should the need to scale up again occur.” 

And for both nurses and patients, knowledge of how to face this disease is reassuring.

“I think that for a lot of people, there was a fear of the unknown, just like back when I started with Legionnaire’s,” Beck-Dougherty. “But I think our responsiveness to the callers really provided better information to them. We have educated them, and I think that helped a lot of people rest a lot easier.