KIRKLAND — A walk through EvergreenHealth’s new brightly lit intensive care unit is calm and quiet, though a flurry of tasks keeps the medical team busy. Some nurses swiftly and expertly pull on respirators and yellow gowns before slipping into rooms with COVID-19 patients, while others have their eyes glued to computer screens monitoring patient activity. Therapists and environmental technicians move in and out of rooms, going through daily check-in or cleaning routines.

The new ICU opened its doors in July, after more than a year of caring for the hospital’s sickest and earliest pandemic patients.

“It was like moving into a new house,” said Merry van Zoeren, a nurse manager in the ICU.

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The 22,000-square-foot facility is spacious, nearly twice the size of the former unit, with nature scenes mounted on the walls, large glass doors and warm wood paneling. But the most significant differences from the past 20 months lie beneath the surface — in the hospital workers who have learned to adapt to new procedures and reevaluate personal priorities in the workplace, all while struggling to find resilience throughout a pandemic.

Changes, big and small, have swept through the suburban Kirkland hospital since it became the center of the nation’s first major identified COVID outbreak in February 2020. In many ways, the virus has pushed medical technology and patient care forward, but the thousands of deaths and pandemic tragedies have stayed with Evergreen staffers, changing the way many are thinking about the industry’s future and their role in it. 

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When the first few coronavirus infections were identified in Evergreen patients in late February, there were no protocols for caring for patients sick with the virus, said Dr. Sharukh Lokhandwala, Evergreen’s medical director of critical care. Most patients then were older residents at nearby nursing home, Life Care Center of Kirkland.

“It was a uniquely challenging time,” Lokhandwala said. “Early on, we were the only hospital that had a large number of people with COVID-19. … We had to pull ourselves up by our bootstraps, and really figure out how to make things work in the hospital.”

Surgeries were canceled. Doors closed to visitors. The hospital set up a drive-thru testing site for its employees and converted part of its eighth floor into a COVID ward. Employees quickly grew familiar with respirators, masks and other personal protective equipment.

Less than two weeks after the hospital confirmed its first patient case of coronavirus, more than 60 additional patients tested positive. Fifteen died.

Since then, those numbers have swelled to 6,030 infections and 157 deaths, plus one hospital employee death. Statewide, more than 670,000 cases and 9,000 deaths have been confirmed as of this week.

“We didn’t have a rule book in March of 2020,” said Mary Shepler, Evergreen’s chief nursing officer. “In some ways, that continues.”

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“New best practices”

Plans for a new ICU had long been in place at Evergreen, but the rapid spread of the virus emphasized the need for certain features, according to hospital leaders.

And months of treating COVID patients is shaping the way staff will care for future patients, including preventing pressure injuries in hospital settings and enhancing guidelines for other respiratory illnesses.

“What we learned in COVID will cover us for many types of patients,” Shepler said. “Out of something like this comes a lot of new best practices.”

The entire floor has switched into “pandemic mode,” van Zoeren said on recent weekday.

The 20-bed ICU has two airway carts — carrying the tools needed to quickly intubate a patient struggling to breathe — bigger rooms to accommodate families, and a unit-wide negative air flow system, drawing air flow into patients’ rooms and preventing spread of pathogens outside, van Zoeren said.

The previous ICU only had four rooms that could accommodate negative air flow.

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Remdesivir, an injection of antiviral medication often used for COVID treatment, is now considered a standard treatment for Evergreen’s ICU patients, along with immunosuppressive drug tocilizumab or anti-inflammatory drug baricitinib.

In addition to goggles and N95 respirator masks, nurses and technicians have also become comfortable pulling on air filtration devices called Controlled Air-Purifying Respirators and Powered Air-Purifying Respirators before entering patient rooms.

When cleaning rooms, technicians wipe down every surface — then wheel in an ultraviolet light disinfection tower which emits purple-pink beams that break up bacteria. Evergreen had just a handful of these devices for the entire hospital before the pandemic started. Now there’s one, donated this year, that lives in the ICU.

Most of the equipment existed pre-COVID but wasn’t in frequent use, Shepler said. Over the past 20 months, using these tools has become second-nature for hospital employees.

“We’ve always known how to use PPE and masking,” Shepler said. “This is on steroids.”

Facility executives, medical directors and ICU doctors throughout the Puget Sound area also now regularly swap numbers on patient flow and hospital occupancy, Lokhandwala said.

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“We’ve been tracking [data] independently of state numbers since it gives more information at a granular level for us,” he said. “It’s sometimes hard to tease out what’s happening on a state level.”

Lokhandwala continued, “We’re all in this together.”

Support for caretakers

Other industry changes are more slow-moving — particularly those surrounding worker support, according to hospital staffers throughout the state.

“In the beginning of the pandemic, we were actually overstaffed because people were like, ‘How can I help? What can I do?’” said Christy Fox, a nurse in Evergreen’s emergency department. “We didn’t know what it was going to look like.”

In recent months, Fox said, she’s noticed more holes in staffing schedules, meaning many workers are less likely to pick up open shifts.

“People are just tired,” she said.

Meanwhile, the state’s onslaught of COVID hospitalizations and deaths continues — and handling them hasn’t really gotten easier, Fox said.

“There are still moments where you know you’ve done everything you can for a patient and it’s not going to be the outcome that anybody hopes for,” she said, pausing to wipe away a tear. “And they’re alone. You’re the only person, maybe, that can give them physical touch because their family can’t be there.”

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Nick Rucker, an Evergreen ICU nurse, said he decided to start working part time last September after months of COVID fatigue caught up to him. He was then working at Virginia Mason Franciscan Health in Seattle.

Before the pandemic, Rucker said, a handful of ICU staffers would often move patients with acute respiratory distress syndrome on their stomachs to help them breathe, a labor-intensive practice called proning. It’s manageable when there’s just a few patients who need to be proned per day, Rucker said.

“When that number goes up to your entire unit and then you have overflow, there’s no way anybody can anticipate that,” he said. “There’s just no way.”

His wife, a pediatric nurse at Swedish, also cut back on hours due to burnout.

“We’re leaving a lot of money on the table, but our quality of life is so much better,” Rucker said.

Evergreen and some other hospitals throughout the state have implemented mindfulness programs to try and limit worker burnout, including a Code Lavender initiative, which provides employees with “emotional first aid,” said Shepler, the hospital’s chief nursing officer.

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The hospital also started offering Schwartz Rounds, quarterly town halls encouraging caregivers to share experiences and feelings from challenging moments at work. And there’s new spaces for “Zen dens” — rooms with music, art and soft lighting — if staffers need a brief reprieve.

Questions remain over whether it’ll all be enough. The state’s health care unions have long been pushing hospitals to do more for pandemic-worn employees, like offering retention bonuses and incentive pay or ending mandatory overtime policies. But many Washington hospitals, including Evergreen, have yet to offer their workers financial pandemic benefits.

“We’re still learning how to care for each other as far as resiliency,” Shepler said. 

She added, “There’s a bigger movement in the world about resilience and taking care of ourselves and perseverance. … We have to make it stick.”

Pushing forward

Evergreen’s ICU remains busy, though the state has passed the peak of the recent surge of delta infections, and cases and hospitalizations are on the decline.

Theresa Smith, an Evergreen ICU nurse, does her best to maintain a healthy work-life balance by spending time outdoors with her husband on her days off and making plans to go paddleboarding or hiking during the summer. It’s hard, however, to forget about the hospital’s continued high number of patients.

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Evergreen this week is caring for 21 COVID patients, nine of whom are in the ICU. Seven of those patients are not fully vaccinated.

Smith had a scheduled day off on a recent weekday, but because a co-worker called in sick, she volunteered to come in.

“We all just help out when and where we can,” said Smith, who’s been an ICU nurse for more than five years.

Workplace camaraderie and teamwork, as well as grateful patients, have largely carried staffers through the long months, said Fox, the emergency department nurse. But the early heartbreak and exhaustion that spilled into the Kirkland hospital more than 600 days ago still haunt its workers.

“I never ever thought that this would be what I would do in my life,” Fox said. “Hopefully we don’t ever have to do it again.”

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