Vituity

Together we will get through this. Facing COVID-19 on the front lines.


Facing COVID-19, Insights from Front-Line Healthcare Teams

A Coronavirus Checklist for Providers

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Latest Updates (March 20, 2020)

  • The CDC updated its recommendations around personal protective equipment (PPE), which may help hospitals conserve these critical resources.
  • The CDC also updated its recommendations around work restrictions and return to work guidelines for infected healthcare workers. In a nutshell, asymptomatic clinicians can continue to work after an exposure, while monitoring symptoms and wearing a facemask for 14 days. Infected clinicians can return to work 3 days after their symptoms have improved plus two negative COVID-19 tests or plus 7 days have passed from when the symptoms first appeared. Stringent work restriction guidelines could compromise patient care as the epidemic ramps up, so it’s important to keep as many clinicians active in the workforce as possible.
  • Some hospitals are moving to limit visitors except for pediatric and end-of-life patients.
  • Protecting the health of your workforce will be crucial during the difficult weeks ahead. Consider reducing hours now while patient volumes are relatively low. To promote social distancing, shift hospital staff meetings to video conferencing and postpone nonessential work travel. If your PPE supply permits, consider allowing all staff to wear surgical masks when interacting with any patient, given the possibility of asymptomatic infected patients.

Best Practices Quicklist

  1. Prepare for an influx of potential COVID-19 patients.
  2. Centralize and coordinate communication – internally and with your public health department.
  3. Control patient flow into your hospital.
  4. Assess and treat non-emergent patients outside the hospital.
  5. Create spaces where contagious patients can be isolated or grouped
  6. Develop clear PPE recommendations (and update them as recommendations evolve).
  7. Manage supplies.
  8. Protect your workforce.
  9. Make smart workforce decisions
  10. Determine your approach to testing.

From Dr. Gregg Miller (Chief Medical Officer, Vituity)

As the number of COVID-19 cases diagnosed in the United States continues to rise, hospitals are preparing to manage potential surges of contagious patients. Preparation has been challenged by rapidly changing guidelines, inconsistent directives, and a lack of testing capability. Many areas around the country are also raising concerns about resources, including a lack of PPE, ICU beds, and ventilators.

Our health system is learning as we go along, which adds to the stress and anxiety all of us in healthcare are feeling. However, many of our local public health leaders are working tremendously hard to address these issues and are to be commended for their diligent efforts to develop new protocols.

At Vituity, our leadership and front-line clinicians are responding quickly to this evolving threat. Our teams are already caring for confirmed or suspected COVID-19 cases—including at the hospital where I practice outside Seattle. We are actively developing protocols for managing the disease while minimizing impact on hospital staff and patients. In addition to providing excellent clinical care, we have focused our efforts on infection control, conserving workforce resources and supplies, educating our teams, and coordinating with public health authorities.

As the epidemic unfolds, I will continue to update this post with the latest guidelines and best practices from public health authorities and our Vituity teams across the country. While each hospital’s response will be unique, our front-line providers have already stressed several common themes. I believe this information may be helpful to healthcare leaders who are preparing their hospitals to care for a surge of patients.

Prepare for an influx of potential COVID-19 patients.

How should clinicians and staff respond when a patient with upper respiratory infection (URI) symptoms presents to the ED? What if an inpatient shows signs of COVID-19?

Isolation protocols, surge plans, and guidelines for staff PPE need to be clearly communicated. Having solid plans in place will help your teams to recognize potential red flags and respond quickly and effectively. If possible, test your systems using actors who portray patients with coronavirus symptoms or high-risk histories.

But it’s not enough just to be prepared for your first COVID-19 patient. You need to be prepared for your first dozen potential COVID-19 patients when they present for care over the span of a few hours. What is your Plan B once your Plan A is overwhelmed with volume?

Centralize and coordinate communication—internally and with your public health department.

Our medical directors on the front lines stress the importance of communication between the hospital leadership, the medical staff, and the local public health authorities. Because guidance about the epidemic changes rapidly, it’s helpful to designate a specific individual from leadership to act as your hospital’s interface between the bedside provider and public health authorities.

This is particularly important because public health guidelines around COVID-19 are changing rapidly, and each community is taking a slightly different approach to testing procedures, work exclusion, and self-quarantine. In addition, test kits remain in short supply in many areas. Your administrator point person should establish regular contact with the county public health department to monitor the emerging situation.

For example, at one hospital in Sacramento, CA, the director of quality tracks the latest developments, curates an online information library for medical staff, and holds twice-daily conference calls to update stakeholders.

Control patient flow into your hospital.

To provide proper infection control, it’s important to screen each person who enters your hospital. To do this effectively, you may need to reduce the number of access points. Have a screener outside each door who can identify high-risk patients and initiate infection control procedures. Screeners should wear appropriate PPE and have supplies for patients. My hospital outside Seattle is asking all visitors to wear an “I’ve been screened” sticker.

In addition, some hospitals are now limiting visitors, except for pediatric and end-of-life patients.

When possible, assess and treat non-emergent patients outside the hospital.

EMTALA requires an in-person evaluation for every patient who presents for care. However, that evaluation need not happen inside the ED. Clinicians can perform parts of the clinical encounter by phone or videoconferencing while the patient remains outside the typical clinical care areas.

Several of our hospitals are now directing patients with URI symptoms in mobile hospital tents outside the ED or creating designated drive-up areas where they can be evaluated in their vehicles. This greatly reduces the chance of spread to other ED and hospital patients.

It’s possible that EMTALA requirement may relax in the face of the pandemic, allowing us to treat ED patients with suspected COVID-19 entirely via telemedicine. For now, consider using telemedicine to reduce contact once the patient has been isolated and examined in person.

While HIPAA-compliant methods are always best, CMS has relaxed HIPAA requirements for telehealth platforms, meaning FaceTime or other consumer systems can be used. Telemedicine also allows you to utilize providers while they are on work restriction and can’t see patients face-to-face.

Create spaces where contagious patients can be isolated (or if necessary, grouped).

Suspected COVID-19 patients who require further medical care and evaluation should be placed immediately in negative pressure rooms per CDC recommendations. But of course, each hospital only has so many. Now is the time to free up as many isolation rooms as possible and stock them with dedicated and disposable equipment. I personally donated my stethoscope to our negative pressure room after examining my first suspected COVID-19 patient.

It’s also important to consider what will happen if you run out of negative pressure rooms. One option is to group a cohort of patients with confirmed COVID-19 in a dedicated clinical space or external tent. You can also create a designated URI waiting room that’s separate from your regular ED waiting room. Several hospitals in the Seattle area have completed quick construction projects to convert units to negative pressure. One hospital in Edmonds, WA, created a negative pressure area in its waiting room, which also acts as a screening station for patients entering the department.

Develop clear PPE recommendations.

The CDC is currently recommending airborne and contact precautions. Guidelines have changed as the epidemic has evolved and are likely to continue to change, given potential shortages of PPE.

The CDC previously recommended wearing gowns, gloves, and N-95 masks (which the website refers to as “respirators”) during all patient encounters where COVID-19 is suspected. Evidence from past epidemics (MERS and SARS) suggests that wearing a surgical mask, gloves, and gown may be equally effective for most patient encounters. However, an N-95 mask should always be used for all aerosolizing procedures (nebulization, oral-pharyngeal swabbing, intubation, etc.).

Realize that whatever you decide now will change later if the epidemic spreads in your community and as your PPE supplies dwindle. When you develop your guidelines, plan one step ahead and be clear about what would trigger a change in future PPE recommendations.

Manage supplies.

Several of our practices reported that their hospitals were locking up and rationing supplies such as surgical masks, hand sanitizer, and PPE. In one case, this became necessary when staff started taking supplies home for personal use. Given the global shortage of PPE, it’s important to monitor your hospital’s inventory and supply chain and use this data to guide policy. For example, it may make sense for healthcare workers on inpatient floors to wear powered air-purifying respirators (PAPRs) and other reusable PPE. See the CDC’s strategies for optimizing the use of eye protection, isolation gowns, face masks, and N-95 respirators.

Protect your workforce.

China’s experience shows that a respiratory epidemic can quickly create dangerous clinician shortages. Your hospital will not be able to function if too many of your doctors, advanced providers, nurses, and ancillary staff are ill or home on work restriction after a suspected exposure. It’s critical to ensure that everyone with patient contact follows infection control procedures, including wearing appropriate PPE. One medical director shared that his ED stations a “sitter” at each isolation room to check clinicians for PPE compliance before entering.

It’s also important to promote social distancing among your hospital personnel. Administrators and clinical leaders can encourage this by shifting staff meetings to videoconferencing and canceling nonessential work travel.

As of this writing, many hospitals are reporting a slight decrease in ED volumes. This could represent an opportunity to send your providers home early and allow them to rest up before the hard days ahead.

Make smart workforce decisions.

It’s also important to establish pragmatic work restriction guidelines. The CDC initially recommended quite aggressive work restrictions for staff with potential exposures. For example, they advised 14 days of work restriction for staff who were only wearing surgical masks and no eye protection who interacted with a masked COVID-19 patient.

This guidance is changing, with the CDC stating as of March 7: “Facilities could consider allowing asymptomatic HCP who have had an exposure to a COVID-19 patient to continue to work after . . . consultation with their occupational health program.” This recommendation has since been adopted by the state of California, which encourages exposed but asymptomatic providers to continue working while wearing surgical masks. Work restriction is always appropriate for providers who are symptomatic or have had a high-risk exposure (for example, were unprotected during an aerosolizing procedure).

The exact protocol for work restriction will vary by case and by hospital. Develop a clear approach that can be easily communicated to staff. As the epidemic spreads, also consider a check-in process where staff prior to each shift can confirm they aren’t suffering from respiratory symptoms and receive an “I’ve been screened” sticker.

As testing becomes more readily available, the use of serial testing for healthcare providers could reduce the uncertainty around work restrictions.

Determine your approach to testing.

As testing capabilities expand, your facility will be challenged with multiple issues. In the initial phase, departments of health have been helping decide which patients to test, facilitating specimen transport and testing, and following up confirmed cases. While the bottleneck has been frustrating, it has supported a relatively clear testing and follow-up process.

As test kits become more available and patient demand for testing climbs, you will face a new set of challenges. It is unlikely your department of health will able to keep up with the demand. At this point, workflows might more closely resemble your current influenza or sexually transmitted disease testing workflow, where the burden falls more on the hospital or clinic.
This will prompt several new questions:

  • What recommendations do you have for clinicians to guide their decisions to test?
  • At what point would you recommend testing for COVID-19 as liberally as flu testing is performed?
  • Should patients be tested for both flu and COVID-19? (While there’s little research on the subject, case reports suggest coinfection is possible.)
  • How will you transport specimens to your closest lab facility?
  • Given that the specimens are a send-out test, how will it be reported back into your EHR?
  • How will you track positive tests and notify patients?
  • How will you notify patients with negative tests?
  • Will you track and work-restrict staff who were potentially involved in cases with positive tests?

While expanded testing capacity is sorely needed, managing these logistics will be challenging.

Conclusion

Preparing for a pandemic is an emotional and financial burden. But we know how to manage respiratory epidemics; we do it every winter. We just dealt with a flu epidemic that sickened more than 30 million Americans and killed 18,000, and we will make it through COVID-19 as well.

Advanced planning is crucial, and there’s reason for hope. After a tragic start, the epidemic in China is showing signs of winding down. It appears that infection control measures have been effective at slowing the spread of the disease in population centers like Shanghai and Beijing. So when it comes to COVID-19, let’s allow ourselves to hope for the best while planning for the worst.