As the Coronavirus pandemic continues to evolve, we've updated the content in this post to include the most recent resources and information. Read the latest: Facing COVID-19, Insights from Front-Line Healthcare Teams.
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. Local leaders are working tremendously hard to address these issues and are to be commended for their diligent efforts to develop new protocols. Our health system is learning as we go along, which adds to the stress and anxiety all of us in healthcare are feeling.
At Vituity, our leadership and front-line clinicians are responding quickly to this evolving threat. With over 100 emergency departments (EDs) on the West Coast, several of our teams have already cared for confirmed or suspected COVID-19 cases—including 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.
On March 4, I invited three of our ED medical directors from areas affected by COVID-19 to share best practices with Vituity clinicians across the country via a live webinar. While each hospital’s response was unique, the presenters highlighted several common themes. I believe this information may be helpful to healthcare leaders across the country.
Best Practices Quicklist
- Prepare before your first suspected COVID-19 case arrives.
- Centralize and coordinate communication – internally and with your public health department.
- Control patient flow into your hospital.
- Assess and treat non-emergent patients outside the hospital.
- Create spaces where contagious patients can be isolated or grouped
- Develop clear PPE recommendations.
- Manage supplies.
- Protect your workforce.
- Make smart workforce decisions
- Determine your approach to testing.
1. Prepare before your first suspected COVID-19 case arrives.
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 personal protection equipment (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?
2. Centralize and coordinate communication—internally and with your public health department.
All three medical directors stressed 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 are 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.
3. Control patient flow into your hospital.
In order 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.
4. 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 video conferencing while the patient remains outside the typical clinical care areas.
Two of our hospitals are preparing to see patients with URI symptoms in mobile hospital tents outside the ED. One is also exploring the possibility of creating a designated parking area near the ED where patients could be evaluated in their cars.
5. 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 just 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 are doing quick construction projects to convert units to negative pressure.
6. Develop clear PPE recommendations.
The CDC is currently recommending airborne and contact precautions. While this guidance is easy to understand, putting it into practice is complex. If this epidemic spreads locally, your facility likely does not have enough PPE and your staff will not have enough time to don and doff it for every single encounter with a URI patient. Here are some questions to guide your decision-making:
- Will you recommend reusing N95s?
- Will you recommend that initial screening occur with just a surgical mask and then convert to N95s for higher-risk patients?
- Will you recommend gown and face shields for all encounters, or only encounters that are higher risk, such as swabbing the nose for sample collection or administering albuterol?
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 what would trigger a change in future PPE recommendations.
7. 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.
8. 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 therefore important 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. Another said that only one clinician per shift (a volunteer) cares for suspected and confirmed COVID-19 patients to limit the team’s exposure.
9. Make smart workforce decisions.
It’s also important to have pragmatic work restriction guidelines. It is not sustainable to send asymptomatic staff home for 14 days due to a low-risk exposure with an unconfirmed case.
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 . . . in consultation with their occupational health program.”
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.
10. 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 on 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 be 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?
- 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 patients and notify them?
- How will you notify negative patients?
- 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.
Advanced planning is crucial
Preparing for a potentially deadly epidemic is always 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. The WHO reported that Chinese researchers seeking to enroll COVID-19 patients in medication trials are coming up short and inpatient bed occupancy is declining. And of course, respiratory epidemics like seasonal influenza, SARS, and MERS have historically faded as spring temperatures increase. So when it comes to COVID-19, let’s allow ourselves to hope for the best while planning for the worst.