More EMERGING HOSPITAL PRACTICES in Response to COVID-19

The worldwide hospital response to COVID-19 is incredible. During this intense time, some of GE's clients have been sharing their front-line practices. This enables each organization to easily gather new ideas and cross-reference their own plans. We’ve captured a few of those practices below. These were collected 5 Mar 2020 – 12 March 2020 from hospitals around the world. The situation is obviously fluid so these are not proven or best practices, but they are real.

 SCREENING

1. Two tents with infrared cameras in place to scan each patient to determine if they are febrile. If yes, they send to one tent. If not, they send to the other. 
2. Created temporary ED assessment pods outside the ED. Clearly marked signs in the parking lot and entrance area dictate flow for patients who believe they are symptomatic to keep them out of ED and move them to a pod. In the pod, patients are screened by MD in protective equipment. Pod “appointments” can also be organized through health department.
3. Working with other area providers and local health department to encourage the public (through news, social media, etc.) to call a hotline and be tested at home to avoid ED visit.

PPE

1. Empowering staff to stop/coach others when PPE is not donned properly; and to escalate to manager. Major focus on accountability.
2. Reinforcing that N-95s can be used up to 5 times under normal circumstances; and should only be used for airborne isolation. Holding everyone accountable (including physicians).
3. Focus on accountability to normal infection control practices.
4. Stockpiling PPE in Command Center conference room with controlled sign-out by CC Staff.
5. Pre-fitting all staff for PPE.
6. Masks pulled from public areas due to disappearing stock.

CONTROLLING Hospital or ED ACCESS 

1. Limiting patient and visitor access to only a few hospital entrances.
2. Screening everyone at the door
3. Shortening or eliminating visiting hours.
4. Asking family and friends to wait outside the ED. Tents with benches have been set-up. Staff get family cell phone # to communicate information.
5. Inpatient staff not allowed to enter or traverse ED without specific reason.

BED MANAGEMENT

1. Adding a physical wall to sub-divide the ED waiting area.
2.  Identifying units to be converted to isolation with 50% effective capacity (when needed) by dedicating every other room to donning and doffing PPE.
3. Reserving units for patients under investigation (PUI).
4. Freeing beds to hold for COVID-19.  Using hospital simulation model (HoF) to test options for where to decant existing patients.
5. Creating ED isolation area with 1:1 RN ratio.
6. Repurposed Gen Med ward (all private rooms) for PUI patients.
7. Rapidly refurbishing an old ICU into a functioning ICU.
8. Swapped a senior care ward (all private rooms) with a respiratory ward (fewer private rooms), so the respiratory ward has majority of private rooms.
9. Cohorting CV19 patients on one campus when possible. Cohorting known COVID19 cases together at a certain facility, or within a unit at each facility when transfer is not possible. Published new guidelines for when it is and is not appropriate to transfer a CV-19 patient.
10. Retrofitting “regular” rooms to negative pressure. One member has converted 96 rooms to NP.

PROMPT CHARTING. Emphasis on proper and prompt charting when COVID-19 has been ruled-out. (So patient can be moved out of isolation. Risk is the decision is made but not charted so the resource is held up)

TRAINING. New emphasis in these areas:

1. Nurse educators retraining when and when not to wear mask; when and when not to mask patient; when and when not to re-use mask.
2. Video training on how to properly don and doff PPE.
3. Retraining EVS staff on proper room clean procedures.

PROTOCOL SHARING. Members have shared protocols for:

1. Safe transfer of highly infectious patients
2. Decision to move PUIs between hospitals
3. ED clinical guidance for PUIs

PLANNING 

1. Bed / Volume, scenario being done with HoF Digital Twin: Assume we convert UnitX to dedicated COVID-19 unit, AND medicine volume grows 5%, 7%, or 10% where do we place the overflow medicine patients? Options: convert Peds Unit to Adult Medicine; increase ICU staffing; shift 6 surgery beds to medicine? What is the realistic yield of doubling down on discharges? At what point must we stop surgeries? 
2. What would it take to retrofit an old closed unit into an ICU?
3. How would we handle dialysis volume if third party outpatient clinics close?
4. How to run the hospital with 20% less staff if schools close? 

HUDDLES.

1. Cancelled in person daily bed huddle. Moved to virtual, added COVID-19 to agenda and expanded attendees to charge nurses, program directors and managers.
2. Implemented social distancing at Operations Meeting. Staff seated every other chair.
3. Added daily system-level huddle. By phone. 4:30pm. 7 days.
4. Hospital-level daily huddle extended from 15 minutes to 30 minutes to include COVID-19 dashboard (link), focus on negative pressure beds, and prep for possible 20% reduction in staff if schools proactively close etc.

LAPTOPS. Spinning up more laptops to enable more non-clinical staff to work remotely