The Ebola Response: Lessons and Changes October 22, 2014

The Ebola Response:Lessons and ChangesOctober 22, 2014

Topic Areas Emergency Department Personal Protective Equipment (PPE) Resource (Staffing and Equipment) Allocation

Emergency Department(Learnings as of October 22, 2014)

Emergency DepartmentLearnings as of October 22, 2014

Emergency Department(Learnings as of October 22, 2014)

Previous Travel Screening Questions • Travel questions were added several years ago to the screening section in response to SARS and the Avian flu. • These were only available in the ED.

Previous Placement in Navigator Previously the Screening section was in the Medication/History navigator within the Emergency Department section of the record.

Previous View on ED Track Board The Travel Screening answers were viewable on the ED Track Board Triage report.

Previous View on Triage Summary Report The Travel Screening answers were visible on the ED Summary report, which is viewable by all clinicians (Inpatient & ED)

Updated Emerging Disease Screening • A change went into the electronic health record early Monday morning, October 13, to address the screening and intervention needs for emerging diseases and in response to CDC guidance. • These changes affect all clinical areas where patients are admitted for care (point of first contact).

Screening Tool • All patients must be screened using this tool. • The tool will be at the top of the: • Inpatient navigators • Triage & Meds/Hx sections of the ED navigators • Physician Navigators • Radiant Tech Navigator Begin Exam and Tech Navigator End Exam

Screening Tool • If the answer to first question is ‘Yes’ then a box will open to document the primary country of travel. • If there is more than one country traveled to, document the highest risk country in the pick list and then put the other countries in the Comment box.

Screening Tool • Answering Yes to either the Travel to Ebola affected country or Arabian Peninsula adds additional questions. • Continue answering questions until the screen is completed.

Completing the Screen • If you need to stop the screen to get the patient in appropriate isolation then Cancel out of the screening and come back to it when the right safety measures have been taken.

Screening Tool • As the questions are answered there will be helpful alerts that appear at the bottom of the page and it will trigger a banner that is visible to all members of the Care team. • These alerts are based on CDC guidelines and on Infection Prevention recommendations for the potential infectious pathogens. • PLEASE NOTE THIS ALERT WILL CHANGE AS CDC GUIDELINES CHANGE.

Alert Banners • Alert banners will appear in many locations so it is visible to the entire Care Team: • ED Track Board • Handoff Navigator • Multiple Reports

Best Practice Alert • When the section is Closed, a BPA will appear. • When the Accept button is clicked, an Isolation order and a Referral to Infection Prevention are placed. • PLEASE NOTE THIS ALERT WILL CHANGE AS CDC GUIDELINES CHANGE.

Discharge/AVS Fail Safe Measure • If the screening is not completed then the Discharge/AVS instructions cannot be printed.

Personal Protective Equipment(Learnings as of October 22, 2014)

PPE – Lessons Learned(Learnings as of October 22, 2014) • The hospital developed a new screening and triage procedure to limit the exposure of staff and other patients. • The hospital has developed unique screening tool built into the EHR to identify patients at risk for serious infectious diseases based on symptoms, travel, and exposure. • The screening tool is being replicated in paper form in their clinics that are not on the electronic health record. • There is a clear process for a patient who is identified as at risk: anytime a patient is determined through screening or exposure to be at risk, the nurse dons PPE, gives patient a mask of they don’t already have one, and escorts them to a private location with a door and notifies infection control. For the dry patient, a gown, mask, gloves, and eye shield are the minimum PPE. The level of PPE escalates as the patient’s symptoms escalate. • The number of treating nurses and doctors is limited to reduce exposure. They are trained in the latest CDC procedure for donning and doffing PPE.

PPE – Lessons Learned(Learnings as of October 22, 2014) • Movement to an isolation room needs to be planned in advance, based on the layout of the ER/ED. • Hospitals with an open ER need to consider how to manage escorting the patient to a solitary room with a door. • Interaction with the patient is limited to one nurse in the room, in high-level PPE, one nurse outside the room to provide support, and one physician, in high level PPE including PAPR. • Rooms are set up so that waste remains in the patient room or outer room, which is not “clean.” Then doffing is done in the patient’s room, using the practiced CDC process, and the staff member steps into a second, clean space one step at a time as directed. Only paper garments are worn—no jewelry (or phones), and then the staff member immediate disrobes and showers. • For a “wet” patient—one with vomiting or diarrhea—a higher level of care is required, including frequent use of antibacterial wipes on any PAPR surface that is contaminated.

PPE – Lessons Learned (Learnings as of October 22, 2014) • When a patient is determined to have or possibly have Ebola, ED staff use high-level PPE (PAPRs) and patient is transferred to the Ebola ICU. • The route to the Ebola ICU limits exposure to others—freight elevators, tunnels, etc. • The Ebola ICU room is separated from other rooms, with negative pressure. The unit is sectioned into hot zone (the patient’s room) and a clean area. • ED and ICU staff (doctors and nurses) are now trained in high-level PPE (PAPRs) with procedures for tracking, repeat training, and training staff after return from leave. No staff can return to work without training. • The CDC trains the staff at the hospital who will be responsible for PPE training for hospital staff.

Resource (Staffing and Equipment) Allocation(Learnings as of October 22, 2014)

Staffing and Equipment Allocation(Learnings as of October 22, 2014) • Ebola patients require nurses with a Registered Nurse (RN) degree at much higher nurse to patient ratios. Typical Non Ebola Patient vs. Ebola Patient • 1:4 regular nurse to patient ratio • 3 or 4:1 very highly skilled nurse to Ebola patient ratio • Nurse with a RN degree perform all tasks with Ebola patients, with no reliance on housekeeping or other support services. • Staffing considerations: • Among the staffing issues that must be addressed by a hospital treating Ebola patients include overtime, PRN requirements and availability, and agency/contract nursing. • Volunteers are needed—the hospital did not require employees to work with Ebola patients. • The normal staffing process cannot be used, as the highest level nurses are required and the normal process does not require volunteers. • It is necessary to rely on managers and supervisors to support staff, and they also may need to provide care to cover shifts.

Staffing and Equipment Allocation(Learnings as of October 22, 2014) • Resources • Large amounts of highest risk waste require several different sizes of containers. • Hospitals treating Ebola patient require an adequate supply of every piece of PPE in every size in every department and a place for storage. The hospital needs to maintain communication with suppliers, as there are varying PAPR systems—some with booties, others with open feet—and there has been a run on supply. • Hospitals treating Ebola patients require dedicated equipment—portable X-ray machines, dialysis, respirator, etc.—and there must be one for each Ebola patient, as the recommendation is that equipment not be shared among Ebola patients.

The Ebola Response: Lessons and Changes October 22, 2014