The Ebola Response:
Lessons and Changes
October 22, 2014
Topic Areas
Emergency Department
Personal Protective Equipment (PPE)
Resource (Staffing and Equipment) Allocation
Emergency Department
(Learnings as of October 22, 2014)
Emergency Department
Learnings as of October 22, 2014
Issue/Problem
Then
Now - Improvements
For monitored patients who
develop a temperature
Contact made with medical
staff at hospital. Staff advised
to notify hospital.
Hospital prepared and met
individual at their car.
Added wet and dry
designation; wet designations
means full Powered Air
Purifying Respirators (PAPRs)
throughout.
Monitored patients
Met with standard PPE at car
and moved to isolation.
Nurse in PAPRs meets patient
outside of ED. Nurse provides
mask to patient and escorts
him/her into isolation room.
Prior to discharge for all at risk
patients
Patients were discharged as
indicated by doctor.
Now, vital signs are taken
within 30 minutes of discharge.
If abnormal, they are
communicated verbally to the
doctor prior to discharge.
Emergency Department
Learnings as of October 22, 2014
Issue/Problem
Then
Now - Improvements
Electronic Health Record
(Screening Process)
Information was in the
electronic health record, but
depending on the screen size, it
may have been necessary for
physicians to scroll down to
find information. A box in the
EHR was checked to indicate
that the nurse had
communicated travel
information to the physician
seeing the patient.
A robust screening process has
been added that includes a
unique screening tool built into
the electronic health record to
identify patients at risk for
serious infectious diseases
based on symptoms, travel, and
exposure.
Emergency Department
Learnings as of October 22, 2014
Issue/Problem
Then
Now - Improvements
Electronic Health Record
(Screening Process)
Information was in the
electronic health record, but
depending on the screen size, it
may have been necessary for
physicians to scroll down to
find information. A box in the
EHR was checked to indicate
that the nurse had
communicated travel
information to the physician
seeing the patient.
A flag was added to draw
attention to travel information
in the EHR. The box is now
larger and in red. Scribes now
will not enter a check in the
box indicating that the
information has been reviewed
until confirming with the
physician that the information
has been communicated to
him/her.
Emergency Department
Learnings as of October 22, 2014
Issue/Problem
Then
Now - Improvements
Electronic Health Record
(Screening Process)
Information was in the
electronic health record, but
depending on the screen size, it
may have been necessary for
physicians to scroll down to
find information. A box in the
EHR was checked to indicate
that the nurse had
communicated travel
information to the physician
seeing the patient.
There is a new emphasis on
face-to-face dialogue to bolster
team communications between
nurse, doctor, and patient—a
move to avoid relying solely on
the electronic medical record.
Emergency Department
Learnings as of October 22, 2014
Issue/Problem
Then
Now - Improvements
Getting Information to
Physicians and
Employees/Training
Alerts, tips, and other
information were conveyed to
staff through the electronic
message board.
High priority information will
now be communicated through
a tool in the electronic health
record with a hard stop
confirmation required from
staff physicians and employees
that they read the information.
Other options include
physicians to be notified by
their departments/entities
through email with confirmed
reply. In addition, all changes
are now to be discussed at
monthly staff meetings.
Emergency Department
(Learnings as of October 22, 2014)
Issue/Problem
Then
Now - Improvements
Unmonitored patients
Patients went through normal
process of entering ED and
waited for triage nurse to
interview them.
The triage nurse intentionally
did not ask key questions, as
travel history was included in
the social history along with
suicide risk, TB exposure and
domestic violence history.
Travel history was taken once
patient was placed in a room.
Signage being added at all
entry doors and the triage
desk, with masks, hand
sanitizer, and emesis bags
requesting that anyone with a
fever or travel history put on a
mask: “IF YOU HAVE A FEVER
OR COUGH, PLEASE PUT ON A
MASK. IF YOU HAVE TRAVELED
TO AFRICA OR THE MIDDLE
EAST IN LAST 3 WEEKS, NOTIFY
STAFF IMMEDIATELY. Please use
hand sanitizer.” The sign will
have a picture of the globe with
the Middle East and Africa
highlighted.
Emergency Department
(Learnings as of October 22, 2014)
Issue/Problem
Then
Now - Improvements
Unmonitored patients
Patients went through normal
process of entering ED and
waited for triage nurse to
interview them.
Nurses are trained to act
rapidly and to be specific about
countries the patient has
recently traveled to or from.
The triage nurse intentionally
did not ask key questions, as
travel history was included in
the social history along with
suicide risk, TB exposure and
domestic violence history.
Travel history was taken once
patient was placed in a room.
A triage nurse asks about travel
history and chief complaint
within 5 minutes of patient
entry into the ED in 90% of
cases, or within a maximum of
10 minutes.
Emergency Department
(Learnings as of October 22, 2014)
Issue/Problem
Then
Unmonitored patients
Patients went through normal
process of entering ED and
waited for triage nurse to
interview them.
Now - Improvements
If a patient is at risk for Ebola
while in the waiting room: (1) the
nurse screener dons protection,
full PPE but not PAPR, (2)
provides a mask to the patient, if
not already masked, and (3)
The triage nurse intentionally did escorts the patient to a private
not ask key questions, as travel
room and closes the door. (If the
history was included in the social patient has been in the sitting
history along with suicide risk, TB area, the area around the patient
is scrubbed and cleaned, and
exposure and domestic violence
people sitting near the patient
history. Travel history was taken are removed from the area, put
once patient was placed in a
in isolation if available, and
room.
counseled on exposure risk.) The
ED physician uses a phone or
intercom to interview the patient
and consults with the CDC if
needed.
Emergency Department
(Learnings as of October 22, 2014)
Issue/Problem
Then
Now - Improvements
Unmonitored patients
Patients went through normal
process of entering ED and
waited for triage nurse to
interview them.
Patients deemed high risk are
either transferred to an
isolation unit by a nurse who
dons PPE (gloves, gown, shoe
covers, face mask and face
shield) or taken to a hospital
with an isolation unit. At this
hospital, the isolation unit is
through the ED back door to an
elevator and one floor up.
Patients being transferred to
another hospital are taken out
the ED doors into an
ambulance.
The triage nurse intentionally
did not ask key questions, as
travel history was included in
the social history along with
suicide risk, TB exposure and
domestic violence history.
Travel history was taken once
patient was placed in a room.
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).
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17
Screening Tool
• All patients must be screened using this tool.
• The tool will be at the top of the:
–
–
–
–
10/22/14
Inpatient navigators
Triage & Meds/Hx sections of the ED navigators
Physician Navigators
Radiant Tech Navigator Begin Exam and Tech Navigator End Exam
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18
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.
10/22/14
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19
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.
10/22/14
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20
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.
10/22/14
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21
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.
10/22/14
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22
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
10/22/14
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23
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.
10/22/14
This material contains confidential and copyrighted information of Texas Health Resources.
24
Discharge/AVS Fail Safe Measure
• If the screening is not completed then the Discharge/AVS instructions
cannot be printed.
10/22/14
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25
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.