1. The Ebola Response: Lessons and Changes October 22, 2014

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

3. Emergency Department (Learnings as of October 22, 2014)

4. Emergency Department Learnings as of October 22, 2014 Issue/ProblemThenNow - 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.

5. Issue/ProblemThenNow - 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

6. Issue/ProblemThenNow - 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

7. Issue/ProblemThenNow - 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

8. Issue/ProblemThenNow - 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

9. Issue/ProblemThenNow - Improvements Unmonitored patientsPatients 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)

10. Issue/ProblemThenNow - Improvements Unmonitored patientsPatients 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. Nurses are trained to act rapidly and to be specific about countries the patient has recently traveled to or from. 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)

11. Issue/ProblemThenNow - Improvements Unmonitored patientsPatients 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. 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) escorts the patient to a private room and closes the door. (If the patient has been in the sitting area, the area around the patient is scrubbed and cleaned, and people sitting near the patient are removed from the area, put in isolation if available, and 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)

12. Issue/ProblemThenNow - Improvements Unmonitored patientsPatients 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. 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. Emergency Department (Learnings as of October 22, 2014)

13. 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.

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

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

16. 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)

17. 10/22/1417 This material contains confidential and copyrighted information of Texas Health Resources. 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).

18. 10/22/1418 This material contains confidential and copyrighted information of Texas Health Resources. 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

19. 10/22/1419 This material contains confidential and copyrighted information of Texas Health Resources. 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.

20. 10/22/1420 This material contains confidential and copyrighted information of Texas Health Resources. 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.

21. 10/22/1421 This material contains confidential and copyrighted information of Texas Health Resources. 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.

22. 10/22/1422 This material contains confidential and copyrighted information of Texas Health Resources. 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.

23. 10/22/1423 This material contains confidential and copyrighted information of Texas Health Resources. 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

24. 10/22/1424 This material contains confidential and copyrighted information of Texas Health Resources. 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.

25. 10/22/1425 This material contains confidential and copyrighted information of Texas Health Resources. Discharge/AVS Fail Safe Measure If the screening is not completed then the Discharge/AVS instructions cannot be printed.

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

27. 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)

28. 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)

29. 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. PPE – Lessons Learned (Learnings as of October 22, 2014)

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

31. 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)

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