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Inside the Covid-19 transformation of the Martin Luther King, Jr. Community Hospital ED

By Clare Wirth

October 27, 2020

    When the new coronavirus struck, Martin Luther King, Jr. Community Hospital (MLKCH's) quickly redesigned its geographical footprint and restructured its workflow to maintain high-quality, efficient ED care while minimizing transmission. 

    Covid-19 guidance from clinicians at the forefront

    Here's how MLKCH's ED responded during the initial surge—and why it's doubling down on these efforts in the event of a new wave of Covid-19 cases.

    Cohort patients to limit infectious spread

    Like many organizations, MLKCH expanded its physical space to manage both Covid- and non-Covid-related health care needs. Since the first wave of Covid-19, the hospital has used military-grade tents to allow RNs to properly screen and mask patients before they enter. As patients arrive, a public safety officer guides them to the triage tent. In the tent, there's an experienced ED RN, an emergency medical technician, a registrar, a public safety officer, and a transportation aide.

    To manage patient flow, MLKCH implemented a two-step triage process: 

    1. Check for immediate resuscitation need, then screen for Covid-19 risk and symptoms.

      Staff take patients in need of resuscitation directly back to the main ED. If the patients meet any Covid-19 risk criteria, staff place an orange wristband on them. These patients are then taken to a respiratory tent or to an isolation room in the ED, depending on their Emergency Severity Index (ESI).

      For stable patients, the RN masks and screens them for Covid-19 based on the latest guidelines from the Los Angeles County Department of Public Health. Screening questions include:

      1. Does the patient have a cough, fever, or shortness of breath?

      2. Has the patient had any close contact with Covid-19 confirmed patients?

      3. Is the patient a health care worker?
    2. Patients move to second-tier triage based on their Covid-19 risk.

    3. Assess patient acuity.
      • For patients with Covid-19 symptomology or risk factors: RNs escort those with time-critical problems (ESI 1-2) to the isolation room in the main ED. Stable patients (ESI 3-5) get further assessments and care in the respiratory tent. The tent includes computer workstations, PPE, a Pyxis station, two ED RNs, and an EMT. It accommodates up to 21 treatment spaces that are separated by six feet of space and a privacy screen.

      • For patients without Covid-19 risk factors: Staff assess their acuity indoors. These patients follow the ED's standard practice paths-of-travel, through the patient entrance.

      MLKCH continues to adapt the triage process as Covid-19 cases fluctuate. For example, following a surge over Memorial Day, the hospital combined the two triage stations dedicated to each step. Consequently, the proportion of patients who left without being seen dropped from 3.3% in June to 1.3% in July.

    Other actions MLKCH took to streamline patient care and protect workers

    In addition to revamping its triage process, MLKCH took additional steps to ensure patients' care needs were being met while protecting its health care workers.

    • Integrate virtual care to preserve PPE and minimize clinician exposure.

      MLKCH repurposed many of its existing iPads usually used for interpreter services. With the iPads, clinical staff virtually connect with patients who do not require hands-on contact. For example, social workers provide virtual consults. Registrars obtain necessary information from patients. Physicians opt for telehealth services for patients with mild respiratory symptoms. And scribes perform their duties remotely. These virtual options all minimize physical contact and PPE use.

    • Provide post-discharge and community-based education and support.

      MLKCH provides thorough follow-up care, prioritizing those who seem at risk of regressing. "Call-back" nurses contact patients to assess their respiratory function and ability to quarantine. They continue to call until patients have improved from their initial visit or until they are symptom-free. These calls secondarily serve as emotional support for discharged patients. Because they had been isolated for two weeks, many expressed gratitude for the interaction and extra support provided by the nurse.

    • Open lines of communication with community stakeholders.

      MLKCH has deployed several channels of communication to support the community. It sent messaging to steer patients toward its telehealth services to avoid unnecessary ED visits. The hospital installed a bilingual Artificial Intelligence chatbot (named Mia for friendly user association) on its website to answer patient questions and guide them to appropriate health actions, including consultation with a physician or nurse.

      MLKCH also sends out information about the safety precautions it's established to ensure patient safety. Staff are providing free educational classes on Covid-19 to community members, starting with the local Boys and Girls Club.  

    MLKCH has quickly adopted and evolved these new operating protocols. It plans to continue to adapt as Covid-19 and flu cases fluctuate to ensure it provides safe and efficient care.

    We would like to recognize the following individuals for being particularly generous with their time and expertise: Nadira Ahmad, Jorge Gonzalez, Gregory Jones, Dr. Jorge Reyno, and Alaine Schauer. MLKCH would like to thank International Medical Corps for donation of the respiratory tent and other critical supplies. For any questions, Nadira Ahmad can be reached at nahmad@mlkch.org.

    Learn more: The 4 key imperatives for your Covid-19 staffing strategy

    Over the past month, Advisory Board researchers have talked to dozens of clinical executives about how they're staffing for Covid-19—from those readying for a surge to organizations already on the other side of their market's apex.

    Advisory Board's Lauren Rewers outlines four lessons learned that all clinical executives should keep in mind as they customize their organization's Covid-19 staffing strategy.

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