| Daily Briefing

What are hospitals changing to prepare for the next 'surge'? Almost everything.

Hospitals are applying lessons learned during the country's first wave of Covid-19 and adopting new operating protocols so they can treat surges of patients with infectious diseases while continuing to provide other services to non-infectious patients, Laura Landro reports for the Wall Street Journal.

How 9 countries responded to Covid-19—and what we can learn to prepare for the second wave

James Linder, CEO of Nebraska Medicine, told Landro that hospitals going forward will essentially need "to operate a hospital within a hospital, taking care of the needs for patients who have had strokes or a newborn delivery or need surgery while dealing with an otherwise healthy 35-year-old who picked up Covid-19 at a social event."

To accomplish that goal, hospitals and health systems are implementing some significant changes that will not only "reduce risk and disease spread," but also "change the way people experience care even in times when there is no [infectious disease] crisis," Landro writes.

Safer patient intake

Patients will see some of those changes in hospitals' waiting rooms, according to Landro.

Landro notes that, as patients infected the new coronavirus flooded hospital EDs, the facilities' waiting rooms became potential venues for transmission. In response, hospitals are trying to find ways to keep patients out of their waiting rooms and to reduce the amount of time potentially infectious individuals spend around other patients and medical staff.

Some hospitals have begun registering patients remotely, which can reduce the amount of time patients spend in waiting rooms once they arrive at the facilities, Landro writes, while others are employing telehealth to evaluate patients remotely and determine whether the patients need to come to the facilities at all.

Nebraska Medicine, for instance, has been using a feature called Digital Front Door, which allows patients to register for appointments 14 days before their visit and to check in for appointments one day in advance. The feature is connected to patients' EHRs and allows them to update their medication lists and health history, as well.

The program also includes a geolocation feature that automatically checks in patients as they get close to the hospital. When the patients arrive, clinicians check their symptoms and assign them a green, red, or yellow sticker based on their condition. Patients with no symptoms of Covid-19 receive a green sticker and are allowed to check in at electronic kiosks. Providers escort patients who are experiencing symptoms of Covid-19, denoted by yellow and red stickers, directly to exam rooms, Landro writes.  

Memorial Health System is using a system called Zero-Contact, which also allows patients to check in for their appointments using their mobile devices. The system instructs patients to complete their registrations from home or in the parking lot outside of the facility, and then sends patients a text when their exam room is ready. Memorial is using the program at two EDs, an urgent care clinic, outpatient clinics, and a drive-thru testing clinic for the new coronavirus.

Memorial also uses the no-contact registration process for maternity patients, Landro reports. Once their room is ready, a staff member meets the maternity patient outside, takes their temperature, and then escorts them to the obstetrics department.

"I can't imagine how challenging patient encounters would have been throughout the Covid-19 pandemic without a zero-contact intake process," said Missy Fleeman, director of patient access at Memorial. "We believe all these initiatives have prepared us for any future infectious-disease surges."

Both Memorial and Nebraska Medicine plan to continue using the programs even after America's Covid-19 epidemic slows. Linder told Landro that Nebraska Medicine plans to keep using its no-contact check-in program "both because patients prefer the convenience and to prepare for any future disease outbreaks."

In addition to no-contact intake programs, many hospitals are employing technologies that allow medical staff to check patients with symptoms of infectious diseases without having physical contact with the patient. 

For instance, Brigham and Women's Hospital has attached an iPad to a robot called Spot, which allows staffers to assess patients from a distance both in the hospital's ED and in a triage tent located outside the hospital. The robot uses thermal imaging to check patients' breathing and assess the patients' other symptoms. 

Meanwhile, some organizations, such as the University of Kansas, are creating new spaces to treat ED patients. University of Kansas designed a mobile ED called Ubulance that features detachable containers that can be connected to an ED and provide additional care space for infectious patients, serving as "a quarantine zone," Landro writes. According to Frank Zilm, the project's leader and director of the university's Institute for Health and Wellness Design, the containers can help to ensure patients don't have to enter the ED. The containers also can be stored off-site when infectious disease surges subside, Landro reports.

Preparing for a surge

In addition to helping protect patients against possible transmission of an infectious disease, the Ubulance also serves as a way for University of Kansas to rapidly increase its capacity to treat patients—a scenario many other hospitals and health systems are preparing for, as well.

Dino Rumoro, chair of emergency medicine at Rush University Medical Center, said Rush is prepared to convert an entire wing of the hospital's infectious disease facility into a negative-pressure ward within hours, which could increase its isolation room capacity from 40 to 100.

Rush also equipped the hospital's main lobby with medical gases, suction, and electrical power that allows providers to convert the lobby into extra care space if needed. According to Landro, the hospital used that space in April to treat patients who were not showing symptoms of Covid-19.

Meanwhile, the Cleveland Clinic has temporarily converted its Health Education Campus, which the Clinic shares with Case Western Reserve University, into a 1,000-bed surge hospital to help address patient influxes amid America's Covid-19 epidemic. In addition, the Clinic is able to convert some areas of its main building into ICUs if needed.

Elsewhere, Wellstar Health System's WellStar Kennestone Hospital is slated to open a new ED building that will double the hospital's capacity for emergency and trauma cases, Landro reports. The building includes multiple entrances, as well as isolation and decontamination rooms for patients with infectious diseases. The building also is connected to the main hospital through a bridge with two levels, so patients and clinicians can be separated from visitors to the hospital. 

"You have to be able to pivot in situations like this pandemic to accommodate care, not only in how you build the facility, but in how you make the processes and flows safer," said Mary Chatman, EVP of WellStar and president of the Kennestone hospital.

Allowing for physical distance between doctors and patients

Hospitals and health systems also are taking new steps to protect medical staff from infectious patients—and vice versa.

The Cleveland Clinic, for instance, is using videoconference technology to help doctors conduct virtual rounds from outside patients' rooms. And in the ICU, the Clinic is placing patients' IV poles and monitors outside their rooms, so medical staff can check on a patient's status without coming in close contact with the patient, according to James Merlino, the Clinic's chief clinical transformation officer.

At Texas Health Resources, patients use tablets placed in ED rooms to input their medical histories, and doctors can view and control the tablets through a connected device outside of the room. Doctors also can use the devices to screen patients without coming in close contact with patients.

The University of California-San Diego uses robots to perform a similar function. The robots carry tablets into patients' rooms so doctors can conduct visits remotely.

Some hospitals are deploying robots to perform duties for nurses, as well, such as delivering medications and handling lab samples, Landro reports.

"Managing this pandemic has taught us a lot about how to keep patients and caregivers safe," Merlino told Landro. "As we turn society back on and get patients in for the care they need, we know we can protect them."

Safer patient follow-up

Since Covid-19 presents a particular risk for readmission, especially among patients with underlying health conditions, some hospitals also are using technologies that allow doctors to follow-up with patients remotely. And some hospitals are even equipping patients with systems and devices that check their vitals remotely, Landro writes.

For instance, Nebraska Medicine developed a tracker that allows Covid-19 patients to monitor and report their symptoms from home. If the system detects any issues, it directs patients to fill out an online questionnaire that is then reviewed by a clinician. According to Landro, the system also can direct patients to self-isolate if they present a possible transmission risk and supply patients with a certificate stating that they can return to work or school.

The Cleveland Clinic has developed a similar at-home monitoring program used for patients with confirmed cases of Covid-19 who are isolating at home or who've been discharged from the hospital. The program allows patients to use a mobile device to note any symptoms they're experiencing and allows physicians to monitor the patients' symptoms.

Merlino said the Clinic intends to use the program even after America's Covid-19 epidemic passes. "We intend to use the same technology to follow up on a variety of different types of patient-care issues," he told Landro, adding, "The applications are really limitless" (Landro, Wall Street Journal, 6/8).

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