key: cord-0059445-kaiycf97 authors: Gao, Yong; Li, Yuncheng; Luo, Jian; Wang, Hua; Su, Ying; Chen, Hui; Han, Xiaodan; Wang, Hongbo title: Emergency System of Designated Hospital for COVID-19 date: 2020-07-23 journal: The Clinical Diagnosis and Treatment for New Coronavirus Pneumonia DOI: 10.1007/978-981-15-5975-4_1 sha: 8a70217851c6cc9cf8bd2bcebe825504199b6847 doc_id: 59445 cord_uid: kaiycf97 Under the guidance of the National Health Commission of the People’s Republic of China, the Emergency Medical Department is established and formed by the medical administration experts from the national medical teams with the objective of “making every effort to improve the recovery rate and reduce the mortality rate” and upholding the working principle of “joint consultation, united consensus, concerted effort and rapid implementation.” It is convened by the medical administration departments of designated hospitals in order to carry out the work focusing on the implementation of core medical system and the improvement of treatment, and its core responsibilities are as follows: Yong Gao Yong Gao Under the guidance of the National Health Commission of the People's Republic of China, the Emergency Medical Department is established and formed by the medical administration experts from the national medical teams with the objective of "making every effort to improve the recovery rate and reduce the mortality rate" and upholding the working principle of "joint consultation, united consensus, concerted effort and rapid implementation." It is convened by the medical administration departments of designated hospitals in order to carry out the work focusing on the implementation of core medical system and the improvement of treatment, and its core responsibilities are as follows: 1. Plan, organize, coordinate, and control the whole process of medical activities in the hospital, maintain a high-quality and efficient operation of the medical system, and make the medical activities at the best state by focusing on the management objectives. 2. Concentrate on severe and critical cases; establish a four-level quality control system: medical groups-ward area-district-hospital, and strengthen the supervision and assessment to secure the implementation of the core medical system and provide a systemic guarantee to enhance the diagnosis and treatment quality of severe and critical patients. 3. Thoroughly discuss and analyze within a group about difficult and complicated cases, as well as severe, critical, and death cases; sum up the experience of successful treatment, unite the consensus on diagnosis, treatment and management, and actively promote the application. 4 . Coordinate and solve the difficulties and problems found during the practice of clinical and medical technical departments, organize, and participate in the grand rescue and consultation of the whole hospital. 5 . Grasp the basic medical information of the hospital accurately, summarize, and submit the medical brief report of the hospital. 6 . Establish and improve the report, investigation, and handling mechanism of medical adverse events. 7. Take in charge of the daily management of the fever clinic and the medical treatment of severe urgent patients in the hospital. 8. Complete other jobs assigned by the epidemic prevention headquarters. Yuncheng Li Response to Difficult and Complicated cases, as well as Severe, Critical, and Death Cases The establishment of the discussion system for difficult and complicated, severe, critical, and death cases shall be based on the actual situation and implemented by different levels in multiple ways during epidemic prevention and control. The participants shall include frontline medical staff at all levels, members of expert groups in each ward area, directors of ward areas, district principals, members of the hospital expert group, and personnel of the Emergency Medical Department. For the COVID-19 patients to be analyzed with other serious systemic diseases and cannot be provided with professional and technical services in the ward area/district, suggestions can be made to the Emergency Medical Department 2 h in advance, and the Emergency Medical Department shall coordinate and allocate relevant experts. The number of participants in the discussion shall be properly limited based on the principle of being highly capable, efficient, and problem-solving. Encourage all medical teams to tackle the problems with rear professional and technical forces of their respective hospitals. Set up a three-level discussion system of ward area-district-hospital for cases. The case discussion at the ward level shall be led by the ward area director, and the discussion time and frequency shall not be limited, but shall meet the requirements of the core medical system and be timely reported to the Emergency Medical Department; for the cases requiring discussion at the district level, the ward area director shall prepare the reporting and discussion materials, and the district principal shall determine the frequency and participants; for the cases requiring discussion at the hospital level, the leader of the expert group shall organize the discussion by at least once a week. The ward area director shall deliver the case materials submitted for discussion at the district and hospital levels to the participants in advance and keep a medical record. The Emergency Medical Department shall dispatch personnel to participate in the discussion and keep a work record. The subjects of case discussion include death cases, critical and severe cases, difficult and complicated cases as well as some cases participating in specific nondouble-blind clinical studies. It is also suggested to include the critical and severe cases with successful treatment to provide learning experiences and submit the refined views and methods to the Treatment Expert Group of National Health Commission for real-time sharing. Establish an expert group for the diagnosis and treatment of difficult and complicated, severe and critical COVID-19 cases to conduct a unified assessment and checklist management of all COVID-19 patients admitted to the hospital, and individualize the treatment plan on the basis of national guidelines to improve the success rate of rescue. Periodically study and evaluate the medical quality status of each ward area and put forward suggestions for improvement to the hospital executives. Establish a joint expert group and a discussion system for severe and critical patients. Carry out multidisciplinary treatment (MDT) for rarely seen difficult and complicated cases, invite members of the national expert group to give guidance, and adjust the existing treatment plan through case discussion and MDT to form a comprehensive treatment plan. Develop a reporting system for the expected death of severe and critical patients, with the purpose of strengthening the management of severe and critical patients. Provide early warning for the potential deadly cases and make active and reasonable intervention, strengthen the responsibilities and timely revise the treatment plan. Jian Luo Quickly establish an emergency management system mainly including the nursing department of the hospital and head nurse of the ward area. The director of the nursing department is fully responsible for the work deployment and implementation, designating the nursing staff of the hospital to be responsible for the clinical nursing quality, nursing safety, and allocation of nursing human resources; the head nurse of each ward area shall ensure the execution of all measures. The director of the nursing department shall timely discover, guide the processing and report various emergencies in case of a sudden outbreak, effectively coordinate with medical treatment, inspection, and logistics departments to solve specific problems in clinical nursing and ensure the treatment of patients. The director of the nursing department shall strengthen communication with the nursing directors of the national medical teams, establish the emergency nursing department and hold regular meetings; the head nurse of the ward area shall closely cooperate with the national medical teams to mutually complete the nursing services of the ward area. Sort out the epidemic prevention, control posts, and establish a highly capable and efficient human resource echelon for emergency nursing. Quickly allocate nurses to their posts according to their age, level, professional title, specialized technical level, and in combination with post needs, so as to maximize their talents and efficiency [1] . Looking at the fact that COVID-19 is an infectious disease mainly transmitted through the respiratory tract [2] and the nursing staff works with great physical exertion under the strict protective equipment, the length of each shift shall be controlled between 4 and 6 h to ensure safety. Companion is not allowed in the isolation ward. The treatment:living care of patients as well as partial infection work of the hospital are all undertaken by the nurses. Sufficient nursing human resources shall be provided with perhaps 3 times the standard for nurses in general wards. The nursing department shall actively communicate with each national medical team and reasonably allocate human resources according to the number of nursing staff in each national medical team to ensure the relative balance of human resources in each ward area [3] . When scheduling the nursing staff, it is advised to reserve a spare shift throughout the day to replace the nursing staffs who are urgently withdrawn from the isolation ward area due to physical discomfort. Develop the nursing process, preexamination and triage process, vital signs checking and nursing process, specimen collection and management process, disease observation and nursing process, nutrition support and nursing process, patient outcome and nursing process, the process of medical staff accompanying the patient to go out for examination, patient admission and referral workflow, ward disinfection workflow, rescue and nursing workflow for critical and severe patients, and psychological assessment and counseling process for COVID-19 patients, etc. Relevant nursing systems and processes: Post the responsibilities of nursing staff in each isolation ward area, the work responsibilities of each shift, the management systems and requirements on staff, the entry and exit process of isolation cabin, the physical condition monitoring process of nursing staff and the standard for emergency exit from isolation cabin, etc. Ensure that the nursing staffs are supported in their work. Patient-related emergency plans: Emergency plans to prevent falling from bed, for patients leaving without permission, for patients with suicidal ideation, and for accidents in the use of infusion pump, ventilator, monitor and defibrillator, etc. Nursing-related emergency plans: Emergency plans for physical discomfort, needle injury, damaged personal protective equipment, excessive moisture, and fall prevention in the isolation cabin. The isolation ward area is strictly divided into the contaminated area, the semicontaminated area, and the clean area. There is no overlap in the three areas, with unified and eye-catching signs in each area. Clean area: Refers to the area kept away from patients and pathogenic bacteria. There are changing rooms, duty rooms, warehouses, restrooms, bathrooms, and dispensing rooms for medical staff in the clean area. Semi-contaminated area: Refers to the area that may be contaminated by pathogenic microorganisms, such as internal corridors, doctor's and nurse's offices, and treatment rooms. Contaminated area: Refers to the area often in contact with patients and contaminated by pathogenic microorganisms, including wards, bathrooms, and toilets for patients. Each isolation ward area is equipped with 30-50 beds, single rooms for suspected patients, double or triple rooms for confirmed patients, and bedside treatment facilities such as oxygen and suction equipment as well as calling and intercom equipment in the ward. All wards are equipped with independent toilets, defecators, showers, hand washing facilities, etc. Separate the clean and contaminated routes with no overlap in strict accordance with the flow of people and materials. Arrange the work areas of medical staff according to the workflow: clean area → semi-contaminated area → contaminated area and set a pass-through changing station at the entrance of the work area at each level. The emergency nursing department shall actively make overall planning and apply for the use of various essential materials. Basic materials: Bed sheets, quilt covers, medical waste bags, cleaning carts, rags, mops, disinfectants, measuring cups, buckets, air disinfectors, etc. Protective materials: Surgical gowns, gloves, KN95/N95 masks, surgical masks, protective suits, isolation gowns or waterproof aprons, special shoe covers, goggles, protective masks, caps, etc. [4] . Rescue materials: Powered air-purifying respirators, ventilators, ECG monitors, defibrillators, micro-infusion pumps, injection pumps, emergency ambulances, CRRT, etc. Special materials: Special materials for ward areas shall be registered and claimed by specially assigned persons in clean areas to ensure rational use and avoid unnecessary waste. Knowledge and Skills The training shall be jointly completed by the emergency nursing department and the ward area, including the epidemiological characteristics of COVID-19, prevention and control systems and measures, operation specifications for nursing, emergency plans for occupational exposure, collection and transport of specimens, disinfection and isolation knowledge, correct procedures for putting on and taking off protective equipment, workflow of each shift, application of common rescue operating skills and equipment, nervousness adjustment before entering the cabin, and physical adaptability training. Combine the multi-session centralized training (the trainees shall wear masks, with a seat spacing >1 m) with network training (WeChat platform and 317hu learning platform) to achieve comprehensive, all-inclusive, hierarchical, and content-rich training management [5] . Uniformly assess the trainees and record the results after the training to discover the problems in a timely manner sum up experience and improve the practical coping skills. Set up a nursing quality control squad to go to each ward area every day for strict supervision, timely report problems and urge the department to complete rectification as soon as possible, to ensure the quality and safety of nursing. Implement the prevention and control measures for infection in the ward, inform hospitalized patients to wear surgical masks in a unified and correct manner, and carry out personal hygiene; assist the infection control department of the hospital to supervise the quality of medical waste treatment, cleaning, and disinfection of cleaning personnel; the head nurse in each ward area shall carry out basic supervision and management through on-site inspection and questions, etc. to ensure the implementation of prevention and control work for infection in the hospital. In order to continuously improve the nursing level of critical and severe patients, information exchange meetings are held regularly every Friday afternoon to share the management, treatment, and nursing experience of critical and severe patients with national medical teams to achieve mutual promotion. As respiratory support is the major management for COVID-19 patients, it is of great importance to standardize the nursing of oxygen therapy in designated hospitals. The respiratory rate, oxygen saturation, and arterial blood gas analysis result of the patient shall be closely monitored, and appropriate mode of oxygen administration and oxygen flow shall be selected according to the degree of hypoxia in the patient. Skin care and management: Skin assessment is included in the first nursing assessment for patients admitted within 2 h, and preventive measures shall be taken for patients with high risks by Braden score; for patients screened with stage III or above pressure ulcers before admission to the hospital, the wound team shall be timely organized for wound assessment and dressing change. Severe/Critical COVID-19 patients admitted to the hospital shall receive management and treatment in isolation according to the laws. Patients' anxiety about the prognosis of the disease, their fear of death, and their self-blame for the infection of their involved family members will result in psychological reactions of stress, anxiety, and panic to different degrees. Therefore, the nursing staff shall use the Psychological Rating Scale for COVID-19 Patients to conduct a preliminary screening of hospitalized patients and perform targeted psychological counseling according to the results. Helping patients to maintain a positive attitude is vital in disease treatment and rehabilitation. For the patients with serious psychological problems and poor counseling effect, the ward area shall report to the emergency nursing department that shall select appropriate personnel to provide psychological counseling for the patients with applicable methods, to relieve them from negative emotions, and make them actively cooperate with the treatment and nursing care. Humanistic care and multiple measures: The nurses in the ward area can take the initiative to act as the "temporary family members" of patients to make them feel the care of loved ones. "Temporary family members" refer to that a nurse claims a patient, understands the need of the patient, solves the difficulties in the patient's life, helps the patient communicate with the doctor for treatment, and assumes the responsibility of accompanying and enlightening the patient; a wishing wall can also be set up in the ward area to let nurses and patients write down their wishes for mutual encouragement and blessing. Provide a channel for nursing staff to relieve their psychological pressure. Timely understand the psychological status of nursing staff in the ward area and provide psychological counseling for nurses with psychological difficulties. Specific measures include but are not limited to warming, understanding, and encouraging messages from head nurses, looking for suitable opportunities for off-duty nurses to vent their negative emotions/get encouragement and support to restore their fighting capacity, carrying out psychological training to distribute their energy, physical strength, and attention rationally and carrying out psychological intervention on nursing staff with great psychological pressure [6] . Establish a guarantee and incentive system for anti-epidemic nursing staff. Provide good food, accommodation, and transportation for nursing staff in isolation ward areas, provide anti-epidemic subsidies, living materials support, rest plan and other measures [7] , give praise, and policy inclination to nursing staff involved in the treatment of COVID-19, and publicize advanced nursing deeds/write nurse antiepidemic stories in an appropriate way to spread positive energy. After being designated as the designated hospital of COVID-19, the logistics management of medical institutions will face a new working situation. The logistics work must ensure that the patient treatment can be smoothly carried out and a strengthened logistics operation management system will be formed as soon as possible. In designated hospitals, the dean of administrative logistics shall be designated to be responsible for logistics support, and a logistics support department composed of existing logistics personnel, social workers, and volunteers shall be set up to carry out the work. The logistics department can set up the following teams according to the situation to ensure all logistics tasks during the epidemic prevention and control of COVID-19. Responsible for contacting the leaders of the hospital in charge and receiving the government anti-epidemic materials and social donation materials and other related affairs. Responsible for the water and electricity kinetic energy protection and the gas support required for patient treatment during the epidemic period. Responsible for the food processing and distribution of all staff and patients during the epidemic period, with each aspect of the work meeting the requirements of biosecurity hospital infection protection. Perform effective sanitation practices and waste removal in various areas in accordance with the requirements of Class A infectious diseases. Ensure the fitting of the requirements of medical rescue equipment and lifesupporting equipment. Responsible for the management of all passages in the designated hospital area and the safety management of patients and assisting in completing the fire safety work. Yuncheng Li and Xiaodan Han Ward rounding system [8] is a routine work for medical staff at all levels to understand and grasp the changes of patients' conditions at any time through the inspection of hospitalized COVID-19 patients, and is the key to ensure timely and effective treatment for COVID-19 patients. In addition to resident doctor rounds, countries and regions can implement ward rounding system according to the regulations of local health administrative departments, which can only be strengthened but not weakened. The deputy chief physician or above of the ward area shall be responsible. The deputy chief physician shall make ward rounds at least twice a week and may increase the number of rounds according to the needs of patients. In case of critical and difficult patients, he/she shall be on call. The professional and technical personnel of attending physicians and above make ward rounds at least once a day. Medical institutions shall establish a hospital-wide medical duty system, including clinical, medical and nursing departments, and logistics departments that provide diagnosis and treatment support, and specify the duties of each duty post and the qualifications and number of duty personnel. All diagnosis and treatment activities during duty must be recorded in the medical record in time [8] . Including resident doctors, attending doctors with low seniority, refresher doctors, and graduate candidates with clinical experience and practicing qualifications of doctors in our hospital; the doctor on duty is responsible for the instant medical work and situation of the patient, timely examining and filling the medical records for patients admitted to hospital urgently, and giving necessary medical treatment. Including senior doctors with attending physician or above in the hospital; the second-line doctor on duty must stick to his/her post in the department and must not leave his/her post; the second-line doctor on duty must keep the duty phone unblocked, and shall tell the on-duty doctor and nurse in the ward area where to go when leaving the ward area due to necessary work. Due to the need of comprehensive diagnosis and management, the activity paradigm for medical staff outside the ward area or outside the institution to assist in finalizing the diagnosis and treatment opinions or providing diagnosis and treatment services is called consultation system [8] . During the process of diagnosis and treatment in each ward area in the hospital, ordinary consultation can be applied for when relevant departments are required to assist in diagnosis and treatment according to the patient's condition or relevant regulations. Invited departments/ward areas shall give consultation opinions or suggestions within 24 h. In the treatment or rescue of acute and critical patients, emergency consultation can be applied for urgent and difficult problems that must be solved by consultation. The second-line doctors on duty of the invited department/ward area must arrive at the consultation ward area within 10 min. Under special circumstances, consultation services can be completed by telephone or network. In case of serious situations or difficulty in operation, surgical consultation can be applied for when higher-level doctors or relevant experts need to participate in the operation and rescue. Consultation in the ward area: Proposed by the attending physician and attended by relevant personnel in the ward area convened by the ward area director. Consultation in the district: Proposed by the ward area director and participated by other departments in the hospital. Consultation in the hospital: Proposed by the district director and participated by multiple districts and professionals. Consultation outside the hospital: Proposed by the ward area director and participated by other hospitals outside the hospital by invitation of the medical department. Teleconsultation: proposed by the ward area director and participated by other ward areas/hospitals outside the ward area/hospital through the teleconsultation system by invitation of the medical department. Ying Su Patients [9] Simplify admission procedures, reduce the flow of patients in the hospital, register patient information with legal name, and achieve admission without card (medical insurance card). Patients will be allocated uniformly by the allocation team of medical department according to the patient's condition and the beds availability in the ward area. Patients are not allowed to be admitted to each ward area by the ward themselves. In general, all patients are admitted and treated in a single room. If beds are insufficient, 2-3 confirmed cases can be received and treated in one unit, and the suspected cases should be admitted and treated in a single room. It is suggested that mild and severe patients should be admitted and treated separately and critically ill patients should be allocated in ICU uniformly. NCP patients with similar underlying diseases are admitted and treated in the same ward area, which is convenient for special diagnosis and management of underlying diseases. The allocation team of medical department (hereinafter referred to as the allocation team) collects the information of the admitted patients (name, sex, age, contact information, ID number, home address, and medical insurance information), evaluates the patient's health condition, and determines the admission ward area and beds. The allocation team informs the nurse station in the ward area to prepare for receiving and treatment and basic information of the patients. The allocation team informs the assistance center to handle the legal name registration and admission procedures. The allocation team informs 120 ambulances to send the patients directly to the designated ward area of the inpatient department. Hospitals shall set up fever clinic and clinic assistance center to facilitate the hospitalization and management for febrile pregnant and lying-in women. Pregnant women with fever, cough, chest distress, runny nose, diarrhea, and other symptoms shall first go to fever clinic for treatment under the guidance of special personnel. Outpatient workup shall include the following items: Chest CT, complete blood count, novel coronavirus nasopharyngeal swab or blood virus nucleic acid assay, novel coronavirus blood antibody assay (IgM and IgG), 3-item respiratory tract virus assay, and screening for A/H1N1 influenza. For pregnant women with confirmed or suspected COVID-19, the staff of the clinic assistance center shall contact the ward for admission and management. For hospitals without an assistance center, the outpatient managing physician shall directly contact the ward for admission and management. The pregnant and lying-in cases with suspected or confirmed diagnosis of COVID-19 shall be reported according to the regulations of epidemic of infectious diseases. Hospitals with isolated obstetrics department are designated hospitals for receiving and treating pregnant women with COVID-19. They do not undertake prenatal examination and postpartum health care for pregnant and lying-in women without COVID-19. If febrile pregnant women have vaginal bleeding, paroxysmal abdominal pain, and other obstetric labor or abortion clinical manifestations, treat separately according to the following two situations: 1. Fever clinics and isolated obstetrics departments shall inform patients of the risk of cross-infection during hospitalization without being confirmed as COVID-19, which may endanger the safety of pregnant women and fetuses. If patients clearly indicate that they know and bear all the effects of the viral infection on their health, they can be admitted to isolated obstetrics department for observation and treatment. 2. Patients with confirmed or suspected of COVID-19 shall be admitted to the isolated obstetrics department for management. For pregnant cases with positive nucleic acid testing, there are indications for admission and management in isolated obstetrics department regardless of gestational age and birth sign. For pregnant cases who have no indications for emergency obstetric care, no pneumonia manifestations and no novel coronavirus testing, the designated hospitals will not accept them. Clinic service shall guide them to other hospitals for obstetric care. (b) If the patient has valuables, such as wallets, bank cards, and other belongings; seal them after disinfection, mark with patient information, and then store them. (c) If the police confirm that the patient's family members cannot be contacted, or if the family members refuse to transfer the remains, inform the hospital security department to coordinate with public security office for disposal. (d) The remains shall not be stored, visited, or held funeral activities such as farewell ceremonies. It is strictly prohibited to open the sealed body bag during the whole process. Functions and deployment of nursing department in response to COVID-19 epidemic Health care associated infections: the hallmark of Middle East respiratory syndrome coronavirus with review of the literature Construction of Nursing Team of First-line Support Medical Team against COVID-19 National Health Committee of the PRC. Guidelines on the scope of use of common medical protective equipment in infection prevention and control against COVID-19 Emergency training and effect of anti-epidemic nurses against COVID-19 Emergency management strategy of nursing human resources in designated hospitals for COVID-19 patients Thoughts on effective psychological assistance during the epidemic period of COVID-19 National Health Commission of the PRC. Key points of core system for medical quality and safety Interim measures for prevention and control of COVID-19 in Wuhan city Notice on further strengthening the transfer and disposal of remains of patients infected with COVID-19 (including suspected cases) Office, the remains of suspected and confirmed patients with COVID-19 shall be disposed according to the following process [10] If the patient's relatives are unable to be present, in addition to the above actions, medical staff shall: (a) Directly contact the police station in the jurisdiction area to provide the identity information of the deceased, the retained family information, and contact information for inquiry and review by the police station.