key: cord-0847459-l7qkpsx2
authors: Turer, Robert W; Jones, Ian; Rosenbloom, S Trent; Slovis, Corey; Ward, Michael J
title: Electronic Personal Protective Equipment: A Strategy to Protect Emergency Department Providers in the Age of COVID-19
date: 2020-04-02
journal: J Am Med Inform Assoc
DOI: 10.1093/jamia/ocaa048
sha: be4fa9712ec3ff084ad9f59a5b654753b9a35d7f
doc_id: 847459
cord_uid: l7qkpsx2

Emergent policy changes related to telemedicine and the Emergency Medical Treatment and Labor Act (EMTALA) during the novel coronavirus pandemic (COVID-19) have created opportunities for technology-based clinical evaluation, which serves to conserve personal protective equipment (PPE) and protect emergency providers. We define electronic personal protective equipment (ePPE) as an approach using telemedicine tools to perform electronic medical screening exams while satisfying EMTALA. We discuss the safety, legal, and technical factors necessary for implementing such a pathway. This approach has the potential to conserve PPE and protect providers while maintaining safe standards for medical screening exams in the ED for low risk patients in whom COVID-19 is suspected.

The novel coronavirus, SARS-CoV-2, and associated respiratory illness, COVID-19, have put unprecedented strain on the US healthcare system and its supply of personal protective equipment (PPE). [1] [2] [3] [4] The CDC has provided strategies for conserving PPE. [5] Despite these measures, PPE shortages are expected in many regions. [6] Telemedicine offerings are rapidly expanding, spurred by waivers expediting telemedicine credentialing and billing for most US providers [7] while relaxing device certification requirements. [8] As of March 30 th , these include emergency evaluation and management codes. Services (CMS) waiver released on March 30 th allows for MSEs to be performed using telehealth equipment during the pandemic. [10] This policy shift presents an opportunity for the use of electronic personal protective equipment (ePPE) to facilitate on-site ED MSEs without physical contact. This represents a novel strategy to maintain patient access to emergency evaluation and treatment while keeping providers safe and conserving PPE.

In this paper: we define ePPE; evaluate telemedicine tools as a medium for ePPE; and discuss safety, legal, and documentation considerations.

Electronic PPE consists of telemedicine tools used by on-site emergency providers to evaluate patients physically in the ED to avoid physical proximity. Though ePPE toolkits overlap with telemedicine toolkits, ePPE is not telemedicine. We make this distinction because, unlike telemedicine, the provider is immediately available on-site to physically examine or resuscitate the patient if screening warrants such action. We liken this approach to the use of two-way phones on opposite sides of glass windows as used in banks and prisons. Instead of glass and phones, we advocate for tablets in environments where physical construction of such barriers is not feasible. As described below, this approach can fulfill EMTALA obligations for MSEs.

While we assert that ePPE within physical EDs is distinct from telemedicine, ePPE's use will be subject to similar technical limitations as traditional telemedicine. The only significant difference is the immediate availability of the provider if the patient is sicker than anticipated. Therefore, we use prior literature from telemedicine to consider the safety implications of ePPE-based evaluations.

Some hospitals have studied the feasibility of emergency telemedicine to keep healthy patients with minor complaints out of the emergency department (ED) with optimistic outcomes. [11] A systematic review of emergency telemedicine found that it is effective for minor, low-acuity situations and for consultations. [12] However, these studies are lacking in rigorous methodology.

To date, we are aware of only one US-based trial evaluating telemedicine tools to perform MSEs, followed by in-person visits. [13] They limited screening to English-speaking patients with triage acuity levels 3-5 (i.e., urgent to nonurgent). [14] At their academic medical center, they screened five patientsper-hour and reduced their left without being seen rate. These data, while limited and not fully generalizable to the current situation, suggest that technology-based screening could improve timeliness of care in addition to protecting staff. We are unaware of any trials of MSEs performed by onsite providers using ePPE exclusively.

The March 30 th addition of emergency evaluation and management codes during the pandemic may provide opportunities to widen the scope for and facilitate the study of emergency telemedicine. [9] Telemedicine tools have been used safely in other settings. Telemedicine-based history and examination is reliable in the outpatient setting, and has been shown to be effective in diagnosing respiratory illness in children. [15] [16] [17] [18] One frequently raised concern is the difficulty of telemedicine-based auscultation without using remote digital stethoscopes. Auscultation of the lungs has been shown to have poor test characteristics for detecting pneumonia as compared with tachypnea, accessory muscle use, and overall clinical impression. [19] [20] [21] [22] Work of breathing assessed via videoconferencing serves as adequate respiratory examination in young, otherwise healthy patients without comorbid heart or lung disease. [17] We believe the benefits of forgoing auscultation during ePPE-based MSE far outweigh the risk given the pressing need to preserve PPE and minimize viral exposure. Greenhalgh et al. from the UK have proposed a structured telemedicine exam for respiratory complaints that is ideal for the described situation.

[23]

To minimize risk, we recommend performing MSEs using ePPE on low risk patients (i.e., 4-less urgent to 5-nonurgent) with reassuring vital signs, few comorbidities, and chief complaints suggesting lower respiratory infection (fever, cough, shortness of breath).

This section provides a review of federal laws as they relate to ePPE-based MSEs. There are standard of care and legal considerations that vary regionally. Consult legal counsel prior to implementing this practice.

EMTALA was passed as part of the Social Security Act in 1986 by Congress to ensure public access to emergency services, regardless of ability to pay. [24] EMTALA defines the medical screening obligations of hospitals with dedicated EDs and of freestanding EDs. Financial penalties for EMTALA violations are substantial. [25] Central to EMTALA is the notion of an MSE, which is intended to evaluate for the presence of emergency medical conditions and facilitate resuscitation and treatment related to them.

The definition of an MSE is broad and articulated by CMS's EMTALA interpretive guidelines [26] : Generally, EMTALA protects patients, but its role in emergency telemedicine is still evolving. Prior literature has discussed the implications of EMTALA in general. [26] [27] [28] [29] and for off-site emergency telemedicine. [30] Widely available pathways for ED-based telemedicine have not been established, with the notable exception of critical access hospitals. [31] There is little published historically on whether an ePPE-based MSE would qualify, though CMS guidance in anticipation of an Ebola outbreak in 2015 suggests that in highly infectious environments, MSEs could be performed via electronic means [32] : Within this context, we propose that MSEs facilitated by electronic means where both clinician and patient are physically present within the ED, but in separate rooms, would allow for rapid and effective evaluation while putting neither patient nor clinician at infectious risk and conserving physical PPE for sicker patients. A March 30 th CMS update to EMTALA enforcement allows for on-site and off-site MSEs by qualified medical personnel using telemedicine equipment supports this notion [10] :

Medical Personnel (QMP). The QMP may be on-campus (and using telehealth to self-contain) or offsite (due to staffing shortages). Either way, the QMP must be performing within the scope of their state practice act, and approved by the Hospital's Governing Body to perform MSEs.

As with any technical project, workflow considerations are as important as technical decisions. Therefore, we do not recommend modifying triage processes (beyond baseline changes necessary for avoiding ED contamination during the pandemic) in order to ensure that critical patients obtain timely traditional care.

There are many locations where an MSE via ePPE could be performed, including an isolated waiting room for respiratory patients or within the triage station itself. The initial provider, usually the triage nurse, is best-suited to determine appropriateness for ePPE and to initiate communications based on their evaluation. This provider would then notify the EMTALA-qualified medical provider, confirm availability for ePPE-based evaluation, and establish a connection. After connecting, the triage staff could provide the patient's name and birthday to initiate the call. The MSE-performing clinician will verify the medical record number for a "two-way handshake" to confirm identity. A streamlined electronic health record-based note could be completed in real time. This note would include documentation of the use of ePPE for tracking and future study.

Based on our review of EMTALA-related precedent and recent waivers relaxing software requirements, this ePPE-based exam for low-risk patients meets the requirements as an MSE. Laboratory testing for infectious diseases such as COVID-19 and influenza can be ordered based on this examination, and if the patient is deemed appropriate for discharge based on evaluation, any vital signs performed, and institutional protocols, they could be discharged at this point. If the provider determines that a more indepth physical exam is needed or the patient requires additional testing or treatment, the ePPE-based visit can progress to a traditional ED visit.

InDoc solutions, a telehealth consulting firm for emergency medicine and primary care, has proposed several additional approaches to implementation of ePPE-based telescreening [33] .

Given the need for rapid deployment in the setting of the ongoing pandemic from SARS-CoV2, we recommend looking to existing, well-used, and flexible ePPE platforms.

Historically, telemedicine requires HIPAA-certified software, which is complex and expensive to obtain.

Rights lifted historical restrictions from the Health Insurance Portability and Accountability Act (HIPAA) requiring certified telemedicine software [8] . Specifically, they allowed the use of more readily accessible We strongly recommend using an application that is well-known to staff and using end-to-end encryption (current options include FaceTime (Apple Inc., Cupertino, CA), Skype (Microsoft Corporation, Redmond, WA), or Zoom (Zoom Video Communications Inc., San Jose, CA). If our recommendations are implemented, it should be noted that features change frequently, so it is important to evaluate candidate applications for adequate security. Additionally, we encourage consultation with local information technology teams to ensure adherence to network and device security standards.

There is not clear precedent for ePPE-based encounter documentation and billing. We recommend using a streamlined electronic health record-based note to facilitate documentation, guided by local information technology standards. We recommend expedited review by compliance committees for adherence to local policy. We also recommend documenting within the medical record that an MSE was performed using electronic PPE.

The supplementary material contains an example note template that we constructed for use with COVID-suspected patients in our external respiratory fast track using our electronic health record (Epic Systems Corporation, Verona, WI). Local coding and billing standards vary, and collaboration with clinical leaders and coding staff will be essential to successful deployment.

The March 30 th addition of emergency evaluation and management codes during the pandemic combined with the March 30 th EMTALA waiver may provide opportunities for off-site MSEs and associated documentation, though this is out of the scope of this article.[9,10]

We recommend using ePPE to protect staff and conserve PPE while providing rapid access to emergency care and fulfilling EMTALA obligations for low risk patients during the coronavirus pandemic. ePPE has potential applicability to settings such as emergency medical services, medical wards, and intensive care units, where ePPE may facilitate more frequent patient contact while reducing staff exposure and conserving PPE. Contributors: Dr. Turer was the primary author responsible for designing the proposal, drafting the manuscript, and organizing the authorship team. Dr. Jones facilitated compliance and legal review, and contributed substantially to the design of the manuscript. Dr. Rosenbloom provided informatics-specific expertise and contributed substantially to the editing of the manuscript. Dr. Slovis provided operational supervision for the project's design and contributed substantially to the editing of the manuscript. Dr.

Ward was the primary advisor of the study, was deeply involved in the conception and design of the proposal and operational plan, and contributed substantially to the editing of the manuscript

Doctors Say Shortage of Protective Gear Is Dire During Coronavirus Pandemic -The New York Times

'It Feels Like a War Zone': Doctors and Nurses Plead for Masks on Social Media -The New York Times

Medical staff describe shortages and rationing of masks as White House assures they're available 'now

Rational use of personal protective equipment for coronavirus disease 2019 (COVID-19): Interim Guidance

Division of Viral Diseases. Strategies for Optimizing the Supply of N95 Respirators

Covid-19: hoarding and misuse of protective gear is jeopardising the response, WHO warns

Medicare Telemedicine Health Care Provider Fact Sheet

Notification of Enforcement Discretion for telehealth remote communications during the COVID-19 nationwide public health emergency

Centers for Medicare & Medicaid Services. Physicians and Other Clinicians: CMS Flexibilities to Fight

EMTALA) Requirements and Implications Related to Coronavirus Disease

Virtually Perfect? Telemedicine for Covid-19

Systematic review of telemedicine applications in emergency rooms

Use of Telemedicine to Screen Patients in the Emergency Department: Matched Cohort Study Evaluating Efficiency and Patient Safety of Telemedicine

Reliability and validity of a new five-level triage instrument

The safety and effectiveness of minor injuries telemedicine

The application of telemedicine to geriatric medicine

Telemedicine: A Reliable Tool to Assess the Severity of Respiratory Distress in Children

Pediatric Critical Care Telemedicine Program: A Single Institution Review

Diagnosing pneumonia by physical examination: Relevant or relic?

Auscultating to diagnose pneumonia

Diagnostic value of signs, symptoms and diagnostic tests for diagnosing pneumonia in ambulant children in developed countries: a systematic review

Clinical features for diagnosis of pneumonia among adults in primary care setting: A systematic and meta-review

Covid-19: a remote assessment in primary care

The Emergency Medical Treatment and Active Labor Act (Emtala): What It Is and What It Means for Physicians

State Operations Manual: Appendix V-Interpretive Guidelines-Responsibilities of Medicare Participating Hospitals in Emergency Cases

When Does EMTALA Apply? The Semantics of Emergency Care

What Medical Professionals Need to Know

Best Practices -Medical Screening Exam

Emergency Telemedicine: Achieving and Maintaining Compliance with the

Critical Access Hospital (CAH) Emergency Services and Telemedicine: Implications for Emergency Services Condition of Participation (CoPs) and Emergency Medical Treatment and Labor Act (EMTALA) On-Call Compliance

Using Telehealth in the Emergency Department to Minimize Risk to Health Care Providers and Conserve Resources During the COVID-19 Response

Electronic Personal Protective Equipment: A Strategy to Protect Emergency Department Providers in the Age of COVID-19

Supplemental Materials: Proposed ePPE-Based COVID Medical Screening Examination Note For use with Epic EHR, Epic Systems Corporation

@HPIBEGIN@ @NAME@ is a @AGE@ @SEX@ with a chief complaint of: @RFV@ Fever: {Yes/No:36314} Cough: {Yes/No:36325} Shortness of Breath: {Yes/No:36317} Sore throat: {Yes/No:36316} Body aches: {Yes/No:36318} GI Symptoms: {GI Symptoms:36323} Recent travel: {Yes/No:36319} Recent sick contacts: {Yes/No:36320} Contact with person known to be COVID positive: {Yes/No:36322} Symptoms have been present for {COVID SYMPTOM DURATION:36324}. ePPE Used: {Yes/No:36327}

@EDTRIAGEVITALS@ General: Well-appearing patient, no acute distress. Eyes: no icterus, injection, or discharge NECK: soft, supple, no meningismus*** CV: Normal rate, regular rhythm, strong distal pulses*** Resp: No increased work of breathing, symmetric chest rise*** Abd: Soft, non-tender, non-distended*** Neuro: Speaking normally, ambulatory Psych: Awake and alert, affect appropriate @EDMEDS@ @PEEND@@MDMBEGIN@ The patient is a @AGE@ @SEX@ presenting with symptoms concerning for viral illness, including COVID-19. *** Based on the patient's presentation, COVID-19 testing is indicated. SARS-CoV-2 testing ordered. The patient has reassuring vital signs, no signs of respiratory distress, is able to self-isolate, and is appropriate for discharge. We provided self-isolation instructions, a guide for accessing results at the patient portal, and strict return precautions