key: cord-0852202-nqmhgd8v authors: Callagy, Patrice; Ravi, Shashank; Khan, Saud; Yiadom, Maame Yaa A.B.; McClellen, Hannah; Major, Thomas W.; Yefimova, Maria title: Operationalizing a Pandemic-Ready, Telemedicine-Enabled Drive-Through and Walk-In Garage Care System as an Alternative Care Area: A Novel Approach in Pandemic Management date: 2021-06-03 journal: J Emerg Nurs DOI: 10.1016/j.jen.2021.05.010 sha: 6d00ac4580209bd3db8c11a837c8474625c38afd doc_id: 852202 cord_uid: nqmhgd8v Objective: Emergency departments (ED) face unforeseen surges in low-acuity patients during pandemics, such as COVID-19. Streamlining patient flow using telemedicine in an alternative care area can reduce overcrowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment (PPE) use. This quality improvement project describes critical elements and processes in the operationalization of a Telemedicine-Enabled Drive-through and Walk-in Garage Care System (Tele-Garage) to improve ED throughput and save PPE during three COVID-19 surges in 2020. Method: Standardized workflows were established for the operationalization of the Tele-Garage for patients presenting with respiratory illness. Statistical control charts present interrupted time series data on the ED length of stay (ED-LOS) and PPE use in the week before and after deployment in March, July, and November 2020. Results: Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the Tele-Garage. On average, ED-LOS decreased 17%, from 4.24 hours during the week prior to opening to 3.54 hours during Tele-Garage operation. There was an estimated 25-41% reduction in PPE use during this time. Conclusion: Lessons learned from this effective telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce overcrowding, improve throughput, and conserve PPE during a pandemic. Pandemics and other disasters create sudden and unique challenges for emergency departments (ED). The rapid patient volume surges that accompany pandemics can quickly tax already-crowded, resource-limited ED. Overcrowding is known to have negative impact on patient outcomes including increased mortality. 1, 2 This issue becomes more pressing when contagious infectious diseases necessitate that health care workers use personal protective equipment (PPE). 3 Supply shortages increase the risk of exposure for both health care workers and other patients. 4, 5 Together, potential overcrowding and PPE shortages necessitate novel approaches to managing ED throughput during pandemics. Coronavirus disease 2019 (COVID-19) pandemic provided an impetus for innovation in the ED since previous disaster preparedness protocols may be insufficient in managing the influx of low-acuity patients with influenza-like illness (ILI). 6, 7 Studies report that although ED visits decreased in the early months of the pandemic, as new COVID-19 cases rates increased locally, so did the admissions from the ED. 8 Multiple case studies have described new operational processes for triage, patient placement, diagnostics, and treatment in response to the pandemic. 3, 9, 10 Yet, few have proposed optimizing patient flow using telemedicine to enable physical distancing and thus reduce PPE use while interacting with patients. 11, 12 This paper describes a quality improvement evaluation of a novel patient flow process that utilizes a telemedicine-enabled alternative care area with drive-through triage to assess and test patients during the COVID-19 pandemic. The lessons learned from the implementation of the Pandemic-Ready, Telemedicine-Enabled, Drive-Through and Walk-in Garage Care System an provide clinical and operational surge capacity guidance to other EDs in preparation for future pandemics. The ED is located in the western United States (US) in a county that reported the first recorded COVID-19 death. 13 The ED was among the first in the US to experience census increases with worried patients experiencing ILI, following potential exposures to positive COVID-19 cases, and possibly exposed staff as patients. Hospital and ED leadership realized that an alternate care area was necessary to care for the rapidly increasing census of low-acuity and potentially exposed patients to create capacity for a possible surge of critically ill ED patients. At the time of the implementation, a literature review for ED surge and capacity response included in our previously published garage simulation for the H1N1 virus in 2009 using a drive-through triage and care system. 14, 15 While there have been descriptions of various triage and patient placement strategies in the ED, 3,16,17 few focused on the utilization of telemedicine. More recently, one academic medical center used iPads to reduce exposure and conserve PPE, 18 while another has used telemedicine carts in the ED-COVID-19 isolation rooms. 11 None have described the use of an alternative care area to streamline ED throughput using telemedicine. The fundamental premise of the proposed ED redesign hinges on an efficient patient flow using a drive-or walk-through system in an alternative care area that is enhanced with telemedicine (i.e., the ED parking garage). Telemedicine refers to the provision of remote clinical services, via real-time two-way electronic communication between the patient and the healthcare provider. 19 The combination of drive-through patient flow and remote telemedicine-based assessment allows for increased physical distancing between the patients under investigation (PUI) for COVID-19, streamlining throughput and reducing overall ED length of stay (ED-LOS). Telemedicine also reduces the need for PPE for remote providers. The goal of this quality improvement project was to evaluate the implementation of the Pandemic-Ready, Telemedicine-Enabled, Drive-Through and Walk-in Garage Care System (Tele-Garage) on ED-LOS and the use of PPE during the multiple surges of COVID-19 pandemic in 2020. The design and implementation of Tele-Garage was based on previous iterations of a drive-through triage and care system. 14 The addition of telemedicine component required changes to the infrastructure and patient flow. The throughput process was designed to screen, evaluate, and test low-acuity ED patients and was scaled for high-volume minimal contact, and PPE conservation. Quickly operationalizing the Tele-Garage from inception to active deployment required collaboration between multiple departments, including ED nurse and physician leaders, Information Technology (IT), Parking and Transportation Service (PTS), clinical engineering and the Office of Emergency Management. The Tele-Garage was operationalized within twelve hours with walk-in and drive-through routes, IT infrastructure, staff, standard work, and telemedicine. The state Department of Public Health authorized the use of the parking garage as an alternative treatment area. Table 1 shows the logic model of the Tele-Garage. Walk-in and drive-in patients were screened by an RN to determine if they were low acuity with ILI. Eligible patients were remotely registered, and secure text messaging was used to exchange clinical information. The patient was assessed, swabbed for a COVID-19 test by physician protocol, participated in a telemedicine visit with the provider, and then discharged. This process required critical elements of infrastructure and optimized patient flow, described in the Results. PPE was conserved via multiple mechanisms. First, instead of the requirement to don and doff between each encounter when in a room, RNs wore the same gown, N95 mask and hair protection when patient was in the vehicle, unless patient was coughing, removing them only during breaks. Gloves were changed between each patient with use of portable hand washing sink or gel. Registration clerk and the medical provider were remote and did not require change in PPE between patients. We evaluated effectiveness of Tele-Garage to increase ED throughput for low-acuity patients and reduce PPE usage using continuous quality improvement methods. Operationalization challenges were tracked and resolved using Plan-Do-Study-Act methods. 20 A quality analyst extracted data metrics for the time period. the Tele-Garage was in use. Data was derived from the Electronic Health Record (EHR) database. Consistent with other studies, 21 daily average ED-LOS was measured in hours from the time of initial presentation to the time of departure from the ED for all patients presenting in a 24-hour period starting at midnight. The percentage of patients with ED visits less than one hour based on the ED-LOS was calculated. One-hour interval was chosen because it was hypothesized to be an average time for a patient to go through the Tele-Garage. PPE usage was estimated based on the number of PPE sets (gloves, fluid repellent long sleeved gown, eye protection and N95 mask) 5 expected to be utilized per low acuity patient prior to and during Tele-Garage implementation. Statistical process control (SPC) plots were used to visualize the interrupted time series prior and when the Garage System was deployed. SPC plots are a quality improvement tool that graph how a process changes over time when an intervention is introduced. 22 The x-mr chart was used to display individual measurements (x) and the moving range (mr) of ED-LOS and PPE use. The p-chart tracked the proportion of patients with ED visit less than 1 hour, which has similar properties to the X-MR chart. We expected the average proportion of patients with ED > 1 hour to increase with each Tele-Garage opening. The project was reviewed by the facility privacy and compliance office and was deemed quality improvement not requiring Institutional Review Board evaluation. Infrastructure. To transform the ED parking garage into an operational telemedicine-enabled alternative care area, IT engineers installed the infrastructure for wireless connectivity. The Tele-Garage then supported internet-enabled equipment, including portable clinical and registration computers, a patientidentifying wristband printer and a paper printer, wireless workstations on wheels (WOWs), and a telemedicine conferencing system. It was also equipped to support a wireless radiology machine for chest x-rays and a wireless point of care system for blood testing. An electricity generator situated outside the Garage provided power to all the wireless equipment. Processes for daily set-up and breakdown/storage were evaluated prior to developing a standard work sheet to promote consistency between staff. They included turning on the generator, attaching extension cords, and placement of WOWs, swabs, and PPE. Table 2 presents the screening questions and inclusion/exclusion criteria. Nonleading questioning were used for an initial identification of patients' presentation to the ED, such as -What brings you to the Emergency Department today?‖. Identification of fever, cough, sore throat, or shortness of breath and without major medical history were used to rule-in patients. Patients who presented without any symptoms but were concerned about potential COVID-19 exposure were also included. Registration. Once patient was screened as clinically appropriate for treatment in the Tele-Garage, the Screener RN sent a secure text message with a picture of the patient's identification and phone number to the registrar located in the main ED. Swabbing. To increase throughput, a protocol was developed which allowed the RN to order a COVID-19 swab per protocol, with provider signature to follow. Based on patient symptoms, the RN initiated a COVID-19 swab protocol order while the patient waited for the medical provider to appear on the telemedicine display. Flu tests were also ordered on the same COVID-19 swab until the end of flu season. Additional orders sometimes also included a rapid strep throat swab test. The RN scanned the patient's armband taped to the vehicle's window and acknowledged the order within the EMR, which allowed the patient's order sticker to print from the WOW. The order sticker was checked with the patient to confirm patient identification and placed on the outer container of the swab. A bright green COVID-19 sticker was also placed on the lid of every swab to notify the lab to take extra precautions, prior to placing it in a single biohazard bag. A lab runner retrieved specimens from the garage every fifteen minutes. A key aspect of the Tele-Garage is the integration of telemedicine to enable remote assessment of pre-screened patients. While telemedicine already had limited use in the ED, it required a nurse co-located in the room with the patient to initiate the software. The platform was modified to be contactless and automatically answer after two rings. No physical contact was required by the patient to operate the telemedicine platform. The telemedicine platform on wheels was positioned near the patient and the camera was adjusted for full patient view. A speaker was positioned at the average level of a seated car driver. The RN notified the ED provider via a secure text message to initiate the telemedicine visit. The provider used a desktop computer within a consult room of the main ED. Upon conclusion of the visit, the provider communicated with the RN through the EMR to initiate discharge. Occasionally, the ED provider securely texted the RN to notify that the patient was to be brought to the main ED based on additional information learned during the telemedicine assessment. Discharge. Pre-printed, standardized discharge instructions available in multiple languages were given to each patient. They included information about test results, including their availability on the hospital MyHealth app within 9-12 hours. A paper printer located in the Garage printed additional discharge instructions, if needed (e.g., for patients receiving a strep test in addition to the COVID-19 swab, or instructions about how to reduce a fever). The Tele-Garage, located in close proximity to the main ED, was an essential component in the optimization of care for low-acuity ILI patients, ED throughput, and staff and patient safety from exposure during the COVID-19 pandemic. It resulted in a reduction in both face-to-face patient interactions and contact time. Physical distancing was maintained, except for the necessary swabbing, and consequently provided an additional level of protection to patients who were concerned about exposure from other patients at an ED. The ED-LOS for patients seen through the Tele-Garage was notably lower compared to usual care in the main ED the week prior. The processes implemented allowed for appropriate resource allocation and maximization of ED rooms for higher acuity ILI patients and patients with non-ILI chief complaints. Additionally, telemedicine eliminated the need for PPE for registrars and providers. Unfortunately, we could not perform a cost estimate analysis of PPE savings due to unreliable data from the supply chain. Telemedicine has been embraced during COVID-19 pandemic as an alternative care modality to reduce minimize front-line provider exposure and conserve PPE. 25 Few case studies have explored using it in the ED to provide physical distancing and reduce interactions with PUI for COVID- 19. 11,18 Our project is the first that combined using an alternative care area such as a parking garage to streamline patient flow for high volume triage in addition to using telemedicine for patient assessment. While the Tele-Garage was deemed an overall success, it overcame several challenges in the three iterations of its deployment. The flow changed with each opening to become even leaner. At first, the screener RN taking a picture of the driver's license or identification card and sending it securely to registration. With higher patient volume in December 2020, it became more efficient to station Registration outside at the opening of the garage to perform a 2-minute registration with a WOW. Triage was also moved to right after registration to leave the treatment area for treatment only. We had the driver turn off the engine to avoid exhaust during the registration, triage, and treatment stages. Each day, a car would not restart. We obtained jumper cables and would jump the car by asking the driver of the car next to them if they could assist. There are limitations to the generalizability of our approach. Other healthcare facilities may not have the facilities (e.g. physical garage space) or the resources to quickly enable wireless connectivity for remote communication with the main ED and telemedicine visit. Additionally, this alternative care area would still be prone to weather elements, especially in harsher climates. The Tele-Garage did not have climate control, with no heat in the winter nor cooling in the summer, which could have impacted staff productivity and satisfaction. Because our facility is in a mild climate area, this was not identified as a pressing issue. Future work may focus on evaluating staff and patient satisfaction with care in the Tele-Garage. Rapid change during disaster situations will continue to challenge emergency nurses. The COVID-19 pandemic was one of those untested challenges. The American Nurses Association Code of Ethics states that nurses have the same obligation to self as to others. Emergency Department leadership worked with staff to find ways to keep staff safe while meeting our ethical obligations to care for infectious or potentially infectious patients. Development of the Tele-Garage is an example of a patient care and flow process which greatly assisted in meeting staff safety and the ethical obligations of patient safety and treatment. A disaster event can be acute, such as a terrorist/natural disaster or evolving, such as the COVID-19 pandemic. The safety of the healthcare team and conservation of safety equipment, such as PPE must be considered during any disaster situation. Utilizing the Tele-Garage has now proven a safe and reliable way to provide care for low acuity pandemic patients. In the future this model can be transitioned to care for low acuity patients from natural disasters, flu surges and potentially contaminant scenarios, creating capacity of higher acuity patients within the ED footprint. Our proposed and evaluated new model of telemedicine-enabled alternative care area patient workflow, the Telemedicine-Enabled Pandemic Garage Care System, can be used as a blueprint by EDs to develop and rapidly implement their own plans to manage low acuity patients safely and effectively. This model can be applied for other surge capacity such as infection contamination scenarios with a surge of communicable infection complaints or to treat minor injuries following natural disaster. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. 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