key: cord-0917700-w3gib5ec
authors: Fisher, Harriet; Re, Cherilyn; Wilhite, Jeffery; Hanley, Kathleen; Altshuler, Lisa; Schmidtburger, James; Gagliardi, Morris; Zabar, Sondra
title: A Novel Method of Assessing Clinical Preparedness for COVID-19 and Other Disasters
date: 2020-09-30
journal: Int J Qual Health Care
DOI: 10.1093/intqhc/mzaa116
sha: 81cc521b9698e9c18584b4d101fd781986590693
doc_id: 917700
cord_uid: w3gib5ec

QUALITY ISSUE: The emergence of COVID-19 highlights the necessity of rapidly identifying and isolating potentially infected individuals. Evaluating this preparedness requires an assessment of the full clinical system, from intake to isolation. INITIAL ASSESSMENT: Unannounced Standardized Patients (USPs) present a nimble, sensitive methodology for assessing this readiness. CHOICE OF SOLUTION: Pilot the Unannounced Standardized Patient methodology, which employs an actor trained to present as a standardized, incognito potentially infected patient, to assess clinical readiness for potential COVID-19 patients at an urban, community safety-net clinic. IMPLEMENTATION: The Unannounced Standardized Patient was trained to present at each team’s front desk with the complaint of feeling unwell (reporting a fever of 101 degrees Fahrenheit in the past 24 hours) and exposure to a roommate recently returned from Beijing. The Unannounced Standardized Patient was trained to complete a behaviorally-anchored assessment of the care she received from the clinical system. EVALUATION: There was clear variation in care Unannounced Standardized Patients received; some frontline clerical staff followed best practices; others did not. Signage and information on disease spread prevention publicly available was inconsistent. Qualitative comments shared by the Unannounced Standardized Patients and those gathered during group debrief reinforced the experiences of the Unannounced Standardized Patients and hospital leadership. LESSONS LEARNED: Unannounced Standardized Patients revealed significant variation in care practices within a clinical system. Utilization of this assessment methodology can provide just-in-time clinical information about readiness and safety practices, particularly during emerging outbreaks. Unannounced Standardized Patients will prove especially powerful as clinicians and systems return to outpatient visits while remaining vigilant about potentially infected individuals.

by providing evaluation and education to a health care system on response to specific patient safety concerns.

Unannounced Standardized Patients are a nimble methodology that can be mobilized to quickly assess the entire clinical system and provide just-in-time information on care related to emerging crises. Unannounced Standardized Patients enable the introduction of a controlled, standardized "stimulus" into healthcare settings (standardizing the patient characteristics, clinical symptoms, medical history, etc.) and provide immediate information on the care they receive. This pilot intervention introduced Unannounced Standardized Patients in February of 2020, a period when COVID-19 was circulating undiagnosed in many regions. They presented with potential COVID-19 symptoms to an urban, community safety-net clinic to assess, or test staff and clinician readiness when faced with a hazardous pathogen.

Clinicians with experience in medical education and simulation -at the request of an urban community outpatient clinic -developed an Unannounced Standardized Patient case to test preparedness for evaluation of an outpatient, potentially infected with COVID-19. The Unannounced Standardized Patient was trained to present at each team's front desk as a 25-year-old female who is a registered patient in the system. The Unannounced Standardized Patient presented with the complaint of feeling unwell (reporting a fever of 101 degrees Fahrenheit in the past 24 hours) and having exposure to a roommate recently returned from Beijing.

The Unannounced Standardized Patient was trained for the case and to complete a behaviorallyanchored assessment of the care she received from the clinical system (11 items), including: 1) response to provided concern and safety protocols followed by front desk staff, 2) overall experience of clinical microsystem and of clinic navigation; and 3) the patient-centeredness of care provided by the team. Training of the Unannounced Standardized Patient took thirty minutes and consisted of patient storyline and overview of the system structure review. Following the visit and prior to completion of the checklist, the Unannounced Standardized Patient participated in a facilitated debrief with clinical staff and leadership. Each visit went undetected until the Unannounced Standardized Patient disclosed that they were an actor during debrief; clinical staff was asked during debrief if they had identified the patient as an actor; they had not. The intervention team also solicited qualitative commentary on the experience from clinical leadership.

Evaluation: 5 Unannounced Standardized Patient visits (n=4) were conducted over a one-month period. Visits revealed variation in degree of clinical preparedness when confronted with a possibly infectious patient; Unannounced Standardized Patients participated in clinical debriefs to provide feedback on best practices and missed opportunities.

In half of visits, frontline clerical staff who first encountered the patient followed best practices in immediately providing a mask and isolating the patient. In both instances, the clinical staff explained the process of isolation to the patient before it occurred. Upon isolation, the Unannounced Standardized Patient reported being visited by a provider for assessment, and further identified them as wearing full personal protective equipment (PPE) (including gloves, gown, respiratory and eye protection) for the duration of the visit. COVID testing swabs were not collected. In half of visits (medicine clinic, lab/radiology), the frontline staff told the Unannounced Standardized Patient to go to another floor or return to the waiting room until further notice without providing a mask or calling a nurse or other clinician to perform a clinical assessment.

Hospital signage for prevention of COVID-19 spread was present in two of the four waiting rooms, and hand sanitizer stations were available in all four waiting areas. Qualitative comments reinforced the experiences of the Unannounced Standardized Patient and hospital leadership (Table 1) .

This just-in-time pilot assessment of an urban community clinic's preparedness for patients presenting with possible COVID-19 or similar emerging infectious diseases captured critical, behaviorally-specific information on team and system performance. Unannounced Standardized Patients gathered three essential pieces of information for hospital leadership including (1) quantitative, behaviorally-anchored information on their experience (2) qualitative, experiential feedback and (3) information from an in-person debrief with the clinical team who cared for them.

Results of the study showed that while clinical systems had protocols in place to engage with patients of possible infectious risk, they were not uniformly implemented. In half of the visits, frontline staff either failed to recognize or solicit triggers that would have merited immediate isolation of the patient. While Unannounced Standardized Patients are an underutilized methodology, we are not the first to employ them for assessing readiness for infectious disease. A pilot study employing Unannounced Standardized Patients to assess infectious disease preparedness in an emergency department found that patients were isolated during 78% of visits and that assessing travel history was correlated with isolation. 8 Our assessment findings were similar. In instances where our Unannounced Standardized Patient was asked travel-related history upfront, they were placed in isolation. Expanding the use and number of our novel methodology to include additional clinical sites in our health system will provide a more thorough understanding of preparedness and allow us to make immediate adjustments to the implementation of safety protocols. Preparing frontline hospitals for emerging infectious disease is critical for the future of patient safety and prevention. 9 Introducing Unannounced Standardized Patients to gather clinical safety data is the first step in identifying the gaps that could lead to systemwide infection.

Deploying Unannounced Standardized Patients provided rapid, inexpensive feedback to the clinical system on its responsiveness to potentially infected individuals. In this quality improvement project, the same Unannounced Standardized Patient case received notably different care at each desk she visited; teams were then able to promptly debrief lessons learned and establish new, relevant protocols. This model can be easily adapted at academic medical institutions who likely have cohorts of standardized patients, who can be trained to present as unannounced. As COVID-19 spreads and 

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