A Blog by Jonathan Low


Jun 16, 2020

Rethinking the Hospital To Prepare For the Next Pandemic

In parts of the US and Europe, urban hospitals dealing with the Covid crisis came close to collapse. Shortages of equipment, of personnel - who themselves were getting sick and infecting yet more patients - and faced with unreliable government backup, they had to improvise and make do.

But thousands of patients died as a result. And with the prospect of second or third waves, as well as future pandemics, hospitals are absorbing lessons learned and redesigning how they work. JL

Laura Landro reports in the Wall Street Journal:

Hospitals don’t want to be caught flat-footed again. More are turning to new protocols and new technology to overhaul standard operating procedure. They are finding ways to triage and check in patients remotely, quarantine the infected in separate facilities and reduce physical contact with caregivers to prevent the spread of disease. And they are improving follow-up with formerly infected patients to look for red flags of disease. The health-care experience may become more automated, becoming less hands-on than people have come to expect. "We have to operate a hospital within a hospital."
Hospitals are rethinking how they operate in light of the Covid-19 pandemic—and preparing for a future where such crises may become a grim fact of life.
With the potential for resurgences of the coronavirus, and some scientists warning about outbreaks of other infectious diseases, hospitals don’t want to be caught flat-footed again. So, more of them are turning to new protocols and new technology to overhaul standard operating procedure, from the time patients show up at an emergency room through admission, treatment and discharge.
They are finding ways to triage and check in patients remotely, quarantine the infected in separate facilities and reduce physical contact with caregivers to prevent the spread of disease. And they are improving follow-up with formerly infected patients—and others—to look for red flags of disease.
The aim is to be able to isolate and treat infectious patients while continuing to provide other vital services that keep people healthy and bring in the revenue hospitals desperately need to keep their doors open.
These changes promise to markedly reduce risk and disease spread—and change the way people experience care even in times when there is no crisis. More aspects of the health-care experience may become more automated and efficient—from check-in through follow-up—but it will also become less hands-on than people have come to expect.
“We have 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,” says James Linder, chief executive of Nebraska Medicine, the teaching hospital and research partner of the University of Nebraska Medical Center, which cared for Covid-19 patients from the Diamond Princess cruise ship.
Here is a look at how a patient’s journey through the hospital is starting to change as pandemics become a looming threat.
Making intake safer
Hanging out in waiting rooms when seeking time-sensitive help at the ER or checking in for surgery has always been one of the great frustrations of hospital care. Now, because of Covid-19 and other potential disease outbreaks, the wait can become deadly.
So, the Covid-19 crisis is pushing hospitals to come up with ways to keep patients out of those rooms.
For instance, more hospitals are remotely triaging and registering patients before they even arrive. Clinicians can consult with patients from their home via telemedicine to help determine how sick they are and if they need to come to the ER at all. From there, admissions are made with as little contact with staff or other patients as possible.
Memorial Health System, which serves counties in the Mid-Ohio Valley, covering southeastern Ohio and northern West Virginia, is using a system from software maker Phreesia called Zero-Contact Intake that allows patients to check in via their mobile devices at two emergency departments, an urgent-care clinic, outpatient clinics and a drive-through clinic that tests patients for Covid-19. At an urgent-care center, for example, signs instruct patients to call from their car. After they answer a few identifying questions, the staff sends them a link so they can complete registration, then follows up with a text telling them when an exam room is ready.
“I can’t imagine how challenging patient encounters would have been throughout the Covid-19 pandemic without a zero-contact intake process,” says Missy Fleeman, Memorial’s director of patient access.
Memorial is also using the virtual registration to reduce risk for maternity patients, who no longer must enter the hospital through the ER. They can register at home or in the parking lot, where a staff member checks their temperature and then escorts them to the obstetrics department with their partners.
The hospital is planning to continue efforts like these after the immediate dangers of Covid-19 have lessened. “We believe all these initiatives have prepared us for any future infectious-disease surges and would expect very minimal interruptions to patient care,” says Ms. Fleeman.
The new safety efforts don’t stop with registering. When patients are ready to enter the ER, they are unlikely to find the traditional single entrance. Those with symptoms of contagious disease will be steered to separate areas where staffers can check them out remotely.
At Boston’s Brigham and Women’s Hospital, an iPad rigged on a four-legged robot called Spot allows staffers to see patients from a safe distance in the ER or a triage tent outside, via a video assessment and a thermal-imaging camera to measure breathing rate, which can change with fever or illness.
Meanwhile, some health-care-design experts are looking for novel ways to separate infectious patients that are more efficient and less stressful for doctors, nurses and patients than the current go-to method—a tent outside the ER.
In Italy, one group is testing the use of shipping containers converted to emergency intensive-care units. And, as part of a 2018 competition for ER design, a team at the University of Kansas designed a chassis called an Ubulance with detachable containers that could be connected to the emergency department like planes docking at an airport gate. The containers could provide care space in an infectious-disease surge, while creating a quarantine zone. Patients would never enter the core emergency department until they were safe for transport, according to Frank Zilm, team leader of the project and director of the university’s Institute for Health and Wellness Design. The containers could be stored off-site and transported back to the hospital as needed.
In addition, as hospitals begin to admit patients for regular procedures like elective surgery, labor and delivery, new safety measures aim to reassure patients it is safe to come.
When the pandemic began, Nebraska Medicine accelerated the rollout of a new feature of its electronic medical records, Digital Front Door, that allows patients to register 14 days before a scheduled visit and check in the day before, at the same time reviewing or updating their medications, allergies and health history.
A geolocation feature can automatically check in patients as they approach the hospital. Patients who have used Digital Front Door or called ahead are directed to specific entrances to wait in cars and be escorted to minimize risk. Staffers are stationed at all entrances to survey patients who, based on symptoms, get a green, red or yellow sticker; green-sticker patients can check in at electronic kiosks if they didn’t check in before arrival, and higher-risk patients are escorted directly to care rooms.
“Everything we are doing is to try to provide a safe experience for patients and providers,” says Michael Ash, Nebraska’s chief transformation officer.
Like Memorial, Nebraska Medicine intends to continue these efforts after the current crisis subsides “both because patients prefer the convenience and to prepare for any future disease outbreaks,” Dr. Linder says.
Preparing for a surge
But preparing for a crisis doesn’t mean just making the traditional emergency room safer. When a crisis hits, hospitals are often hugely overcrowded, so patients are often stuck waiting for attention from overworked staffers. And that can mean catching an infectious disease like Covid-19 or worsening your condition due to other hazards and infections if you are already afflicted.
“It’s very important to prevent the hospital from becoming a disease amplifier,” says Dr. Richard Waldhorn, a contributing scholar at the Johns Hopkins Center for Health Security who studies hospital emergency preparedness and clinical professor at Georgetown University School of Medicine.
Rush University Medical Center in Chicago opened a new tower in 2012 designed to treat infectious disease without exposing other patients. Dino Rumoro, chairman of emergency medicine, says an entire wing at Rush can be converted within hours into a negative-pressure ward—where rooms are equipped with technology that prevents airborne diseases from escaping, increasing its isolation-room capacity to 100 from 40.
Rush also designed its main lobby with medical gases, suction and electrical power in its structural pillars, which can be deployed quickly to let the lobby handle space needs in a massive patient surge. In April, the hospital prepared and used the space to treat non-Covid patients.
The Cleveland Clinic in Ohio temporarily converted the Health Education Campus it shares with Case Western Reserve University into a 1,000-bed surge hospital during the pandemic, with 327 of its patient beds for low-severity Covid-19 patients; it will decide soon when to return the space to its original use but leave infrastructure in place so it can ramp up again if necessary. The hospital can also convert areas in its main building such as postanesthesia units to serve as intensive-care units.
Some large regional health-care systems have built new emergency departments with better disaster preparation. In Marietta, Ga., WellStar Health System’s WellStar Kennestone Hospital will soon open a 263,000-square-foot emergency-department building. The facility will double the hospital’s current emergency and trauma capacity, enabling it to treat more than 600 patients daily. It includes dedicated isolation and decontamination rooms that can be used for patients who present with infectious disease, behavioral-health or chemical-contamination issues, and multiple entrances for different levels of patient severity.
Rather than being stacked up in a crowded waiting room, patients will be fast-tracked quickly into individual rooms. Across the street from the main hospital and medical-center campus, the new building is connected by a bridge with two levels so patients and clinicians can always be separated from visitor traffic, and it has its own imaging and X-ray facilities so patients don’t have to be transported to the main hospital for tests.
“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,” says Mary Chatman, executive vice president of WellStar and president of the Kennestone hospital.
Keeping doctors and patients at a distance
Once patients are admitted to the hospital, they continue to be at risk for infection, whether in the intensive-care unit, the surgery suite or regular rooms, since diseases can be spread by staffers’ hands and contaminated surfaces.
To make it safer for patients and staffers alike, some hospitals are trying to limit contact. Patients may see less of their doctors and nurses—or at least see them more via video consults—as tech takes over some nursing and monitoring duties.
Instead of the usual practice of making rounds in hospital wards with a crowd of doctors gathered at the patient bedside, the Cleveland Clinic is doing virtual rounds with one doctor in the room and others connected via videoconference outside. In intensive-care units, instead of placing IV poles and monitors next to the patient, they are now positioned outside the room so nurses can check patients’ status without unnecessary exposure for both, according to James Merlino, the Cleveland Clinic’s chief clinical transformation officer.
“Managing this pandemic has taught us a lot about how to keep patients and caregivers safe,” says Dr. Merlino. “As we turn society back on and get patients in for the care they need, we know we can protect them.”
Still, he stresses that patient care won’t suffer because of the protective measures. Nurses are still in rooms when hands-on care is needed. And to ensure there are enough doctors to lend a hand for critically ill patients, the Cleveland Clinic has a program to train teams of 10 doctors in different specialties that are in less demand during a pandemic—including surgeons, rheumatologists and pediatricians—to work in intensive care if needed due to a surge in cases.
In addition, more hospitals are putting devices in patient rooms that can be used for consults and virtual family visits. At Texas Health Resources, which operates 27 hospitals, tablets are placed in emergency-department rooms and controlled by other tablets kept outside the room. Doctors use them to take an initial history from patients in isolation or ask follow-up questions, and nurses use them to check on patients more often without risking exposure.
At the University of California San Diego, researchers are building robots with tablets that go into patient rooms for telehealth visits. In addition to keeping unnecessary exposure to a minimum, it potentially enables doctors to have more-frequent visits with patients because they don’t need to take time to don and doff protective equipment, says Dr. Laurel Riek, professor of computer science and engineering and director of the Health Care Robotics Lab.
Mechanized helpers may also see more service in hospital wards. Before the pandemic, robots were being adopted to perform tasks that take nurses away from direct patient care, such as fetching and delivering medications and supplies to patient rooms and handling lab samples. Now some hospitals are using robots for help with disinfection, such as shuttling ultraviolet-light machines that kill germs from room to room. And a robot design called Moxi is being used more often to deliver clean personal protective equipment and testing supplies, according to manufacturer Diligent Robotics.
One concern is that robots used to perform more hands-on care in infectious-disease outbreaks might upset or frighten patients.
“Patient care isn’t just inserting an IV and taking vital signs, there’s also the connection between the clinician and the patient,” says UCSD’s Dr. Riek. “In cases of patients who are isolated for weeks at a time, this connection is especially important as they are not receiving frequent human contact.”
Doing better follow-up
Readmissions are a persistent issue for patients who are being treated for any condition. Diseases like Covid-19 heighten the risk, especially for people with other issues, such as diabetes and heart disease, that can be aggravated by an infection.
Now health-care facilities are stepping up efforts to track patients at home—a system that is useful at any time, of course, but particularly critical when a disease crisis could arise quickly.
So, caregivers are providing patients with devices linked to their electronic-medical-records systems to check on things like blood pressure, oxygen levels and heart rate. Hospitals are also mining electronic health records to determine which patients in their population might be more vulnerable to infection, such as those who are older or have chronic health conditions such as diabetes and kidney disease.
Nebraska Medicine created a symptom tracker and quarantine tracker that lets patients record their symptoms daily from home, and if there are issues, the system walks them through an eVisit—an online questionnaire whose answers go into a queue that is reviewed by a doctor or other clinician. If a person is asymptomatic but directed to quarantine, the system does a daily check-in, and after the prescribed duration of the quarantine, it generates a certificate patients can use to send to anyone, such as an employer or university, if needed to enable them to return.


The Cleveland Clinic and its medical-records vendor, Epic Systems, developed a Covid-19 home monitoring program for patients with confirmed infections who are isolating at home, as well as for patients discharged after a hospital stay. Patients can use a mobile device to enter symptoms including temperature, and clinicians monitor responses and step in if a patient’s condition worsens.
The technology won’t just help improve preparedness for a crisis, it will also help patients overall, says Dr. Merlino of the Cleveland Clinic. “We intend to use the same technology to follow up on a variety of different types of patient-care issues,” he says.
For example, he says, newly diagnosed heart-disease patients, who need frequent checkups and possibly adjustments to their medication, could use the system to relay important data to their doctors remotely.
“The applications are really limitless,” Dr. Merlino says.


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