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Executive Summary

Executive Summary

As the coronavirus disease 2019 (COVID-19) pandemic spreads across the globe, providers, governments, and other stakeholders are developing strategies to prepare for and respond to the surge of testing and treatment demands associated with the virus.

As Cerner interacts with health systems around the world, who are in various stages regarding COVID-19-specific response, most are following strategies aligned with the Plan, Build, Supply and Staff, and Operate framework across different venues of testing and care. The framework is described as follows:

  • Plan: Anticipate needs for testing surge and begin planning.
  • Build: Build the necessary infrastructure to meet the response, such as facility modifications, technology, computing environments, and systems.
  • Supply and Staff: Equip the organization with the appropriate equipment, supplies, and staff members.
  • Operate: Support operations and the continuous evolution of workflows, staff, and systems to support real-time learning and adjustments to address the changing dynamics your teams will experience.

In support of this framework, Cerner has created our support strategies to align with this approach. These strategies are rapidly evolving as the pandemic progresses throughout different parts of the world as will Cerner’s efforts evolve to support client needs. Cerner encourages you to share additional strategies and workplans you find effective in the COVID-19 Client Collaboration Forum in uCern Connect. Together, we can share this knowledge and help others who are working to combat the pandemic across their communities.

General Surge Expansions Considerations

Assumptions

The following assumptions are made with the general surge expansion considerations:

  • The organization has activated their Incident Command System (ICS) as part of their emergency response to COVID-19 as a public health crisis.
  • The organization ICS includes the combination of facilities, equipment, personnel, procedures, and communications designed to aid in the management of resources during the incident response.
  • Health systems, as a participant in your regional emergency operations centers addressing the COVID-19 crisis, will receive value from a standardized supply and demand data set to track their progress in meeting the needs of their communities and their workforce.
  • The organization recognizes the importance of standardizing operational and patient impact metrics for response to regulatory or public health agency requests.
  • The following assumptions are made in regard to electronic health record (EHR) configuration for surge capacity:
    • Cerner-recommended configuration guidelines are being used based on early client experiences. These configuration recommendations continue to evolve and are published on the COVID-19 Recommendations page on Cerner.com.
    • For location configuration, the organization will start with a copy of an existing unit and modify the unit as needed.
    • The existing naming structure will be used to minimize downstream affects. Consider adding a naming convention that is easily identifiable so that you can remove it later.
    • Billing addresses currently used will be the same as existing addresses.
    • Existing interfaces will be used when possible for the location build (many can accommodate additional beds to an existing unit).

Cerner suggests tracking the following key metrics and makes available a configuration guide that supports standardized reporting tools.

  • Health System Capacity and Volume/Utilization:
  • Beds: Total Capacity and Utilization Rates (Conventional and Disaster/Expansion)
  • Critical Care Beds: Total Capacity and Utilization Rates (Conventional and Disaster/Expansion)
  • Emergency Department Capacity (Conventional and Disaster/Expansion)
  • Emergency Department Visits (Last Calendar Day 2400-2359)
    • By complaint or disposition diagnosis (such as respiratory illness or influenza-like illness)
  • Mechanical Ventilators: Total Capacity and Utilization Rates
  • Operating Room Capacity (Conventional and Expansion)
  • Surgeries Scheduled (Daily); Elective, Urgent, Emergent
  • Advanced Imaging Capacity and Utilization: CT Scanning Capacity and Utilization
  • COVID-19 patient only capacity and utilization
  • Isolation Beds (contact, droplet, negative pressure rooms); (Conventional and Disaster/Expansion)
  • Morgue Capacity: (Convention and Disaster/Expansion)
  • Workforce Capacity (By role, skill set or certification, and COVID-19 status)
    • RNs Needed, RNs Scheduled, RN Sick Calls
    • RTs Needed, RNs Scheduled, RT Sick Calls

Supply Chain Impact

  • Personal Protective Equipment 
  • N95 masks (sizes small and medium), number on hand 
  • Masks with face shields, number on hand
  • Gowns, number on hand

Respiratory Testing Capacity

  • COVID-19 testing kit inventory and utilization
  • Influenza testing kit inventory and utilization

Patient Impact

  • Patient COVID-19 Testing Status (Positive, presumptive positive, patients under investigation)
  • Number of COVID-19 Hospital Patients
  • Number of COVID-19 Patients on Mechanical Ventilator
  • Currently Admitted COVID-19 Patients on Ventilators
  • Number of COVID-19 Hospital Onset Patients
  • Number of COVID-19 Overflow PatientsNumber of COVID-19 Patient Deaths (Last Calendar Day 2400-2359)

Core Infrastructure

It is imperative that your technology team evaluates whether your system has enough computing and other technology capacity – including storage and network – to handle the load of additional units, beds, or locations to ensure that your system is highly available and performing at the level your clinicians need. Also evaluate your user devices and biomedical equipment.

Complete a system capacity and performance analysis across the full spectrum of your system technology architecture, Provide an assessment of your system capacity, including the following items:

  • Storage
  • Database hardware
  • Application hardware
  • CareAware® hardware and service deployment
  • Citrix® (User access layer)
  • New workstation and printer configuration if new locations are being added.
  • Network
    • Internal network capacity, including the VPN between facilities, to ensure that additional load can be handled.
    • If new network range is added for a new location, ensure that all ACLs are opened and applied for connectivity.
    • Wired or wireless network connectivity.

If you are a Cerner client and use the Cerner remote-hosting technology services (RHO), work directly with your CernerWorks client owner, who will collaborate with you on this scalability evaluation. As a preparatory step, it is important to document and share your specific plans with your client owner. This includes if you are adding additional facilities and how many units, beds, and staff will be added.

User Devices

Reasonable access to the appropriate user devices plays an essential role in preparing for surge capacity. While you must take into consideration a number of variables (such as venue, flow, resourcing, networking, and so on), a number of constants exist as well. Cerner recommends limiting the sharing of devices to limit cross touching, which can lead to contamination. Whenever possible, consider using medical grade, disinfectant ready devices. Consider implementing the following general department user guidelines regarding these devices:

  • Communication device
    • Mobile
    • Stationary
  • Workstation – Input device
    • Laptop
    • Desktop
    • Handheld device
    • Thin Client
    • WOW
    • Medical grade monitor, keyboard, and mouse
    • Downtime workstations
  • Peripherals
    • Barcode scanner
    • Document scanner
    • eSignature device
    • Dragon® Medical One microphone or PowerMic Mobile® license
    • Badge reader
  • Printers
    • Laser printer
    • Wristband printers
    • Label printers
    • Prescription printers
    • Printer label stock
  • Tracking Boards
    • CareAware Capacity Management®
    • Laboratory
    • FirstNet®
    • Perioperative

Biomedical Devices

As additional beds are opened for use, a review of basic connectivity for medical devices is required. Common items to include with the review are sufficient power outlets and capacity, network connectivity, environmental controls, and capacity of vendor systems (such as monitor gateways) to add devices. As beds may require different devices depending on the use case, it is best to include biomedical engineer staff in initial discussions to ensure that these considerations are taken into account.

If you need additional technology analysis or are experiencing technology or staffing limitations, contact your Cerner client account executive.

The following list includes recommendations for managing your workforce with general surge expansion considerations:

  • Scope of practice for licensed professionals: Work with your department leaders, Human Resources partners, medical staff governance, and local licensing bodies to examine scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, radiology technicians, physical therapists, and medical assistants. These may be sources of delegated clinical care during maximum capacity demands.
  • Licensing: Work with the appropriate licensing bodies and academic partners to expedite licensing for near-graduates and nonproductive foreign medical graduates. Additionally, examine the relicensing of retired health care professionals or those not currently in direct patient care roles.
  • Supplementing Critical Care Intensivists: Work with medical leadership to coordinate hospitalist coverage to cover and scale the increase in critical care medicine consults.
  • Communication with your workforce: Work with your HRO and marketing or communications department to develop a daily messaging strategy to stay in communication with your workforce. Communicate both new clinical information as well as guidance on anxiety management and other support resources.
  • Prescreen employees: Follow your organizational policy regarding the screening process for staff members before their work assignments.

As your organization evaluates opportunities to extend locations by opening new rooms and beds or opening new facilities, Cerner's recommendation for laboratory services is to use your existing laboratory services wherever possible. Instead of opening a new laboratory location, use your existing laboratory locations, even if the plan for the new location may include a new laboratory in the future. To extend your new patient care locations to your existing laboratory services, define the test routing and specimen tracking configurations to accommodate the new locations. Reference Pages are available that contain configuration and design steps on the following topics:

Testing for Active Infections

Testing for COVID-19 Antibodies

Blood Bank Transfusion

Reporting and Notification

Reference Laboratories

Instrument Interfaces

Syndromic Surveillance and Electronic Lab Reporting

See COVID-19 Laboratory in Model Experience for more information.

Additional Considerations for Free-Standing Pediatric Hospitals

The pediatric population presents specific considerations when planning for a surge. Topmost is the need to plan from a community perspective rather than in the hospital. Decisions to transfer or divert any adult or pediatric patient should be made collaboratively and with the engagement of state and local government as necessary and appropriate.1 In addition, when planning for visitors, the needs of the family must be addressed. The following recommendations were based on published guidelines as well as direct communications with multiple freestanding pediatric hospitals, including Children’s National, Nicklaus Children’s Hospital, Children’s Hospital of Orange County, and other free-standing pediatric hospitals across the U.S.

Unique Considerations for Pediatric Hospitals

  • For pediatric patients, it is a necessity to include at least one family member to accompany the minor throughout their treatment journey.
  • Although pediatric hospitals do not treat and manage adults, in the situation of a pediatric patient testing positive and the accompanying family member has symptoms, each organization should develop a policy on whether to test family members. Regardless of the decision to test family members, encourage self-quarantine encouraged for stable patients with mild conditions.

A Local, National, or International Outbreak has Occurred

  • Although hospital capacity has not increased, planning incorporates local needs.
  • Begin increasing capacity. Consider adding additional ED beds, tents, or both.
  • Consider converting inpatient beds to meet potential demand increase, with particular focus on the physical equipment appropriateness by age group. Medications and medical supplies as well as orders, documentation needs, and evaluate CDS tools for adults for managing a potential influx of older pediatric or even adult patients.
  • Coordinate with other local hospitals to determine the feasibility of accepting additional pediatric patients.

Contingency Planning

  • Transfer of pediatric patients from local hospitals that are nearing capacity.
  • If accepting area patients, consider privileging pediatricians from sending hospital to augment receiving hospital staff.
  • Consider increasing age limits and accept patients from local area. COVID-19 experience has resulted in upper age limit increased anywhere from 25- to 30-year-old.
  • Plan for a potential crisis level:
    • Consider temporary or emergency privileges for adult medicine providers from partner hospitals.
    • Consider position configuration and training for those adult provider positions in EHR. This includes orders, documentation needs, evaluation, and CDS tools.

Crisis Planning

  • Consider accepting adult patients, focusing on those with minimal comorbidities and lower acuity.
  • Credential physicians to see adult patients based on credentials in good standing with partner hospital. Follow the process for granting temporary privileges during a disaster according to medical staff bylaws of the respective organization.2
  • Increase the nurse pool by adding to the roster and confirming a valid license, in good standing.
  • Ensure appropriate onboarding and training to support new staff.
  • Ensure balancing the needs of an expanded patient population with staff experience and skill.

Reference:

  1. “Coordinating Hospital Care for Children to Increase Capacity for the Surge in COVID-19 Patients.” Children's Hospitals, 3 Apr. 2020, www.childrenshospitals.org/-/media/Files/CHA/Main/Quality_and_Performance/covid19/covid_cha_pediatric_consolidation_guidance.pdf.
  2. “Credentialing and Privileging - Temporary Privileges.” The Joint Commission, 3 Oct. 2019, www.jointcommission.org/en/standards/standard-faqs/critical-access-hospital/medical-staff-ms/000002257/.
  3. “Critical Updates on COVID-19.” American Academy of Pediatrics. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/
  4. “FAQs: Management of Infants Born to Mothers with Suspected or Confirmed COVID-19.” American Academy of Pediatrics. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/faqs-management-of-infants-born-to-covid-19-mothers/

The following learning strategies and considerations are recommended during general surge expansion considerations:

  • Deploying existing training models to meet the need of rapidly deploying a workforce to meet surge demand may not be possible. For this reason, Cerner recommends scaling back virtual or in-person content to include only essential information. This may mean to expect and plan for higher levels of end-user support as staff and providers get started.
  • Training strategy may need to flex based on time to deploy additional staff. Consider using a combination of videos from the eLearning Library, learning journeys through the Cerner Learning Framework, remote training and coaching or existing organization-specific training materials depending on time available to train new staff.
  • Essential eLearning is available to support quickly onboarding new or redeployed staff. For organizations with the Cerner Learning Framework, the Surge Essentials Learning Journeys can be imported into the learning portal. This learning content can also be accessed as a web course: Surge Essentials Learning. Additional roles may be added to this learning content.
  • Additional considerations:
    1. What knowledge does the additional staff have today? Are they currently using Cerner solutions and being redeployed to a new area, or are they new users?
    2. How will staff be notified of training?
    3. What devices will staff use to complete training?
    4. What kind of tracking of learning completion is necessary?
    5. Have help desk staff been trained on new locations and technology usage?

Note that this guide is intended to serve as a tool for surge planning and operations. The detailed configuration operations and recommendations are available on the COVID-19 Recommendations page on Cerner.com.

In addition, Cerner has provided a platform for clients to collaborate on their COVID-19 response in the COVID-19 Client Collaboration Forum.

Field Screening and Testing Surge

Assumptions

The following assumptions are made with the field screening and testing surge:

  • Enhance patient and provider safety by limiting exposure and maximize resource utilization.
  • Maintain compliance with EMTALA regulations while implementing new screening and testing capabilities.
  • Options for screening and testing can include drive through and alternative field testing sites to decrease risk of exposure to others.

The following list includes planning recommendations for field screening and testing surge:

  • Facility Planning Principles: Each organization’s facility plan will vary based on the physical plant’s capability to limit exposure, maximize resource utilization, and optimize patient flow.
  • Determine the Patient Population to Test:
    • Established patients versus all patients.
    • Patients with symptoms only or all patients regardless of clinical status. (If symptoms only, your organization will need a mechanism to screen.)
    • Patient type can include:
      • Walk-in or self-referral.
      • Referral by provider.
      • Referral by employer.
      • Telephonic or electronic screening.
  • Community Communication Planning: Consider communication strategies on screening and testing specifics.
  • Determine the Patient Flow at the Facility:
    • Consider prescreening a patient before the patient exits the vehicle.
    • Consider that drive through screening is more efficient and easier to control than walk in. For more information on the Cerner-recommended workflow, see Curbside Screening and Management Workflow.
    • Display signs on where to go and what number to call to get registered while patients wait in line to be tested.

Each clinical screener will need the following items:

  • A workstation to search for patient information and the patient’s chart.
  • A label printer for specimen labeling. Cerner recommends a 1:1 ratio for these devices to avoid cross contamination and allow for more efficient screening.
  • Do not share label printers between clinicians for the following reasons:
    • Decreases the likelihood of mislabeling a specimen.
    • Simplifies the build and maintenance of back-end configuration.

Consider the below resourcing and supply needs for your staff during a field screening and testing surge.

  • Plan for Staffing Needs
    • Identify the number and type of staff.
    • Identify the training needs for staff members in this role.
  • Supplies: Identify the types of supplies to most efficiently run field operations and its secure storage.
  • Cerner Learning Considerations: Essential eLearning is available to support quickly onboarding new or redeployed staff. For organizations with the Cerner Learning Framework, the Surge Essentials Learning Journeys can be imported into the learning portal. This learning content can also be accessed as a web course: Surge Essentials Learning. Additional roles may be added to this learning content.

See the links below for more information on EHR build recommendations for field screening and test surging.

The following items are additional operational considerations during a field screening and testing surge:

Emergency Department Unit and Potential Onsite Expansion

Assumptions

The following assumptions are made with the ED unit and potential onsite expansion:

  • Current capabilities are inadequate for the testing surge.
  • ED surge rooms and beds are built in the EHR under the existing ED configuration.
  • Aimed at unburdening the ED during high surge events of low-acuity patients who do not need emergency care.
  • The goal is to get ambulatory and potentially infectious patient screened and segmented and identify patients with acute or emergent conditions for care in the ED.

With an ED unit and potential onsite expansion, it is critical to plan for physical space.

  • Surge Level 1 (20 percent over capacity): Split the existing ED in half (respiratory isolation versus regular).
    • Use a separate respiratory waiting room and other public health compliance accommodations (ideally with a separate outdoor entrance).
  • Surge Level 2 (100 percent over capacity): Expand to additional pods in the ED or near the ED
    • Evaluate pods currently closed, convert to isolation pods, and activate when needed.
    • Evaluate other locations near the ED that can be converted into isolation pods, activate when needed.
  • Surge Level 3 (200 percent over capacity): Stand up field EDs through temporary structures.
    • Use tents or other existing structures in proximity.
    • Ensure compliance with public health distancing recommendations.
  • Consider initial patient screening outside of the ED.
    • Screen patients in the parking lot to keep patients in vehicles.
      • If no urgent or emergent issues, refer the patient to the field screening or testing.
    • Place a nurse screener outside the ED entrance.
      • Mask all patients going to the respiratory side of the ED.
      • Put tape on the floor six feet apart so patients know where to safely stand while waiting to be screened.
    • Locate the various key functions (such as prescreen, preregistration, and triage) to comply with public health recommendations.
    • Ensure that patient flow minimizes exposure to others.
    • Use the phone in patient rooms to conduct interviews for full registration to minimize exposure to staff and reduce in and out trips to conserve supplies.

The following list includes technology considerations for ED unit and potential onsite expansion:

  • General considerations:
    • Use FaceTime, Skype, or voice on patient’s cell phones to conduct interviews if no room phone is available.
    • Conduct assessments with virtual technology, such as FaceTime, Skype, camera doorbells, an iPad app, Microsoft Teams, Zoom, or Amwell telehealth services.
    • Create additional points of registration:
      • Workstation (with dual screens if space allows).
      • Wristband printer.
      • Laser printer.
    • Set up prescreen or triage areas:
      • Workstation.
      • A barcode scanner for patient verification.
      • Label printer for specimen labeling.
    • Add additional set up to treatment areas:
      • Workstation with a barcode scanner.
      • A Bluetooth scanner is recommended for cleanliness purposes as the cord will not touch patient.
  • Additional tracking boards to display FirstNet.
  • Add a vendor gateway connection for patient physiological monitors.

The following list contains staffing, supplies, and learning recommendations and considerations for an ED unit and potential onsite expansion:

  • Plan for Staffing Needs
    • Identify the number and type of staff.
    • Identify training needs for staff in this role.
    • You may need to cross train staff depending on the need. For example, nurses managing ventilators if short on respiratory therapists.
  • Supplies
    • Secure storage.
    • Determine whether an adequate number of devices exist. Consider both handheld devices and workstations on wheels.
  • Cerner Learning Considerations: Essential eLearning is available to support quickly onboarding new or redeployed staff. For organizations with the Cerner Learning Framework, the Surge Essentials Learning Journeys can be imported into the learning portal. This learning content can also be accessed as a web course: Surge Essentials Learning. Additional roles may be added to this learning content.

COVID-19: Emergency Medicine

The following items are EHR build considerations for ED unit and potential onsite expansion:

The following items are other operational considerations for an ED unit or potential onsite expansion:

Acute Care Capacity Expansion

Assumptions

The following assumptions are made with the acute care capacity expansion:

  • All non emergent use of critical care capable beds has been discontinued.
  • All surgery requiring postprocedural critical care recovery should be discontinued.
  • As bed critical care needs intensify, all elective surgery bed discontinued to preserve PPE/ventilators and operating rooms that could house multiple cohort COVID-19 positive critical patients.
  • All surge expansion plans are predicated on some analysis modeling time frame and numbers projected.

The following list contains planning considerations for an acute care capacity expansion:

  • For every bed converted to ventilator capability, conduct an inventory of current critical care bedside equipment, bedside supplies, bedside consumables, and bedside staffing. Replicate the same for each new bed created.
  • Determine the effect for supply chain, stocking personnel, and mechanisms to deliver to bedside. Routine pharmaceutical (and control thereof) and emergency drugs and fluids need critical consideration.
  • For connectivity purposes, evaluate beds already in this system for additional device connectivity needs, such as CareAware iBus, central monitoring, nurse call capability, and video monitoring.
  • Confirm that sufficient network drops and power outlets exist for the density of medical devices in each new location.
  • Evaluate for adequacy for diagnostic testing needs.
  • Establish a team to perform continual monitoring and triage of patients across levels of care.
  • For beds extended into routine care areas, evaluate the complete infrastructure needs (such as medical gases, emergency power, wall suction, lights, water, and so on).
  • Utilize Cerner’s predictive algorithms to maximize limited resource use. See supporting links under Other Operational Considerations

In collaboration with our clients we are sharing lessons learned and operational considerations experience which can easily be accessed here.

The following list contains technology considerations for an acute care capacity expansion:

  • Allocate additional workstations to accommodate increased staffing:
    • Ensure that barcode scanners are deployed to point of care areas for patient verification.
    • Leaving workstations in each room is recommended to reduce spread.
  • Add a label printer in each isolation room for labeling of specimens.
  • Add additional 724Access workstations with UPS devices for each new department. Ensure that at least one is connected locally to a laser printer for printing during downtime.
  • Add additional tracking boards to display the Capacity Management Patient Flow tracking shell.

The following list contains staffing, supplies, and learning recommendations and considerations for an acute care capacity expansion:

  • Collaborate with the Incident Command Center and coordinate to accommodate staffing for unit-based surge arrivals. See Leverage Workforce Management Solutions for COVID-19 for more information.
  • Cerner Learning Considerations: Essential eLearning is available to support quickly onboarding new or redeployed staff. For organizations with the Cerner Learning Framework, the Surge Essentials Learning Journeys can be imported into the learning portal. This learning content can also be accessed as a web course: Surge Essentials Learning. Additional roles may be added to this learning content.

The following items are EHR build considerations for acute care capacity expansion:

Operational reporting during acute phases is critical to assess needs for further expansion plans as well to determine daily staffing needs and supply consumption. By appropriately reconfiguring expanded bed as ICU beds in the EHR and bed capacity systems, one can accurately track and accurately report ICU utilization. The new location must be tracked so Command Centers can easily assess where available beds exist.

Phased Implementation

Surge Level 1 (20 Percent Overcapacity)

Plan for physical space, such as the locations of existing Med/Surg/Tele/All ICU and Critical Care/OR/RR/Post Procedure RR.

  • Determine separate locations for positive versus negative diagnosis. Cohort whenever possible.
  • Determine how patients are moved through the system to minimize exposure to others.
  • Follow infection prevention requirements:
    • Determine which patients require negative pressure versus airborne isolation.
    • Areas without negative flow require patient to wear a mask.
  • Allocate clinician workspace separate from isolation areas.
  • Secure PPE and supplies =.
  • Consider a strict visitor policy.
  • Consider in room support for video visits with loved one.
  • Offer capabilities for in room video support visits for patient education and loved ones.

Surge Level 2 (100 Percent Overcapacity)

Plan for physical space, such as the locations of repurposing the existing Med/Surg/Tele/All ICU and Critical Care/OR/RR/Post Procedure RR/Vacant Units/Non-Clinical spaces.

  • Determine separate locations for positive versus negative diagnosis. Cohort whenever possible.
  • Determine how patients are moved through the system to minimize exposure to others.
  • Follow infection prevention requirements:
    • Determine which patients require negative pressure versus airborne isolation.
    • Areas without negative flow require patient to wear a mask.
  • Allocate clinician workspace separate from isolation areas.
  • Secure PPE and supplies.
  • Enforce a strict visitor policy.
  • Consider in room support for video visits with loved ones.
  • Offer capabilities for in-room video support visits for patient education and loved ones.
  • Create an ethics committee policy for any ventilator prioritization.
  • Review all infrastructure needs (such as medical gases, emergency power, wall suction, lights, water, and so on).

Surge Level 3 (200% over capacity) (see Scenario 4)

Roles/Processes/Technology Enabled Care Delivery

Below are roles to consider for care of delivery.

 

Role

Description

House Supervisor/Unit Director/Charge Nurse

  • Use all previously established collaboration with the nursing supervisor and Incident Command System. If not established, create a daily active role for participation in planning, policy guidance, and triage process.
  • Understand the Technology and Process. If no connectivity exists, follow the downtime procedures.
  • Review daily staffing needs. See Shift Assignment or Clairvia Leverage Workforce Management Solutions for COVID-19 for more information.
  • Use the Workforce Crisis Projection Tool.
  • COVID-19 Worklist COVID-19 Acute Care
  • Facilitate touch base meetings with the Clinical Leader Organizer.
  • Provide visibility to ED Real-Time Dashboard for patient throughput and placement needs Overview of ED Dashboard.
  • Facilitate frequent interdisciplinary unit and command center huddles with data driven tools.
  • See Apache/CarePredictor Tracking COVID-19 patients in APACHE Outcomes for more information.
  • Sequential Organ failure Assessment (SOFA) PowerForm to calculate patient risk. See COVID-19: Critical Care Reference Build for more information.

Direct Care RN and LPN

(Float pool provisioning for access)

  • Understand the Technology and Processes.
  • If no connectivity exists, follow the downtime process.
  • Telehealth conference with family for any patient being discharged to the home.

Supervising ICU Physician

Use all previously established collaboration with the nursing supervisor and Incident Command System. If not established, create a daily active role for participation in planning, policy guidance, and triage process.

Physician Provider Critical Care

  • Determine the need for expansion of shift staff (such as the number of intensivists per shift).
  • Determine use of “jeopardy” providers when shift providers are overwhelmed.
  • Determine expansion of numbers and roles of advanced practitioners.
  • Determine role of residents with attention to maintain appropriate supervisory oversight.
  • See APACHE/Care Predictor: Tracking COVID-19 patients in APACHE Outcomes for more information.
  • Sequential Organ failure Assessment (SOFA) PowerForm to calculate patient risk. See COVID-19: Critical Care Reference Build for more information.

Physician Acute Care

  • Provide multiple EHR views for those who cross venues.
  • Ensure that clinical privileges attached to EHR position do not limit clinical function.

Appendix: Relevant Resources

“Augmenting Critical Care Capacity During a Crisis.” Society of Critical Care Medicine.

http://sccmmedia.sccm.org/documents/LMS/Augmenting-Critical-Care-Capacity-During-Disaster/story_html5.html

Christian, Michael D., et al. “Introduction and Executive Summary: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement,” CHEST Journal, October 2014, https://journal.chestnet.org/article/S0012-3692(15)51985-5/fulltext#cesec40.

“COVID-19: Strategies for Optimizing the Supply of PPE.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 26 Mar. 2020,

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.

Emanuel, Ezekiel J., et al. “Fair Allocation of Scarce Medical Resources in the time of Covid-19: NEJM.” New England Journal of Medicine, 23 Mar. 2020, https://www.nejm.org/doi/full/10.1056/NEJMsb2005114.

HHS Healthcare Emergency preparedness gateway, https://asprtracie.hhs.gov/COVID-19

“Management of Patients with Confirmed 2019-NCoV.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Mar. 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Maves, Ryan C., et al. “Intensive Care Unit Preparedness During Pandemics and Other Biological Threats.” Critical Care Clinics, Elsevier, 12 July 2019, https://www.sciencedirect.com/science/article/pii/S0749070419300405?via%3Dihub#tbox1.

Create New Field Hospital

Assumptions

The following assumptions are made with the consideration of an acute field hospital site:

  • If no connectivity is available, downtime procedures are in place.
  • The goal is to unburden the hospital during high surge events of low acuity patients.
  • Locations may vary from tent, hotel, parking structure, vacant hospital, convention center, and so on.
  • Locations should be specified for stable COVID-19 versus non-COVID-19 based on surge needs.
  • Field site should have dedicated space for respiratory resuscitation and stabilization needs.
  • Staffing plan is completed in advance of the care to be delivered.
  • Equipment is secured in advance of care delivery.
  • Security is onsite for assistance and safety.
  • Variation may exist due to items such as network availability and timing of the go live.
  • Consider balance of integration with health system versus wanting to keep documentation from impacting client environment.

Additional assumptions to consider for an emergency department (ED) field hospital are as follows:

  • Maintain compliance with EMTALA regulations for any new locations https://www.cms.gov/files/document/qso-20-15-emtala-requirements-and-coronavirus-0311-updated-003pdf.pdf-1
  • The current capabilities are inadequate for surge events.
  • ED, surge rooms, and beds are built out in the EHR under the existing build.
  • The goal is to unburden the ED and hospital during high surge events of low-acuity patients who do not need immediate care.
  • Additional goals include getting the ambulatory and potentially infectious patients screened and segmented and identify patients with acute or emergent conditions to be cared for in the ED or hospital.

Many models are under consideration. The two primary models are listed below, but Cerner recognizes that a mix of models exist throughout the country.

Health System Operated Free Standing Hospital (Not Government Sponsored)

  • Single Incident Command Center.
  • Primarily reliant of own resources.
  • Primarily internal referrals, diversions, and transfers in the same health system.
  • An expansion of the current Cerner EHR footprint.

Independent Free Standing Field Hospital (Government or Other Entity Sponsored)

  • Single Incident Command Center and management to coordinate with multiple stake holders.
  • Likely shared resources and staffing beyond a single health system.
  • Referrals, diversions, and transfers can be across many health systems.
  • FEMA is authorized to federalize civilian volunteers to work in these centers.
  • Development of a new Cerner EHR footprint or extension of current EHR footprint

Examples:

Cerner Client Examples of Free Standing Field Hospitals

 

Operated By

Government

Cerner Client

Government

 Cerner Client

EHR Approach

Extension of existing EHR Footprint

Extension of existing EHR Footprint

Extension of existing EHR Footprint

New Cerner EHR Footprint

Locations

Operating

United Kingdom

Michigan

Missouri

New York

The following list contains planning considerations for an acute care field facility:

  • Secure equipment, devices, and personal devices
  • Evaluate the complete infrastructure needs, such as HVAC, medical gases, emergency power, suction, lights, water, and so on(LINK)
  • UPS for critical equipment to prevent surges
  • Wired or wireless connectivity
  • Staff communication devices (such as CareAware Connect or walkie-talkie)
  • Nurse call system options
  • Crisis documentation toolkit is available to minimize documentation burden (Coming Soon)
  • Visualization of the patient (such as Cerner Patient Observer)
  • RTLS for staff exposure tracking
  • Cerner Patient Observer
  • Communication with family and loved ones
  • Patient transportation and coordination
  • Imaging needs
  • Pharmacy and medication dispensing
  • Laboratory, collection, and diagnostic testing needs
  • Most common policies, which include:
    • Visitor policy
    • Ethics policy on the triage of ventilators

Establishing Teams

Team Goals:

  • Ensure that the field facility delivers the highest standard of crisis clinical care.
  • Ensure that occupational work health and safety requirements are met.
  • Ensure the coordination, assignment, and allocation of clinical staff.
  • Oversight of team morale and welfare

 

Teams:

Include the following members in the teams:

  • Care Coordination Team Lead or Charge Nurse: Coordination of receiving, placement, discharges, and transfers
  • Direct Care Oversight Team: Interprofessional monitoring and triage of patients
  • Service Delivery Teams: Ancillary services (supplemental services other than room, board, medical, and nursing services)

 

The following list includes acute field hospital design considerations:

  • Facility signage.
  • Transport entrance at point of entry to facility.
  • Patient holding area for proper bed assignment in the Patient Placement Board- in CareAware Capacity Management.
  • Items are available at registration:
    • Workstation
    • Wristband printer
    • Laser printer 
  • Bed arrangement strategy: Beds are six feet or more apart with privacy divisions.
  • Specific space for resuscitation and stabilization.
    • Communication with the Care Coordination team for transfer to appropriate level of care.
  • Nursing station ratio to patient beds and proximity (one station to 15 beds)
    • Workstation with a barcode scanner(such as Bluetooth)
    • Label printer
  • Discharge lounge.
  • Medical equipment and PPE storage
    • Determine the effect for supply chain, stocking personnel, and mechanisms to deliver to bedside. Routine pharmaceutical (and control thereof) and emergency drugs and fluids need critical consideration.
  • Decontamination room with considerations for:
    • Proper disposal of PPE and contaminated equipment
    • Specific area for doffing and donning PPE
  • Mortuary: Internal to field surge location and external resources to properly store overflow.
  • Weather related considerations.
  • Connectivity for technology supported care delivery.
  • For connectivity purposes, evaluate for additional device connectivity needs, such as CareAware iBus, central monitoring, nurse call capability, and video monitoring.
  • Confirm that sufficient network drops and power outlets exist for the density of medical devices in each new location.

The following list contains technology considerations for an acute care capacity expansion:

  • Domain needs or extensions to support technology enabled care delivery and data capture.
  • Allocate additional workstations to accommodate increased staffing: Centralized workstations with label printer and barcode scanner.
  • Add a label printer in each isolation room for labeling of specimens.
  • Add additional 724Access workstations with UPS devices for each new department. Ensure that at least one is connected locally to a laser printer for printing during downtime.
  • Add additional tracking boards to display the CareAware Capacity Management Patient Flow tracking shell.
  • Network WAN and data center bandwidth capacity review. Network connectivity to new location needs to be evaluated and determined.
    • Evaluate Access Control Lists (ACLs) need and modify as needed to accommodate additional new network space.
  • Depending on the network decision, this may impact available functionality. Ensure that you understand workflows that will be used in the new facility.

The following list contains staffing, supplies, and learning recommendations and considerations for an acute care capacity expansion:

  • Collaborate with the Incident Command Center and coordinate to accommodate staffing for unit-based surge arrivals. See Leverage Workforce Management Solutions for COVID-19 for more information.
  • Cerner Learning Considerations: Scenario-specific essential learning recommendations for key roles are in process and coming soon. This content will contain learning assets for essential tasks to quickly train new or redeployed staff to support this scenario.

While the acute field facility is in use, operational reporting is critical to guide the Incident Command Center in decisions such as the need to increase capacity by adding additional acute field sites or close existing acute field sites due to a decrease in demand. The accuracy of the data relative to census, referrals, and transfers will be dependent upon the naming and tracking of the new acute field sites built in EHR.

ED Field Hospital Considerations:

  • Laboratory POC Testing
    • If testing a Results to Endorse workflow, might want to steer away from Message Center pools because of the complexity of build and users opting in or out.
    • Discuss specimen collection flow requirements.
  • Radiology
    • If printing requisitions, consider the workflow without printing to reduce steps; consider out of service or contaminated equipment.

Roles/Processes/Technology Enabled Care Delivery

Listed below are the roles and expectations of those roles during the acute care field surge hospital.

Care Coordination Team Lead and Charge Nurse

  • Use all previously established collaboration with the nursing supervisor and Incident Command System. If not previously defined, establish an active role for daily participation in planning, policy guidance, and triage process.
  • If no connectivity, follow the downtime procedures.
    • Attend frequent interdisciplinary unit and command center huddles with data driven tools
  • Use the following solutions and applications:
  • Shift Assignment or Clairvia Leverage Workforce Management Solutions for COVID-19 to help determine daily staffing
  • Clinical Leader Organizer
  • Cerner Patient Observer
  • APACHE or Care Predictor Tracking COVID-19 patients in APACHE Outcomes

Direct Care RN and LPN (Float Pool Provisioning for Access)

  • Direct care per policy.
  • Cerner Crisis documentation kit available to minimize documentation burden. (Coming soon)
  • Use Telehealth to conference with family for any patient being discharged to the home.
  • If no connectivity, follow the downtime procedures.

Supervising ICU Physician

  • Use all previously established collaboration with nursing.
  • Use previously established communications with the supervisor and Incident Command System. If not previously defined, establish a daily active role for participation in planning, policy guidance, and triage process.

Physician Provider Critical Care

  • Determine the need for expansion of shift staff the number of intensivists per shift).
  • Determine use of jeopardy physicians when shift physicians overwhelmed.
  • Determine the expansion of numbers and roles of advanced practitioners.
  • Determine the role of residents with attention to maintain appropriate supervisory oversight.
  • Use APACHE and Care Predictor Tracking COVID-19 patients in APACHE Outcomes

Physician Acute Care

  • Provide multiple EHR views for those who cross venues.
  • Ensure that clinical privileges attached to the EHR position do not limit clinical function.

Cerner Client Resources:

Venna, Srivani. “Cerner EHR Power London’s Nightingale Hospital for Covid-19 Patients.” Verdict Hospital, 6 April 2020. https://www.hospitalmanagement.net/news/cerner-ehr-covid-19/:

Cerner. “Cerner Millennium EHR to Be Used at London’s 4,000-Bed Temporary Hospital.” https://www.cerner.com/gb/en/blog/cerner-millennium-ehr-to-be-used-at-london-4000-bed-temporary-hospital

Journal Resources:

Christian, Michael D., et al. “Introduction and Executive Summary: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement,” CHEST Journal, October 2014, https://journal.chestnet.org/article/S0012-3692(15)51985-5/fulltext#cesec40.

“COVID-19: Strategies for Optimizing the Supply of PPE.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 26 Mar. 2020,

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html.

Emanuel, Ezekiel J., et al. “Fair Allocation of Scarce Medical Resources in the time of COVID-19: NEJM.” New England Journal of Medicine, 23 Mar. 2020, https://www.nejm.org/doi/full/10.1056/NEJMsb2005114.

“Augmenting Critical Care Capacity During a Crisis.” Society of Critical Care Medicine.

http://sccmmedia.sccm.org/documents/LMS/Augmenting-Critical-Care-Capacity-During-Disaster/story_html5.html

“Management of Patients with Confirmed 2019-NCoV.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 20 Mar. 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Maves, Ryan C., et al. “Intensive Care Unit Preparedness During Pandemics and Other Biological Threats.” Critical Care Clinics, Elsevier, 12 July 2019, https://www.sciencedirect.com/science/article/pii/S0749070419300405?via%3Dihub#tbox1.

Virtual Health NEW

Assumptions

Acute Care

The following assumptions are made with the acute workflows during a virtual health surge:

  • Virtual beds may be used for the following scenarios:
    • Acute care bed capacity is insufficient and can be expanded with virtual beds.
    • Minimize staff exposure to potential infection vectors.
  • Staffing ratios may be changed.
  • Patients will be triaged and dispositioned to the appropriate unit based on acuity and care requirements.
  • Virtual acute care beds will be built in the EHR under the existing facility configuration.

Ambulatory

The following assumptions are made with the ambulatory workflows during a virtual health surge:

  • Clinical personnel appropriately staff video visits.
  • Patients and providers have audio and video capabilities that have adequate internet and network connectivity.
  • Health care providers are using their digital properties (such as a website and portals) to communicate COVID-19 recommendations.

Acute Care

The following list includes planning recommendations for acute workflows during a virtual health surge:

  • Virtual Observation Unit
    • Instruct low acuity patients who are either COVID-19 positive or have COVID-19 symptoms to self-quarantine. Place these patients on a virtual rounding list, and nursing will follow up by phone every 48 to 72 hours. If a patient’s condition worsens, the patient is re-triaged and transferred to the appropriate unit. Improved patients can be discharged from the list.
    • Guidance on using Cerner Patient Observer for this purpose is available in the COVID-19: Device Connectivity on Model Experience.
  • Virtual Hospital Unit (Hospital at Home)

This includes midlevel acuity patients that qualify for admission in a non-surge environment. Patients are typically tolerating COVID-19 relatively well with moderate symptoms and are capable of home monitoring (such as by phone, support, internet access, and so on). Patients can self-quarantine and then be virtually admitted to an EHR bed and rounded on daily by a provider. Patients will be issued wearable O2 saturation, temperature, and blood pressure monitors that synchronize to a dashboard. Nursing will monitor the dashboard 24 hours a day, seven days a week, and patients are contacted immediately for any significant change in condition. If a patient’s condition changes, the patient is re-triaged and transferred to the appropriate unit.

If home health or paramedicine is available, home oxygen may be considered as an adjunct to home care.

Ambulatory

The following list includes planning recommendations for ambulatory workflows during a virtual health surge:

  • Patient-enabled screening and triage
  • GetWellNetwork is providing a self-screening and education loop that helps patients assess their symptoms and provides feedback on self-care. This provides organizations with details on patients and where they are in the screening process. For more information on GetWellNetwork, see the following discussion on uCern Connect: https://connect.cerner.com/thread/4927397.
  • Patients also can self-screen through a CDC screener tool in HealtheLife. This tool is designed to help educate patients based on the CDC recommendations but does not integrate with an organization's workflow.
  • Clinician-assisted screening and triage
  • Offer scheduled and unscheduled telemedicine screening and evaluation for symptoms or findings concerning for COVID-19. Patients will be dispositioned to appropriate secondary screening, testing, or virtual or inpatient admission.
    • Ensure that staff members are educated and trained on telemedicine platforms that will be used. Post patient education materials on your website or portal.
    • Ensure that staff who are scheduling virtual visits have minimized workflow disruption and have clear communication to patients and providers on context of patient visits. Ensure that a process is in place to accept new patients and get them into the EHR to ensure timely follow up after screening.
  • Plan on the type of services that will be offered through telehealth
    • Screening for COVID-19, including care for those who are minimally symptomatic
    • Scheduled video visits
    • Urgent care (such as drop-in patients)
    • Follow-up visits and communication are offered to recently discharged patients
    • Remote patient management
    • Symptom checker
    • Hours that telehealth is available
  • Provide coding education for staff. See the COVID-19 Pandemic regulatory guide for more information on policy, compliance, and reimbursement changes,

Establish clear guidance on network connectivity, device, and browser requirements for clinicians. Additionally, communicate device, internet connection, and browser requirements for patients.

Consider the following technology recommendations:

  • Patient-enabled screening and triage
  • Clinician-assisted screening and triage
    • For specific recommendations, contact your Cerner account team.
    • Cerner recommends that you use Wi-Fi connection when available. Patients can use cellular connection (3G/4G) as well.
    • A minimum bandwidth for video visits is 3 MB.
    • Patients can use mobile devices as well as desktop
    • Providers will likely use desktops or laptops. The preferred browser is Google Chrome; however, providers can use other browsers.
    • Ensure that laptops or desktops are equipped with audio and video capability.
    • For the best provider experience, complete visits using laptops, which allows providers to use dual screens to have video on one screen and the EHR on the other.
    • When accessing the service on a managed network, such as a corporate office, coordinate with your network administrator to ensure that communication with the appropriate web addresses and ports are open.
  • Virtual Observation Unit
  • Virtual Hospital Unit (Hospital at Home)

When conducting virtual visits with patients, you will need a support line for patients to call if issues arise. You will also need support for clinicians who are conducting these visits on or off-site.

The following items are recommendations for resourcing and staffing during a virtual health surge:

  • Patient-assisted screening and triaging: Determine if you are going to dedicate clinicians to a schedule to take virtual triaging or if you will open this up to all clinicians to practice when they are available.
  • Clinician-assisted screening: Determine the process of converting patients from virtual screening to in-person testing. Determine who notify the arrival of patients, what type of process in the EHR needs to occur to track the entire episode (physician order), what the testing site needs, and directions for the patient.
    • Non-Clinician Staffing Model (groups that need to be aware of this offering and its impact to their department):
      • Access Management: Registration and Scheduling
      • Health Information Management: Coding, Chart Reviews, and so on
      • Revenue Cycle: Billing
      • Payer Contracting/Relationship: Ensuring that commercial payers are in sync with billing
      • Help Desk Support: For patients and clinicians
      • Internet and Connectivity Network Team
      • Security
    • Clinician Staffing Model
      • Use only existing network providers
      • Use contracted telehealth providers
      • Hybrid (for example, using existing providers for regular business hours and contracted providers for after hours)
      • Nurses and Physician Assistants
      • Behavioral Health Providers.
    • Virtual Observation Unit
    • Virtual Hospital Unit (Hospital at Home)

See the links below for more information on building your EHR for a virtual health surge.

The following items are additional operational considerations during a virtual health surge:

  • Reporting that can track the entire episode from triage to screening
  • Revenue reports
  • Tracking patient experience
  • Compliance with CMS requirements related to billing telemedicine services
  • Marketing and engagement strategies for creating awareness to your community
  • Regulatory guidance for telemedicine is available in the COVID-19 Pandemic regulatory guide

Virtual Patient Interaction with Loved Ones

Due to the need for isolation in care environments, many patients will be interested in virtually connecting to loved ones while in a care setting. While some patients may have access to a mobile device for calls or video chats, consider supplying tablets with a video chat capability. The additional network bandwidth will vary based on chat application and must be considered in capacity plans.

Ambulatory

Assumptions

The following assumptions are made with the continued operation in an ambulatory care setting:

  • The organization has an existing ambulatory network that it owns and manages.
  • Ambulatory clinics are discouraging patients with known or possible COVID-19 from scheduling appointments in the typical manner to mitigate potential spread.
  • A patient population who require ongoing care for chronic and acute conditions unrelated to the pandemic
  • Face-to-face visit volumes will tend to decrease.
  • Revenue will tend to decrease.
  • Workforce fluctuation will occur as workers may be directly affected by pandemic (such as they have the disease or are awaiting results) or indirectly affected (such as they are flexed to other areas of the health system and not available for ambulatory work).

The following list includes planning recommendations for the continued operation in an ambulatory care setting:

  • Determine staffing needs based on current and predicted volume trends.
  • Update the contact information for ambulatory staff. 
  • Update protocols for phone triage, including refill requests, appointment requests, and so on (for non-COVID-19 conditions). Protocols should allow staff to work at top of the license as defined during the emergency declaration
    • Assure protocols include orders and whether they require co-signature.
  • Create triage protocols for patients with COVID-19 like symptoms.
  • Establish protocols for ongoing care for non-COVID-19 related cases:
    • Well child visit as an example
      • Remote with in person component just for immunizations and measurements.
      • Cohort in person visits by time of day to separate sick from well visits.
    • Chronic care visits.
  • Create appropriate documentation templates, quick visits, and autotext to address protocols and staff working at top of license (protocols are for COVID-19 and non-COVID-19 related conditions).
  • Push to have patients enroll in the patient portal. See COVID 19 Patient Portal in Model Experience for more information.
  • Arrange to provide Telehealth(audio only or audio and video). Determine whether individuals can Telehealth by appointment only or allow for “drop ins”.
  • Plan to monitor and comply with changing regulatory and coding requirements.
  • Optimize use of mobile technology for providers.

The following list includes technology considerations for with the continued operation in an ambulatory care setting:

  • Provide devices for use at home (either a personal device using VPN or a health system supplied device).
  • Provide technology to support Telehealth.
  • Allow for remote printing (for example, requisition for third-party suppliers).
  • Verify interfaces are correct, especially if adding or modifying locations.
  • Ensure that home devices have connectivity. (Coming soon to the Virtual Health section.)
  • Review and revise mobile device management policy

The following list includes resourcing and staffing recommendations for with the continued operation in an ambulatory care setting:

The following list includes build recommendations for with the continued operation in an ambulatory care setting:

  • Build Telehealth capabilities:
  • Create orders for COVID-19 testing.
  • Implement protocols for triaging call with exposure to COVID-19 or COVID-19 like symptoms and ability to document
    • This includes orders for COVID-19 screening. Protocol versus those routed for co-signature. See COVID-19 Ambulatory in Model Experience for content and screening packages.
  • Create separate message pools to route all COVID-19 results. (This is not needed if a health system-wide mechanism is already in place.)
  • Configure alerts to quickly identify those who are positive.
  • Provide patient education updates for COVID 19. (Click Patient Education for more information.)

Additional Build Resources:

The following list includes other operations considerations for the continued operation in an ambulatory care setting:

  • Use reports to assess the volume of calls, clinic visits, telehealth visits, and refill requests.
  • Use revenue reports.
  • Use patient tracking and results communication.

Relevant Resources

  1. “Outpatient and Ambulatory Care Settings: Responding to Community Transmition of COVID-19 in the United States.” Centers for Disease Control and Prevention. 7 Apr. 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html
  2. “Checklist to Prepare Physician Offices for COVID-19.” AAFP. https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID-19-office-prep-checklist.pdf

Post Acute and Home Care

Assumptions

The following assumptions are made with long-term post-acute care considerations:

  • The organization recognizes the importance of standardizing operational and resident impact metrics for response to regulatory or public health agency request.
  • Cerner-recommended EHR configuration guidelines are being used based on early client experiences. These configuration recommendations continue to evolve and are published on the COVID-19 Recommendations page on Cerner.com
  • For transfer from the Post-Acute Setting: CDC guidance recommends keeping residents in the nursing facility unless the care cannot be provided outside of the acute hospital.
    • Facilities should follow the CDC guidance for COVID-19 for all positive or presumptive cases in long term care and working with state disaster planning agencies, consider designated units, floors, or specialized nursing centers.
    • Facilities should implement consistent staffing to ensure the same staff work with designated COVID-19 units or non-COVID-19 residents to minimize the opportunity for spread of the infection.
    • If a resident requires skilled services such as IV fluids, oxygen, and other treatments due to their respiratory symptoms, facilities can provide Medicare covered skilled services to eligible beneficiaries without the three-day acute stay typically required.
    • The three-day stay waiver also permits providing Medicare covered skilled nursing services from other settings, such as ambulatory medicine or home if all other coverage requirements are met.
    • Facilities should have conversations with residents and their families about the risks of hospitalization during this COVID-19 pandemic period. Advance directives should be updated after the discussions.
    • Assisted living centers and independent living centers are encouraged to shelter in place, limit admissions without negative COVID-19 testing, and quarantine the new admission for 14 days. Outside medical appointments should be avoided and use of telehealth recommended.
  • For discharge to a post-acute setting:
    • As the COVID-19 crises continues and residents progress through the various phases of their illness, some if not many, may require additional care beyond what is standard for the routine med-surg discharge. Identification and coordination of these care needs will be critical to avoid clinical deterioration readmission.
    • If the discharged patient originated from a post-acute setting (such as an inpatient rehabilitation facility, skilled nursing facility, assisted living facility, or independent living facility), those facilities may not be able to receive the resident post-discharge due to a variety reasons.
    • Unless organizations own these post-discharge resources, collaboration with and organization of the post-discharge community will play an important role in freeing up acute care capacity.

The following list contains planning recommendations for long-term post-acute care considerations:

  • Cerner released enhancements to Cerner Millennium to help clients effectively screen and monitor resident populations. Organizations are encouraged to immediately incorporate the latest update in the Infectious Disease Travel Screen PowerForm in Cerner Millennium. See FLASH20-0073-1 for more information.
  • Cerner’s Rehababilitation Strategy team has published information regarding our Model Experience related to COVID-19 and the waivers being issued for inpatient and outpatient rehabilitation by CMS. Recommendations for Inpatient Rehabilitation Facility (IRF) patients being housed off unit and telemedicine are included. Recommendations for a COVID-19 worklist to aid in patient screening, tracking, and care coordination is also included.
  • Cerner’s Long-Term care Strategy team has created information regarding our Model Experience related to COVID-19 as it relates to skilled nursing facilities. That information is available at the following link: COVID-19: Long Term Care.
  • As more data becomes available, carefully monitor post-discharge resources being used by your and other health care organizations involved in the patient surge. Use NaviHealth for available post-acute facility capacity.
  • Explore alternative methods to support patients in the home environment:
    • Virtual visits, such as video or telephonic.
    • Remote patient monitoring devices to measure oxygen saturation and vital signs.
    • Coordination with DME to furnish required home medical equipment.
    • SDoH resources such as meal and pharmaceutical delivery.
  • Consider alternate sites to discharge patients such as nearby hotels (see alternate care sites resource).
  • Cerner suggests tracking the following key metrics:
  • Resident COVID-19 testing status
  • Number of COVID-19 residents
  • Facility capacity and volume and utilization
  • Total bed capacity
  • Isolation bed capacity
  • As part of daily capacity assessment, monitor the status of institutions from whom you have received patients and to whom you would normally transfer patients
  • COVID-19 resident only capacity and utilization
  • Workforce capacity (by role, skill set or certification, and COVID-19 status)

Plan for Supply Chain Impact

  • Personal Protective Equipment (PPE)
  • N95 masks and number on hand
  • Masks with face shields and the number of masks on hand
  • Gowns and the number of gowns on hand

Monitor Respiratory Testing Capacity

  • COVID-19 testing kit inventory
  • Influenza testing kit inventory

The following technology considerations are made for long-term post-acute care considerations:

User Devices

Reasonable access to the appropriate user devices plays an essential role in preparing for surge capacity. While you must consider several variables (such as venue, flow, resourcing, networking, and so on), a number of constants exist as well. Cerner recommends limiting the sharing of devices to limit cross touching, which can lead to contamination. Whenever possible, consider using medical grade, disinfectant ready devices. Consider implementing the following general department user guidelines regarding these devices:

  • Communication device
    • Mobile
    • Stationary
  • Workstation – Input device
    • Laptop
    • Desktop
    • Handheld device
    • Medical grade monitor, keyboard, and mouse
    • Downtime workstations
  • Peripherals
    • Barcode scanner
    • Document scanner
    • eSignature device
    • Dragon® Medical One microphone or PowerMic Mobile license
    • Badge reader
  • Printers
    • Laser printer
    • Wristband printers
    • Label printers
    • Prescription printers
    • Printer label stock

Biomedical Devices

As additional beds are opened for use, a review of basic connectivity for medical devices is required. Common items to include with the review are sufficient power outlets and capacity, network connectivity, environmental controls, and capacity of vendor systems (such as monitor gateways) to add devices. As beds may require different devices depending on the use case, it is best to include biomedical engineer staff in initial discussions to ensure that these considerations are considered.

Additional Considerations

  • Use care management tools available
  • Use video visit capabilities available
  • Use NaviHealth for available post-acute facility capacity
  • GetWell Network – COVID-19 Loop

If you need additional technology analysis or are experiencing technology or staffing limitations, contact your Cerner client account executive.

The following list contains resourcing and staffing considerations for long-term post-acute care:

  • If acute care phase is diminishing, consider repurpose of additional nursing staff to support post-acute care facilities.
  • Scope of practice for licensed professionals: Work with your department leaders, Human Resources partners, medical staff governance, and local licensing bodies to examine scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, radiology technicians, physical therapists, and medical assistants. These may be sources of delegated clinical care during maximum capacity demands.
  • Licensing: Work with the appropriate licensing bodies and academic partners to expedite licensing for near-graduates and nonproductive foreign medical graduates. Additionally, examine the relicensing of retired health care professionals or those not currently in direct patient care roles.
  • Communication with your workforce: Work with your HRO and marketing or communications department to develop a daily messaging strategy to stay in communication with your workforce. Communicate both new clinical information as well as guidance on anxiety management and other support resources.
  • Prescreen employees: Follow your organizational policy regarding the screening process for staff members before their work assignments.

The following resources are available for EHR build considerations:

See General Surge Expansion Considerations

Alternative Care Site Monitoring

Assumptions

  • CareTracker can help unskilled and possibly nontraditional caregivers to monitor isolated, undiagnosed populations.
  • In a variety of scenarios, a need exists to isolate certain undiagnosed populations of individuals and monitor them for a period to screen for the possibility of COVID-19 infection. This identification and monitoring can reduce the likelihood of community spread from asymptomatic individuals.
  • This strategy is being deployed in several settings; for example, relocating homeless populations to hotels or convention centers, and quarantining cruise ship passengers in their cabins for several weeks at a time.
  • To capture data on these individuals, monitoring agencies need the ability to stand up lightweight documentation solutions to capture basic social and demographic data, vital signs, and basic observational screening data. This data can be collected on a regular basis by nontraditional caregivers that may have little or no knowledge of traditional EHR solutions.
  • Organizations need a portable solution that can collect this basic information and recognize individuals who are at greater risk of infection. Higher risk individuals then can be more frequently monitored for infection and for the possible need to transfer them to a higher acuity facility.

  • Select sites that can accommodate the isolation of individuals while also accommodating all activities of daily living for the impacted individuals.
  • Access to private bathrooms and the ability to accommodate meal service are key considerations in maintaining the isolation and preventing the spread of disease.
  • Consider additional factors, such as PPE for housekeeping and other necessary services, when establishing a site.
  • Suitable environments could be hotels, cruise ships, college dormitories, or other similar locations.
  • Sites should be prepared to institute rapid testing of residents, rapid isolation, and containment if a resident has symptoms and rapid transfer of resident if symptoms progress.

  • Two primary personnel groups use CareTracker:

    • Admission and discharge personnel
      • Admissions and discharges are entered directly in the CareTracker file maintenance web pages using a laptop running Internet Explorer 11.
      • These users require stable Internet access.
      • Ideally, they will have access to a standard Microsoft Windows-compatible printer.
    • Caregivers and monitoring personnel:
      • These users will access CareTracker using one of the following types of devices:
        • An iPad or iPhone running iOS 13
        • A laptop running Google Chrome
      • They will need access to Wi-Fi. The application will handle brief outages of Internet access for spotty Wi-Fi, but the user must be connected to the network to log in and synchronize data to the server.

  • These environments should have clinical oversight; however, CareTracker is suited for use by nontraditional caregivers who are capable of interviewing individuals and taking basic vitals, especially temperature, and manually entering results in CareTracker.
  • Appropriate caregivers should have the ability to use standard touchscreen devices, and gather basic observational information including temperature and other vitals.

  • CareTracker is designed to function as a stand-alone application for gathering this information.
  • Organizations can configure CareTracker to capture a wide variety of textual, numeric, multiple choice, or free-form documentation. As a pure SaaS application, these changes can be made quickly and pushed out to all caregivers as additional screening needs are required.
  • Facilities, rooms, and beds must be built in CareTracker so that individuals can be assigned to locations. Individuals then can be found easily for screening.
  • Results from vitals and screening information can be aggregated into dashboard views. These dashboard views can help identify individuals at high risk of infection who need to be monitored more frequently and potentially quarantined or transferred to a facility suited for a higher level of acuity.

  • While CareTracker is an excellent tool for gathering data at the point of care with minimal application-specific training to caregivers, it is NOT a full EHR.
  • It is important for those deploying the application to understand that CareTracker can help them observe and report on a group of individuals identified as needing treatment. That care should be recorded using an EHR such as the Cerner Millennium-based ambulatory or acute care EHRs.
  • CareTracker does not record or monitor orders, medications, treatments, physicians’ or nurses’ notes, and so on.