TRIAGE DECISIONS

ED EBOLA TRIAGE ALGORITHM: A TOOL PROCESS FOR COMPLIANCE

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Authors: Shelly Schwedhelm, MSN, RN, NEA-BC, John Swanhorst, BSN, RN, Suzanne Watson, BSN, RN, CEN, and Jamie Rudd, BSN, RN, Omaha, NE Section Editors: Andi L. Foley, MSN, RN, CEN, and Diane Gurney, MS, RN, CEN Ebola Situation

Nebraska Medicine (formerly known as The Nebraska Medical Center) Biocontainment Unit has cared for 3 patients with known Ebola virus disease (EBV). The unit and staff have been prepared for 9 years to care for a patient with a highly infectious disease. In early August 2014, prior to the first Ebola patient being brought to Nebraska Medicine, the ED Director, also the Nursing Director of the Nebraska Biocontainment Unit, developed an ED Ebola triage algorithm to be used at the front door by the ED Greeter Nurse. With the ease in global travel, preparation is essential.

Ebola Triage Process

Between August 7 and September 23, 2014, the paper version of the algorithm was used to provide specific details about the patient’s history, personal protective equipment (PPE) to be used, where specimens should be sent, and what countries in West Africa the Centers for Disease Control and Prevention had determined were Ebola-affected areas (Figure 1). A multifaceted communication strategy was used to educate the ED staff. E-mails were sent, and laminated copies of the algorithm were posted in all triage rooms, at the registration desk, and on our communication Shelly Schwedhelm, Member, Nebraska State Council, is Director, Emergency Department, Trauma and Emergency Preparedness Services, Biocontainment Unit, Nebraska Medicine, Omaha, NE. John Swanhorst, Member, Nebraska State Council, is Registered Nurse, Emergency Department and Biocontainment Unit, Nebraska Medicine, Omaha, NE. Suzanne Watson, Member, Nebraska State Council, is ED Manager, Nebraska Medicine, Omaha, NE. Jamie Rudd, Member, Nebraska State Council, is Application Senior Analyst, Nebraska Medicine, Omaha, NE. For correspondence, write: Shelly Schwedhelm, MSN, RN, NEA-BC, Emergency Department, Trauma and Emergency Preparedness Services, Nebraska Medicine, 987461 Nebraska Medical Center, Omaha, NE 681987461; E-mail: [email protected]. J Emerg Nurs 2015;41:165-9. 0099-1767 Copyright © 2015 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2015.01.003

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bulletin board. The algorithm and process were discussed at change-of-shift huddles. In addition, the ED Nurse Manager discussed the screening process one on one with numerous staff. The ED Nursing Director attended resident education providing real-time feedback on patient situations, as well as lessons learned, and reinforced the importance of prompt recognition, PPE adherence, and communication. Practice Implications

A policy is only as good as its real-life execution, and practice makes perfect. When the possibility of an Ebola-infected patient entering our emergency department was examined, it was decided that the policy needed to be straightforward. Proper execution of the strategy would occur through clear and concise on-the-job training and instructional tools. The Biocontainment Unit staff were used as a resource to provide emergency nurses and medical staff with hands-on training in the process of donning and doffing of PPE. Regarding the realworld application, clear instructions with both word and picture steps were placed in our main triage room with a supply kit that offers the nurse the exact supplies needed for proper PPE for this type of patient (http://www.nebraskamed.com/ biocontainment-unit). Electronic Tool Adds Hardwired Capability

An electronic version of the algorithm was developed and implemented on October 10, 2014 (Figure 2). For multiple reasons, it was necessary to move this workflow to the electronic format. First, we needed to provide visibility to downstream providers of the information that was obtained in triage. Second, we needed to be able to provide administrators with an audit trail of who had viewed the patient’s information and how it was acted on. Lastly, an electronic system could provide guidance about what steps are needed to care for the patient as well as an electronic tool could be easily adapted to add or remove countries quickly if needed or consider other highly infectious diseases that also required screening. Concerns were raised that fever might not be the best trigger for beginning the screening process. Fever may not be the first symptom an Ebola-infected

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FIGURE 1 Triage for suspected Ebola: paper version. EVD, Ebola virus disease; PPE, personal protective equipment. Data modified from Nebraska Medicine.

FIGURE 2 Electronic Ebola triage process. PPE, Personal protective equipment. Data from Nebraska Medicine.

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FIGURE 3 Best practice advisory to direct isolation procedures. Data from Nebraska Medicine.

FIGURE 4 Best practice advisory to direct documentation of provider communication (arrow). Data from Nebraska Medicine.

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FIGURE 5 Best practice advisory to direct infectious diseases consultation order (arrow). Data from Nebraska Medicine.

patient experiences, or it could be masked by antipyretics. Because of this, the team decided to have the travel history direct the triage process.

How the Electronic Ebola Triage Process Works

Travel screening is done either by a greeter nurse for walk-in patients or by the primary nurse for patients arriving by ambulance. When a patient answers yes to the first question regarding travel outside of the United States in the past 21 days, the other questions gather additional information. Instructions in red guide the nurse to immediately isolate the patient to protect himself or herself, the patient, and others.

If, during screening, a patient has a positive response regarding travel to the affected hot spots in West Africa and a temperature greater than 38.6°C (101.5°F), two best practice advisories (BPAs) appear on the screen (Figures 3 and 4). These are instructions on what to do with the patient, as well as what needs to be documented in the electronic health record. The first BPA (Figure 3) instructs the nurse to place the isolation order. The order is pre-populated with the rationale. The second BPA (Figure 4) fires to remind the nurse to document the notification of the staff physician. The medical provider will receive his or her own BPA on initial opening of the patient’s medical record (Figure 5). The link embedded will take him or her directly to an order to consult our infectious diseases physician group for further evaluation.

FIGURE 6 Biohazard symbol notifying staff that an isolation order has been placed. Data from Nebraska Medicine.

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FIGURE 7 Banner notifying staff of a patient’s positive travel history. Data from Nebraska Medicine.

Downstream Communication

After the isolation order has been placed, a biohazard symbol (Figure 6) appears next to the patient’s bed number on the track board. A banner appears at the top of the reports contained within the electronic medical record to alert staff to a positive travel history for 21 days after the patient has returned to the United States (Figure 7).

Conclusion

Preparation is critical in the ED care of Patients Under Investigation (PUI) for the Ebola virus (EBV). By equipping the ED team with the tools needed for Ebola triage processes, automated history alerts and agile

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electronic tools, PPE protocols, supply kits, and knowledge about what to do and when, safe care of PUI for EBV can be achieved. Acknowledgment

We acknowledge the work done by analysts Charlotte Brewer, BSN, RN, Craig Reha, PharmD, BCPS, and Ron Carson, BA, in helping with the electronic health record changes.

Submissions to this column are encouraged and may be sent to Andi L. Foley, MSN, RN, CEN [email protected] or Diane Gurney, MS, RN, CEN [email protected]

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ED Ebola triage algorithm: a tool and process for compliance.

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