In a recent post, Gregg Miller, MD, CEP America’s director of performance and quality, discussed best practices for responding to potential cases of Ebola virus disease (EVD). In today’s post, James Kim, MD, describes how his hospital is putting these principals into practice. Dr. Kim is emergency department (ED) medical director at Pomona Valley Hospital Medical Center (PVHMC) in Pomona, Calif.
Perspectives: Thanks for joining us, Dr. Kim. Can you tell us a little about your department’s experience with EVD?
Dr. Kim: Sure. PVHMC is a 65-bed emergency department located in East Los Angeles County. Because Los Angeles is a port of entry with a large international population, EVD preparation has been a huge priority for us. So far, we’ve had two ambulatory patients present to the ED who screened "high-risk" at triage. While both of them were ruled out, they provided us with the opportunity for a "trial run" to test the protocols we’ve been developing. So it was a very valuable experience.
Perspectives: I understand PVHMC is designated as a disaster resource center (DRC). Tell us a little about that and how it relates to EVD response.
Dr. Kim: As a DRC, we’re the lead hospital coordinating disaster and mass casualty response in East Los Angeles County. As such, we receive federal and county grants for training, outreach and the purchase of medical equipment and supplies.
Disaster response at PVHMC is headed by a coordinator and a multidisciplinary disaster response committee. They’ve been excellent resources for our ED and have organized some invaluable hands-on training for us. For example, they teamed up with our infection prevention committee to supervise us as we practiced donning and removing hazmat suits and PAPR respirators. They also advocate on our behalf with the administration to make sure we have access to the equipment we need.
As a DRC, we also have access to funds and equipment that relatively few hospitals have. We’ve actually got a semi-permanent containment tent set up outside our ED entrance. If needed, this would allow us to isolate potential EVD patients outside the hospital, which greatly reduces the danger to staff and the public. And it’s an ideal setup, because it’s got negative pressure ventilation and an anteroom for donning and removing personal protection equipment (PPE). Sometimes we worry that it might look a little ominous to the patients coming and going, but in general, I think they’re happy it’s there.
Perspectives: Sounds like you have access to some fantastic expertise. Have you had a chance to share what you’ve learned with other CEP America hospitals?
Dr. Kim: Absolutely. And honestly, I feel like I’ve learned as much as I’ve shared. When it comes to EVD response, our CEP America leadership has been great about keeping on top of recommendations and disseminating key information as it becomes available. The medical directors also network with one another to share our learning and experiences.
I think it benefits PVHMC as well. The ED director and I sit on our hospital-wide Ebola response committee, so we have many opportunities to share what we've learned from the Partnership.
Perspectives: Have you implemented any of the practices you’ve learned from your CEP America colleagues at PVHMC?
Yes. Probably the biggest one is the use of telecommunications for initial screening. When potential cases appear, some EDs have providers and nurses don PPE and screen high-risk patients face-to-face. Of course, those personnel then have to be isolated until the patient is cleared, which leaves the ED understaffed and disrupts care for other patients.
So now when the triage nurse identifies a high-risk patient, we direct the person to a designated room right off the waiting room with a telephone inside. The physician then calls in to complete the screening. Based on the responses, we either release them for care as usual or activate our EVD response algorithm.
We find this workflow makes good use of our resources. It helps us meet our goals of minimizing infection risk without disrupting the care of other patients. We’re currently working on some scripting to make the process more comfortable for the patient, but in general the patients we’ve screened this way have been very understanding.
Perspectives: What challenges are you still working on when it comes to caring for potential EVD patients?
Dr. Kim: A big one is identifying team members who are willing to care for these patients. In theory, individual providers and nurses can’t refuse, but we’d rather not put anyone in a difficult position. It’s bad for the team, and it’s bad for the patient. So PVHMC is asking for volunteers from the emergency department, environmental services, critical care, the lab, pharmacy and so on who are willing to be on call and respond if a case comes in.
I think another challenge is resisting the urge to do too much too fast. In the emergency department, it’s against our culture to step back and slow down when a patient is in need. But I think experience across CEP America hospitals has shown us that it’s best for everyone to limit contact with the patient while EVD is ruled out. If an EVD patient ever comes in ambulatory, chances are they’ll be quite stable for a while. So it’s really important to take a deep breath, slow down and follow every step of the protocols we’ve developed.
Perspectives: Thanks so much for sharing. Any parting thoughts?
Dr. Kim: I think our CEP America Partnership has really come together to share our learning and disseminate best practices around EVD response. It’s almost like we’re formulating best practices together using the collective experience of over one hundred emergency departments from across the country, which is really exciting.