While some state hospital associations are leveraging their collective power to reassure patients that accessing needed care is important and safe, there are steps individual hospitals and emergency departments (EDs) can take, too.
For instance, the ED at Lodi Memorial Hospital (LMH), a 150-bed community hospital in Lodi, CA, has addressed the issue of declining volume with a multifaceted approach that uses data regarding specific patient concerns, health outcomes, and human-centered design (HCD) techniques.
Laura Wong, MD, PhD, a resident physician in the department of surgery at the University of California, San Francisco (UCSF), became a part of this initiative from her work with The Better Lab, an HCD concern at UCSF that works to solve a variety a of healthcare problems.
“When the COVID-19 pandemic began, my PI [principal investigator] and a number of other healthcare designers in the community, academia, and industry all came together to create what we called the Emergency Design Collective,” she explains. “It was [established] to be a national group of designers that could quickly solve problems that we saw developing.”
First, the group focused on other pandemic-related issues. For instance, Wong became interested in looking at what specialists could do to help offload emergency medicine personnel who were anticipating a surge in COVID-19 cases. However, circumstances shifted quickly.
“The discussion in February was about how to prepare for a surge. Come March, we were talking about how to prevent layoffs because volume had gotten so low,” Wong says.
Suddenly, there was a financial crisis and a healthcare crisis. The group worked to nail down specifically what was preventing patients from visiting the 36-bed ED at LMH, and what the overall impact of this phenomenon was in terms of health outcomes. Immediately, it was clear cardiac emergencies still were happening, even though many of those cases were not making it to the ED.
“Data from our EMS medical director [showed] that they had seen more codes in the field than ever before, that almost all of those patients were declared dead in the field, and were COVID-19-negative when they tested them,” Wong reports.
Specifically, EMS reported they responded to 45% more cardiac arrests in March than in February, data that strongly suggested people were waiting too long to access care. Further, all stroke patients who arrived at the ED in March arrived too late to receive thrombolytic therapy.
This was counter to previous data showing the hospital typically delivers thrombolytic drugs to three to eight stroke patients per month.
What was clear from these data was patients in the community were reluctant to come to the ED, even in cases where they were experiencing significant health problems. “We really felt like this was a public health issue that was only beginning to be covered in the news,” Wong shares.
The HCD workgroup partnered with LMH to address the problem, starting with a series of patient interviews regarding their experiences with healthcare both before and after the start of the pandemic. What was evident from these discussions was that fear of contracting COVID-19 was the overarching concern. Notably, other subthemes emerged, too, which Wong and colleagues published to help other EDs dealing with the same depressed-volume concerns.1
During patient interviews, the authors learned many people perceived hospitals as “infectious reservoirs,” and believed they would be at high risk for virus exposure. Further, patients were largely unaware of what mitigation tactics were in place to protect patients from exposure. They needed guidance from healthcare providers about when a trip to the ED was appropriate.
The interviews also revealed patient perceptions often developed by watching national news coverage of coronavirus hotspots, leading them to believe local conditions were more severe than was the case.
To address patient fears of contracting COVID-19, the HCD team worked with healthcare leaders to essentially divide the ED in two: a respiratory pod and a non-respiratory pod. After screening at the main entrance, patients would be sent to one pod depending on whether they exhibited respiratory symptoms. However, there were some challenges with this approach.
“A big problem was that we were using our fast-track area as the non-respiratory area. That was not designed for high-acuity patients,” Wong says. “One thing we noticed was that the two spaces can be closed off from each other, but there was a whole string of rooms that were in the main ED [or respiratory pod], but basically had back doors into the low-acuity area [as well].”
Consequently, these rooms were designated as “high acuity” rooms for the non-respiratory pod, a place where providers would feel comfortable performing tasks such as administering thrombolytic medicine, Wong notes.
Each pod required separate staff, an issue that was settled fairly easily, according to Wong, as there were providers who already preferred the fast-track area. Those employees stayed where they were once the space was transformed into the non-respiratory pod. However, overnight, when there is only one provider working, that provider would have to cover patients in both pods, although there are still separate support staff stationed in each area.
Reorganizing the ED and patient flows in this way required significant changes, but the transition went smoothly. “One of our biggest champions was the nurse manager, who just really got things done,” Wong says.
Also, Wong believes ensuring all staff members and providers were consulted about the proposed changes made a difference. It is a small ED that sees about 60,000 patients a year. Gathering everyone’s input was not difficult. “Involving [staff] in the decisions just kind of helped them get over some of the barriers to change,” Wong says. “A lot of the nurses said they felt more comfortable with the division, even though it made some of their staffing workflows a little bit more difficult.”
There was some finessing of the new approach as it became clear some changes would be helpful. For instance, when the HCD group members completed their first prototype for dividing the ED, they had not devised a way for moving patients if they went to the non-respiratory side and then developed COVID-19 symptoms, Wong relates.
“The first day, we started putting [those] patients on strict precautions on the non-respiratory side,” she recalls. “[Both] patients and staff felt that was a problem, and that we needed to prioritize moving those patients to the other side ... even though we had to deep-clean two rooms, that was better overall for people’s comfort.”
As an added layer of protection for both patients and clinicians, provisions were made so anyone entering the hospital was equipped with a mask, hand sanitizer, and wipes for any items they brought with them.
Once all changes were implemented, the HCD group and the hospital mounted a communications campaign aimed at educating patients about the significant precautions and why they were in place.
To spread this message, the hospital sent a short email to everyone in the health system’s database, informing them the hospital was open and able to provide needed care. The email also made it clear the hospital had appropriate personal protective equipment available, and that procedures were in place to keep patients safe.
In addition, the hospital attracted some local media coverage about its work. Wong and colleagues stated that in mid-April, the medical and nursing directors contacted the local newspaper to provide information about the ED. The authors said it was important this information came directly from the hospital and respected clinicians, trusted sources of information.
Further, the hospital leveraged social media to provide guidance on what types of symptoms are indicative of an emergency, and should trigger a visit to the hospital. The HCD group also developed a relatively simple social media-type post depicting the steps the hospital has taken to keep patients safe. It is hard to say for sure what impact the redesigned ED and the messaging campaign have made in terms of making people feel more comfortable about seeking needed care. Within a few weeks of implementation, volume to the ED had recovered from about 50% of normal at its most depressed state to about 80% of normal, Wong observes.
“We have been trying to ask people what changed for them, and what made them feel like they could come in now,” Wong says. “A lot of people have said that word of mouth in the community has started to get around ... that the ED is safe.” She also notes patients have reported they feel more comfortable with the divided ED space.
Wong is unsure what platform (newspaper, social media, or email messaging) has delivered the biggest return, but one lesson regarding healthcare messaging was immediately apparent: simple is better.
“People wanted to know about cleaning and things like that, but they didn’t want to be flooded with information,” she explains. “That was something we heard over and over again. When we went into a lot of detail about cleaning, people felt like it was too much.”
What is important is relaying trusted information to consumers so they understand the situation clearly and accurately. “We heard a lot from people that the news had very much skewed their views of what was happening in the community,” Wong shares.
Now that the changes in the ED have been in place for several weeks, will they become permanent? “Everyone keeps saying we have a new normal, and I think some of these changes will persist,” Wong observes.
However, there likely will be additional finessing, particularly considering a more recent requirement that every patient undergo testing for COVID-19 before admission, a task that slows patient flow for that group. While patients who are disposed to go home are moving through the ED at about same pace as before the changes, the admitted patients are definitely taking longer, Wong reports.
- Wong L, Hawkins J, Langness S, et al. Where are all the patients? Addressing Covid-19 fear to encourage sick patients to seek emergency care. NEJM Catalyst. May 14, 2020.