EXECUTIVE SUMMARY

A hospital in Florida enacted a program to screen every employee daily for symptoms of COVID-19. Their experience holds lessons for the next pandemic.

  • Everyone entering the building was processed through screening stations.
  • Forehead thermometers were not entirely reliable. High readings required oral temperature confirmations.
  • Staff and visitors with COVID-19 symptoms were immediately tested for the virus.

The Miami (FL) Cancer Institute achieved a feat that many healthcare institutions aspired to during the worst of the COVID-19 pandemic: screening every employee and visitor every day for COVID-19 symptoms before allowing them into the facility. The logistics may be useful to other hospitals in the next disease outbreak.

Miami Cancer Institute screens 100% of its employees because it serves a high-risk cancer population and must ensure no one is symptomatic. In some periods, they have screened 2,000 people a day with 50 staff members performing the screening process.

The effort was accomplished with support from the Baptist Health System, which coordinated the COVID-19 response for its nine hospitals, says Michele Ryder, MSN, MSHSA, RN, CENP, chief operating officer and chief nursing officer of Miami Cancer Institute. The health system and the Miami facility used the recommendations from the Centers for Disease Control and Prevention (CDC) and the more targeted Florida state guidelines to develop a comprehensive testing program, Ryder says.

While many hospitals were moving patients out to make room for expected COVID-19 patients, Miami Cancer Institute determined it could not interrupt chemotherapy or radiation treatments. That made it one of the few facilities treating patients full time on a regular basis during the height of the pandemic, Ryder says.

“We knew we had to not only keep our patients safe so they could continue their treatments, but we also had to do well by our employees,” Ryder says. “If we were going to run at full volume, we had to develop a distinct screening system. We had to do it very quickly to establish a system that screened visitors, patients, and staff.”

Screening and Temps

Anyone who entered the building first had to answer screening questions and take their temperature. The hospital kept a paper log of each screening until Paul Lindeman, MD, medical director of informatics, helped develop an electronic screening tool and log.

“We initially thought of five screening areas because we were looking at the entrances and the doors to our buildings. We quickly realized we needed to take that down to two entrances so that we would have enough screeners to last us long term,” Ryder says. “It took us between 40 and 50 people every day to man these screening centers.”

The screeners were selected from a wide range of employees who could be pulled from their usual work without adversely affecting patient care or overall operations of the facility, including environmental and dietary staff, she explains. They were trained on how to use the new database and ask the screening questions. The hospital developed 16 new workflows to direct them through the process.

“The workflows were reviewed daily and updated according to the most recent CDC recommendations, which was an important risk control element as well as making sure we were screening most effectively,” Ryder says.

The hospital also increased the use of telehealth to reduce patient visits. Pharmacists reviewed treatment protocols, looking for any potential medication changes that could lengthen the time between patient visits, Ryder notes.

The screening was conducted from 6 a.m. to 6 p.m., with coverage for all staff and patient visits, seven days a week. Each screening station included primary and secondary areas. If an employee or visitor answered yes to a screening question in the first area, that person had to go to the secondary area for testing.

“All of these things happened between March 16 and March 30, a two-week period in which everything was transitioning very quickly at full tilt,” Ryder says. “At the end of March, we implemented a no-visitors policy when we got to the point that we had as many visitors as we had patients. We had between 600 and 800 patients, so then we had that number of visitors, also. It was too much.”

Visitors Banned

At one point the hospital was screening 2,000 people a day. Eliminating visitors helped keep the system functional and was consistent with the guidelines for social distancing, Ryder says. The hospital’s patient experience staff stepped in to assist patients who arrived without the family members who might normally help them enter and exit the facility.

The hospital also used online platforms for cancer support groups and other meetings that needed to continue when visitors could not enter the facility.

Lindeman also introduced a software program to the screening stations that allowed the tracking of symptoms. “We essentially implemented an entire COVID clinic at Miami Cancer Institute. When you pull into the parking garage, someone greets you and asks you screening questions,” Lindeman explains. “If you answer yes, you go to secondary screening, and if you answer no, you enter primary screening. We emptied out our cafeteria and turned it into a very structured area for our primary screening.”

Double-Checking Fevers

Checking for fever was a first step. After some experience, hospital leaders determined the thermometers used for forehead temperatures were not 100% reliable. Anyone with a reading of 98°F or higher was directed to another station for an oral temperature reading. An oral reading of 100.4°F was an immediate fail. Any temperature below that allowed the person to continue to primary screening.

Any “yes” answer in primary screening directed the person to secondary screening, where advanced practice providers probed for more specific information about symptoms such as coughing.

“You’re getting a provider visit right there at our on-site screening, with zero wait time. That trained medical professional is able to ferret out if this is a new cough, any changes, any reason to suspect that this could be a relative symptom of COVID-19,” Lindeman says. “If the answer is yes, you moved on to our testing tent where, if you were an employee and not registered in our EMR [electronic medical record], you are registered on the spot and tested by advanced practice providers in full PPE [personal protective equipment], with a dedicated donning and doffing area.”

Everyone tested is registered in the symptom-tracking software system, which includes an app downloaded on the subject’s cellphone. Miami Cancer Institute uses the app to communicate with testing subjects. The app also asks the user for updates on symptoms twice a day. Negative responses sort to the top of a status board, showing hospital leaders who is not doing well and may need more attention, Lindeman explains.

Military Training Helped

Some of the success of the screening program can be traced to the military backgrounds of several hospital leaders, notes Matt Baumann, MBA, assistant vice president of operations and formerly with the U.S. Marine Corps. Their skill set and approach to rapid problem-solving helped the hospital launch such a large screening program in a short time, he says.

A command center provided hospital leaders oversight of the entire screening operation, Baumann explains, with Ryder at the head and functional leaders from several departments. The command center monitored all data and issued communications to staff.

The hospital’s screening program was a variation on a standard rapid-response Marine Corps exercise, the evacuation of a U.S. embassy overseas, Baumann says.

“Instead of screening for American citizens vs. non-American citizens, we were filtering out the symptomatic and potentially exposed people coming to the facility,” Baumann says. “One of the biggest successes for us was that our initial design became our permanent design. What we had initially on day one remained in place for the next three months, because it is a widely applicable screening process that works in different environments and with different purposes.”

SOURCES

  • Matt Baumann, Assistant Vice President of Operations, Miami (FL) Cancer Institute. Phone: (786) 596-2000.
  • Paul Lindeman, MD, Medical Director of Informatics, Miami (FL) Cancer Institute. Phone: (786) 596-2000.
  • Michele Ryder, MSN, MSHSA, RN, CENP, Chief Operating Officer, Chief Nursing Officer, Miami (FL) Cancer Institute. Phone: (786) 596-2000.