Admission Control

Nov. 15, 2011
In 2009, hospitals all over the United States were affected by an outbreak of the swine influenza A (H1N1), virus - some more severely than others. One of the first areas of the country affected was the Southeast; with Florida and Georgia at the forefront.
Praveen Chopra

In 2009, hospitals all over the United States were affected by an outbreak of the swine influenza A (H1N1), virus - some more severely than others. One of the first areas of the country affected was the Southeast; with Florida and Georgia at the forefront. When the World Health Organization declared the severity of the influenza as a global pandemic, healthcare providers were forced to deal with not just the virus itself, but the misinformation and fear that prompted hundreds of patients to crowd emergency departments seeking tests and medications.

“We were seeing a high degree of false alarms,” says Praveen Chopra, vice president and CIO at Children's Healthcare of Atlanta, a three-hospital, 510-bed organization. “People were coming in because they had heard about H1N1, and they were bringing their children to our ED.”

Breaking Down “Operation Prevent Flu”

When concerns about the H1N1 virus prompted fear among patients and led to overcrowding in the emergency departments, Children's Healthcare of Atlanta took action. Despite having just a small window of time, the Pandemic Task Force was able to devise a plan to help educate patients and prepare staff to deal with the outbreak by completing the following tasks:

  • Create “Operation Prevent Flu” hub on the Children's intranet site with updates, links and resources for staff

  • Create influenza planning dashboard providing daily metrics of patient volumes by location and chief compliant, ED turnaround times and admissions

  • Develop H1N1 hotline email address for physicians and employees

  • Update order sets to quickly revise flu-testing orders

  • Use monthly and weekly clinical manager memos to disseminate information, answer questions and recruit backup staffing

  • Establish flu clinics using an electronic staffing system

  • Create flu Web site for patient families containing information, teaching sheets and an interactive protocol to determine need for medical intervention

  • Host interactive Webinars for physicians and staff

  • Partner with local media to host online QandA sessions, press conferences and community blogs

  • Utilize school listserv to disseminate flu-testing information to school administrators

Daniel Salinas

Daniel Salinas, M.D., senior vice president and chief medical officer at Children's, says, “One of the things we found out early was that there was a lot of misconception and misinformation. So we decided we had to stand up as the experts and do what we can to make sure we take care of the kids and also allay some of the families' fears.”

Wasting no time, Children's developed a plan to educate patients and staff about H1N1, using technology and resources it already had. The result was Operation Prevent Flu, a multidisciplinary initiative that was so successful it became a model for other health organizations.

Jim Fortenberry

At the core of the effort, which involved more than 100 staff members, were two primary goals: to increase responsiveness and efficiency among the staff, and to more effectively manage the volume of patients in the ED (See the sidebar for more information about the project). “In the overwhelming majority of children, the H1N1 virus only caused a mild to moderate flu-like illness,” says Jim Fortenberry, M.D., who serves as pediatrician-in-chief at Children's Healthcare of Atlanta, and medical director, Division of Critical Care Medicine, at the Egleston campus. “So what we were trying to do was to help educate, reassure and guide families, and also help provide resources for community physicians on what needed to be done. Our focus was on how we can control patients getting into the ED in the first place.”

Getting the word out

One of the first steps was to develop a triage system - accessible by phone or Internet - in which patient families answer a series of questions to determine whether an ED visit is necessary. The Information Systems and Technology (ISandT) department partnered with physicians as well as the Call Center staff to develop an evidence-based algorithm and post it to the organization's Internet site. “We took the knowledge we had and transferred it into a question-and-answer toolset that would act as a decision tree for families,” says Chopra.

The protocol proved successful, according to Renee Watson, manager of infection control at Children's. During Labor Day weekend, when the second wave of H1N1 was at its height, 80 percent of patients who used the algorithm were instructed to stay at home and take over-the-counter medications - and the large majority of them did just that, she says. “If all or even some of those patients had presented to the hospital, it would've further disabled our system.”

What was critical, says Salinas, wasn't just that Children's had a site offering patients assistance, but that it was up and running within a short time period. “Our ISandT team really stepped up to the table for us. They had other projects, but they put them to the side to focus on this.”

The lobby at Children's Healthcare of Atlanta at Scottish Rite, one of the organization's three campuses
Gary Frank

Another key component of Children's H1N1 response was to create a business intelligence dashboard that interfaced with the EpicCare (Epic Systems, Verona, Wis.) EMR system to provide daily updates on flu-related admissions, chief complaints and ED turnaround times. Putting it all together, however, required a village. According to Chopra, the ISandT, quality and emergency departments worked to pull data from the EMR system to generate reports for the dashboard, and Pediatric Emergency Specialist Daniel Hirsh, M.D., and Gary Frank, M.D., medical director for quality and medical management were instrumental in building queries that brought the data to the forefront. “We provided a very effective dashboard showing all of the key indicators so that people have information at their fingertips to make good decisions.”

Both Frank and Hirsh believed it was critical to provide staff with quality data as the virus reached the pandemic stage. “With our dashboard, we got a sense of not just how busy we are, but also where the trends are moving. Is it is getting better or is it getting worse?” says Hirsh. “We got a sense of what types of patients were coming in and what level of acuity, and we got a sense of what burden this was having in terms of bed availability.”

And that information, says Frank, helped Children's more effectively manage resources. Despite the fact that ED volumes were 2.5 times higher than the typical flu season, turnover times were around the same as the prior year, he reports. “And the number of patients who left the ED without being seen remained very low. So because of the information sharing and the planning that went into this, we were able to remain highly efficient as an organization at a time when we were hit by a pandemic.”

While the dashboard was effective in assisting with resource planning, practice alerts proved pivotal in communicating orders for the treatment - and particularly, testing - of potential H1N1 patients. “We used a best practice alert within our EMR system to guide physicians,” says Chopra, so that if new data became available on a test or treatment, clinicians were notified right away. “If you provide more meaningful information, then people can make good decisions. So that's what we tried to do.”

According to Fortenberry, one of the roadblocks physicians faced was that the rapid flu tests being requested by patients were not specific to the H1N1 virus and therefore not accurate. “This was another area where we utilized technology,” he says. First, a message was sent out to community physicians that Children's wasn't going to perform the rapid test in its EDs. Second, the test was removed from the order set, ensuring that physicians couldn't request it. “We used our CPOE (computerized physician order entry) system to create pop-up practice alerts to help guide physicians and let them know that a viral culture is what was recommended to help determine if the patient had H1N1.”

All hands on deck

Interestingly, having to develop and launch a multipronged initiative in two weeks wasn't the most daunting task facing the leaders and the staff at Children's. Instead, it was dealing with massive amounts of data coming in from multiple directions and converting it into useful information to aid in decision-making, says Frank. In addition to internal metrics such as patient volume, room status and availability of antiviral medications, gloves, masks and other supplies, Children's was getting statistics from the Centers for Disease Control and Prevention (CDC, Atlanta) that had to be incorporated into the dashboard. “Many organizations are data rich and information poor. I think what we did very successfully is use technology to be able to share that type of information,” he adds.

The Egleston campus, one of Children's Healthcare of Atlanta's three hospitals

And it was done using resources that were already in place, according to Chopra. “It was an optimization thing. We used the people we have and we leveraged technology. That's why this is truly innovative. We didn't spend a lot of money buying new things; we just applied what we've learned in other areas and brought it together to solve a problem.”

What made that possible, say the leaders at Children's, is the culture of collaboration that exists throughout the organization. When the Web-based protocol needed to go live, the IT staff put its other projects aside and worked with physicians to create the algorithm on the site, according to Salinas. “There was an incredible collaboration between technology and clinical medicine.”

Hirsh agrees. “This was as example where everybody just played a part without worrying about the silos,” he says. “Everyone was stretched thin in terms of resources, but we all just worked to get the task done.”

From Dress Rehearsal to Live: How Children's of Atlanta Geared Up for H1N1

In the spring of 2009, Children's Healthcare of Atlanta experienced a wave of the H1N1 virus that helped the organization prepare for what was to come later in the year. “We started to see surges in our ED and immediate care volumes, and we started to see how concerned families were about H1N1,” says Daniel Salinas, M.D., chief medical officer. “We still didn't know how the virus was going to pan out, but we knew we had to be prepared, so we created this multidisciplinary task force which involved a medical management team, an infection control team, a facilities and patient placement team, a staffing team, a supply team and a communication team.”

Because little was known about the H1N1 virus, it was essential that Children's put together an effective plan of action - and fast, according to Gary Frank, M.D., medical director for quality and medical management. “We very quickly had to get organized around how we were going to manage the situation and what type of information was going to be available on the system level,” he says. “It became clear very early on that a large part of how we respond had to do with data, so we developed the ‘Operation Prevent Flu’ page. We put a tremendous amount of resources available for our internal audience and we developed external sites for the general community. So there was that aspect of very quickly making information available to a large audience.”

That audience included not only hospital-employed physicians, but also community physicians, patient families and administrators at local schools. And that, says Renee Watson, manager of infection control, was no simple task. “We were really being pounded from a few different areas because of the emotion of the disease. Schools were telling students they had to go to the ED and take a test, receive antiviral medications and get a note if they wanted to return to school. We really had to do a lot of communicating in a very multifaceted way.” Part of that included meeting with superintendents and community health commissioners to educate them on the appropriate ways to manage students who may have been exposed to H1N1.

Another area that needed attention was keeping pediatricians updated on the latest recommendations, which meant sifting through all of the data available, according to Frank. “We estimated that if pediatricians read every piece of information and every guideline that came out every day from the American Academy of Pediatrics, the Medical Association of Georgia, the CDC and the World Health Organization, it came out to about 13-14 hours a day. They were inundated, so what we did was bubble down the high points and give them valid information in a very timely way so they knew what the take-home messages were.”

It was no easy task, but in paving the way with a plan highlighting the optimal ways to educate patients and staff during a pandemic, Children's of Atlanta blazed the trail for other organizations, according to CIO Praveen Chopra. “We accomplished more than we thought we would. We thought that we wanted to inform the patients and the families, but actually we ended up helping community physicians and other hospital systems that were looking for information on how to react to H1N1.”

Fortenberry, who served as spokesperson for the project, was most impressed with how quickly Children's responded to the potential crisis. “In large organizations, sometimes there's a tendency to want to overanalyze,” he says. “But in this case, there was an immediate recognition that we needed to do something. And people in all layers of senior leadership shared the attitude that if the physicians, clinicians and nurses think this is the right thing to do, then we're going to provide the resources. This was a case where the technology and the medical staff using it really synched up together well.”

H1N1 … and beyond

Like most large-scale projects, Operation Prevent Flu wasn't launched to solve one immediate problem, but instead, to build a foundation for how similar issues will be handled going forward. According to Frank, the staff met after H1N1's status was downgraded to discuss what worked and what did not, and to make sure that the lessons learned were applied to better prepare the organization for emergency situations. “One of the things we've already done is modified the influenza dashboard into a surge planning dashboard, so that in the future, it'll be up and available from day one,” he says.

Going forward, the dashboard will also include inpatient data as well as quality markers, says Hirsh. “This way, it's essentially a system dashboard at all times,” which he believes will help position Children's for the future. “We've always had the infrastructure, but now it's even stronger. So when the next outbreak comes along, instead of taking two weeks to get everything together, it might take two days.”


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Healthcare Informatics 2010 March;27(3):30-36

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