Children may be less susceptible than adults to the most serious symptoms of COVID-19. Nevertheless, when Seattle became an early U.S. hot spot, the clinical and operational leaders at Seattle Children’s Hospital immediately set up an emergency operation center and an incident command structure to rework many of its policies and procedures. Among other things, the hospital is coping with sick patients and staff as well as serious shortage of personal protective equipment.
In an April 2 webinar sponsored by the International Society for Quality in Health Care, three Seattle Children’s executives spoke about their organization’s COVID-19 response and their ongoing commitment to quality and safety during the emergency.
Ruth McDonald, M.D., interim chief medical officer for operations, stressed the importance of setting up the emergency operations center and incident command structure. At Seattle Children’s, it was launched on Jan. 22, the day after the first case was confirmed in Washington state. She said the structure allows information to flow up from the front-line clinical and logistics staff members through managers to the emergency operations center. Teams in different groups hold huddles several times per day. Planning and operations team leaders do rounding to enforce new tools and methods are being put in place and to hear about how we need to change,” she said. “You have to be fluid and respond quickly and change training materials as the situation changes in the state and in the U.S.”
Seattle Children’s had to make major changes, including cancelling elective procedures and using a broad array of telehealth and virtual visits in the ambulatory setting as well as in the hospital itself. They created a 20-patient isolation unit for patients who test positive. They started doing virtual rounding of inpatients, bringing together physicians with family members, pharmacists, nutritionists and others. The hospital had to change visitation policies, allowing only essential caregivers. Many staffers were ordered to work from home. Even getting staff to the hospital, when they were fearful of using public transportation or shuttle buses, proved challenging. “We engage our analytics team and have a dashboard that is updated daily,” McDonald said. They have tested almost 1,300 patients, with only 13 testing positive and most of those are at home recovering. Among the work force, 4.5 percent of those tested, or 35 people, have tested positive.
One of the biggest issues the hospital faces is a shortage of personal protective equipment (PPE), added Danielle Zerr, M.D., M.P.H., the medical director of infection prevention. Because children’s hospitals have fewer COVID-19 cases, they are low on any priority list for supplies. “We have been following CDC guidance, but we are challenged by a shortage of PPE, including masks and disposal components of CAPR [respirator] units. We have had to change guidance to front-line staff on how to best use available PPE,” Zerr said. “We have quickly gone to extended-use strategies to preserve resources.”
She explained that to preserve PPE, they also have reduced the number of times physicians enter a room to once per day unless it is essential that the patient be evaluated again.
Zerr noted that the CDC is beginning to make comments about requiring masking all staff all the time. Other hospitals are starting to do this. “If we implement it here, our supply would hold out about two weeks,” she said. About 50 percent of the hospital’s masks are donated, some FDA-approved and some not. “We are trying very hard to communicate to the work force that home-made masks should be used as a last resort.”
Kristina Toncray, M.D., a physician director of safety event analysis, noted that even in an emergency, the hospital’s approach parallels the work they do regularly in quality and safety in terms of knowing what is happening on the front lines and a commitment to resilience. “We can’t do root cause analyses, but we always look at whether we have data to understand what we need to be doing,” she said. In terms of resilience, they work with provider group leaders to come up with lists of who can be a backup if you become ill and what other providers can work in your area.
Toncray said that even during a pandemic, they also follow the six domains of quality identified by the Institute of Medicine in 2001, including equity in decision-making. The hospital must continue to monitor for non-COVID events such as hospital-acquired conditions. You have to make sure those don’t get lost in the shuffle. She added that the emergency has forced the hospital to reconsider the priority of other projects. For instance, Seattle Children’s was beginning a systemwide IT project. “We need to postpone that for now,” she said. “You have to think about priorities in your organization and where they now fit in and let people know.”
