Boston Medical Center COVID19 Response, Fever/ILI Clinic Operations Date of last update: Sunday, March 15, 2020 – 9:45 PM

1. Clinical Guidelines and Disposition for Hospital Access Point Screening -

2. ILI Clinic / Ambulatory Surge Guidelines-

a. Patients arrive ONLY via the following methods until testing is available more broadly: i. Per ED ILI triage guidelines, patient arrives masked and referred by ED ILI triage if:

1. Patient <=65 2. Pulse ox >93%

ii. Patient arrives masked and referred from entrance screeners if 1. Temp >= 100.4 2. Patient is Symptomatic / Unwell

iii. Patient arrives masked and referred from clinic if BMC COVID 19 testing guidelines are

met and testing is deemed necessary by Ambulatory testing algorithm This is TBD, additional operational support and clinic awareness required

b. Location:

i. Shapiro Lobby (Effective 3/16/2020) ii. Yawkey Lobby (Effective _________)

iii. Tent on Yawkey/Menino side (Effective ________)

c. Hours: i. 7:30A - 8:15P (staffed by Primary Care; open for patient arrivals 8A-8P)

ii. 8P - 7:30A (Patient reports to ED)

d. EPIC Operations: i. Epic DEPs

1. Shapiro Lobby: SHA ILI 2. Yawkey Lobby: YAW ILI 3. Tent on Yawkey/Menino side: TBD

ii. Access: All staff (MAs, Providers, Operations) need Ambulatory Epic Access

iii. Screening Tools: Travel Screening Operational, updated as CDC recommendations

warrant Point of Contact: Rebecca Mishuris Relevant Document: EMerge Travel Screening Tip Sheet, Registration

Symptomatic/ Unwell Asymptomatic/ Well

>=100.4 temp

Patient: Mask + ILI clinic Visitor: Mask + Home

Patient: Mask + ILI clinic Visitor: Mask + Home

<100.4 temp

Patient: Mask + ILI clinic Visitor: Mask + Home

Patient: Business as usual Visitor: Current Visitor Policy

iv. Registration Functionality: Quick registration will be utilized with back end complete registration completed by Revenue Cycle. Point of Contact: Joseph Ianelli Relevant Tip Sheet: ILI Clinic New Patient Registration Relevant Tip Sheet: ILI Clinic Existing Patient Registration Relevant Document: See Appendix I

v. Testing Order Sets: Must be available from all relevant locations, all providers must have access. Ideally providers will have set to favorites / quick access Point of Contact: Rebecca Mishuris Relevant Tip Sheet: ILI Clinic Encounter, MD

vi. After Visit Summary: To include COVID 19 precautions, CDC Guidelines, patient

education, contact information for additional support and visit summary. Point of Contact: Rebecca Mishuris Relevant Document: COVIDavs.PDF

vii. Patient Tracking: Workbench report + ICD10 Codes to be used to track identified patients / tested patients. Will incorporate into daily census

e. IT Hardware: i. Regular printer

ii. Label printer iii. WOWs: n = 1 per provider staffing ILI clinic location iv. Cyrcom Phones: n = 2 per ILI clinic location; one labeled ‘Clean’ for registration, one

labeled ‘Hot’ for use during screening

f. Required Equipment and Supplies: i. Chairs, placed at least 6 feet apart

ii. Dividers / Privacy screens iii. Vital machines: At least one per MA/Provider team, with disposable thermometer

shields iv. Testing supplies, including bags for proper bagging procedure

Point of Contact: Jason Worcester, MD Relevant Document: Boston Medical Center, COVID19 Lab Testing Guidelines; See Appendix II

v. Need mobile carts to hold supplies: Must have adequate number considering MA/Provider teams and ‘Clean’ verses ‘Hot’ supplies

vi. Office Supplies: Scissors, Index Cards, Tape, Markers, Plain Printer Paper vii. Tyvek Wristbands to identify patient transfers to ED

viii. Signage: Multilingual guidance for patients, guiding them to proper queues ix. Communication:

1. Location of Clinic 2. Process for Referral 3. Hours of Operations 4. Inclusion / Exclusion of patient types 5. Communication with collaborating departments

a) Emergency Department b) Lab c) Emergency Management

d) Environmental Services / Support Services

x. Hand Hygiene: Designate facility for handwashing, prop door open Shapiro ILI Clinic: Shapiro Lobby Men’s Restroom, with signage Yawkey ILI Clinic: TBD Yawkey Tent: TBD Menino Tent: TBD

xi. Staff Restrooms: Designate facility for staff

Shapiro ILI Clinic: Shapiro Lobby Women’s Restroom, with signage Yawkey ILI Clinic: TBD Yawkey Tent: TBD Menino Tent: TBD

g. Staffing: i. Operational Leadership

1. Operations Manager + Escalation Plan 2. Point of Contact in Incident Command Center

ii. Provider Coverage

1. MDs/Residents/NPs 2. Family Medicine vs. Internal Medicine = Pediatric Considerations

iii. Medical Assistants

1. Must meet criteria: Individuals that are not at elevated risk / immunocompromised or those who live/care for immunocompromised individuals

2. Must be able to vitalize patients 3. Bi-Lingual capabilities preferred

iv. Registration

1. Must meet criteria: Individuals that are not at elevated risk / immunocompromised or those who live/care for immunocompromised individuals

2. Bi-Lingual capabilities preferred 3. Familiarity with Epic recommended 4. Can be substituted by MA Quick Reg Workflow, if operational

h. Regulatory, Precautionary Protocols and Processes:

i. MAs, Providers, Staff should be fit tested for N95 Respirator 1. OSHA Respirator Medical Evaluation Questionnaire to be completed

Point of Contact: Cathy Korn Relevant Document: BMC_Respiratory Medicine Eval Questionnaire_OSHAptA.docx

ii. All ILI Clinic Staff should have working knowledge of donning/doffing required PPE in accordance with active precautions

1. PPE does not need to be changed between patients. Only gloves need to be changed. 2. PPE training will be conducted for providers by RN educators

3. Replenishment of PPE supply should be requested through Incident Command Center

Point of Contact: Cathy Korn

Relevant Tip Sheet: Donning and Doffing for COVID – 19

iii. Testing Guidelines for Sample Handling 1. COVID 19 Lab Testing Guidelines should be followed 2. Proper Bagging Technique should be followed Point of Contact: Jason Worcester, MD Relevant Document: Boston Medical Center, COVID19 Lab Testing Guidelines; See Appendix II and Appendix III

iv. Testing Follow Up 1. A centralized model will be utilized, operationalized via Epic Workqueue 2. Ordering ILI Clinic Provider / Support Staff will be accountable for all resulting and

follow up of COVID 19 results Point of Contact: _____

3. ILI Clinic Operating Procedure: a. Clinic Set Up:

i. ‘Hot’ areas / personnel: Comes in contact with patient ii. ‘Clean’ areas / personnel: No direct contact with patient

b. Workflow:

i. ‘Clean’ Registration 1. Masked patients are directed to registration desk 2. Quick registration is completed 3. Epic encounter is created 4. Travel Screening is completed 5. Patient Labels are printed and placed on Index Card 6. Index Card is handed to patient with instructions to retain card 7. Patients are directed to either ILI clinic seat or overflow waiting area

ii. ‘Hot’ Medical Assistant

1. Collects Index Card from Patient, completes patient verification, using 2 identifiers 2. O2 Sat and Temperature obtained, BP if necessary 3. Vitals are recorded on Index Card 4. If vitals do not meet ILI Clinic criteria, draw line through patient label (Mis-Triage)

Relevant Tip Sheet: ILI Clinic Encounter, MA

iii. ‘Hot’ Provider 1. Wearing PPE, per BMC Protocol, in accordance with current precautions, and new

outer gloves for each patient, obtains Index Card with patient label and Vitals 2. Uses ‘Hot’ COW (and Cyracom if necessary) to access Epic and find patient encounter 3. Enters Vital Signs found on Index Card 4. Completes clinical questionnaire in Epic Note 5. Determines whether COVID 19 Testing is appropriate, using Testing Algorithm as guide 6. If Testing Not Indicated: Provide patient with wellness instructions, AVS and complete

encounter 7. If Testing Indicated: Uses COVID 19 order set within Epic Encounter. This is a smart

set. Labels for Lab samples print (may require manual print, dependent on location) 8. Place lab label on sample vial, confirming patient name and DOB to confirm identity 9. Obtain N/P swab 10. Cap vial and confirm closed

11. Follow proper bagging procedures and hand off to ‘Clean’ MA 12. Provide patient with final instructions, AVS and complete encounter 13. If Emergency care is required place Tyvek Wristband on patient and discharge to ED

Relevant Tip Sheet: ILI Clinic Encounter, MD

iv. ‘Clean’ Medical Assistant 1. Handles Lab Sample, once in ‘Clean’ Bag and follows ‘Clean’ bagging procedure

Point of Contact: Jason Worcester, MD Relevant Document: Boston Medical Center, COVID19 Lab Testing Guidelines; See Appendix II

v. Visio Flow of Clinic Operations

Ensure patient is masked, complete Quick Reg and

Epic Travel Screen

Place patient label on Index Card, give to pt

ILI Clinic Patient Flow / Staff Handoffs

Temp > 100.4? Symptoms displayed?

No

STARTPatient Arrives at ILI Clinic

Move patient to MA vitals station

(or overflow waiting)

Hot MA: Access Patient Chart

Complete Vitals, write O2 Sat and Temp

on Index Card

STOPDraw line through Pt Label

Visit = Mis -Triage

Yes

Review Vitals and Travel Screen via Encounter

Access Patient ChartCOVID 19 Testing

Warranted?

NoSTOP

Complete visit, provide AVS, Remove and dispose gloves

Yes

Order COVID 19 Panel (Order and Labels to Print)

Collect SamplesLabel Sample

Properly Bag Sample

ED Treatment Warranted?

NoSTOP

Complete visit, provide AVS, Remove and dispose gloves

STOPComplete visit, provide AVS, Remove and dispose gloves

Contact Expect LinePut Wristband on Pt

Print AVS

Yes

Patient Access Staff

Medical Assistant Provider

Key

Identify Patient Escort to ED (as necessary)

Contact patient via phone

Collect missing registration information,

update Epic Record

START*

Patient encounter complete, Registration incomplete

STOPRegistration Complete

*If Patient proceeds to Emergency Department or is Admitted after ILI Clinic visit, Registration will follow standard information gathering processes

Clean MA: Complete Sample Clean Bagging

Procedure

STOPPlace packages sample in specimen collection area

Wipe Clean Bag with Purple Top Wipe

APPENDIX I: Quick Registration Minimum Required Fields

MEDICAL SCREENING

Date____________ Time____________ Existing BMC Patient Y/N

Last Name___________________First Name____________________________ Sex : M_F_G

D.O.B___________________

Address__________________________________________________Zip Code___________________

Contact Phone #_____________________________________

Marital Status__S__ M__D__

Preferred Language____________________

Insurance Carrier _______________________________________________

Emergency Contact

Name________________________________________

Phone #______________________________________

Relationship__________________________________

Registration Contact Number: If needed for follow up

(857) 292-9418

APPENDIX II: Boston Medical Center, COVID19 Lab Testing Guidelines

Boston Medical Center COVID19 Lab Testing Guidelines Updated Saturday, 3/14/2020; 6:04PM ______________________________________________________________________ Criteria for Testing for COVID: MA DPH Guidelines for COVID has previously been expanded. Testing for patients with fever and/or respiratory illness no longer requires prior approval by MA DPH. MA DPH guidance for testing MUST be followed: https://www.mass.gov/doc/covid-19-pui-criteria/download. Currently the BMC clinical Laboratory is sending most specimens to the ARUP reference lab who as of today, has changed their collection to nasopharyngeal swabs. A brief summary of new MA DPH testing criteria guidelines is shown below:

• Testing for most persons with fever and/or respiratory illness will be sent twice daily and performed at the ARUP reference lab in Salt Lake City Utah. • Hospitalized patient with fever and pneumonia/ARDS • Healthcare worker/EMT • Close contact to confirmed case or part of cluster in congregate setting (school,

prison, etc) • Close contact in home (must have fever and lower respiratory tract symptoms) • Travel from Level 3 area (must have fever and lower respiratory tract symptoms) • Provider MUST confirm eligibility at https://www.mass.gov/doc/covid-19-pui-

criteria/download • If specimen is to be sent to the MDPH state lab, then the Provider MUST FULLY

COMPLETE the State lab testing form (refer to the link on the test order). Clinical History and Symptoms must be included.

• Testing for others with fever or mild-moderate respiratory illness not meeting above criteria will be tested by a commercial lab • Only risk factor is older age and comorbidities • Only risk factor is travel to affected area (US and overseas)

Lab Testing at either state or commercial lab: • Use the Order Panel for COVID19. • Collect

• For Commercial Lab • 1 nasopharyngeal swab

• For State Lab • 1 nasopharyngeal swab accompanied by the MDPH test form fully

completed (including clinical history) by physician. Any issue with this form will cause testing delays

• Put swab in UTM (Universal Transport Media) vials as follows: • Most will go to Commercial Lab (currently ARUP)

• put 1 nasopharyngeal and in one vial for COVID testing • ED orders for Comprehensive Respiratory Panel if ordered will be

performed on same tube as COVID, one tube = both tests now. • ILI STATIONS (beginning Monday 3/16/2020) for Flu/RSV PCR,

testing will be performed on the same tube as the COVID-19) • If going to State Lab (ED orders only)

• Provider MUST FULLY COMPLETE the State lab testing form (refer to the link on the test order). Clinical History and Symptoms are required.

• put 1 nasopharyngeal swab in one UTM vial for COVID testing (and for Comprehensive Respiratory Panel if ordered). One tube = both tests now!

• Label samples – use one large label per vial if nasopharyngeal. If other sample types are used, please write on label.

• Bag samples - one specimen per bag • Send samples to the lab via P-Tube – be sure vials are capped tightly • Lab accessions, packages, and ships sample twice daily to the appropriate laboratory

Results

• Results will be available in Epic • Lab will page the ordering provider with positive results. • Command Center receives reports on testing and results • Expected turn around at least 24 to 72 hours after receipt by the reference laboratory

Proper bagging of Hazardous Samples:

All medical Staff should be wearing appropriate PPE based on clinical guidance when collecting

biological samples from a patient.

A) Proper handling of Hazardous Samples requires 2 clinical staff.

1 “Dirty” staff member

o Meaning they physically handle the sample

1 “Clean” staff member

o Meaning they do not come in physical contact with patient or sample.

B) If possible, specimen samples should be labeled ahead of testing and bagging

Proper Bagging Technique:

1) “Dirty” staff member: Collect Sample and place in appropriate vial

2) “Dirty” staff member: Place vial in plastic specimen bag

a. Ensure samples are appropriately labeled

3) “Dirty” staff member: Roll up sample in specimen bag to create as small of a package as

possible

4) “Clean” staff member: Take a new plastic specimen bag and roll the top/sides down to

create a wide opening for the specimen/bag to be placed into.

5) “Dirty” staff member: Place specimen/bag into new specimen bag

6) “Clean” staff member: Roll new bag up and seal

7) “Clean” staff member: Take purple top wipe and clean outside of bag

Sample can be placed in pneumatic tube system and sent to lab.

Appendix III: BMC Testing Criteria, COVID 19

Criteria for Testing for COVID:

Who to Test: MA DPH Guidelines for COVID have been expanded. Testing for patients with fever and/or respiratory illness no longer requires prior approval by MA DPH. MA DPH guidance for testing MUST be followed: https://www.mass.gov/doc/covid-19-pui-criteria/download. A brief summary of new testing criteria guidelines is shown below:

• Hospitalized patient with fever and pneumonia/ARDS • Healthcare worker/EMT with fever or signs/symptoms of respiratory illness • Close contact to confirmed case or part of cluster in congregate setting (e.g. school) • Close contact in home WITH fever and signs/symptoms of lower respiratory tract illness (eg

cough, shortness of breath, pneumonia. • Travel from Level 3 area WITH fever and lower respiratory tract symptoms) • Provider MUST confirm eligibility at https://www.mass.gov/doc/covid-19-pui-

criteria/download, which is confirmed within the Epic order panel

How to Test:

• Currently the BMC clinical Laboratory is sending most specimens to the ARUP reference lab which as of today, has changed their collection to a single nasopharyngeal swab.

• Testing for most persons with fever and/or respiratory illness will be sent twice daily and performed at the ARUP reference lab in Salt Lake City Utah.

ED and Inpatient Order Panel

Collect a single Nasopharyngeal swab (NP) submitted in a viral transport tube (UTM or VTM) to test for COVID-19 and the Comprehensive Respiratory Panel (from the same swab).

You no longer need to collect both NP and oropharyngeal (OP) swabs for COVID testing. Be sure to label the tube with the patient label and small label. If it is not a nasopharyngeal

source, note it on the label. If ID guides to send to the MDPH state lab, you MUST send the UTM/VTM (the Universal

Transport and Viral Transport Medium) and the MDPH paper form COMPLETELY FILLED OUT with patient information including clinical information about the patient. Link to the form is in the order panel.

• If specimen is to be sent to the MDPH state lab, then the Provider MUST fully complete the State lab testing form, including clinical information (link is found within the Epic order panel)

The Influenza Like Illness (ILI) station’s order panel will go live Monday 3/16/2020 with instructions

Collect a single Nasopharyngeal swab (NP) submitted in a viral transport tube (UTM or VTM) to test for COVID-19 and the Influenzae A&B/RSV PCR (from the same swab).

Be sure to label the tube with the patient label and small label.

Note that the NP/OP swab is NOT recommended or necessary; the recommendation is to perform a single NP swab. If you collect these in the same tube, you must submit a separate NP swab in a separate tube for any additional testing (i.e., comprehensive respiratory panel or influenza A&B/RSV). The order for this can be found in Epic under Additional Testing.