EVD Screening Design Sprint Report Report Final.pdfProject Description | 4 Project Description Project Aim This project was designed to understand barriers to effective Ebola Virus

EVD Screening Design Sprint Report

Penn Medicine Center for Health Care InnovationCarolina Garzon & Damien Leri | November 2014

Contents

Executive Summary 3

Project Description 4Project Aim. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Target Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Strategic Assumptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Findings from the contextual inquiry and research phase 5Conceptual grounding for patient and staff behaviors . . . . . . . . . . . . . . . . . . . . . . 5Potential Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Number of patients who recalled the screening question accurately . . . . . . . . . . 6Key Problems to Solve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Results from pilots at the HUP ED and a CPUP family practice 8Pilot 1 HUP ED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Pilot 2 CPUP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Proposed Solutions 11Shifting the decision making from the patient to the staff . . . . . . . . . . . . . . . . . . 11Making the screening official . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Providing staff with the necessary tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Become the source of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Recommendations 12Implementation recommendations for Ambulatory Practices and ED staff beyond the entrance area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Implementation recommendations for the EDs’ entrance area. . . . . . . . . . . . . . . 12Follow-Up Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Acknowledgments 14

Appendix A 16Screening processes implemented as of the end of this project . . . . . . . . . . . . . . 16

Appendix B 18Materials used during Pilot 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Appendix C 20Materials used during Pilot 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Appendix D 22Implementation materials for Ambulatory Practices and ED . . . . . . . . . . . . . . . . .22

Appendix E 24Additional Recommendations for EVD Preparedness . . . . . . . . . . . . . . . . . . . . . . 24

Appendix F 25General Recommendations for future infectious diseases’ screening . . . . . . . .25

Executive Summary | 3

Executive Summary This project was designed to understand barriers to effective Ebola Virus Disease (EVD) risk screening at the HUP ED and CPUP practices, and to test design solutions that would improve risk screening for patients and providers at these locations. The recommendations of this project can be applied to future screening processes for other contagious illnesses.

Process

The project started with a contextual inquiry and research phase to analyze the cur-rent screening processes and identify possible barriers. Followed by a design phase to develop an improved screening process. This process was then tested during a first pilot at the ED at HUP. The process was then improved upon based on our findings and tested in a second pilot with a control group at a CPUP family practice. After the second pilot final recommendations and implementation materials for improved screening where developed.

Findings

During the contextual inquiry and research phase we identified the following prob-lem areas to concentrate on to improve current screening procedures:

• Staff members’ fear of exposure to EVD due to uncooperative patients.

• Room for misunderstandings due to the wording of the current screening ques-tions and the public’s lack or information of EVD.

• Feeling of inapplicability that can lead to patients not answering screening ques-tions truthfully even if they could have been exposed to EVD.

• Language barriers that can lead to patients misunderstanding screening ques-tions and therefore answering inaccurately.

• Lack of information on the patients’ side that can lead to unnecessary panic and false positives, especially if the public’s attention on EVD is heightened when an infected person is being treated in the area.

• Patients’ fear of discrimination by UPHS staff based on race or country of origin.

• Repetitive screening that can lead to staff not screening patients consistently due to patients’ complaining for being screened repeatedly.

Results

The pilots showed that the improved screening brought the following results:

• Increased the number of patients sharing their travel history with the staff from 0% in the control group to 55% in the test group during the pilot.

• Improved patients’ collaboration with the screening.

• Removed the feeling of discrimination during the screening.

• Reduced language barriers between patients and staff.

• Increased the staff’s satisfaction with the screening process.

Recommendations

• Shifting the decision making from the patient to the staff by implementing an open first screening question. This allows our staff to determine potential risk based on our knowledge of EVD instead of on the patient’s judgment of their risk of being infected.

• Making the screening official with sign indicating that screening is part of our standard and that it is being done for everyone. It shifts the decision to screen away from the staff (as individuals) toward Penn Medicine (as an institution), reducing the chances of a patient thinking they are being screened because of a personal preference.

• Provide staff with the necessary tools to efficiently determine potential risk, an-swer patients’ concerns and effectively communicate with patients with language barriers.

• Become the source of information for EVD preparedness. Minimize misinfor-mation caused by the media and the Internet. Showing that we are prepared to handle any possible cases in an effective manner.

Project Description | 4

Project Description

Project AimThis project was designed to understand barriers to effective Ebola Virus Disease (EVD) risk screening at the HUP ED and CPUP practices, and to test design solutions that would improve risk screening for patients and providers at these locations.

BackgroundEarly and accurate risk screening is a critical step toward diagnosis and control of infectious diseases such as EVD. By correctly identifying and routing a potentially infected person, we can begin safe containment, diagnosis and treatment. These steps affect the patient’s prognosis while also protecting the community from further spread of the virus. The death of Eric Duncan after discharge from a Dallas ED while symptomatic from EVD revealed that timely identification and appropriate triage of at-risk patients is critical to both patient outcome and calm in the community.

A complex set of operational procedures is required to support timely and orderly risk screening and triage of potentially exposed patients. There are several points where these processes can break down, potentially leading to fear, perception of discrimi-nation, operational inefficiencies, and false positives and negatives. Our project aims to reduce the chances of such failure by identifying barriers to target behaviors and operational practices for both patients and providers.

Target BehaviorsPatients should accurately answer the screening questions.

Staff members should correctly perform the screening and triage of each patient they encounter.

Methods

Phase 1

Identify barriers to identifying and triaging patients with high risk for EVD. This was done by qualitative inquiry: ethnographic observation and in-depth semi-structured interviews of about 20 patients.

Phase 2

Develop materials to improve the screening process, and pilot test in the HUP ED.

Phase 3

Refine the materials and pilot test the new versions in an outpatient clinic comparing the traditional screening methods to the newly implemented materials.

Strategic AssumptionsBehavioral factors (such as attitudes) can vary from one week to the next depending on the nature of the epidemic and its media coverage.

The chance of an EVD-infected walk-in patient is extremely low. However, the screen-ing process still affects all patients and staff; we are looking at “side effects” of the experience.

Our interventions could be repurposed for future epidemics or other such uses.

Our interventions should be shareable to other health systems in the US and else-where.

Findings from the contextual inquiry and research phase | 5

Findings from the contextual inquiry and research phaseOne problem with the current screening questions1 is the prevalent opinion of the public that Ebola might be a threat to others but not to themselves.

ED Question

1. Have you or anyone you have had close contact with traveled outside the Unites States in the last 21 days? (If answered yes to question 1 go to question 2).

2. Have you or anyone you have had close contact with traveled to Guinea, Liberia, or Sierra Leone?

CPUP Question

1. Have you traveled to Guinea, Liberia, and or Sierra Leone or had contact with some-one who has traveled to one of these regions in the past 21 days?

When the question “Have you traveled to…” is asked to a patient, what they think we are really asking them is “Can you tell us if you have Ebola?” which explains why some patients answer with “I don’t have Ebola” to the screening questions. The response is similar to the one airline passengers give when asked, “Have you left your bags unattended at any time?”. Nearly all people answer “no” to this question even if their bags were unwatched for a period of time (e.g., in a hotel closet while at a meeting). This occurs in part because most people believe (correctly) the probability of some-one putting something dangerous in their bags while they were not watching is very slim. In contrast, the probability of being detained, delayed and inconvenienced if they answer truthfully is much higher.

A second critical finding was that patients tend to get their information from social media sites like Facebook. This information isn’t always reliable and so this source spreads misinformation.

1 For more information on the screening processes implemented as of the end of this project see appendix A.

Conceptual grounding for patient and staff behaviorsWe used the integrated behavioral model 2 as a framework for identifying potential barriers to the target behaviors of both patients and staff members. This model helps analyze a person’s intention of performing a certain behavior based on their attitude towards a behavior, other’s expectations and behaviors and the person’s own ability to perform the behavior.

Potential BarriersWe identified the following potential barriers from the model, and used these as the basis for our interview questions.

Patients StaffAttitudes • Fear of quarantine.

• Discomfort with the questions.• Feeling of inapplicability.

• Fear of a positive screening result identified too late in the process.

• Feeling bad for having to ask screening questions repeated-ly to the same patients.

Norms • Stigma about virus.• Perception of discrimination.

• Worry of patients feeling discriminated against due to screening.

Perceived control + self efficacy

• Concern whether answers to screening questions affect the care received.

• Low confidence that screening is effective.

• Lack of preparation to ask pa-tients questions about Ebola.

• Awkwardness of repeatedly screening a single patient.

2 Glanz, Karen, Barbara K. Rimer, and Frances Marcus. Lewis. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco: Jossey-Bass, 2002. Web. <http://www.med.upenn.edu/hbhe4/part2-ch4-integrated-behavior-model.shtml?1>.


Patients StaffKnowledge and skills

• Communication barriers, such as language.

• Not understanding the ques-tions.

• Lack of time or interest to consider the question before answering answer.

• Mistakes in asking questions correctly.

• Mistakes in handling ques-tions, impartial answers, language barriers, etc.

Beliefs • I am not at risk.• Disclosing travel/contact info is

a waste of time.

• An infected patient may try to get access to care by lying during screening.

Number of patients who recalled the screening question accuratelyDuring the contextual inquiry phase we asked patients to tell us what they had been asked during the screening. Our results suggested that patients often misunderstood the intent or content of screening questions as determined by their ability to accurate-ly recall the questions.

Total Patients in Sample: 16

Total Patients in Sample

Recalled Travel Component Correctly

Recalled Contact Component Correctly

HUP ED 9 3 1

Outpatient Clinic 7 1 1

Key Problems to Solve

Staff fear of exposure

We found that staff are most concerned that they could be exposed to EVD in the event that a potentially infected patient would purposefully not answer screening questions truthfully to avoid the perceived risk of denial of care.

Staff also fears the possibility of an uncooperative patient refusing to answer the questions at all.

Room for misunderstandings

We also found out that the screening procedures offer room for misunderstandings, including:

• Patients don’t let the staff finish asking the questions before answering.

• Staff and patients often don’t understand what is meant by “contact” in the second part of the question.

In both cases patients may not be identified soon enough or patients who were not at risk trigger false alarms. This could lead to unnecessary delays in patient care and to fear among other patients in the waiting room.

Feeling of inapplicability

The concern with this is that if people think that Ebola is something that could happen to others, but not to themselves, they could tend to downplay the probability of being infected even if the were traveling to an affected area. In which case they would think that answering yes to the screening question wouldn’t be necessary.

Language barriers

Some patients arriving at our facilities have a limited command of English. Indeed, screening questions and materials are not available in the native languages of the countries where EVD is endemic. This presents a barrier for screening.


Lack of information

Patients expressed getting their information about EVD from unreliable sources including social media. No patient expressed getting information from an official source like the CDC. This can lead to misinformation being spread in the community that can cause unnecessary stress or lead to patients following incorrect instructions to avoid getting infected. The interviews showed a lack of information regarding how the disease is spread and endemic areas.

Fear of discrimination

African American patients or patients coming from Africa have expressed feeling that they are only being screened because of their skin color or their accent. This may be driven by how the question is being asked, and by patients not seeing that others before and after them are also being screened.

Repetitive Screening

We found that patients complain to the staff about being asked the screening ques-tions multiple times during their experience in the ED or CPUP practices. Staff there-fore becomes reluctant to ask the screening questions ”downstream.” This problem is highlighted in the outpatient setting where initial screening questions may be asked when an appointment is made sometimes weeks before the patient is seen.

Results from pilots at the HUP ED and a CPUP family practice | 8

Entrance

Patient’s path

A

MetalDetector

Sidew

alk

B

C C

D

Results from pilots at the HUP ED and a CPUP family practiceWe piloted new screening questions and materials, developed over the course of 4 days, to target the key problems discovered during the first phase of the project. The pilots took place in two phases: A first pilot in the HUP ED, and a second pilot at a CPUP family practice conducted based on learnings from the ED experiment. The second pilot included a control group to compare the new materials and questions to standard work-flows.

Pilot 1 HUP ED

Duration

4 hours (12 pm to 4 pm)

Materials Tested3

A. Open-ended screening question:

• When was the last time you were out of the US?

• Have you had close contact with anyone returning from Sierra Leone, Guinea or Liberia in the past 3 weeks?

B. Informational material for the staff.

C. Poster announcing screening.

D. Sign indicating the date 21 days ago.

3 For a copy of the materials used during pilot 1 see appendix B.

Positioning of the materials at the ED’s entrance:

Results from the ED Pilot

Gathered from observation of the improved screening processes and through inter-views with the staff:

• Patients reacted better to the open question; they showed less hostility toward the guards than observed during the contextual inquiry.

• Avoiding specific mention of affected countries upfront lowers the feeling of being discriminated against.

• The staff used the poster announcing the screening to normalize the screening procedure for all patients. Concerned patients were friendlier once they were shown that the screening was standard procedure.


• Staff expressed that they were glad to have information materials from UPHS covering the countries affected, how it is spread and how to avoid exposure.

• The open ended screening question didn’t increased the time patients spent at the entrance. The time spent being screened and entering the ED is mainly determined by the time patients spend emptying their pockets, going through the metal detector and gathering their personal items afterwards.

Pilot 2 CPUP

Duration

4 hours (12 pm to 4 pm)

Materials Tested4

A. Open screening question:

• When was the last time you were out of the United States?

• Have you had close contact with anyone returning from Sierra Leone, Guinea or Liberia in the past 3 weeks?

B. Informational material for the staff.

C. Informational material for patients.

D. Sign indicating the screening on the PSR’s counter.

E. Poster announcing screening in the elevator.

F. Sign indicating the date 21 days ago.

4 For a copy of the materials used during pilot 2 see appendix C.

Positioning of the materials at the practice’s entrance

Results from the Pilot at a CPUP family practice

Gathered from observation of the improved screening processes and through inter-views with the staff:

Test Group

Total patients

Patients answering both screening questions1

Patients reporting travel outside of the US

20 20 11 Control GroupTotal patients

Patients listening to the whole screening question2 before answering

Patients who had said “yes” to the travel part of the question

18 12 0

Patient’s path

Elevator Elevator

Registration Desk Waiting Room

E E

A B C F

D


• Patients reacted better to the open question. The new wording removes the patients’ judging of whether or not the screening is applicable to them.

• Not mentioning the countries affected upfront lowers the feeling of being dis-criminated against.

• 55% of patients in the test group indicated travel outside the country in the past vs. 0% in the control group, shifting the decision making from the patient to the staff.

• Patients in the test group felt more compelled to talk about the topic.

• Having a map of the affected region available helped overcome language barri-ers.

• The poster announcing the screening was shown by the staff to patients showing concern for being screened. Patients bothered by the screening were friendlier once they were shown that the screening was standard procedure.

• Staff expressed that they were glad to have information materials from UPHS covering the countries affected, how it is spread and how to avoid exposure.

• The open ended screening question didn’t increased the time patients spent at registration. In the test group the PSR was able to attend to the same amount of patients as the PSR in the control group.

Proposed Solutions | 11

Proposed Solutions

Shifting the decision making from the patient to the staff Based on our pilot results, we recommend implementing an open first screening question:

“When was the last time you traveled outside of the United States?” followed by

“Have you had close contact with anyone returning from Liberia, Guinea, Sierra Leone in the past three weeks?”

From our pilot we found that rephrasing the first question shifts the judgment of whether or not a patient is a person of interest from the patient to our staff. This allows our staff to determine potential risk based on our knowledge of EVD instead of on the patient’s judgment of their risk of being infected.

Making the screening officialA desk sign indicating that the screening is part of our standard procedures and that everyone has to answer the questions normalizes this experience for everybody. This has been helpful for the staff when a patient reacts negatively to the screening procedures. It shifts the decision to screen away from the staff (as individuals) toward Penn Medicine (as an institution), and emphasizes that the screening is not conduct-ed based on information in the patient’s chart, race, country of origin or the patient’s accent.

Providing staff with the necessary toolsWe recommend using:

1. A staff-facing sign indicating the specific date 21 days ago, making it easier for the staff to determine risk when a patient gives them an exact return date from a trip outside of the US. Eliminating room for interpretation and errors and reduces the amount of time staff has to invest in calculating if the travel date of a patient is of concern.

2. An EVD information sheet for staff in charge of screening. This provides useful information for the staff about EVD and provides them with a map of the affected region. The map has helped the staff overcome language barriers and communi-cate with patients who have trouble communicating in English. The staff reacted very well to this sheet as it helps them be better informed about EVD.

Become the source of informationA Penn Medicine information sheet minimizes misinformation, shows that we are pre-pared and it helps spread information from a reliable source. The materials should be available in several languages including French to help overcome language barriers and reduce speculation and anxiety caused by misinformation from the media and the Internet.

Recommendations | 12

Recommendations5

Recommendations marked with (*) are based on ideas given to us by staff in the ED and CPUP.

Implementation recommendations for Ambulatory Practices and ED staff beyond the entrance area.

• Screening algorithm with an open ended first screening question.

Readily available for patients:

• Informational materials for patients in several languages including French.

• Provide an indication of the screening procedures taking place.

To show patients only when necessary:

• Provide visual materials to staff to both inform about EVD and help them com-municate with patients. Offer versions of these materials in several languages including French.

For staff only:

• Notifying the telephone scheduling service not to make notes on the patient file regarding if the patient answered with no to the screening questions.

• Provide staff with a sign indicating the date 21 days ago. This can be laminated to change the date daily with a dry erase marker without printing a new sign each day.

5 For a copy of the recommended materials for implementation see appendix D. For additional recommendations regarding EVD preparedness see appendix E. For general recommendations regarding infectious diseases screening see appendix F.

Implementation recommendations for the EDs’ entrance area.

• Screening algorithm with an open ended first screening question.

Readily available for patients:

• Informational materials for patients in several languages including French.

• Provide an indication of the screening procedures taking place.

• (*) Provide personal item bags and space for patients away from metal detector to gather personal items after screening in the ED. To increases screening speed and efficiency at the ED’s entrance. Improving patient’s demeanor when waiting to enter for treatment.

To show patients only when necessary:

• Provide visual materials to staff to both inform about EVD and help them com-municate with patients. Offer versions of these materials in several languages including French.

For staff only:

• Provide staff with a sign indicating the date 21 days ago. This can be laminated to change the date daily without printing a new sing each day.

Follow-Up RecommendationsThis is a recommendation for follow-up tasks after implementation. We would offer to meet with the staff in charge of follow up to explain what are the important areas to concentrate on and discuss how to approach both patients and staff, including interviewing techniques and how to avoid alarming patients unnecessarily.

Between 1 and 3 weeks after implementation, we would be willing to visit the ED and one ambulatory practice for a 2-hour observation session, paying specific attention to metrics related to patient/staff experience and flow.

Recommendations | 13

Questions for the staff could include:

• How has the new screening process changed your interaction with patients?

• Which areas would you like to improve and why?

• Do you feel comfortable that patients are answering accurately?

• Do you feel confident that the screening process is keeping you and others safe here?

Questions for a patient could include:

• Which questions were you asked during your interaction with the staff?

• How do you feel about those questions?

• Are you concerned of being exposed to Ebola?

• If so in which situations?

• How can we improve the way we are handling Ebola screening?

Things to look for during observation:

• Implementation of each part of the screening.

• Implementation of the support materials.

• Use of the support materials offered.

• Patients’ reaction to the screening.

AcknowledgmentsJennifer Barger MS, BSN RNED, Quality & Safety Coordinator and Forensic Nurse Specialist, HUP ED; Joe Forte, Director of HUP Security; HUP security staff; Tia Hope, Practice Manager at 7 Mutch, Penn Family Care; Giang Nguyen MD, MPH, Medical Director, Penn Family Care; Attending Physician, Penn Presbyterian Medical Center, Assistant Professor of Family Medicine and Community Health at the Hospital of the University of Pennsylvania; Nicole Miller, PSR at 7 Mutch, Penn Family Care; Staff of Penn Family Care; Rosemary Frasso PhD, MSc, MSc, CPH of the Center for Public Health Initiatives.

Appendix

Appendix A | 16

Appendix A

Screening processes implemented as of the end of this project

HUP ED

A. Screening process at the entrance.

B. Screening protocol for guards at the entrance.

C. Screening protocol for when a patient’s file is accessed or created on Emtrac.

TriageArea

GreetingArea

Entrance

Waiting Room

To the fast track waiting area

To the ED

Patient answering no during screening

Patient answering yes during screening at the entrance

Patient answering yes during screening at the greeter

Patient answering yes during screening at triage

Triage nurse meets the patient to ask follow up questions

1

2

2

MetalDetector

Sidew

alk To the ED

Appendix A | 17

CPUP Family Practice

A. Screening process at the reception.

B. Screening protocol for when a patient’s file is accessed or created on Epic.

Patient answering no during screening

Patient answering yes during screening at registraton

Elevator Elevator

Registration Desk

To a waiting area

Waiting Room

To a waiting area

To a waiting

area

To a designated room for follow up questions 1

Appendix B | 18

Appendix B

Materials used during Pilot 1

A. Open-ended screening question. B. Informational material for the staff.

“When was the last time you were out of the US?”

Patient Screening ProcessAsk...

“During this trip were you in Sierra Leone, Guinea, Liberia or Mali?”

Ask...

NoYes Prefer not to answer

Provide patient with mask and gloves and ask...

“Do you have any weapons on you?”

Yes No

Ask patient to proceed to the driveway to answer some follow up questions.

Notify triage nurse about patient.

Ask patient to place weapons in a plastic bag and lock weapons

in gun locker.

Ask patient to go through the metal

detector and proceed to ED’s registration desk

“Have you had close contact with anyone returning from Sierra Leone, Guinea, or

Liberia in the past 3 weeks?”

Yes No

Ask... Ask...

LESS than 3 weeks ago NEVER or MORE than 3 weeks ago

Ebola Facts

How does Ebola spread?

Through direct contact with the blood or other body fluids of a sick person or person who has died of Ebola.

If a patient has been in one of the areas with

Ebola, is he/she at risk of getting Ebola?

He/she cannot get Ebola from a person unless they have symptoms of disease.

The patient is at risk only if he/she does the following with a person who has Ebola and has not taken special steps:

∙ Have contact with blood or other body fluids.

∙ Provide medical care.

∙ Join in a funeral rite where you touch the person who has passed.

Where is Ebola?

Ebola is mostly in three countries in West Africa: Guinea, Liberia, and Sierra Leone.

Ebola does not pose a large risk of spreading within the U.S.

Map of the affected region

It is not spread through food, water, or the air.

Appendix B | 19

C. Poster announcing screening.

D. Sign indicating the date 21 days ago.

Infectious diseases information

As part of our standard procedures we will be asking you about your travel history outside the US. This is necessary to ensure the most appropriate and timely care.

Penn Medicine is prepared to keep everyone safe. If we find that you might have been exposed to an infectious disease, a doctor or nurse will ask further questions. Your answers will not delay you from being treated.

Your life is worth Penn Medicine.

October 23rd

October 23rd

Appendix C | 20

Appendix C

Materials used during Pilot 2

A. Open screening question. B. Informational material for the staff.

Ebola Facts










Where is Ebola?

Ebola is mostly in three countries in West Africa: Guinea, Liberia, and Sierra Leone.





Patient Screening Process

After Oct. 24th or less than 3 weeks Before Oct. 24th MORE than 3 weeks

Ask...

“During this trip were you in Sierra Leone, Guinea, or Liberia?”

Ask...

NoYesPrefer not to answer

Indicate yes in the system. Ask the patient about symptoms...

“Do you have any of the following symptoms...?”

Yes No

Mark the answers in the system. Bring patient into the assigned room to answer some follow up questions.

Notify doctor in charge of following up with the patient.

Continue with the patient’s registration

as usual.



Yes No

Ask... Ask...

Appendix C | 21

C. Informational material for patients.

D. Sign indicating the screening on the PSR’s counter.

E. Poster announcing screening in the elevator.

F. Sign indicating the date 21 days ago.

Infectious Diseases Screening

At Penn Medicine, taking care of you is our top priority. To do this well we will be asking you a lot of questions including travel history.

The more we know the better we can care for you.


Any travel before October 24th is fine



What is Ebola? Ebola is a bad infection caused by the Ebola virus.

What are the symptoms?

Symptoms can include:

• Fever • Vomiting • Headache • Stomach Pain • Joint and Muscle Aches • Lack of Appetite • Diarrhea • Bleeding

What should I do to make sure I don’t have Ebola?

• If you have been in an area with Ebola less than 21 days ago and are not sick, take your temperature 2 times each day.

• If you have a fever greater than 101 degrees, call your health-care provider for advice.

• If it has been over 21 days ago, you are not at risk of getting sick from Ebola.


It is spread through direct contact with the blood or other body fluids of a sick person or person who has died of Ebola. It is not spread through food, water, or the air.

Where is Ebola?

Ebola is mostly in three countries in West Africa: Guinea, Liberia, and Sierra Leone. Ebola does not pose a large risk of spreading within the U.S.

Ebola Questions Ebola Questions











Where is Ebola?


If I have been in one of the areas with Ebola, am I at risk of getting Ebola?

You cannot get Ebola from a person unless they have symptoms of disease. You are at risk only if you do the following with a per-son who has Ebola and have not taken special steps:

• Have contact with blood and body fluids

• Provide medical care

• Join in a funeral rite where you touch the person who has passed

How is Ebola stopped?

People can help stop Ebola by not going to places with Ebola. If you must go to an Ebola area:

• Wash hands often.

• Do not touch blood and body fluids.

• Do not touch items that may have touched the blood or body fluids from a sick person.

• Avoid funeral rites that involve touching the body of someone who died from Ebola.

Dissclaimer: The information provided by the University of Pennsylvania Health System is for educational purposes only and should not be used for diagnosing or treating a health problem or disease. It is not a substitute for professional care. Published 10/24/2014.













At Penn Medicine, taking care of you is our toppriority. To do this well we will be asking all of our patients a lot of questions including travel history.



Appendix D | 22

Appendix D

Implementation materials for Ambulatory Practices and ED

Screening algorithm for Ambulatory Practices and the ED beyond the entrance area. Screening for the ED’s entrance area..


Patient Screening Process

After Oct. 24th or less than 3 weeks Before Oct. 24th MORE than 3 weeks

Ask...

Ask...

NoYesPrefer not to answer

Indicate yes in the system. Ask the patient about symptoms...

“Do you have any of the following symptoms...?”

Yes No

Mark the answers in the system. Bring patient into the assigned room to answer some follow up questions.

Notify doctor in charge of following up with the patient.

Continue with the patient’s registration

as usual.



Yes No

Ask... Ask...



Patient Screening ProcessAsk...


Ask...

NoYes Prefer not to answer

Provide patient with mask and gloves and ask...

“Do you have any weapons on you?”

Yes No

Ask patient to proceed to the driveway to answer some follow up questions.

Notify triage nurse about patient.

Ask patient to place weapons in a plastic bag and lock weapons

in gun locker.

Ask patient to go through the metal

detector and proceed to ED’s registration desk



Yes No

Ask... Ask...

After [Date] or less than 3 weeks Before [Date] MORE than 3 weeks

Appendix D | 23

Sign indicating the screening on the counter.

Sign indicating the date 21 days ago (only visible to staff).

Informational material for patients.

Informational material for the staff



































Where is Ebola?

Ebola is mostly in three countries in West Africa: Guinea, Liberia, Sierra Leone and Mali. Ebola does not pose a large risk of spread-ing within the U.S.

Ebola Questions Ebola Questions











Where is Ebola?


Any travel before ____/____ is fineEVD Hotline 215-614-0524 (for Clinicians with patient-related questions) 215-615-2929 (for general questions)






At Penn Medicine, taking care of you is our toppriority. To do this well we will be asking all of our patients a lot of questions including travel history.



Fold Here

Fold Here

Fold Here

Ebola Facts










Where is Ebola?

Ebola is mostly in three countries in West Africa: Guinea, Liberia, Sierra Leone and Mali.




Appendix E | 24

Appendix E

Additional Recommendations for EVD PreparednessRecommendations marked with (*) are based on ideas given to us by staff in the ED and CPUP.

Visual PPE Instructions

Labeling PPE materials with the step number that corresponds to the steps on the instruction manual. If putting on the large gloves is step 1, the box with the large gloves should be marked with a 1.

• Reduces the time that staff spends checking folders for instructions.

• Can reduce the instances where the staff makes errors and has to start all over again.

Improve equipment labeling in STP

Having clear, consistent labeling and placement of equipment in the STP, so that staff can find equipment without having to learn where it is. Labels should be large enough to be read from the other side of the room with the PPE on.

• Increases efficiency and staff safety inside the STP.

Inform the patient throughout the journey

Be prepared to provide a road-map for a patient that screens positive (PUI) about what will happen and what to expect.

• Reduces patient anxiety and increases cooperation.

Information for the patient’s companions

Be prepared to provide guidance to a patient’s companions regarding precautions to take and what to expect.

• Reduces their anxiety and increases cooperation.

Clarify procedures for outpatient practices regarding follow up procedures

with a patient that screens positive during a visit (*).

After a positive risk screen to the travel/contact question, ambulatory practices may benefit from clarification regarding what equipment they should use and what next steps to take.

Appendix F | 25

Appendix F

General Recommendations for future infectious diseases’ screening

Readily available for patients

We recommend when possible using open-ended questions.

• Transfers the responsibility of determining whether a patient might have contract-ed an infectious disease from the patient to the staff.

Offer informational materials for patients in several languages including French.

• Reduces speculation and anxiety caused by misinformation from the media and the Internet. Can help overcome language barriers.

• Shows preparedness and increases trust in Penn Medicine.

Provide an indication of the screening procedures taking place.

• Serves as an indication to the patients that screening procedures are mandated for everyone coming to the practice and are not done based on information from a patient’s file or on the staff’s personal preferences.

• Shows preparedness and increases trust in Penn Medicine.

To show patients only when necessary

Provide visual materials to staff to both inform about the infectious disease you are screening for and help them communicate with patients. Offer versions of these ma-terials in several languages including the official languages of the affected regions.

• Helps overcome language barriers and avoid misunderstandings.

• Gives staff enough information to judge if the information given by a patient is of concern or not.

For staff only

Provide staff with all the tools necessary to implement screening without having to spend too much time learning them.

• Eliminates room for interpretation and errors. Reduces the amount of time staff has to invest in calculating if the travel date of a patient is of concern.

Test Screening Procedures

• Identifies implementation problems and limitations of screening procedures. Allows for input from staff regarding possible improvements.

Documents

EVD Screening Design Sprint Report Report Final.pdfProject Description | 4 Project Description Project Aim This project was designed to understand barriers to effective Ebola Virus