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    Leveraging existing quality improvement communication strategies during the COVID-19 crisis

    Background

    Responding to the 2019 Coronavirus pandemic has been an unex- pected and unprecedented challenge for Emergency Medicine leaders and frontline clinical staff. At our university-affiliated, tertiary care emer- gency department (ED) in Boston, departmental, hospital, and health sys- tem leadership has provided extensive communication and training surrounding operational changes, including personal protective equip- ment (PPE) management, COVID-19 testing policies, potential role reassignments, occupational health policies, and others. However, as case numbers began to grow it became clear that frontline clinicians and staff also required guidance regarding the management of COVID-19. Given the rapidly-changing data surrounding typical symptom presentations, affected demographics, therapeutics, and ED man- agement strategies for COVID-19, our ED Quality and Safety leader- ship identified the need for a rapid and reliable method to disseminate the latest insights and recommendations. We there- fore launched a twice-weekly, video-based ED COVID Case Confer- ence (ED CCC) on March 18, 2020, with the following goals: (1) to facilitate discussion regarding ED management and disposition de- cisions; (2) to provide updates on current clinical recommenda- tions; (3) to disseminate information related to current

    departmental and hospital case trends.

    Methods

    Given the need to identify and operationalize a clinical manage- ment communication tool as rapidly as possible, Q&S leadership looked to existing methods of case review and dissemination of clinical learning for guidance. Like many others, our department has a monthly Morbidity and Mortality conference which focuses on cases that represent opportunities for system or individual clini- cian practice learning. These have traditionally been prepared and presented by a senior resident. We adapted this format for the ED CCC with the following key differences: to streamline the review and presentation process, cases were identified and moderated by an attending physician member of the Q&S leadership; case slides were initially prepared by a nurse member of the Q&S leadership; cases were selected to facilitate discussion surrounding diagnosis and management, regardless of improvement opportunities; to allow for rapid dissemination of information, the ED CCC is planned to be held up to twice weekly until the end of the acute phase of the COVID-19 crisis.

    The first ED CCC, hosted securely on a password-protected enter- prise Zoom(R) platform, was held for only the ED faculty (including at- tending physicians and a pharmacist), in order to obtain feedback and make iterative improvements to the format. Subsequently, all ED clini- cal staff – including staff nurses, resident physicians, advanced practice providers (APP), pharmacists, and Respiratory therapists – were invited to attend. Given the large number of attendees, expert discussants were identified from key role groups (critical care attending physician, senior resident, chief APP, pharmacist, clinical nurse specialist) to reduce chat- ter throughout the video conference. Other attendees were encouraged to utilize Zoom(R)’s chat function to relay questions and comments, which were compiled by a member of the ED Q&S administrative lead- ership staff, researched, and reported back with answers during the fol- lowing conference.

    Each one-hour conference includes the following elements, allowing for discussion during each case:

    1524 Correspondence / American Journal of Emergency Medicine 38 (2020) 1515-1539

    Review of current real-time departmental and hospital COVID-19 statistics and trends

17. Formal case presentations and expert discussion
18. Key teaching points from latest clinical recommendations
19. Updates from prior conference’s cases
20. Results

    Five ED CCC have been completed. Attendance grew from approxi- mately 50 attendees for the first conference to greater than 100 partic- ipants. Clinical management topics covered within case presentations have included the following: characteristics of respiratory compromise in COVID-19 patients and how this differs from typical respiratory fail- ure identification and management; decision making surrounding ad- mission versus discharge of COVID-19 patients; decision making related to BiPAP and CPAP; pharmacologic Management considerations and toxicities related to COVID-19 medications; staff safety and utiliza- tion of physical ED space; patient and family experience concerns; and clinician and staff wellness.

    Thematic analysis of the questions posed and topics discussed in the Zoom(R) chat function revealed several frequently-referenced areas of interest, including medication initiation recommendations; disposition and decision-to-admit considerations; clinician and staff wellness and burnout prevention, particularly related to the safety of their families; and departmental and hospital workflows (inclusive of triage concerns).

    Feedback

    Feedback from participants has been overwhelmingly positive, in- cluding direct feedback to the conference organizer by email and in per- son Participants report being particularly appreciative of guidance surrounding appropriate laboratory testing, medication management, and disposition planning. Initial feedback suggested that a major area of improvement would be to include community affiliate ED staff. A more formal feedback process via secure online survey software has been initiated to allow for anonymous recommendations of topics to be covered or areas for iterative improvement.

    Challenges

    infectious disease and critical care specialists. Initial discussions are also underway regarding the feasibility of inviting participants from other specialties to view livestreams of the conferences, and possibly to create a repository of content for future learners.

    Conclusion

    The 2020 COVID-19 pandemic may be the largest acute challenge ever faced by EDs in the United States. Leveraging existing Q&S infra- structure and communication tools has been critical in keeping frontline staff informed regarding up-to-date clinical management recommenda- tions. Importantly, there has been a secondary interpersonal benefit of the ED CCC, as staff have appreciated the ability to come together – albeit virtually – for support and discussion during a time where many report feeling isolated and fearful. As this public health crisis un- fortunately grows, we plan to continue the ED CCC indefinitely, incorpo- rating iterative changes based on ongoing feedback and circumstances.

    Jonathan D. Sonis MD, MHCM*

    Lauren Black RN, MS Joshua Baugh MD Theodore I. Benzer MD, PhD Bryan D. Hayes PharmD Ali S. Raja MD, MBA, MPH

    Benjamin A. White MD Susan R. Wilcox MD Brian J. Yun MD, MBA, MPH

    Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America

    *Corresponding author at: Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Founders 850,

    Boston, MA 02114, United States of America.

    E-mail address: [email protected].

    Emily L. Aaronson MD, MPH Department of Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA, United States of America Lawrence Center for Quality and Safety, Massachusetts General Hospital,

    Boston, MA, United States of America

    4 April 2020

    There have been several obstacles to overcome in launching the CCC under such dynamic circumstances. First, given that the conference needed to be held virtually, typical privacy considerations were made more challenging. To overcome this and gain legal approval to continue, all conferences are password protected and standard peer review protected disclaimers are provided both in conference invitations and at the start of each individual conference. Second, with growing num- bers of participants across all ED role groups, management of discus- sants has become increasingly challenging. To mitigate this, all lines are muted by the host at the onset of each conference, and a pre- determined smaller group of discussants provides commentary at vari- ous points throughout the hour. Other participants are asked to provide comments and questions in the chat function as previously discussed.

    3.3. Growth considerations

    After pilot testing the CCC format with the faculty group only, the conference was broadened to include all ED clinical role groups in its second week. In an effort to incorporate feedback that staff working in community affiliates would benefit from the conference’s content, these groups were included as of April 3, 2020 after obtaining hospital leadership and legal approval. Next steps include increased involve- ment of expert discussants from outside emergency medicine, including

    https://doi.org/10.1016/j.ajem.2020.04.021

    Areas of academic research with the impact of COVID-19

    The SARS-CoV-2 virus has significantly affected the health, economy, and socio-economic fabric of the global society. The costs involved in the containment and treatment of this infectious disease are exorbitantly high, which even the wealthiestand developed countries are finding it difficult to sustain. COVID-19 pandemic has severely impacted the crude, stock market, gold and metals and almost all areas of the global market [1]. Large research laboratories and corporate houses are work- ing with a high speed to develop medicines and vaccines for the preven- tion and treatment of this dreaded disease. To deal with these current health management challenges, we need a comprehensive understand- ing of the effect on the health system, global business, and culture. COVID-19 was declared a pandemic by the WHO on 11th March 2020 [2]. COVID-19 has become an international emergency in a short period and will have long-lasting effects. There is an urgent need to identify and study the areas of academic research which will be impacted by COVID-19 [3].