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It is possible that patients will be transported into your facility and

you will know when they are arriving.

You may be in a position where you're actually organizing this transport.

Here at UNMC, Dr. John Lowe was placed in charge

of orchestrating the transportation from airports to the hospital.

Long before this transport occurs, Dr.

Lowe recommends establishing relationships with key players in your community.

>> So there are a number of relationships that are vital to transport of this nature

where you're looking to isolate, high level isolation patient transport.

The first and foremost is clearly between the sending,

receiving hospital and the EMS service.

We had had some early, we call them near misses, where we had patients

brought to us that were suspected of having a viral hemorrhagic.

And then by, either by the time they got to us or somewhere in transit,

the labs came back that they, in fact, did not have viral hemorrhagic.

What we learned through those experiences was that it's not as simple as

just an EMS service brings a patient, drops them off,

hospital takes them, and ambulance leaves, right?

There's all of these other finer details that need to be worked out together as

a group.

So EMS service needs to know what are they doing after they hand off the patient.

Are they accompanying the patient all the way to the room?

Are they stopping at the curve?

Are they going to decon shower location at the ED?

So there's a whole host of things that could happen, and

by working through all those and establishing that relationship

everyone can be assured that they're safe and they know what to do.

So, for us that meant EMS providers come all the way up into the patient room.

And as they come out of the patient room,

our healthcare providers doff them out of their PPE.

So this was something that we navigated through,

establishing that relationship to where our EMS partners said,

we're comfortable in donning the PPE, and operating in it.

But we know that the major weakness to this PPE is deficiencies in

how we take it off.

And they felt that our environment lent itself to doing that effectively, and

that our staff had gone through so much training on how to doff PPE,

that they asked that we accommodate their people all the way up into our unit and

doff them out, just like our health care workers.

So we accommodated that.

Our original plan was that they'd stop at the curb and take care of themselves.

And so in working through that relationship we found that it was

important to tweak that.

Aside from that, public health, we cannot understate the importance and

value in public health.

So for our location,

public health has jurisdiction as to whether or not we receive patients.

So, whenever we open our unit to receive a patient,

it's a joint decision between our clinical medical director and

the medical director for the state public health department.

And then we also have local public health, that if anything goes wrong on the ground

when we're moving a patient, or deconning an ambulance, or carting off waste, it's

going to fall to local public health's jurisdiction, because it's in their area.

So maintaining those relationships.

And how we maintain those relationships is that we either

develop protocols together or we share our protocols.

So that when they need to answer how is this group taking care of X, if X is

deconning an ambulance, or disposing of waste for an ambulance, or isolating

a patient in transit, they have that information, and they are aware of it.

They're not caught off guard or anything like that.

So those are two, I would say, of the most important relationships.

There were also some cursory relationships that we had never

developed until we actually transport a patient.

So law enforcement was kind of a afterthought,

we realized we needed security and emergency management.

So, in Nebraska we have the added benefit,

if you will, of having the full spectrum of weather.

So, as I mentioned, we transported three patients.

One was transported in the snow, one in the ice, and one in dark under rain.

Having emergency management at the table in the early planning,

as soon as we activated instant command, emergency management was brought in.

So they were aware of the potential transport window,

the routes, and especially for the snow days.

These were the cleanest,

most cleared roads you'd every traveled on in the middle of a snowstorm.

Because they knew our route and were taking care of it to make

sure that the risk of having an automobile accident or

something like that was reduced as much as we could.

>> Once those relationships are in place, you begin the process of coordinating all

the agencies, writing plans and protocols, and finally, testing those plans.

>> Yes, so that's kind of a two prong question.

We started in planning for

transporting patients that need high level containment or isolation.

Really in the planning phase, how do we isolate these patients?

What's the most appropriate methods, both for health care worker safety, but also so

that in a manner that the patients can tolerate and that will be safe for them?

So for us that meant drafting theoretical plans and protocols,

and then taking them through tests, through exercises.

So we did a number of exercises from various small scale tabletops,

where we're just working through the concepts of the plans and whether or

not they were adequate.

All the way up to full scale exercises, where we actually put patients in

an ambulance in another state and drove them all the way to ours.

We learned a lot at each phase of those.

But I think where we learned the most about our operational protocols and

what needed to be tweaked were when we actually did the full scale exercise.

Then on top of that, as soon as we found out we were receiving our first patient,

we went back to all those plans and quickly revised them.

Because there were things that now, knowing and doing all of those

theoretical planning and exercising, we had to make up what pathogen it was.

So you're always playing this guessing game that this protocol is applicable to

this wide range of diseases.

And knowing that it was Ebola allowed us to scale down some things, and

mandated that we scale up other aspects of our protocol.

>> Experience has certainly taught us to learn from others.

So that we can change our plans or

write new plans based on the expertise of others.

Here are some lessons learned from the Nebraskan medical experience.

>> I think one of the major things that we learned was the importance of incident

command, hospital incident command, in helping manage movement of those patients.

So what we found out, and this was actually a lesson learned.

So we treated three patients.

And with the first patient, we did not do this.

So this is something that we went and debriefed.

And we did an after action.

And we realized that we can improve a number of items by activating our incident

command earlier in the process.

So for us, instead of looking at utilizing incident command to support

biocontainment level patient care when the patient arrived, we now activate

it as soon as we know that there's a potential for a patient to arrive.

Which may be 48 hours, it may be 72 hours,

it may be days before the patient actually arrives.

But there's so much coordination and logistics that needs to be done.

And the only way it can really be done adequately, and

with adequate documentation for potential reimbursement later,

is if incident command has been stood up.

The other fun story that I like to share on that is,

with that first patient that arrived,

our experience was somewhat unique in that we received a patient off of an airplane.

And as you know, flight times change.

Even in flight, your arrival time can change based on winds and

things like this.

So, for us that came to reality at 3 AM in the morning when our

plane's arrival time got moved up about an hour and a half at 3 AM.

And so we had essentially nine different agencies,

all involved in that patient's transport, that had to be contacted at 3 AM.

And without having an incident command structure activated,

that meant we were trying to wake people up in the middle of the night and

let them know that they now needed to move their timeline up two hours.

By doing that with subsequent patient transports with incident command,

we just kicked that message to the incident command,

they pushed it out to those other agencies, and

they used their incident command structure to notify the appropriate people.

Much easier, and more quick.

>> So far in this course, you have most of the knowledge and tools you need to

care for a patient in your facility who requires high-level biocontainment.

We have one more module left to touch on a few other related topics.

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Inbound Transportation: Planning and Community Collaboration of Patients

High Level Biocontainment for Healthcare Facilities

Meet the Instructors