Hospital Operations

COVID Email Address


EMAIL BOX NAME PRIMARY BOX OWNER EMAIL ADDRESS
System Incident Command Winjie Miao, SEVP Chief Experience Officer COVIDCommand@texashealth.org
Liaison Officer Command David Tesmer, Chief Community & Public Policy Officer COVIDLiaison@texashealth.org
Public Information Command Mark Riordan, VP Stakeholder Engagement COVIDPIO@texashealth.org
Hospital Channel Operations Kirk King, COO Hospital Channel COVIDHOSP@texashealth.org
THPG Channel Operations Dr. Shawn Parsley, President & COO, THPG COVIDTHPG@texashealth.org
Clinical Channel Operations Dr. Andy Masica, CMO Reliable Health COVIDCLINICAL@texashealth.org
Planning Command John Mitchell, COO Amb/Post-Acute/Channel Sup Services COVIDPlanning@texashealth.org
Logistics (Supplies) Command Shaun Clinton, SVP Supply Chain Mgt COVIDSupplies@texashealth.org
Finance Command Rick McWhorter, EVP & Chief Financial Officer COVIDFinance@texashealth.org
Human Resources Command Carla Dawson, Chief People Officer COVIDHR@texashealth.org
Logistics (ITS) Command Joey Sudomir, SVP, Chief Information Officer COVIDITS@texashealth.org




THR Inpatient Surge: Unit/Room Preparation Checklist






ED Surge Triage Plan Process Map






Bed Activation Workflow






Clinical Guideline for Environmental Cleaning


Room Type Pressure Relationship ACH Minutes between Patient Occupancy
Patient Room N/A 6 46
Operating Room + 20 21
C Section Suite + 20 21
ED Triage - 12 35
Radiology Areas N/A 6 46
Bronchoscopy - 12 35
Isolation Rooms - 12 35
Cath Lab + 15 28
Trauma Rooms + 15 28

Texas Health Resources Guideline for Environmental Cleaning

Legend

(+) = Positive Pressure Relationship/Out

(-) = Negative Pressure Relationship/In

(N/A) = Not Applicable Air Pressure Relationship

  • Once a patient has been discharged or transferred, Healthcare Personnel (including environmental services) may clean the room before the air exchanges have occurred if they are wearing the appropriate PPE for the disease (e.g., gown, gloves, facemask, and face shield for COVID-19).
  • Gown and gloves should always be worn during cleaning, even after air exchanges have occurred.
  • Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol-generating procedures are performed.
  • If the patient wore a surgical mask during the entirety of their stay, the air exchange requirement is NOT required before cleaning the room or placing another patient in the room.

(Reference Table is based on Texas Administrative Code 25)

References:





Intubation Box Cleaning


Directions for cleaning and storing intubation boxes:

Use low-level disinfection wipes

  1. Unfold a clean wipe and thoroughly wet surface.
  2. Allow for appropriate contact time.
  3. Use clear water to wipe surface.
  4. Let air dry.
  5. If available, utilize UV disinfection for 3 minutes per side. Both inside and outside surfaces.
  6. Store in any clean, dust free environment.




Ventilator Request Process






Request Process for Transporting Medical Devices

To request transportation of THR assets, Biomed (HTM) On-Call Contacts:

  • Arlington/HEB/Southlake: (817)-239-7383
  • Alliance/Denton/Flower Mound: (940)-208-9347
  • Allen/Plano: (817)-239-6801
  • Azle/Fort Worth: (817)-247-4784
  • Cleburne/Southwest/Stephenville: (817)-822-5881
  • Dallas/Kaufman/Rockwall: (817)-239-6417

Please ensure as much advance notice as possible to expedite the request.





Anesthesia Machine to Ventilator Workflow






Facility Units Capable to Handle Anesthesia Power Requirements


Facility ICU PACU M/S
Allen Y Y N
Alliance Y Y N
Arlington Y Y N
Azle Y Y N
Cleburne Y Y N
Dallas Y Y N
Denton Y Y N
Fort Worth Y Y N
HEB Y Y N
Kaufman Y Y N
Plano Y Y N
Southwest Y Y N
Stephenville Y Y N




Tips for Managing Anesthesia Devices

Helpful tips for how to manage anesthesia devices have been created by entities across the system. Please reference the bullets below for additional information.

  • Air/Oxygen Mixing- A helpful tip for mixing the air and oxygen is to set the airflow to 10 L/min when operating an anesthesia device as a ventilator. From that point, the user can adjust the oxygen up or down on the device. This action will change the delivered FiO2.
  • Operating Maintenance-Set running flows at 150% of minute ventilation will preserve the Soda-Lime, as well as keep the circuits dry.
  • Device Button Location- The anesthesia device buttons locations are different than a typical ventilator. The anesthesia provider can guide the RT team in locating the needed buttons on the machine.
  • Managing Nitrous Gas Alarm- When placing an anesthesia device in ICU, the Nitrous gas source alert will sound and pop up on the screen to alert staff (due to the unavailability of gas in the ICU). Please note, the devices do not need Nitrous gas for ventilation. You can silence the audio alarm. The onscreen alert will remain lit.
  • In Room Machine Accommodation- The anesthesia device has a large footprint. Consider removing additional furniture out of an ICU room before setting up the anesthesia device.
  • Re-check Reminder- Consider scheduling routine re-checks for the anesthesia devices every 72 hours to ensure all staff is present, as needed. Please note the machine will alarm if not checked.
  • Managing EMR Documentation- If RT is managing the device, documentation will be consistent with the standard daily workflow. Some entities will use the anesthesia provider to manage the device. Their documentation will change from the normal daily workflow. Please review the Anesthesia Training Tip Sheets, located on the SharePoint site under “What's New”.




Inventory Tip Sheet For COVID-19 Anesthesia Device Transition

In the event of ventilator shortages from a surge of COVID-19 patients, please reference the below recommendations for part/supply information and replacement intervals for transitioned anesthesia devices. Please note the frequency is based on manufacture recommendations and should not be a substitute for clinical judgment. For additional questions related to part/supply and interval replacement information, please reach out to the respective role at your entity for support (RT, Materials Management, Anesthesia Provider).

Table for GE Anesthesia Devices

The above are minimum thresholds as the interval of the replacement times are dependent on the patient and the settings on the anesthesia machine

Table for Draeger Anesthesia Devices

The above are minimum thresholds as the interval of the replacement times are dependent on the patient and the settings on the anesthesia machine





Anesthesia Machine to Ventilator SOPs

Draeger Anesthesia Machine

12 amp pull

Procedure:

  • Step 1: Reference the “COVID-19: Usage of Dräger anesthesia devices for long-term ventilation”
  • Step 2: Remove all vaporizers and flush out any residual agents in the breathing system.
  • Step 3: Disconnect any N20 gas tanks/lines from the system
  • Step 4: Ensure the scavenging system is connected, if scavenging is unavailable disconnect the scavenging hose and scavenging bag
  • Step 5: Perform the full start up procedure
  • Step 6: Connect a 3L breathing bag for use 
  • Step 7: When starting a case ensure gases are flowing at least 150% of the minute volume of the patient is required
  • Step 8: Have a trained clinician configure the device settings per the appropriate ventilation mode desired
  • Step 9: Routinely check the CO2 absorber and replace as needed
  • Step 10: Routinely check the breathing system and water trap for moisture and remove/clean as needed

Notes from Draeger:

Notice: Unit is not designed for long term standalone ventilation use so doing so is considered “off-label” use

IT IS HIGHLY RECOMMEND THAT THE ATTACHMENT “COVID-19: USAGE OF DRÄGER ANAESTHESIA DEVICES FOR LONG-TERM VENTILATION” BE READ BEFORE USAGE!

A MANUAL RESUSCITATOR MUST ALWAYS BE AVAILABLE AT THE DEVICE FOR EMERGENCY USE!

  • This is not designed like an ICU vent medical personnel using the device must be well trained and familiar with the unique performance characteristics of the devices.
  • Several modes may behave differently than in intensive care ventilators. (see pg. 11 for more details)
    • The user must understand the mode Man/Spon (Manual or Spontaneous Ventilation) which is a unique ventilation mode that is not available in most intensive care ventilators.
    • The influence of the APL-valve must be understood as well. Users with no anesthesia background may expect that it also limits airway pressure during mechanical ventilation. The APL-valve has no influence in mechanical ventilation.
  • The devices are designed to be tested each 24 hours to ensure readiness for operation. If the device test is not done, the readiness of operation is not tested, furthermore particularly the flow measurement may become inaccurate. Unlike many ICU ventilators, the flow measurement of the anesthesia device cannot be calibrated during operation.
  • For performing the system test the patient must be disconnected from the anesthesia device and for this time sufficient ventilation of the patient (e.g. via the resuscitator) has to be ensured.
    • The system test takes up to eight minutes and assistance of an experienced user is required for this step
    • If a system tests each 24 hours is not feasible due to clinical reasons, we recommend performing the test at least each 72 hours to reduce the likelihood of device malfunctions.
  • To avoid that the rebreathing of the patient creates excessive additional humidity in the system, a fresh gas flow of at least 150% of the minute volume of the patient is required.
  • The usage of a very large breathing bag (e.g. Dräger 3-liter breathing bag) is recommended to avoid that the spontaneous breath of the patient is limited by the size of the breathing bag.
  • Only mechanical filters are suitable in long-term ventilation as with electrostatic filters the filtering performance is reduced when they become too humid. (See pg. 8 for solutions for use w/mechanical filters)
  • To ensure system functionality the water trap has to be emptied or exchanged before it becomes full. The required frequency of doing this depends on the humidity of the sample gas.
  • Ensure that no N2O hose and no N2O cylinder are connected to the anesthesia device.
  • The user must be able to check the proper device status, ensure that all accessories are properly connected, and that the device is able to generate gas flow and pressure at the patient connector.
    • Accessories to check includes, but not limited to:
      • Ventilation hoses
      • Bacteria filter
      • Gas sampling line
      • Manual breathing bag
      • Water traps
  • As the Dräger anesthesia devices are not designed for long time usage. The overall status of the device and its accessories has to be checked on regular base
    • At least each 12 hours (ideally more frequently) you must check:
      • Exhausted CO2-absorber
      • Full water trap
      • Standing water in breathing hoses
      • Excessive condensation at filter
  • The user interface of Dräger anesthesia devices CANNOT be protected against non-authorized users. Therefore, the operating organization must ensure that non-authorized users cannot approach the device to avoid that settings are changed, or therapy is stopped
  • The alarm and safety concept of Dräger anesthesia is designed for a permanent presence of the user within a distance of up to four meters. Therefore, a remote supervision (e.g. via central station) is not sufficient.
    • In case of situations in which a user is not within direct proximity of the device it has to be ensured that the alarm volume is set to maximum (100%) to increase the probability that potentially live threatening situations are recognized in time.
  • For enabling the device to generate the necessary alarms all alarm limits have to be set patient specific
  • In general leakages are not compensated by Dräger anesthesia devices.
  • The rebreathing of exhaled patient gases furthermore leads to another difference to ICU ventilators. The oxygen concentration of the inhaled gas (measured as “FiO2”) may differ to the set oxygen concentration in the fresh gas as the result from mixing fresh gas with rebreathed gas of the patient. Therefore, special attention must be given to the FiO2 values and the FiO2 low alarm.
  • In contrast to many ICU ventilators, the gas measurement of anesthesia devices is a side stream monitoring. Therefore, the gas measurement values and waveforms have a delay of several seconds.


Resource A: Draeger Customer Letter


Resource B: Draeger Cleaning Agent Guide


Resource C: Draeger SARS-CoV-2 and handling of Dräger Anesthesia Workstations


GE's Appendix A: COVID-19 - Requests for information regarding the off-label use of GE Healthcare anesthesia devices for ICU ventilation


GE's Appendix 1: Intended Use/Indications for Use


GE's Appendix B: Setup and Monitoring Instructions – Anesthesia Machine as an ICU Ventilator





Reprocessing Disposable Video Laryngoscope Blades

Note: Due to supply shortages and COVID-19 pandemic situation, reprocessing will need to continue at least until June 1, 2020.

Supply items for reprocessing include: Verathon (Spectrum LoPro, GVL Stat), Ambu (King Vision Standard aBlade), Medtronic (MacGRATH MAC Blade)

Department Utilizing Blade:

  1. Once a disposable video laryngoscope blade is used, completely saturate the blade with a hospital approved disinfectant, while protecting the HDMI connection if applicable
  2. Follow the hospital process for transportation of contaminated instruments
  3. Transport to sterile processing department

SPD Washing:

  1. Hand wash blade with enzymatic detergent (ex. Prolistica) and utilize enzymatic sponge (ex. Ruhof or Koala) for at least 2 minutes
  2. Rinse blade with deionized water
  3. Follow the facility guide to completely dry blade

SPD Sterilization:

  1. Check the integrity of the blade by inspecting for cracks, scratches, etc. as well as the HDMI imaging if applicable
    1. If the blade does not pass the integrity check, dispose of the blade
  2. Perform ATP test on blade (ex. ProCheck, Resi, Ruhof)
    1. If the ATP test is positive for protein, this constitutes as a failed test
    2. If the blade fails the test, reprocess and do not count as an additional use
  3. Mark individual blade for tracking each time item is reprocessed
  4. Package blade in total encased peel pack (ex. Tyvex) with a chemical indicator
  5. Place blade in hydrogen peroxide sterilizer (ex. Sterris Vpro Max, Sterrad NX or 100NX) on non-lumen cycle with a biological incubation test and chemical indicator
  6. Read test and confirm “pass”
    1. If biological incubation test fails due to moisture, reprocess blade and count as an additional use
  7. Once the blade has passed the test, store blade until instructed to use.


Reprocessing Disposable Video Laryngoscope Blades Process Map






Hospice Locations Identified by Entity


Entity Number of Beds Location within the Facility
THA 6 beds Behavioral Health
THAL 4-6 beds Outpatient Rehab
THAM 6 beds Hospice Unit
THAZ 7 beds Endoscopy Unit
THC
THD 15 beds Season’s Hospice Unit
THDN 2 beds (non-COVID) no defined location at this time but plans have been created
THF
THFM
THFW 16 beds Harris 2
THHEB 19 beds Oncology
THHV
THK 2-3 beds OB
THP No space in hospital. Looking at THCDS.
THRW 5 beds Special procedures prep and recovery
THS 5 beds Med / Surg
THSH
THSL
THSW 8-11 beds PACU




Hospice Beds Implementation Checklists


4 Bed Plan

Staffing Durable Medical Equipment Medications: IV Push
2 Providers per shift: 1 RN, 1 LVN OR 2 RN 3 regular Hospital beds and 1 bariatric hospital beds with Linens and pillows (hospital laundry service and food service) Morphine 3.5 gm per week
IV Hep Lock Dilaudid 125 mg per week
Housekeeping staff - frequent disinfecting protocol Oxygen connections for nasal cannula or mask Ativan 335 mg per week
PPE: Gloves, gowns, N95 masks, goggle/face shields, hair nets, shoe covers if required, surgical masks Haldol - 200 mg per week
Hospital provided Attending Physician or physician group to make daily rounds OR hospital grants permission to hospice physician who can act in attending physician role PCA Pumps if med shortage, IV push with syringes with lock; Sharps containers in each room Versed - 335 mg per week
Foley Equipment Robinul - 34 mg per week
Hospice to provide Social Work and Spiritual Care Coordinator chucks, wipes, quilted positioning pads for beds (if available) Dulcolax Suppositories - 8 per week
Barrier Cream (Lantiseptic, Zinc oxide, Medseptic, Desitin) IV Tylenol - 28 gm per week
Hospice to provide Hospice Clinical Liaison for hospice oversight Personal Care Supplies IV Benadryl - 2.5 gm per week


6 Bed Plan

Staffing Durable Medical Equipment Medications: IV Push
2 Providers per shift: 1 RN, 1 LVN OR 2 RN 4 regular Hospital beds and 2 bariatric hospital beds with Linens and pillows (hospital laundry service and food service) Morphine 5 gm per week
IV Hep Lock Dilaudid 125 mg per week
Housekeeping staff - frequent disinfecting protocol Oxygen connections for nasal cannula or mask Ativan 500 mg per week
PPE: Gloves, gowns, N95 masks, goggle/face shields, hair nets, shoe covers if required, surgical masks Haldol - 300 mg per week
Hospital provided Attending Physician or physician group to make daily rounds OR hospital grants permission to hospice physician who can act in attending physician role PCA Pumps if med shortage, IV push with syringes with lock; Sharps containers in each room Versed - 500 mg per week
Foley Equipment Robinul - 50 mg per week
Hospice to provide Social Work and Spiritual Care Coordinator chucks, wipes, quilted positioning pads for beds (if available) Dulcolax Suppositories - 13 per week
Barrier Cream (Lantiseptic, Zinc oxide, Medseptic, Desitin) IV Tylenol - 42 gm per week
Hospice to provide Hospice Clinical Liaison for hospice oversight Personal Care Supplies IV Benadryl - 4 gm per week


8 Bed Plan

Staffing Durable Medical Equipment Medications: IV Push
3 Providers per shift: 1 RN, 1 LVN, 1 Tech OR 2 RN, 1 Tech 6 regular Hospital beds and 2 bariatric hospital beds with Linens and pillows (hospital laundry service and food service) Morphine 7 gm per week
IV Hep Lock Dilaudid 125 mg per week
Housekeeping staff - frequent disinfecting protocol Oxygen connections for nasal cannula or mask Ativan 750 mg per week
PPE: Gloves, gowns, N95 masks, goggle/face shields, hair nets, shoe covers if required, surgical masks Haldol - 450 mg per week
Hospital provided Attending Physician or physician group to make daily rounds OR hospital grants permission to hospice physician who can act in attending physician role PCA Pumps if med shortage, IV push with syringes with lock; Sharps containers in each room Versed - 700 mg per week
Foley Equipment Robinul - 67 mg per week
Hospice to provide Social Work and Spiritual Care Coordinator chucks, wipes, quilted positioning pads for beds (if available) Dulcolax Suppositories - 17 per week
Barrier Cream (Lantiseptic, Zinc oxide, Medseptic, Desitin) IV Tylenol - 56 gm per week
Hospice to provide Hospice Clinical Liaison for hospice oversight Personal Care Supplies IV Benadryl - 6 gm per week


12 Bed Plan

Staffing Durable Medical Equipment Medications: IV Push
4-5 Providers per shift: 2 RN, 1 LVN, 2 Tech OR 2 RN, 3 Tech OR 3 RN, 1 Tech OR 3 RN, 1 LVN, 1 Tech 10 regular Hospital beds and 2 bariatric hospital beds with Linens and pillows (hospital laundry service and food service) Morphine 10 gm per week
IV Hep Lock Dilaudid 125 mg per week
Housekeeping staff - frequent disinfecting protocol Oxygen connections for nasal cannula or mask Ativan 1 gm per week
PPE: Gloves, gowns, N95 masks, goggle/face shields, hair nets, shoe covers if required, surgical masks Haldol - 600 mg per week
Hospital provided Attending Physician or physician group to make daily rounds OR hospital grants permission to hospice physician who can act in attending physician role PCA Pumps if med shortage, IV push with syringes with lock; Sharps containers in each room Versed - 1 gm per week
Foley Equipment Robinul - 100 mg per week
Hospice to provide Social Work and Spiritual Care Coordinator chucks, wipes, quilted positioning pads for beds (if available) Dulcolax Suppositories - 25 per week
Barrier Cream (Lantiseptic, Zinc oxide, Medseptic, Desitin) IV Tylenol - 84 gm per week
Hospice to provide Hospice Clinical Liaison for hospice oversight Personal Care Supplies IV Benadryl - 8 gm per week





COVID-19 Showers & Changing Area Tip Sheet

Overview

As the number of COVID-19 patients increases at Texas Health hospitals, we should have plans in place to provide staff a place to shower and change after their shift is over prior to going home so that they can decrease the risk of potentially bringing COVID-19 back to their families and people they live with.

Process

  • If your facility has a fitness center, consider utilizing this space
  • If your facility does not have a fitness center or if the fitness center is not centrally located within the hospital, consider utilizing:
    1. Closed floors, rooms on low volume floors
    2. Physical Therapy or Cardiac Rehab
    3. OR and/or L&D locker rooms
    4. If none of the above are viable options, please reach out to HannahTupper@texashealth.org for assistance with potential alternatives
  1. Create a shower schedule
    1. Suggested shower times: 6:00 A.M. – 8:00 A.M and 2:00 P.M. – 8:00 P.M.
    2. Methods for scheduling – for all the options below there will need to be a point person/team to manage requests and track volume of staff utilizing showers
      1. Set up entity call number for scheduling
      2. Set up entity SharePoint webform to use for scheduling
      3. Assign staff (ex: fitness center staff) to man check-in for showers
  1. Grant all staff access to showers and changing areas
  2. Provide plastic bags for used clothing/dirty scrubs for staff to safely transport clothing home
  3. Work with EVS to set cleaning schedule for showers – increase frequency of cleanings if possible
  4. Communicate availability of showers and changing areas to staff via e-mail
    1. Utilize the Shower & Changing Area Announcement Flyer (Attached Below)

Shower & Changing Area Announcement Flyer






Hotel Rooms for Caregivers