Table 1

Evolution of screening protocol and factors that influenced specific changes from 28 February 2020 to 5 May 2020

DateCOVID-19 guideline interpretationScreening protocol implementation and changesInformation disseminationKotter’s stage applied/mechanism
28 Feb 2020
  • Travel to China in last 14 days (CDC)

  • Testing was expanded to include Iran, Italy, Japan and South Korea, whereas previously testing was only available to those who visited China

  • Stanford aligned with CDC guidance

  • General media

  • Posted protocols in care areas of physician charting computers charge nurse station

  • Create a vision for change (stage 3)

  • Communicate the vision (stage 4)

2 Mar 2020
  • Change from current state of security staff performing screening (SHC)

  • Within Stanford protocol, security staff replaced by nurses to screen patients for country of travel

  • Complex screening protocol necessitated change to a staff member with clinical background

  • Physician–nursing alliance initiated with an email including instructions for how they should complete screening

  • Department chair synergistically allied with SHC C-suite

  • Create Urgency (stage 1)

  • Form a powerful coalition

    (stage 2)

  • Create a vision for change (stage 3)

  • Communicate the vision (stage 4)

  • Remove obstacles (stage 5)

4 Mar 2020
  • Expanded testing beyond only travel criteria (CDC)

  • Changed from current process of county public health department had to be notified of all PUIs prior to testing. (SHC)

  • Testing was expanded to any symptomatic patient with symptoms of severe lower respiratory illness requiring hospitalisation

  • Testing able to be done in-house, and no longer requiring county health department approval for testing and processing.

  • Department’s electronic medical record system was updated to include clinical decision support within order panels to reduce confusion

  • Create a vision for change (stage 3)

  • Communicate the vision (stage 4)

  • Remove obstacles (stage 5)

  • Build on the Change (stage 7)

7 Mar 2020
  • Workflow changed from only triage nurse making screening decisions (SHC)

  • Dedicated physician was added to screening workflow available for triage consultation for PUI

  • Notice to nursing with email and new workflow posted in department

  • Form a powerful coalition

    (stage 2)

  • Build on the Change (stage 7)

9 Mar 2020
  • Broader testing criteria for admitted patients than CDC mandates. (CDC and SHC)

  • Standardised discharge instructions were made available for patients being discharged with results pending.

  • COVID-19 results pending admission pathway was added with cohorting of patients awaiting results in the hospital.

  • Any patient being admitted with influenza like illness was tested for COVID-19

  • Weekly departmental newsletter

  • Leadership rounding consisting of Chair and Medical Director to observe effectiveness of changes and boost morale

  • Interdepartmental meetings among clinical leaders

  • Form a powerful coalition

    (stage 2)

  • Create a vision for change (stage 3)

  • Communicate the vision (stage 4)

  • Remove obstacles (stage 5)

  • Create short-term wins

    (stage 6)

  • Build on the change (stage 7)

11 Mar 2020
  • Implementation to include testing for vulnerable populations (eg, homeless, nursing home patients; SHC)

  • COVID-19 results pending excluded from observation care area

  • Formalised pathway to admit all homeless persons pending COVID-19 results.

  • Updated posted flowchart

  • Leadership rounds with nurse quality manager, medical director, nurse manager

  • Weekly residency conference updates by chair

  • Create urgency

    (stage 1)

  • Remove obstacles (stage 5)

  • Create short-term wins

    (stage 6)

13 Mar 2020 (I)
  • Broadened criteria from prior recommendations that only symptomatic patients being admitted with lower respiratory infection or travel history be tested. (SHC)

  • Changed criteria to test any symptomatic patient with influenza-like symptoms

  • ‘Required testing’ criteria added institutionally for any patient being admitted with influenza-like illness

  • Weekly town hall meetings with the department of emergency medicine

  • Create urgency

    (stage 1)

  • Communicate the vision (stage 4)

  • Remove obstacles (stage 5)

  • Build on the change (stage 7)

13 Mar 2020
(II)
  • Institutional expansion of testing from only patients who likely required admission. (SHC)

  • Clarification of COVID-19 orders to include testing for patient to be discharged

  • Outside tent testing area added

  • EHR order set updated to reduce confusion and facilitate ease of order

  • Form a powerful coalition

    (stage 2)

  • Create a vision for change (stage 3)

  • Communicate the vision (stage 4)

  • Remove obstacles (stage 5)

  • Build on the change (stage 7)

  • Anchor the change (stage 8)

5 Apr 2020
  • Stanford implemented asymptomatic testing. (SHC)

  • Broadened testing criteria for asymptomatic and unable to screen patients (eg, dementia, stroke patients)

  • Rapid result COVID-19 testing offered for specific patient presentations

  • Weekly town hall

  • Twice a week COVID-19 newsletter

  • Posting of updated algorithm in all physician care areas to improve compliance

  • EHR order set updated

  • Create a vision for change (stage 3)

  • Communicate the vision (stage 4)

  • Remove obstacles (stage 5)

  • Create short-term wins (stage 6)

  • Build on the change (stage 7)

  • Anchor the change (stage 8)

  • CDC, Centers for Disease Control and Prevention; EHR, electronic health record; PUI, patient under investigation; SHC, Stanford Health Care.