key: cord-0685283-baymfk75 authors: Schreyer, Kraftin E.; del Portal, Daniel A.; King, L. J. Linus; Blome, Andrea; DeAngelis, Michael; Stauffer, Karen; Desrochers, Kevin; Donahue, William; Politarhos, Nancy; Raab, Claire; McNamara, Robert title: Emergency Department Management of the COVID-19 Pandemic date: 2020-07-09 journal: J Emerg Med DOI: 10.1016/j.jemermed.2020.07.022 sha: 72ee86f4931d22fd42d5f4531c4fa94dbfcc2797 doc_id: 685283 cord_uid: baymfk75 Abstract Background Emergency Departments (EDs) need to be prepared to manage crises and disasters in both the short and long term. The COVID-19 pandemic has necessitated a rapid overhaul of several aspects of ED operations in preparation for a sustained response. Objective of the Review:We present the management of the COVID-19 crisis in three EDs (one large academic site, and two community sites) within the same health system. Discussion Aspects of ED throughput, including patient screening, patient room placement, and disposition are reviewed, along with departmental communication procedures and staffing models. Visitor policies are additionally discussed. Special considerations are given to airway management and the care of psychiatric patients. Brief guidance around the use of personal protective equipment is also included. Conclusions A crisis like the COVID-19 pandemic requires careful planning to facilitate urgent restructuring of many aspects of an ED. By sharing our departments’ responses to the COVID-19 pandemic, we hope other departments can better prepare for this crisis and the next. Emergency Departments (EDs) need to be prepared to manage crises and disasters in 31 both the short and long term. 1 Unlike events that merit an immediate short-term response (e.g. 32 weather emergencies, mass shootings), infectious outbreaks, including the COVID-19 pandemic, 33 require a prolonged, sustainable response. According to the World Health Organization's 34 hospital emergency response checklist, several critical actions should be prioritized to support a 35 safe and effective disaster response. These include swift adaptation to increased demands, 36 effective use of limited resources, and maintenance of a safe environment for healthcare workers 37 through a well-coordinated and communicated operational effort. 2 Often, an incident command 38 system for each hospital or health system is used to coordinate the multi-pronged response 39 required for a crisis or disaster of large magnitude. A similar structure can be utilized on a 40 departmental level to coordinate the response by one ED, or by several EDs within the same 41 health system. 1 42 We present the management of the COVID-19 crisis in three EDs within the same health approximately 47,000 and 40,000 visits annually. While our management plans were coordinated across all three EDs, implementation at each site varied slightly because of 48 differences in size, staffing, and available resources. Key differences between the main 49 academic site and the community sites are highlighted as academic and community subdivisions 50 in the following sections. We additionally note the outcome of each item on the management 51 plan as a success or failure within our department. During a crisis, transparent, accurate, and timely information exchange is critical to 56 establish trust in leadership, ensure safe and informed decision making, and guarantee effective 57 cooperation between the operational leadership team and those on the front lines in the ED. As 58 the COVID-19 pandemic crisis began to unfold, key members of the ED operations leadership 59 team came together to formulate a plan to provide regular updates to the staff in the face of an 60 ever-evolving situation. We chose to create an ED operations framework document for each 61 campus that was used to disseminate site specific information pertaining to patient screening, 62 room placement, testing, disposition, PPE use, and staff exposures. In addition to the daily ED operations calls, there was also an ED steering committee that The ED frameworks and operations and steering committee calls were very successful. As the pandemic progressed and departmental changes stabilized, the operations calls were 80 changed from daily to weekly, and the steering committee calls were changed to every other 81 week, and ultimately disbanded. The ED leadership team call schedule was found to put an 82 additional strain on departmental leaders, who were already stretched thin. To preserve the 83 wellness of the operational leaders, the call schedule was foregone after a few weeks. The screening program was successful at identifying patients at-risk for COVID-19 in the 95 early stages of the pandemic. However, over time, it was found that many other symptoms could 96 be indicative of COVID-19 infection, and so, even though the screening protocol remained in 97 place, all patients were ultimately considered to be at risk for COVID-19. Our main campus ED, prior to COVID-19, was 50 treatment spaces. Of these spaces, 21 101 were closed door rooms and the remainder were separated by curtains. We recognized the need 102 to increase the number of fully enclosed rooms to diminish aerosolization between treatment 103 spaces. In a phased approach that minimized the impact to ongoing ED operations, we installed 104 barriers of thick corrugated plastic with zippered doors, each with a translucent area of plastic to 105 be able to monitor patients from the adjacent nurses' station. Eight existing negative pressure 106 rooms in the ED were designated for sicker respiratory patients on arrival, who were more likely 107 to need aerosol-generating procedures such as high-flow nasal cannula, BiPAP, or intubation. A 30ft x 50ft tent was rented and placed outside the ambulance and adjacent walk-in 109 entrances of the ED. A nurse was positioned outside those entrances during peak arrival times, 110 directing any stable patients with respiratory complaints or fever to be triaged in the tent. The additional ED treatment spaces. The registration staff that had previously occupied that area was 142 temporarily relocated to allow for the ED expansion. The lobby conference room was In lieu of a tent, a temporary structure was constructed just outside of the ambulance 146 entrance at Community Site 1. To maintain linear flow through the ED, triage was relocated to 147 that structure during hours it was operational. All patients, regardless of complaint, were then 148 triaged in the new structure prior to entering the ED. Initially, the new structure was also staffed 149 with a physician assistant or nurse practitioner, in order to screen the lowest risk patients away, 150 with instructions to self-isolate and arrange outpatient testing, as was done at the tent located at 151 the main ED. However, as low acuity COVID volume declined, these providers were redeployed 152 from the screening structure to additional internal treatment spaces. Prior to the COVID-19 pandemic, Community Site 2 also had 19 treatment spaces. The 154 footprint lent itself to physically separating the Respiratory ED from the Non-Respiratory ED. The Fast Track area of the ED, which was comprised of five closed door rooms, was converted 156 into the Respiratory ED. The internal waiting room located in the fast track was converted into inclusive of laboratory testing, including infectious and coagulation markers, imaging, specimen 235 collection, and isolation precautions. Portable fingertip pulse oximeters for home use were purchased for distribution. Initially, 246 given a limited supply, these devices were given to discharged patients with risk factors for 247 decompensation (age over 50, diabetes, chronic heart or lung disease, immunocompromise) with 248 a borderline oxygen saturation. As more devices were obtained despite increased national 249 demand, the criteria for dispensing them was relaxed, so that more patients could be given an 250 opportunity to monitor their illness. The visitor policy changes were understood by patients and well-received by staff. However, prior to the pandemic, in-person ED consultation was not available at any site. In 295 order to minimize transfers to the CRC, a telepsych process was established. and was unable to safely quarantine (i.e. resided in a shelter or group home) was admitted. Patients requesting evaluation for substance use disorder who were at risk for alcohol or 309 benzodiazepine withdrawal were similarly screened for COVID-19 symptoms and only those 310 with negative screens were transferred to the CRC. Patients not at risk for alcohol or 311 benzodiazepine withdrawal were discharged to quarantine at home with outpatient resources. The telepsych program had minimal success because of staffing availability at the CRC. An attending psychiatrist was only available for telepscyh consults during weekdays, and 315 therefore, patients presenting to the ED after hours or on weekends could not participate in the 316 telepsych program. A crisis like the COVID-19 pandemic requires careful planning to facilitate urgent 319 restructuring of many aspects of an ED. Throughput protocols and workflows must be 320 restructured to allow for screening of at-risk patients and safe and expedited dispositions of all 321 patients, while maintaining staff safety. Often, physical restructuring of the department must be 322 done with ingenuity to optimize and expand treatment capabilities. Efforts must be made to best 323 utilize providers who are unfamiliar with the ED context. By sharing our departments' responses Emergency Department Management. McGraw Hill. Chapter 333 49, Emergency Department Disaster Planning and Response World Health Organization. Hospital emergency response checklist: an all-hazards tool 335 for hospital administrators and emergency managers National Center for Immunization and Respiratory Diseases, Division of Viral Diseases Evaluating and Testing Persons for Coronavirus Disease Are bronchodilator nebulizers superior to MDIs 328 We would like to acknowledge every member of our departments. Their dedication to patient 329 care inspires us every day.