key: cord-0928591-jqumplvm authors: Miller, Gregg A.; Buck, Cameron R.; Kang, Christopher S.; Aviles, Jennifer M.; Younggren, Bradley N.; Osborn, Scott; Keay, Catharine R. title: COVID‐19 in Seattle—Early lessons learned date: 2020-04-19 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12064 sha: 1ea458eab2b3f5427bc4cc81b6a3349039c620c9 doc_id: 928591 cord_uid: jqumplvm The coronavirus disease 2019 (COVID‐19) pandemic has rapidly evolved and now dominates the attention and full efforts of the emergency medicine community, both domestic and abroad. Seattle is the site of the initial diagnosed COVID‐19 cases and fatalities in the United States. We provide an overview of the system‐level response of 6 Seattle emergency departments and the Washington state chapter of the American College of Emergency Physicians (ACEP) to the COVID‐19 pandemic. Local efforts involved the spectrum of emergency response including on‐ and off‐site triage strategies, an approach to personal protective equipment, testing and reporting protocols, early treatments, communication strategies, the impact on front‐line providers, and ongoing work. directing patients to avoid EDs for less serious respiratory symptoms. 5 Also, multiple health systems are expanding their telehealth capabilities, offering patients virtual care options and alternatives. Finally, perception exists among physicians that many patients are staying away from the EDs due to fears of being exposed to the virus during a visit. Though our ED volumes have declined, our inpatient capacity is stretched. Hospitals in the Pacific Northwest were already experiencing a high inpatient census, usually running close to or over capacity. One hospital reports all ventilators are currently being used with no additional units available. Our hospital systems have cancelled noncritical surgical cases to optimize current capacity as part of surge planning. We are also noting contraction of the available blood supply. While at this point most of our institutions maintain some intensive care unit (ICU) and inpatient bed capacity, due in part to rapid efforts to expand critical care beds, we expect conditions to change in the next few days to weeks. Personal protection equipment guidelines have changed rapidly based on local institutional supply and are continuing to change. In general, due to dwindling PPE supplies, our usage transitioned to the World Health Organization (WHO) guidelines of contact/droplet precautions, reserving airborne precautions for high risk/aerosolizing procedures such as intubation, high-flow nasal cannula, bilevel ventilation, and nebulized treatments. 6 In general, however, high-risk procedures are avoided in all respiratory patients when possible. Our current PPE practice is in contrast to much of the rest of the country, and to the CDC guidelines, which had been recommending broad airborne precautions. 7 We wear surgical masks rather than respirators for typical patient encounters, in addition to face shields, gowns, and gloves. If TA B L E 1 List of cohort hospitals The treatment of COVID-19 is constantly evolving. Within the first 2 weeks, there was limited information regarding the optimal care for admitted patients. While the vast majority of COVID-19 patients are managed in the outpatient setting, many have been hospitalized. We In some cases, we are using remdesivir on a compassionate-use protocol, though we understand this protocol will be modified in favor of clinical trials. Some facilities are also participating in a clinical trial, enrolling all qualified, consenting admissions into a 5-day and 10-day arm trial of remdesivir (no placebo). We are not starting ED patients on chloroquine or antivirals. At least 2 Seattle emergency physicians have been infected by COVID-19; it has not yet been ascertained if the infections were work-or community-related exposure. One has recovered without major complication. Several additional physicians were placed on work restrictions after confirmed COVID-19 exposure. Once these physicians tested negative for COVID-19, they were allowed to return to work while wearing a mask and being monitored for symptoms. These individuals were not required to refrain from work for 14 days as had been recommended by the CDC at the time. The transmissibility and mortality related to COVID-19 requires a significant re-tooling of ED processes to deal with endemic disease. uniform policy for what to do when a staff member has been exposed, tests positive, and exhibits symptoms will mitigate stress, and conserve scheduling and sustained sufficient staffing. We found it necessary to have backup staffing readily available when personnel are notified, quarantined, or become symptomatic on short notice. We know that we will get through this. While we have certainly seen concern and anxiety in our patients and staff, we have also seen tremendous resolve and courage. We are grateful to our international colleagues who have shared their knowledge and insight, proud of our partners on the front lines of this event, and appreciate the opportunity to share our experiences and lessons learned with those who will also potentially face this challenge and future events. 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Northwest Healthcare Response Network COVID-19 in Seattle-Early lessons learned The authors have no conflicts of interest to disclose. https://orcid.org/0000-0003-4770-1501