key: cord-0949502-vhvngxzm
authors: Whiteside, Tess; Kane, Erin; Aljohani, Bandar; Alsamman, Marya; Pourmand, Ali
title: Redesigning emergency department operations amidst a viral pandemic
date: 2020-04-15
journal: Am J Emerg Med
DOI: 10.1016/j.ajem.2020.04.032
sha: ddf2e41081955599408908ecf6b211f5a0846462
doc_id: 949502
cord_uid: vhvngxzm

Abstract As shown by the current COVID-19 pandemic, emergency departments (ED) are the front line for hospital-and-community-based care during viral respiratory disease outbreaks. As such, EDs must be able to reorganize and reformat operations to meet the changing needs and staggering patient volume. This paper addresses ways to adapt departmental operations to better manage in times of elevated disease burden, specifically identifying areas of intervention to help limit crowding and spread. Using experience from past outbreaks and the current COVID-19 pandemic, we advise strategies to increase surge capacity and limit patient inflow. Triage should identify and geographically cohort symptomatic patients within a designated unit to limit exposure early in an outbreak. Screening and PPE guidelines for both patient and staff should be followed closely, as determined by hospital administration and the CDC. Equipment needs are also greatly affected in an outbreak; we emphasis portable radiographic equipment to limit transport, and an upstocking of certain medications, respiratory supplies, and PPE.

The current pandemic caused by the rapid spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) demands urgent guidance for clinicians faced with the novel illness. Emergency departments (ED) are the front lines for hospital-and-community-based care, serving as the main points for triaging patients as infected versus non-infected and sick versus not-sick. EDs across the nation are overwhelmed with patient numbers at baseline. A review by J o u r n a l P r e -p r o o f the National Emergency Department Survey showed annual ED visits increased from 89.6 million to 139 million from 2006 to 2017 (an increase of 18.4%). (1) (2) This issue of overcrowding has the potential to increase exponentially during times of viral outbreak. For example, during the H1N1/2009 pandemic, one study estimated that the rate of ED visits attributable to influenza increased to 1,000 per 100,000, doubling the average annual rate of 500 per 100,000 population for seasonal influenza. (3) It is essential that strategic measures be taken to anticipate surges in ED patient visits, particularly during times of infectious disease outbreak.

EDs maintain order through structured workflow and careful departmental geographic planning. However, the typical organization must be largely disrupted when anticipating how to limit infectious spread and care for enormous patient volume. The main concern during such times is to maintain high quality and high efficiency care, with emphasis on patient and provider safety, when demand far exceeds capacity. Though many departments throughout the country have disaster preparedness protocols in place, individual outbreaks differ by severity of illness, route of transmission, and level of contagion, which dramatically alters the number of patients presenting to hospital facilities for screening and/or care. Thus a more general guideline, as presented here, will help address the overarching issues that will occur with any viral epidemic/pandemic. This paper will address some of the ways to adapt daily routines in the ED to better manage times of elevated airborne disease burden, specifically identifying areas of intervention to help limit crowding and spread during viral respiratory disease outbreaks.

Interventions that limit unnecessary patient visits during a respiratory disease outbreak are essential to mitigate infectious exposure and maintain expeditious ED workflow. A panel of J o u r n a l P r e -p r o o f expert emergency physicians placed highest priority on ED interventions that would alleviate high patient volume, with their greatest concern being ED crowding.(4) Specific interventions included triaging patients to the most appropriate care setting through a website or call center, then standardizing ED admission criteria for patients with respiratory symptoms. This same panel felt disease severity was a lesser issue in the ED setting and more important for inpatient management. (4) Limiting patient inflow can be accomplished by triage points before and upon ED arrival.

Before presenting to the hospital, patients can be directed to a telemedicine visit for triage. While some portion of these patients will ultimately require hospital-based care, many can be counseled and/or tested in the outpatient setting. Once at the hospital, diverting low-risk patients with respiratory symptoms to an alternate site of care, such as a medical tent, is a strategy to protect ED bed capacity. At George Washington University Hospital during the COVID-19 pandemic, a tent was set up outside the hospital and adjacent to the outpatient clinic building. Patients who arrived to the ED with concern for COVID-19 were directed to the tent and seen by an APP if they met criteria for age, heart rate, and temperature. Patients who did not meet these criteria were deemed higher risk and triaged to a designated ED treatment space. (Figure 1 ) ED directors should engage hospital leadership immediately to expand inpatient capacity, canceling elective surgeries and adding ICU and negative pressure rooms where feasible. With a reduced OR schedule, ED treatment spaces that typically would be occupied by 'boarding' patients can be recovered. 

With highly contagious viral disease that has both airborne and fomite transmission, a major problem is nosocomial transmission. Large health systems may designate one hospital to serve as the primary hospital for infected patients. Within a single ED, there are no clear guidelines on the best organizational model, though it is clear that major adjustments must be made quickly when addressing highly contagious respiratory disease outbreaks. During the SARS outbreak, no decisions were made in the early stages of the outbreak about whether to cohort suspected and/or probable cases of SARS into a centralized section in emergency departments.(6) Thus, it is important to have collateral plans ready to put in place for when such viral outbreaks reoccur. One of the highest priority interventions should be to limit the number of staff and patients exposed by geographically cohorting patients with presumed or confirmed J o u r n a l P r e -p r o o f infection.(4) This operational approach must be implemented in the early stages of an outbreak as the efficacy declines significantly once an infection becomes widespread.

When cohorting patients it is most appropriate to designate a specific area of the department and establish a static geographic assignment model. In this model, providers and nurses are assigned specific rooms and automatically assigned patients who arrive in these rooms. When cohorting patients, the care team would be assigned solely to the rooms in that cohort, thus limiting interaction with outside patients and staff. The providers and nurses may sit together at a workstation near the assigned room ( Figure 2 ). (7) In terms of staffing these cohorts, it is most appropriate to use long shifts and overtime hours to limit the amount of staff turnover.

Additionally, if possible, use staff who are immune (recovered) in these units and negative pressure rooms for these patients. 

Healthcare workers are particularly vulnerable to transmission of respiratory infections Additionally, although an initial face-to-face examination of the patient is typically required, subsequent interactions (updates, discharge instructions) may take place via phone or video-chat. Thus, EDs may wish to have smart phones or portable electronic devices (tablets or iPads) available for patients to communicate with staff who are outside the room.

J o u r n a l P r e -p r o o f New housekeeping protocols must be developed in conjunction with the Environmental Services director. Additional supplies may be needed. Additional staff may be added or diverted from other settings during times of peak room turnover. When the ED is seeing more than 100

PUIs per day, a 2-hour room clean time for contaminated rooms can devastate ED operations / flow and have real impact on patient care.

An essential aspect of infection control is testing and quarantining healthcare providers/staff as appropriate. Data from the COVID-19 pandemic in Italy suggests that EDs should be prepared to have at least 10% of staff become ill.(8) Thus, a conservative approach much be taken with strict guidelines for monitoring and testing healthcare providers (HCP).

Such exposures include prolonged close contact to COVID-19 patients without proper PPE or using a mask instead of a respirator during aerosol-generating procedures. Asymptomatic HCPs with low-risk exposures are able to work but should self-monitor with supervision from occupational health (or other hospital entity) for two weeks after last exposure. Low-risk exposures include most interactions with appropriate PPE. Self-monitoring includes making sure they are afebrile and asymptomatic before reporting to work.(13) This system collapses in communities with high rates of infection, where it is assumed that most HCPs have been exposed and must still work if asymptomatic and wearing appropriate PPE. ED administration may consider implementing a system to evaluate staff for fevers and/or respiratory symptoms prior to starting work. Any HCP with fever or respiratory symptoms should immediately self-isolate. To mitigate impact on scheduling, EDs can have additional staff backup on the schedule to cover in the case that another staff member calls out.

Additionally, HCPs should be given priority for rapid-turnaround testing as this has enormous impact on available staff during a critical time.

During a surge of a particular infectious disease, different formulations or quantities of medications may be required. Most importantly, metered-dose inhalers pose a smaller risk of infectious spread via respiratory droplet than nebulizers and are the preferred mode of delivery.

As discussed above, the Surviving Sepsis Campaign classifies nebulized treatments as an aerosol-generating procedure that requires the administrating healthcare provider to wear fitted respirator masks like N95 or FFP2. 

Radiographic personnel (including radiologists and technicians) are among the first-line healthcare workers at increased risk of exposure during a viral respiratory disease outbreak.

Diagnostic imaging facilities should be prepared with guidelines to handle such an event. This includes using portable radiographic equipment whenever possible, which limits patient transport and can be easily cleaned afterwards. (17) The American College of Radiology has recommended against the use of CT as a first-line screening tool for viral respiratory infections, like COVID-

infection control measures should be in place before scanning subsequent patients. (17) According to the CDC and Spaulding Criteria, these equipment pieces are only in contact with intact skin and are therefore considered "noncritical items". They can be cleaned via low-level disinfectants, which include isopropyl alcohol and ethyl alcohol, with single-use disposable disinfectant towels.(18) The use of satellite radiography centers and/or dedicated radiographic equipment can also decrease the risk of transmission. Additionally, if it is required that a patient be transported to the radiology department, it is essential that individual be wearing appropriate PPE throughout transport.

Appropriate ventilatory support is a main concern when preparing for, and responding to, viral respiratory disease outbreaks. Looking at the current COVID-19 pandemic, the prevalence of several to critical hypoxic respiratory failure is 19%.(19) Current guidelines recommend the use of high-flow nasal cannula over non-invasive positive pressure ventilation (NIPPV) for COVID-19 patients; this is due to the high failure rate and increased risk of intubation associated with NIPPV use in patients with non-cardiogenic acute hypoxemic respiratory failure.(10) High flow oxygen is also thought to be lower risk for aerosolization than NIPPV.

The guidelines recommend early endotracheal intubation, which should be performed in a negative pressure room to prevent diffusion of the pathogen. Individual outbreak scenarios require unique responses. Strategies will vary largely based on hospital and department size, availability of staff, number of surrounding hospitals, community size, populations affected, and extent of disease spread. Additionally, the concerns addressed here are not exhaustive; they represent challenges to care in a viral respiratory disease outbreak and may not be applicable to other types of contagions. Finally, there is limited data with which to validate some of these interventions due to the recentness of the COVID-19

pandemic. There is a need for more formal evaluation of intervention quality and efficacy to further our understanding of the best response.

As the front-line for healthcare during a viral respiratory disease outbreak, EDs must be prepared to make expeditious operational adjustments to meet the expanding patient volume and limit infectious spread. The suggestions presented here limit unnecessary ED visits via establishment of a call-center, isolate patients through effective triage and geographic cohorting, mitigate viral spread with appropriate screening and PPE, and address equipment and medication stock concerns. While any viral outbreak requires an individualized response, sharing these suggestions for operational planning may assist in the development of emergency management protocol and better prepare departments during this pandemic and in the future.

J o u r n a l P r e -p r o o f o Asymptomatic HCPs with low-risk exposures are able to work but should self-monitor with supervision for two weeks after last exposure o HCPs with medium/high risk exposures should undergo active monitoring, including restriction from work until 2 weeks after last exposure.  Implement a system to evaluate staff for fevers and/or respiratory symptoms prior to starting work  Any HCP with fever or respiratory symptoms should immediately self-isolate.

 Have additional staff backup on the schedule to cover  HCPs should have priority for rapid-turnaround testing ED stocking and supply  Obtain an appropriate supply of PPE and establish allocation procedures  Increase inhaler and spacer stock o Instruct EMS/staff to preferentially use inhaler treatments  Obtain additional stock of paralytics, induction agents, and medications for postintubation sedation  Confirm Pyxis availability and emergent access to these medications  Disposable tape measurers for patient height and a wall reference with ideal body weights to help establish appropriate initial ventilator settings

 Use portable radiographic equipment whenever possible Figure 2 . Cohort symptomatic patient to rooms in an isolated area of the department (blue). Using a static geographic assignment, designate providers and nurses to be assigned to these areas only. The non-cohort rooms (orange) can remain with the baseline department staffing model. 

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