The United States has seen an increase in COVID-19 infection, which has now exceeded China and Italy. Thus, we wanted to take this as an opportunity to talk about how our health care system is adapting to address this surge —specifically, how EDs are changing their operations to address such an unprecedented event.
Shock and Awe
In late 2019, the world discovered that a new strain of the coronavirus, 2019-nCoV (later renamed to SARS-CoV-2), was causing widespread and severe respiratory illness in Wuhan City of the Hubei Province of China. This illness became known as COVID-19. The ensuing aggressive global efforts to curb viral spread created virtually instant tidal waves in both the public health landscape and the global economy. Efforts to avoid shortages of critical resources such as ventilators, ICU beds and PPE through “flattening the curve,” a now mainstream phrase, are underway. The world has witnessed the saturation of health care systems in China and Italy, where the demand for these resources has outstripped supply and resulted in desperate rationing. With infection widespread in the U.S. and numbers of confirmed cases now exceeding those recorded in China, it is important to take note of how our health care system is adapting to address this surge—specifically, how EDs are changing their operations to address such an unprecedented event. On March 25, EMRA's Administration & Operations Committee hosted a virtual conference on "Operationalizing COVID-19 Care" with Nida Degesys, MD, who is helping organize the COVID-19 response at the University of California, San Francisco (UCSF). This article will summarize key, actionable takeaways from that discussion as well as on-the-ground updates from New York City and other hospitals across the country to inspire innovation among EMRA members on the front lines.
What Steps Are EDs Taking to Address the COVID-19 Pandemic?
Nearly every aspect of patient care — from triage to discharge, from documentation to intubation — has been revised in an effort to streamline care. Concerns around minimizing provider exposure to SARS-CoV-2 and conserving essential equipment have led to sweeping changes in how patients are approached clinically.
PPE Conservation and Minimizing Provider Exposure
Given concerns that SARS-CoV-2 is spread via both droplets and aerosolization, the national PPE shortage is an ongoing concern. Hospitals facing high volumes of COVID-19 patients are taking different approaches to in solving this problem. Strategies utilized at UCSF and other institutions have revolved around the distilled concepts of "reduce-reuse-recycle." Ensuring an adequate supply of clean scrubs and jackets, as well as washable PPE gowns, is key.
- Reduce: UCSF is limiting the number of providers in rooms with patients suspected of having COVID-19 infection to further avoid contamination and utilization of PPE. For many patients, a phone system is used to interview the patient from outside the room, while a "doorway exam" ensures they appear nontoxic with no increased work of breathing. This strategy limits providers' exposure and reduces PPE use. One-time order sets for nurses minimizes patient room entry and exit, further conserving equipment while enhancing safety for nursing staff. Initially, only attendings were seeing suspected COVID-19 patients at some NYC academic hospital centers in an effort to avoid excess exposure and PPE use. However, as volume and acuity quickly surged, residents became essential parts of treatment teams.
- Reuse: Different measures have been required to ensure a proper supply of PPE. Several hospitals in NYC now recommend PPE be worn all shift to conserve the number of N95 masks available. Droplet masks are being worn over N95s to enhance their longevity, and face-shields are being widely utilized to further protect against contamination. Contact precaution gowns and gloves are being worn either throughout a shift or changed between patients. N95 masks are used across multiple patients and multiple shifts until visibly soiled, until exposure to an aerosolizing procedure, or some variation thereof. Some institutions have given each provider 3 N95 masks and instructed them to rotate through them on a 3-day schedule - though the virus can survive up to 72 hours on some surfaces.
- Recycle: Some institutions have initiated plans to recycle used masks through sanitation procedures using ultraviolet light or vaporized hydrogen peroxide. Masks that have been visibly soiled, even by facial makeup, cannot be successfully recycled. Consequently, some institutions have started to urge (and in some cases mandate) employees not to wear makeup, lip balm, or face cream.
The Rise of Telehealth
Given the limited geography of ED spaces, the ability to virtually see patients over telehealth platforms has offered decreased provider exposure, more rapid throughput of visits, and saved precious space and rooms in EDs. Telehealth pay parity laws, ensuring medical services delivered virtually are reimbursed at similar rates to in-person visits, have helped this rise in certain locations. Residents and attendings have been involved in these services, offering thousands of patients medical advice without physically arriving at the ED. This has been a particularly valuable service given the closure of many primary care clinics due to quarantine and distancing efforts. Similar to the aforementioned "doorway exam," telehealth calls have allowed efficient risk stratification of concerned patients. Residents and attendings who are unable to work due to quarantine protocols have engaged in telehealth as a way of serving as caregivers in the midst of this pandemic. Telehealth also allows the health care team to follow up on PUIs who are sent home.
At some institutions, a virtual triage system is being used to screen patients even before they step inside of the hospital. This allows patients who screen positive to be directly placed into the COVID-19 area of the ED, minimizing exposure to others. Virtual triage can be initiated prior to the patient entering the hospital at tents/kiosks set up outside. Many hospitals are using these tents to take a patient's temperature and screen for any travel history and symptoms. As part of this process, patients may be asked to take a simple survey via a laptop provided or on their phones through a QR code. Their responses can be composed into an H&P that is linked to the EMR, which the provider may edit and finalize.
Intubation and Respiratory Care
Many interventions taken to support COVID-19 patients in respiratory distress are also dangerous for providers - increases the risk of aerosolization of the virus. Strategies exist which can help decrease these risks. At both UCSF and in several NYC hospitals, video-laryngoscopy (VL) intubations have been highly encouraged given their speed, increased first-pass success rates, and ability to allow providers to intubate further from the airway.
Sites are also limiting the number of providers in rooms for intubations. At UCSF, 4 personnel are present at the bedside for intubations: attending physician, registered nurse, respiratory therapist, and resident physician.
At an academic tertiary care institution in NYC, only residents and attending physicians are at the bedside for the intubation, with all other personnel entering the room after successful endotracheal tube placement and connection to the ventilator (creating a closed breathing circuit, minimizing viral spread).
The intubating provider who is likely to achieve first-pass success, depending on familiarity and recent procedural experience, is encouraged to intubate. Given the limited number of negative-pressure rooms available, patients are intubated in these rooms and then relocated to ensure the room's availability for future intubations. For similar reasons, BiPAP and high-flow nasal cannula are initiated only in negative pressure spaces. Some pre- and peri-intubation hypoxia is tolerated in an effort to avoid bagging patients, which generates infectious fomites via further aerosolization.
How Are Physical ED Spaces Changing?
A surging volume of patients, both the worried well and critically ill, have forced EDs to face new challenges. The backbone of UCSF's response has been to develop Accelerated Care Units (ACUs), which take the form of medical tents pitched in the hospital parking lot adjacent to the emergency department. Designed similar to surgical suites, they aim to offer space for separation of COVID-19-infected patients with those who are not, particularly those at risk for complications such as the elderly, cardiac patients, and those who are immunocompromised.
With support from the local fire marshal and city regulation officers, UCSF constructed this ad hoc new wing onto their ED in a matter of 10 days. Several operational measures were put in place to maximize the effectiveness of the tents, including swabbing for COVID-19 in the outdoors to limit aerosolization in enclosed spaces and granting physicians the ability to access medications to help increase flow efficiency.
Similarly, in several NYC hospitals, a surge in patient volume has led to the creation of additional ED space and a temporary release from certain EMTALA obligations. Consequently, hospitals facing an insurmountable number of well-appearing but worried individuals have been allowed to turn away people without a medical screening exam. This concession was granted to operationalize medical tents outside several city hospital sites. They are largely staffed by nurse screeners who have been given authority to divert individuals from the ED, with coronavirus swab testing and vital signs performed at their discretion. Those deemed sick, or at high risk, can then be directed into the physical ED.
Medical directors have also scrambled to change the internal structure of several EDs to help prepare for worsening surges and critically ill patients. Once open ED spaces have now have temporary "walls" up to create "clean zones" and "COVID-19 zones."
Additional negative pressure isolation rooms are also being developed around any capable space, with more makeshift walls creating the frame. One academic tertiary care center in NYC has expanded the footprint of the ED by repurposing observation spaces as full treatment zones, including individual isolation rooms used for the purposes of intubation. The number of resuscitation bays available to ED staff in this model has more than doubled. Similar models have also been implemented broadly elsewhere.
System-Based Flexibility in Response to COVID-19
There is also widespread evidence that hospital systems have begun sharing resources in an effort to alleviate the patient burden. This movement towards fluid and flexible health care systems is meant to help allocate resources —where they are needed and as they are needed — in an effort to avoid overwhelming anyone's health center.
In New York City, hospitals established central command centers to keep a close eye on system-wide resources including ventilators and ICU bed availability. Given the "local epicenter" model of infection that NYC has observed, in which certain neighborhoods are affected at different rates than others, systems hope they can utilize one hospital's excess resources to support other sites as they face increased volumes. Meanwhile New York City Health and Hospitals, a city-funded and city-run hospital system, has pooled ventilators, ambulances, and even staff so they can be sent to hospital sites most in need.
Keeping staff macroscopically informed of dynamically changing protocols has been key. UCSF has taken to online tech platforms that are constantly updated and widely available to clinical staff. They have also been training personnel working in their ACU with a one-to-one coaching model. Further measures taken at UCSF to streamline efficiency include the creation of a call system that informs patients of COVID-19 swab results; when call-backs are performed, it is done by discharge coordinators who are given algorithms and scripts to follow, maximizing the efficiency of these personnel.
What Changes Can Residents Bring to Their ED?
While some of the aforementioned changes require coordination with central hospitals, city officials, or even state authorities, others are immediately relevant and can be implemented in residents' clinical realm:
- If facing PPE shortages, talk to your ED administration about conservation efforts discussed above, including minimizing N95 changes, encouraging "doorway exams" and minimizing providers within the space of a suspected COVID-19 patient.
- Consider launching a PPE drive with hospital support to recruit supplies for your hospital.
- Try altering your intubation strategy to maximize first-pass success, and minimizing individuals within the immediate space.
- Encourage resident involvement in telehealth programs where they exist, and utilize your ED space creatively to keep suspected COVID-19 patients at a safe distance from high-risk individuals and providers, including tent-spaces and of "COVID-19 Clean" zones.
- Advocate with your local, state, and national government to encourage protections for health care workers and maintenance of critical disaster response systems.
Share Your Thoughts
What approaches have your institutions developed to combat the COVID-19 pandemic? Please tweet strategies tried with hashtag #CombatingCOVID. Be sure to mention @emresidents and authors. We are all in this together and would love to hear from you!
In March, the EMRA Administration & Operations Committee hosted a webinar with UCSF's Nida Degesys, MD, who helped establish the system's response to COVID-19. Watch the video here.
Nearly every EMRA committee has hosted similar events. Browse the COVID-19 webinars here.
Medical students, EMRA has made concerted efforts to help you navigate the murky waters of medical education. Find the webinars here.