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ACEP COVID-19 Field Guide

Table of Contents

Infection Prevention and Control Recommendations for Patient Arrival and Triage

Triage
  • If a patient is arriving via transport by EMS, EMS personnel should contact the receiving emergency department or health care facility and follow previously agreed upon local or regional transport protocols. 
  • Advise patients and visitors entering the facility, regardless of symptoms, to put on a cloth face covering or face mask before entering the building and await screening for fever and symptoms of COVID-19.
  • Post visual alerts (eg, signs or posters such as Figure 5.2) at the entrance and in strategic places (eg, waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about hand hygiene, respiratory hygiene, and cough etiquette. 
    • Instructions should include wearing a cloth face covering or face mask for source control as well as how and when to perform hand hygiene.
    • Take steps to ensure that everyone adheres to hand hygiene, respiratory hygiene, and cough etiquette; all patients should follow triage procedures throughout the duration of their visit.
  • Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand rub (ABHR) with 60% to 95% alcohol, tissues, and no-touch receptacles for disposal, at health care facility entrances, waiting rooms, and patient check-ins.
  • Install physical barriers (eg, glass or plastic windows) at reception areas. 
  • Consider establishing triage stations outside the facility to screen individuals before they enter.
  • Ensure rapid, safe triage and isolation of patients with symptoms of suspected COVID-19 or other respiratory infection (eg, fever, cough).
  • Ensure triage personnel who take vitals and assess patients wear a respirator (or face mask if respirators are unavailable), eye protection, and gloves for the primary evaluation of all patients presenting for care until COVID-19 is deemed unlikely.
    • Triage personnel should have a supply of face masks or cloth face coverings; these should be provided to all patients who are not wearing their own cloth face covering at check-in, assuming a sufficient supply exists.
  • Prioritize the triage of patients with symptoms of suspected COVID-19.
  • Isolate patients with symptoms of COVID-19 in an examination room with the door closed. If an examination room is not readily available, ensure the patient is not allowed to wait among other patients seeking care.
  • Identify a separate, well-ventilated space that allows waiting patients to be separated by 6 or more feet, with easy access to respiratory hygiene supplies.
    • In some settings, patients may opt to wait in a personal vehicle or outside the health care facility where they can be contacted by mobile phone when it is their turn to be evaluated.
  • Prioritize patients with suspected COVID-19 who require admission to a hospital or congregate care setting (eg, nursing home) for testing.

More information and additional strategies to minimize chances of exposure can be found in the “Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.”

Figure 5.2 Sample poster that serves as a visual alert. Credit: CDC.

Sample poster that serves as a visual alert

 

Existing Emergency Department Pandemic Preparation

Authors: ACEP Emergency Department (ED) Redesign Task Force

Recommendations for emergency department (ED) preparation for high-risk infectious diseases (HRID) are provided below. These recommendations are intended as considerations. The ability to implement these suggestions in any given department may depend on the disease involved, the mode of transmission, and pre-existing capacity and ED design. Certain infection prevention strategies are preferred, but when not possible, alternative modalities are suggested.

Please note: These HRID preparation considerations are limited to the physical (built) environment and do not include other important risk mitigation strategies, such as the elimination of hall beds and boarding of inpatients in the ED.

Common Areas/ Public

Arrival/Entrance  

  • Triage for presence of HRID
    • Promote pandemic infection concern alert notification by EMS (via established communication methods) prior to patient arrival at ED for patient assignment/placement/logistics/planning.
    • Implement temperature screening outdoors, at entry, and/or tele-screening
    • Refer asymptomatic/minimally symptomatic patients to remote site for testing after ED medical screening exam
  • Flow management
    • Implement wayfinding and signage system directing visitors/patients to appropriate entrance

Waiting Room and Common Areas

  • Capacity management
    • Post capacity limits in any non-clinical space (ie, break rooms) to allow for social distancing
    • Utilize remote meetings whenever possible
  • Flow management
    • If possible, separate entrance and egress
  • Triage for presence of HRID
    • Screen individuals for signs and symptoms of infection prior to entry to waiting room
  • Risk mitigation to reduce transmission
    • Install high-efficiency air filters as supported by your HVAC system.
    • Exchange upholstered chairs for seating made of plastic or another easily disinfected material
    • Provide face-level clear barriers between face-to-face contact locations at check-in desk, and/or have triage/check-in staff in mask and eye-covering
    • Utilize touchless check-in/payment methods, include QR codes and mobile devices etc.
    • Institute masking policy including supplying masks at reception, universal masking, and masking/eye-covering for triage/check-in staff
    • Remove unnecessary furnishings, decorative items, or other items that are difficult to disinfect, so it is easier to clean surfaces regularly
    • Cohort patients with signs and symptoms of infection
      • Establish separate waiting rooms, or separate locations within same waiting area, for screen positive and screen negative patients
      • Consider outdoor space/tents for screen positive patients
    • Provide EPA approved cleaning products at each workstation to allow individuals to disinfect between users
    • Discourage bringing personal items into the workplace. Any items brought should be left in a single location, such as a desk drawer or locker if possible
      • If lockers are used for storing personal items, they should either be assigned to one person or disinfected between users
    • Install high-efficiency air filters as supported by your HVAC system.
      • If possible, create negative pressure waiting space for PUI/infected patients
      • If this is not possible, discuss with facilities the best available alternative to improve ventilation (example: HEPA filters). Additional information can be found in the ASHRAE Position Document on Infectious Aerosols.
  • Physical distancing
    • Maintain as much space between workstations as possible (ideally six feet between individuals)
    • Demarcate distance requirements where queuing may occur
    • Rearrange furniture to promote six-foot distance between chairs and remove excess chairs
    • Create outdoor break or dining areas
  • Protective equipment
    • Place hand sanitizer stations in common areas
    • Install PPE storage units/stations in patient triage areas 
    • Consider placing face-level clear barriers around workstations

Treatment - Resuscitation/Trauma

  • Capacity management
    • Limit number of personnel allowed in bay based on minimum needed
    • Post "Limited entry to clinically necessary personnel only." 
    • Find alternative locations to store items required in the remainder of the ED to limit the necessity of entering the bay for supplies
    • Limit visitors allowed in bay
    • Consider installing telemedicine capabilities to allow observers to chart without entering bay and allow tele-consults
  • Flow management
    • Re-route through traffic and transportation of patients so that they do not need to enter bay
  • Triage for presence of HRID
    • Screen all traumas and other patients entering the bay for s/s of HRID including via EMS in-code
    • Consider placing an outdoor screening area for triage prior to entry to bay
  • Risk management to reduce transmission
    • Cohort patients with signs and symptoms of infection
      • If possible, establish separate bays or separate locations within same bay for screen positive and screen negative patients
    • When available, create a separate resuscitation bay for patients with s/s or diagnosis of HRID
    • Install high-efficiency air filters as supported by your HVAC system
      • Consider creating negative pressure bays
      • If this is not possible, discuss with facilities the best available alternative to improve ventilation (example: HEPA filters). Additional information can be found in the ASHRAE Position Document on Infectious Aerosols.
    • Remove all unnecessary items from bay to limit necessity for cleaning/disinfecting large quantities of items between patients
    • Procedural equipment (eg, airway) preparation for disposable "to go" packs
    • Keep items stored in bay covered either in storage units with doors or plastic covering
    • Perform plain films via portable machine
      • If patients are cohorted to a PUI/infection + unit, consider assigning one machine, if available, to that unit only
    • Designate low, medium, and high-risk zones within the bay (ie, “green”, “yellow”, and “red” zones)
      • Only allow those absolutely necessary in higher risk zones
      • Post PPE requirements for all zones
      • Store supplies in low risk (“green zones”) whenever possible
  • Physical distancing
    • Consider physician workstation/reading modifications (eg, plexiglass dividers)
    • Consider physical barriers (ie, clear plastic/glass barriers/movable walls/screens) between/ within treatment areas to create individual care spaces between patients
      • Utilize sliding doors or tent flaps with zippers, such that these spaces can be closed from common areas during AGPs or other high-risk patient care procedures, depending on the pathogen
  • Cohorting
    • When available, create a separate resuscitation bay for patients with s/s or diagnosis of HRID
  • Protective Equipment
    • Place PPE storage units at entry to resuscitation bays
    • Place hand sanitizer immediately outside and inside all patient care areas

Diagnostic

General Radiology  

  • Risk management to reduce transmission
    • If patients are cohorted to a PUI/infection + unit, consider assigning one machine, if available, to that unit only 
    • Position x-ray tube six feet away from patient
    • Utilize disposable cartridge cover for each patient use
    • Perform cartridge cleaning between each use
    • Install high-efficiency air filters if supported by HVAC system

Computed Tomography (CT)/Magnetic Resonance Imaging (MRI)

  • Risk management to reduce transmission
    • Identify scanner(s) available only for PUI/infection + patients
    • Implement predetermined down time between patients to allow ventilation of radiology rooms

Point of Care Ultrasound (POCUS)

  • Risk management to reduce transmission
    • Decontamination of entire system after each use with disinfectant recommended by EPA
    • If patients are cohorted to a PUI/infection + unit, consider assigning one machine, if available, to that unit only 
    • Use of a handheld ultrasound system may allow for better disinfection between patients

Additional information can also be found on the CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic

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