ACEP COVID-19 Field Guide

Authors: Jessica J. Kirby, DO, FACEP; Chukwuagozie Iloma, DO, MHA/INF; Amy Khong, MD; Michael Magee, Jr, DO; Naomi Alanis, MS, MBA; Jared Willis, MD; and James P. d’Etienne, MD, MBA, FACEP; John Peter Smith Health Network, Fort Worth, Texas

Introduction

Many patients, whether infected or potentially infected with highly contagious COVID-19, are expected to seek care in the emergency department.¹ With this in mind, facility changes are inevitable for both urban and rural emergency departments. Staging areas, such as tents, split-flow models, and split-cohort models, are key to minimizing infection in the hospital and managing surge volumes safely and efficiently in a way that mitigates harm to patients and staff.

Emergency department crowding is a critical problem during disaster management, when acute, unscheduled care may be in high demand and processes must be adapted for safety. It is well known that pandemics and other disasters increase demand for hospital services, causing especially high emergency department utilization. During the 2009 H1N1 pandemic, already overcrowded emergency department visits increased in the US by 18%.² That event exemplified the need for emergency departments to have disaster management plans in place for the safe and efficient management of surging volumes and to mitigate potential harm to patients, visitors, and staff. Infectious disease disasters pose particular challenges, whether or not emergency department volumes increase.

Emergency physicians are accustomed to modifying processes, as the need arises, to improve patient safety, efficiency, and emergency department flow. A common management strategy is to establish split-flow models of care as volumes increase. By decreasing variability of patient type in different areas of the department, improvements are seen in door-to-provider and door-to-disposition times. Split-flow models decrease variability in care while increasing emergency department efficiency, and they can be applied and rapidly adapted to surge or disaster situations.³

For more information, see “Creating a COVID-19 Surge Clinic to Offload the Emergency Department.”

Split-flow emergency department model

A split-flow emergency department model is designed to triage patients who present to the emergency department into two categories: “sick” and “less sick.” Initial decisions are often based on a nurse-assigned emergency severity index (ESI) score at the first point of entry or triage. The staff assigned to triage varies in different health systems. ESI is a widely used, 5-level triage system based on patient acuity and anticipated resource utilization.¹ The 5-level system ranges from level 1, representing the most life-threatening conditions, to level 5, requiring no resources. Studies in nonpandemic situations show that implementation of a split-flow model reduces emergency department door-to-doc (D2D) times and decreases emergency department length-of-stay (LOS).² Both metrics are desirable in high resource utilization situations; therefore, how split-flow models can be optimized during an infectious disease pandemic, such as COVID- 19, must be considered. Additionally, it is pertinent to explore how these metrics can be adapted in diverse settings, such as rural emergency departments and large urban academic centers.

Front-end processes

Split emergency department flow can reduce the risk of infection and mitigate overcrowding in a pandemic situation when acute, unscheduled care can quickly overcome resources. Emergency departments across the country must put plans in place to identify and sort patients before entry.

The following recommendations can be adapted to suit resources according to availability at individual sites. It is important to acknowledge that rural emergency departments are often faced with different challenges, such as physician shortages and financially strained hospitals, while urban academic centers have their own unique challenges.³

Some process modifications to consider in an infectious disease pandemic include:

• Closure of traditional entrance and redirection of those seeking care to an alternative entrance staffed and equipped for infection surveillance, safety, and triage, which can have the following effects:
  • Primary effect: reduced unintentional flow into the department;
  • Secondary effect: reduced congestion; and
  • Tertiary effect: early isolation of potentially infected patients.
• New front-end process with the addition of physicians or advanced practice providers (APPs) (physician assistants or nurse practitioners) to enhance triage capabilities.
• Introduction of telehealth or tele-triage to decrease exposure to potential pathogens, increase the workforce, and allow for adaptive scheduling. It also provides the opportunity for high-risk physicians to participate in care while reducing their own risk.
• New front-end triage process to separate high-suspicion patients from low-suspicion patients.
• Addition of front-end treatment spaces to rapidly assess and discharge low-suspicion, low-acuity patients.

Any change in front-end processes should include a quality monitoring system.

Front-end structure and process

An important aspect of the front-end triage process is screening for suspected COVID-19 patients. According to the WHO, it is important to screen and triage these patients appropriately at the first point of contact with the health care system.⁴ The screening process should aim for high sensitivity to ensure that as many suspected high-risk patients as possible are correctly identified. Front-end triage can categorize patients into three categories: COVID-19 Not Suspected; COVID-19 Considered — Probable Mild Illness; and COVID-19 Suspected — High Risk.

• COVID-19 Not Suspected
  • These patients are well appearing with normal vital signs and no affirmative answers to COVID-19 screening questions.
  • They have no concerning history, suspected exposure, or signs or symptoms of COVID-19 and are triaged to enter the emergency department for further evaluation, are triaged to a rapid care area, or are discharged directly from triage, if appropriate.
• COVID-19 Considered — Probably Mild Illness
  • Patients in this category are well appearing with a resting oxygen saturation of >93% on room air, do not desaturate on ambulation, and have a respiratory rate <20 breaths per minute. They may, however, answer affirmatively to any of the following screening questions: low-grade fever, cough, malaise, rhinorrhea, or sore throat. They do not have concerning signs, such as shortness of breath, difficulty breathing, increased respiratory symptoms (ie, sputum or hemoptysis), or GI symptoms (ie, nausea, vomiting, and/or diarrhea), and have no changes in mental status.⁵
  • These patients may be discharged home, often directly by the clinician in triage, after an appropriate medical screening examination (MSE). Triage is a good opportunity to use telehealth if it can be incorporated as part of the disaster management response. For patients that can be discharged after an appropriate MSE, follow-up care and monitoring should be arranged. The importance of appropriate screening and quality oversight in this cohort cannot be overemphasized, as some patients will have additional findings that warrant further evaluation at an area of higher care.
• COVID-19 Suspected — High Risk
  • These patients appear ill. They answer in the affirmative to one or more of the illness triage questions. They have a resting oxygen saturation of ≤93% on room air or desaturate with ambulation, are age >60 years with pre-existing medical conditions (ie, diabetes mellitus, hypertension, congestive heart failure, COPD, or chronic kidney disease, or are immunocompromised), have acute mental status changes, have tachypnea (RR >20), have tachycardia (HR >120), or are hypotensive (BP <90/60).
  • These patients need additional evaluation and stabilization. They should ideally enter through a designated entrance that is designed for safety and then guided to the appropriate area of the emergency department for suspected COVID-19 patients.

Back-end (main emergency department) process

A modified emergency department process includes the separation of patients based on suspicion of COVID-19 infection and the level of care needed.

As previously mentioned, medical staff in the front-end screening process who perform an MSE can either discharge patients home or triage patients to another area of the emergency department for further evaluation and care. The location of care is based on the level of suspicion of COVID-19 and level of care needed. Ideally, the three areas should be separated, or have physical barriers between them, and have easily visualized designations with signage and processes appropriate to the levels of caution needed.

1. Clean area: Low-suspicion COVID-19 (or other noninfectious pathologies) patients can be seen in a “clean” fast track or other “clean” part of the main emergency department. Unfortunately, asymptomatic carriers may also be in this area, so appropriate protections and guidance need to be followed.
2. Area with suspicion: This is an “in between” area for patients that are not highly suspicious for COVID-19 but have the potential for upgrade. Ideally, the area with suspicion should be geographically located between the clean and contaminated areas. Patients screened into the COVID-19 Considered — Probably Mild Illness category go here. Higher levels of care, including the potential for resuscitation, may be seen in this location if the illness is not suspected to be COVID related.
3. Contaminated area: All patients with a high index of suspicion for COVID-19, who are screened into the COVID-19 Suspected — High Risk category, go here. Although many patients who screen as “high suspicion” may be well enough to eventually be discharged to self-quarantine, this area needs to be equipped for high-acuity care, have negative pressure rooms, and ideally have rooms separated by walls and doors. Staff need to ensure the highest level of personal protection in this area.

Although the separation of these areas lends well to emergency departments with multiple physician and APP shifts, it can be modified so that nursing and patients are separated into different sections, while physicians cover all areas. Physical barriers that require navigating between areas can slow the rapid movement of physicians. Donning and doffing stations placed at appropriate entrances and exits to each area can help reinforce safety and infection control.

References

1. Graff S. Ahead of the curve: PENN ER tents at the ready for COVID-19 surge. Penn Medicine News website. Published 2020 Apr 13.
2. Wallingford G, Joshi N, Callagy P, Stone J, Brown I, Shen S. Introduction of a horizontal and vertical split flow model of emergency department patients as a response to overcrowding. J Emerg Nurs. 2018 Jul;44(4):345-352. doi: 10.1016/j.jen.2017.10.017
3. Gonfiantini M, Han Y, Lotito B, et al. Assessment of a split flow emergency department implementation: a discrete event simulation approach. Conference Paper: Healthcare Systems Process Improvement Conference; 2015 Feb; Orlando, FL.
4. Rabinowitz HK, Paynter NP. MSJAMA. The rural vs urban practice decision. JAMA. 2002 Jan 2;287(1):113. doi:10.1001/jama.287.1.113-JMS0102-7-1
5. World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance. WHO website. Published 2020 Mar 13.
6. World Health Organization. Q&A on infection prevention and control for health care workers caring for patients with suspected or confirmed 2019-nCoV. WHO website. Published 2020 Mar 31.

Split cohorting

By modifying front-end processes and implementing split-flow processes based on both patient acuity and the level of suspected infection, patients are cohorted to improve care, reduce cross contamination, and improve emergency department operations. In a pandemic situation such as COVID-19, patients can be cohorted into areas that are clean, have moderate suspicion, and are contaminated, as previously described. This process allows emergency departments to minimize the volume of patients, by discharging patients from triage and clinicians in triage (or tents) and isolating patients with respiratory symptoms away from others. This idea can be extrapolated to other settings, such as physician clinics, hospital wards, and even residential care facilities.

• Clinics: A surge (or triage) clinic can be established adjacent to the main clinic, where low acuity patients can be evaluated for fever and/or respiratory symptoms.¹ This concept and practice are exemplified by telemedicine visits designed to prevent otherwise stable patients from having to leave their home.
• In hospital: For patients requiring hospitalization, implementing hospital-isolation units and wards where intermediate or low-suspicion patients are separated as quickly as possible reduces cross-contamination risk and potentially conserves much needed personal protective equipment (PPE).¹
  • While test results are pending, persons under investigation (PUIs) should be isolated in their own individual patient room.
  • Hospitalized COVID-19–positive patients can be roomed together to alleviate strain on resources, including nursing, staffing, and PPE. This model works for both the floor and ICU.

References

1. Mitchell R, Banks C; authoring working party. Emergency departments and the COVID-19 pandemic: making the most of limited resources [published online ahead of print, 2020 Apr 1]. Emerg Med J. 2020;emermed-2020-209660. doi:10.1136/emermed-2020-209660

Protective Barrier Enclosures And Use of Negative Pressure

According to the U.S. Food and Drug Administration (FDA), health care workers: 

• Should not use passive protective barrier enclosures without negative pressure  as they may not be effective in decreasing HCP exposure to airborne particles, and in some circumstances, may instead increase HCP exposure to airborne particles. 
• Their use may also contribute to complications such as:
•  increased intubation times, 
• lower first-pass intubation success rates,
•  increased patient hypoxia time
• damage or tearing to PPE from the enclosures. 
• These complications may be due in part to the barrier enclosure design characteristics and restricted mobility of the HCP’s arms in a restricted space to maneuver the accessories needed to establish a definitive airway.

If electing to use a protective barrier enclosure for additional protection during aerosolizing procedures by HCPs, FDA recommends the use of devices that incorporate negative pressure.

• FDA has authorized the use of several negative pressure barrier enclosures, which can be found on FDA’s Emergency Use Authorization website. 

Based on detailed review of data showing decreased HCP exposure to airborne particles, usability, and other safety and performance measures of negative pressure devices, the FDA continues to believe that the known and potential benefits for emergency use of these devices, when used as authorized, continue to outweigh the known and potential risks and do not present public health or safety concerns at this time. Although it is unknown whether negative pressure devices have the potential for similar complications as passive devices, at this time, the FDA does not have reasons, or evidence of any adverse events to believe that is the case. 

It is important to note that:

• Protective barrier enclosures (with or without negative pressure) should never be a replacement for using PPE.
• Any protective barrier enclosure should be removed if it impedes the HCP’s ability to perform a medical procedure on a patient.

Tents: an adjunct for efficiency in the front-end process

The use of tents to augment front-end processes, screen patients, and perform initial assessments is a valuable tool when triaging patients and separating COVID-19–suspected patients. Tents are an effective method to reduce the burden of patients seen in the emergency department while decreasing the potential exposure of non–COVID-19 patients and staff. If nurse-only triage is done in the tent, the protocols performed should be designed for high sensitivity, to rule in COVID-19–suspected patients and ensure a higher level of infection control for patients who enter the emergency department.

During pandemics such as COVID-19, increases in patient volume and acuity can lead to long emergency department wait times. The use of tents during the H1N1 pandemic showed that they can decrease the rate of elopement (12.9% to 1.8%) and decrease disposition time (282 to 152 minutes).¹ Tents may also prove to be cost effective by allowing the rapid and efficient discharge of appropriate patients, improving provider efficiency and decreasing the elopement rate.²

Upon arrival, patients should receive an initial screening. Criteria for being triaged to the tent may include fever (temperature of >37.2°C [99°F]), cough, sore throat, shortness of breath, upper respiratory infection, or GI symptoms. Other criteria include:¹

• Not overtly dyspneic or toxic appearing;
• Normal respiratory rate;
• Age <60 years;
• HR <130 bpm; and
• Pulse oximetry >93%.

Patients who are too ill for the tent and are suspected of COVID-19 pathology should be taken to the contaminated area and should be cohorted. Patients who are well enough to be evaluated in the tent can be seen by the emergency department physician, physician assistant, or nurse practitioner. Novel use of telehealth with a provider evaluating patients in the tent can extend the medical provider workforce, can allow high-risk physicians to evaluate suspected patients from a safe zone, and is well accepted by patients. Previously healthy individuals, without risk factors, can be safely discharged from the tent. Some locations are even arranging for low-risk patients with mildly decreased oxygen saturation (>92%), who are otherwise well appearing, to receive home oxygen, thus preventing hospital admission. Patients who are discharged with new home oxygen supplementation should be educated on use, understand emergency department return precautions, and have scheduled follow-up care.

Follow-up can be done via telehealth or as an expedited return visit in the triage tent.³ The overall goal of the tent is to reasonably and safely discharge as many COVID-19–suspected patients as possible. Clinicians in the tent should be reminded to have a lower threshold for return visit to the emergency department if symptoms worsen. If patients return for an unscheduled follow-up visit, they should be considered higher risk and perhaps be seen in the appropriate area of the emergency department, rather than in the tent. One caution in the tent is to not be too focused on COVID-19. Remember that the usual complaints will still present to the emergency department and can mimic complaints from COVID-19.

Patients deemed appropriate for tent evaluation should be given a surgical mask, and appropriate spacing between patients should be accommodated. Staffing at minimal appropriate levels to maintain safety is appropriate. Whenever possible, limit to one technician and one nurse in full PPE for the safety of the first contact crew. Rotate staff at regular intervals to reduce fatigue and stress. Our institution uses nursing staff for the initial history, examination, and ESI assessment and a telehealth physician for the relevant history, examination, and medical decision-making. History and examination are kept as focused as possible. Access to electronic health records, as always, is helpful and augments the medical history when available. Physicians are encouraged to have a low threshold to have patients evaluated in the appropriate area of the emergency department if there is concern. Ideally, the tent will be under negative pressure and have regular interval cleaning between patients. Unidirectional flow of patients with a direct route into the COVID-19 emergency department area are important considerations when planning tent location and size. An appropriate goal is to move patients through the tent and have a final disposition decision (home or further evaluation in the emergency department) within 10 to 15 minutes of arrival.¹

Telemedicine has taken on an expanded role in recent years and can be an important adjunct for the triage tent screening process. Relaxed regulations and the waiving of HIPAA penalties have facilitated the establishment of telemedicine in the tent with programs such as FaceTime and Skype. Check with your hospital administration to determine what may be best for your site. Telemedicine in the triage tent has the added benefits of reduced PPE usage, reduced exposure of physicians to potentially sick patients, allowing physicians with medical exclusions to participate, and variability of shifts for physicians who have been working mentally and physically taxing shifts, caring for high volumes of critically ill patients.³ Some physicians welcome the change in work during telemedicine tent shifts.

References

1. Pershad J, Waters TM. Use of tent for screening during H1N1 pandemic: impact on quality and cost of care. Pediatr Emerg Care. 2012;28(3):229‐235. doi:10.1097/PEC.0b013e318248b266
2. Orman , Bucher J. COVID-19: triage tent logistics [audio podcast]. Hippo Education ERcast website. 2020 Mar. 
3. Gavin N, Mills AM, Olsen EL, et al. COVID-19 SAEM National Grand Rounds: COVID-19 response: lessons learned from an academic health system in New York City [webinar]. SAEM website. 2020 Apr 4.
4. Rubinson L, Mutter R, Viboud C, et al. Impact of the fall 2009 influenza A(H1N1)pdm09 pandemic on US hospitals. Med Care. 2013;51(3):259‐265. doi:10.1097/MLR.0b013e31827da8ea
5. Rosenberger LH, Hranjec T, Politano AD, et al. Effective cohorting and "superisolation" in a single intensive care unit in response to an outbreak of diverse multi-drug-resistant organisms. Surg Infect (Larchmt). 2011;12(5):345‐350. doi:10.1089/sur.2010.076
6. Michael SS, Bickley D, Bookman K, Zane R, Wiler JL. Emergency department front-end split-flow experience: 'physician in intake'. BMJ Open Qual. 2019;8(4):e000817. Published 2019 Nov 18. doi:10.1136/bmjoq-2019-000817

Surge planning

The US government has developed an “Alternate Care Site (ACS) Toolkit” to help state, local, tribal, and territorial (SLTT) entities address potential shortages in medical facilities during the 2020 COVID-19 pandemic. This toolkit provides a general blueprint for an ACS that could be used by other federal agencies, states, or local jurisdictions to establish a similar capability. This blueprint details the type and level of care provided, the various roles and responsibilities of the necessary personnel, and the development, operation, and demobilization of the ACS.

Additional crisis standards of care for EMS documents, including sample state protocols, can be found on the EMS.gov COVID-19 resources website.

COVID-19Surge

COVID-19Surge is a spreadsheet-based tool that hospital administrators and public health officials can use to estimate the surge in demand for hospital-based services during the COVID-19 pandemic. A user of COVID-19Surge can produce estimates of the number of COVID-19 patients that need to be hospitalized, the number requiring ICU care, and the number requiring ventilator support. The user can then compare those estimates with hospital capacity, using either existing capacity or estimates of expanded capacity.

Additional Information can be found in “Allocation of Scarce Resources in a Pandemic: A Systematic Review of U.S. State Crisis Standards of Care Documents.”

Strategies to mitigate health care personnel staffing shortages

At >minimum> healthcare facilities must:>

• Ensure any COVID-19 vaccine requirements for HCP are followed, and where none are applicable, encourage vaccination, including booster dose, as recommended by CDC.>
• Understand their normal staffing needs and the minimum number of staff needed to provide a safe work environment and safe patient care under normal circumstances.>
• Understand the local epidemiology of COVID-19-related indicators (e.g., community transmission levels).>
• Communicate with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP (e.g., hiring additional HCP, recruiting retired HCP, using students or volunteers), when needed.>

Contingency Capacity Strategies to Mitigate Staffing Shortages

Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities.

• Cancel all non-essential procedures and visits. Shift HCP who work in these areas to support other patient care activities in the facility. Facilities will need to ensure these HCP have received appropriate orientation and training to work in these areas that are new to them.>
• Attempt to address social factors that might prevent HCP from reporting to work, such as need for transportation or housing that allows for physical distancing, particularly if HCP live with individuals with underlying medical conditions or older adults.>
• Consider that these social factors disproportionately affect persons from some racial and ethnic groups, who are also disproportionally affected by COVID-19 (e.g., African Americans, Hispanics and Latinos, and American Indians and Alaska Natives).>
• Identify additional HCP to work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of HCP.>
• As appropriate, request that HCP postpone elective time off from work. However, there should be consideration for the mental health benefits of time off and that care-taking responsibilities may differ substantially among staff.>

Developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection.

Allowing asymptomatic HCP who 1) had a higher-risk exposure to SARS-CoV-2 and 2) are not known to be infected with SARS-CoV-2 and 3) have not received all COVID-19 vaccine doses, including booster dose, as recommended by CDC, to continue to work onsite throughout their 14-day post-exposure period.

• If permitted to work, these HCP should be tested 1 day after the exposure (day 0) and, if negative, again 2, 3, and 5-7 days after the exposure. If testing supplies are limited, testing should be prioritized for 1-2 days after the exposure and, if negative, 5-7 days after exposure.>

Either an antigen test or nucleic acid amplification test (NAAT) can be used.  Antigen tests typically have a more rapid turnaround time but are often less sensitive than NAAT.  Antigen testing is preferred for symptomatic HCP and for asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days.>

• These HCP should still report temperature and absence of symptoms each day before starting work.>
• They should use a respirator or well-fitting facemask at all times in the facility.>
• If HCP develop even mild symptoms consistent with COVID-19, they should either not report to work, or stop working and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing.>
• If HCP are tested and found to be infected with SARS-CoV-2, they should ideally be excluded from work until they meet all Return to Work Criteria. HCP with suspected SARS-CoV-2 infection should be prioritized for testing.>

Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows:

• HCP with mild to moderate illness who are not moderately to severely immunocompromised:>
• At least 5 days have passed since symptoms first appeared (day 0), and>
• At least 24 hours have passed since last fever without the use of fever-reducing medications, and>
• Symptoms (e.g., cough, shortness of breath) have improved.>
• HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised:>
• At least 5 days have passed since the date of their first positive viral test (day 0).>

Healthcare facilities may choose to confirm resolution of infection with a negative antigen test or NAAT.>

If HCP are permitted to return to work before meeting all conventional >CDC Return to Work Criteria>, they should still adhere to the recommendations described below.>

• Patients (if tolerated) should wear well-fitting source control while interacting with these HCP.>
• HCP should be reminded that in addition to potentially exposing patients, they could also expose their co-workers.>
• A respirator or well-fitting facemask should be worn continuously even when they are in non-patient care areas such as breakrooms.>
• They should practice physical distancing from coworkers at all times.>
• If they must remove their respirator or well-fitting facemask, for example, in order to eat or drink, they should separate themselves from others.>
• They should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen.>

Crisis Capacity Strategies to Mitigate Staffing Shortages

Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing

Allow asymptomatic HCP who 1) had a higher-risk exposure to SARS-CoV-2 and 2) are not known to be infected with SARS-CoV-2 and 3) have not received all COVID-19 vaccine doses, including booster dose, as recommended by CDC, to continue to work onsite throughout their 14-day post-exposure period without testing.

• These HCP should still report temperature and absence of symptoms each day before starting work.>
• They should use a respirator or well-fitting facemask at all times in the facility.>
• If HCP develop even mild symptoms consistent with COVID-19, they should either not report to work, or stop working and notify their supervisor or occupational health services prior to leaving work. These individuals should be prioritized for testing.>
• If HCP are tested and found to be infected with SARS-CoV-2, they should ideally be excluded from work until they meet all Return to Work Criteria. HCP with suspected SARS-CoV-2 infection should be prioritized for testing, as testing results will impact when they may return to work and for which patients they might be permitted to provide care.>

If shortages continue despite other mitigation strategies, as a last resort consider allowing HCP to work even if they have suspected or confirmed SARS-CoV-2 infection, if they are well enough and willing to work, even if they have not met all CDC Return to Work Criteria.

• Considerations for determining which HCP should be prioritized for this option include:>
• The type of HCP shortages that need to be addressed.>
• Where individual HCP are in the course of their illness (e.g., viral shedding is likely to be higher earlier in the course of illness).>
• The types of symptoms they are experiencing (e.g., persistent fever, cough).>
• Their degree of interaction with patients and other HCP in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment?>
• The type of patients they care for (e.g., consider patient care only with patients known or suspected to have SARS-CoV-2 infection rather than immunocompromised patients).>
• Healthcare facilities (in collaboration with risk management) should inform patients and HCP when the facility is operating under crisis standards, specify the changes in practice that should be expected, and describe the actions that will be taken to protect patients and HCP from exposure to SARS-CoV-2 if HCP with suspected or confirmed SARS-CoV-2 infection are requested to work to fulfill critical staffing needs.>
• If HCP are requested to work before meeting all criteria, they should be restricted from contact with moderately to severely immunocompromised patients (e.g., transplant, hematology-oncology) and facilities should consider prioritizing their duties in the following order:>
• If not already done, allow HCP with suspected or confirmed SARS-CoV-2 infection to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services.>
• Allow HCP with confirmed SARS-CoV-2 infection to provide direct care only for patients with confirmed SARS-CoV-2 infection, preferably in a cohort setting.>
• Allow HCP with confirmed SARS-CoV-2 infection to provide direct care only for patients with suspected SARS-CoV-2 infection.>
• As a last resort, allow HCP with confirmed SARS-CoV-2 infection to provide direct care for patients without suspected or confirmed SARS-CoV-2 infection. If this is being considered, this should be used only as a bridge to longer term strategies that do not involve care of uninfected patients by potentially infectious HCP.  Strict adherence to all other recommended infection prevention and control measures (e.g., use of respirator or well-fitting facemask for source control) is essential.>
• If HCP are requested to return to work before meeting all Return to Work Criteria, they should still adhere to recommendations described below.>
• Patients (if tolerated) should wear well-fitting source control while interacting with these HCP.>
• HCP should be reminded that in addition to potentially exposing patients, they could also expose their co-workers.>
• A respirator or well-fitting facemask should be worn even when they are in non-patient care areas such as breakrooms.>
• They should practice physical distancing from coworkers at all times.>
• If they must remove their respirator or well-fitting facemask, for example, in order to eat or drink, they should separate themselves from others.>
• They should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen.>

Additional information, including CDC’s Contingency and Crisis Capacity Strategies and can be found in the Strategies to Mitigate Healthcare Personnel Staffing Shortages document.

UMMS-JHM Crisis Standards of Care (CSC) Interim Guidelines

There has been much written about Crises Standards of Care (CSC) however it has not been clear what triggers allow a hospital to designate as falling under CSC to legitimize this status. Teams from University of Maryland (UMS) and Johns Hopkins Medicine (JHM) have developed Interim Guidance to allow some standardization across institutions. Since the >initial> presentation several hospitals in Maryland, both within and outside their systems have notified the Governor and CMS that they declared needing to go to CSC using this criteria.

Please note: this resource is not published or reviewed by ACEP and is meant to serve as a resource and example for clinicians to use to help develop their own tools.

Introduction

This document is designed to address the challenges that hospitals may face, which in turn, will define the standard of care applicable under these challenged circumstances.  Standard of care is determined by the circumstances under which health care providers and team members are working, and is defined by what is reasonable under the same or similar circumstances. What is reasonable operationally for an unchallenged hospital is different than what is reasonable for a hospital facing significant resource challenges. Under conventional conditions, hospitals are not facing resource or other challenges and thus are able to provide care that is customary and usual.  When a hospital is confronted with  resource challenges but can reasonably adapt to those challenges, the care delivered may be different but functionally similar to care that is provided in conventional conditions (contingency conditions).  Crisis conditions exist when the resource challenges, whether they be staffing challenges, space challenges or supply challenges (or a combination of these factors) place such a burden on the hospital that it cannot adequately adapt to the challenges and thus must modify its practice standards in order to provide care.   Literature often refers to these modified practices as “crisis standards of care” (“CSC”).  

Background

As Maryland has experienced the COVID pandemic, hospitals across the State have been acting urgently to build up capacity with more beds, more equipment, and more skilled caregivers.  As a result of the continued pandemic and COVID hospitalizations, as well as pandemic effects on the health care workforce and bed availability, Hospitals have or likely will face significant challenges in maintaining the critical resources necessary to care for hospitalized patients.  It is at this point that hospitals will need to consider implementation of CSC.  This document is an effort to outline the indicators, triggers and process for Maryland hospitals to determine when CSC should be implemented.  

Indicator/Trigger Guidelines

Hospitals implementing CSC should have exhausted all efforts to resolve the deficiencies in resources resulting in the need for CSC.  Efforts to resolve these deficiencies could include transfer of the patient to another hospital, recruitment or re-deployment of staff or securing equipment/supplies from throughout the hospital system or from the State. Hospitals within larger health systems should leverage all available system resources prior to implementation of CSC.  Prior to instituting CSC, hospitals should have reached their highest Surge Capacity.  

It is important that hospitals track, at least on a daily basis, the indicators involved in caring for patients.  These indicators generally fall into three categories: (1) census, (2) staffing, and (3) material resource availability.  By tracking the data for these indicators, hospitals will be able to determine when the hospital’s demands exceed the available resources and thus implementation of CSC should be considered. 

Indicators:

• Census:
• Inclusive of units/areas that were stood-up/implemented to accommodate volume during the surge
• Specialty areas will be included in the appropriate level of care areas listed below (i.e. pediatrics, mother-baby, etc.) Intensive care units/Critical care areas
• Intermediate care units
• Medical and surgical acute care areas/telemetry units
• Behavioral Health Units and Emergency Departments
• On Red/Yellow alert?
• Boarders and boarder locations
• Perioperative and procedural areas
• Ambulatory areas
• Operative Schedule: at what % capacity are the Operating Rooms running?
• Staffing:
• What is the nurse/health care professional to patient/other ratio (all applicable units/areas/services)? What is the stretch metric in staffing that applies to the operational service line (all applicable services/areas)?
• Are other critical provider disciplines affected?
• Respiratory therapy
• Radiation techs
• Pharmacists and/or pharmacy technicians
• Who is doing what?
• Has the Hospital diverted OR staff to staff other units?
• Are students or volunteers available to assist in caregiving?
• Has the Hospital deployed retired or un-licensed personnel into its work force?
• Are providers using emergency privileges? 
• Direct care services and operations services
• Direct care services – i.e. pharmacy, care management, rehabilitation, respiratory therapy, etc.
• Operations services – facilities, etc.
• Material resource availability:
• Life sustaining resources
• Ventilators
• Blood
• Dialysis machines
• ECMO 
• PPE
• Non-life sustaining yet necessary equipment (e.g. feeding pumps, end title CO2 monitors, etc.)
• Medications (both COVID-19 specific and otherwise)

Triggers:

The specific metrics to be monitored for triggering the implementation of CSC are set forth in the section below. Certain of these metrics may trigger implementation of CSC independently or in combination. At least three (3) triggers listed in Attachment A must be met before implementing CSC and one such trigger must include either:

1. boarder census in the Emergency Department;
2. surgical volume reduction; or 
3. changes to nursing/patient ratio.

Process for Implementing CSC

CSC shall be implemented ethically and transparently. Based on specific trigger thresholds identified, the Hospital CEO, in consultation with the Hospital’s Incident Command, has the authority to make the decision that the hospital needs to consider implementing CSC and to which resource(s) they apply. That decision should be immediately communicated to the Health System’s Unified Command for final approval prior to implementation.  The date and time that CSC begins and ends should be documented within the Hospital's Incident Command Structure and the Health System’s Unified Command.  In addition, review of metrics and data supporting ongoing CSC should be performed on a daily basis.

Once the Hospital has submitted the data supporting its plan to implement CSC, Hospital leadership should work with Regulatory and Compliance to comply with any State and/or Federal notification requirements. In the event that the Governor has not declared a State of Emergency, any plan for CSC must be submitted to the Secretary of Health of the State of Maryland prior to implementation. Approval prior to implementation by the Secretary of State is not necessary once the submission has been made.  The submission will need to be supported by documentation of data that reflects the triggering metrics of the CSC.  The triggers for implementation of CSC should be consistently reviewed on an ongoing basis, in order to determine continuation of CSC.   

Certain administrative or more routine tasks may also be modified as a result of CSC status.  Such activities may include, but are not limited to:

• Documentation
• Co-signing of orders
• Certain routine checks (e.g. checking ventilators every 2 hours as opposed to every 1 hour)

This process should also be communicated to Hospital Unified Command and documented within the hospital’s Incident Command Structure.  Communications will then be circulated with hospital leaders, staff, front line workers and the community as a whole, as approved by the Hospital Unified Command. 

Allocation of Scarce Resources

The allocation of scarce resources (ASR) may be a part of CSC , but would be implemented in accordance with separately developed ASR algorithms and frameworks depending on the specific resource identified (e.g., ventilators, medication, etc.).  

Termination of CSC

In general, CSC should be intended for use for an extended period of time, as opposed to hours or limited to one shift.  This is an important concept and one that should be kept in mind as Hospitals put into place their process for triggering and rescinding CSC status.   As a concept, CSC can be triggered on day 1 should certain equipment not be available and resolve on day 2 once the supply of that piece of equipment is restored.  With that said, it may not be beneficial to rescind the CSC on day 2 unless the metrics demonstrate there is no risk of having a scarcity of the equipment for the next several days.  The metric of staffing may be particularly fluid and as such monitoring staffing for the near future should be considered before rescinding CSC if the metric of staffing was integral to implementing CSC.

The Hospital will be responsible for monitoring the criteria and will rescind CSC status once it is determined that CSC status is no longer applicable.  The Hospital CEO, in consultation with the Hospital Incident Command and the Health System’s Unified Command, will immediately communicate any rescission of CSC and document the date and time of any rescission within the Hospital Incident Command structure.

Triggers to Implement CSC Status

In order to implement CSC Status, a hospital must demonstrate and document that it has at least 3 of the triggers listed below.  One of those triggers must include either #1, 2 or 3.

1. > 50 % of ED acute bed capacity with boarders for > 12 hours expected to continue for > 24 hours 
2. Urgent and/or emergent procedures/surgical cases are delayed. 
3. Nursing ratios on a unit are increased above the locally set standard for > 12 hours and expected to continue for at least 24 hours.  
1. for example: ICU 1:3 or IMC 1:4 or Med-Surg 1:6 or ED 1:4
4. Non-clinical staff deployed to active patient care activities
5. Clinical staff redeployed to specialty care units outside of their standard specialty.
6. Use of non-traditional locations with less resources (e.g., gases, suction, infection control, etc.,) than would be available in the correct traditional care setting.   
7. Clinically significant supply, drugs, or equipment resource limitations which alter the ability to maintain the standard of care – 
1. Need to allocate lifesaving scarce resources (e.g., ICU, vents, key medications)
2. e.g., – ECMO, Dialysis, Respiratory Support Devices
8. Healthcare infrastructure limitations which impact our ability to maintain standards of care; e.g., facility degradation due to flood, fire, prolonged IT outage

ACEP statement on the role of pediatric emergency medicine in COVID-19 

Authors: James (Jim) Homme; Marianne Gausche-Hill; Chris Amato; Dale Woolridge; Paul Ishimine; Mike Gerardi; and the ACEP Pediatric Emergency Medicine Committee

ACEP recognizes that the training* of the American Board of Pediatrics (ABP)–based Pediatric Emergency Medicine (PEM) physician may allow these individuals to safely care for certain patients with common disease patterns that extend beyond traditionally assigned age limits.

ACEP supports redeployment and utilization of ABP-boarded or ABP-eligible PEM physicians to meet the increased demand for care of patients during the current COVID-19 pandemic in which local or regional health care systems are overwhelmed, or to improve institutional pediatric readiness.

ACEP appreciates the preparation and efforts already implemented by pediatric and PEM clinicians in pediatric emergency departments and hospitals targeted to meet the current and anticipated surge demands for care of patients outside the typical pediatric age range.

References and multimedia include:

• COVID-19 projections
• Abir M, Nelson C, Chan EW, et al. Critical care surge response strategies for the 2020 COVID-19 outbreak in the United States. RAND Corporation; 2020.
• Episode 138 COVID-19 Part 2 – ED Surge Capacity Strategies in the COVID-19 Pandemic
• Canadian Association of Emergency Physicians. Surge capacity and the Canadian emergency department. Published 2020 Mar 24.
• World Health Organization. Operational considerations for case management of COVID-19 in health facility and community: interim guidance, 19 Mar 2020. WHO website.  

* Training that occurs both in medical school and during reciprocal training during fellowship (ie, training in a specialty reciprocal to the fellow’s prior residency)

Elective surgeries

Refer to the American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses, and American Hospital Association’s “Joint Statement: Roadmap for Resuming Elective Surgery After COVID-19 Pandemic.”

The American College of Surgeons has also provided “COVID 19: Elective Case Triage Guidelines for Surgical Care.”

Telemedicine

References include:

• Medicare telehealth coverage expansion during COVID-19 public health emergency. American College of Emergency Physicians; 2020.