ACEP COVID-19 Field Guide

Table of Contents

Facility Changes

Work Safety

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


During pandemics, many patients infected or potentially infected with highly contagious respiratory viruses like COVID-19 seek care in the emergency department, increasing demand for hospital services.1 Emergency department crowding is a serious problem during disaster management when acute, unscheduled care may be in high demand and processes must be adapted for safety.

During the 2009 H1N1 pandemic, demand in already overcrowded emergency departments increased by 18% in the United States.2 That pandemic exemplified the need for emergency departments to have disaster management plans in place to efficiently manage surging volumes while mitigating potential harm to patients, visitors, and staff. Staging areas — such as tents, split-flow models, and split-cohort models — are key to minimizing the spread of infection and managing increased patient volumes safely and efficiently.

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

Split-flow emergency department model

Emergency physicians are accustomed to modifying processes as the need arises. A common management strategy to increase efficiency as patient volumes increase is the split-flow model of care. Split-flow models decrease the patient variability within different areas of the emergency department, which shortens door-to-clinician and door-to-disposition times.3

A split-flow emergency department model triages patients into the categories “sick” and “less sick.” Initial decisions for categorization 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, five-level triage system based on patient acuity and anticipated resource utilization.1 The five-level system ranges from level 1, which represents the most life-threatening conditions, to level 5, which represents conditions that require no resources. Studies in nonpandemic situations have shown that a split-flow model reduces emergency department door-to-physician times and decreases emergency department length-of-stay (LOS).2-5 Both metrics are essential in high resource utilization situations like infectious disease pandemics.

Front-end processes

Emergency departments across the country must put plans in place to identify and sort patients at the front-end of emergency care, before entry. The following recommendations can be adapted to suit the resources at individual sites. Rural emergency departments will face different challenges from referral centers or urban academic centers.6

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

  • Closing traditional entrances and directing patients to an alternative entrance that is staffed and equipped for infection surveillance, safety, and triage. This change in entrance can have the following effects:
    • Primary effect: reduced unintentional patient flow into the emergency department
    • Secondary effect: reduced congestion
    • Tertiary effect: early isolation of potentially infected patients
  • Establishing a new front-end triage process to separate high-suspicion from low-suspicion patients.
  • Establishing a new front-end process that includes physicians or advanced practice providers (APPs) (physician assistants or nurse practitioners) to enhance triage capabilities. Pre-pandemic studies support that having a “physician in intake” model can improve operational metrics, including door-to-physician times, LOS times, and left-without-being-seen (LWBS) rates. This process also allows for prompt discharge of low-acuity conditions, potentially preventing patient exposure to pathogens while in the emergency department.7
  • Introducing telehealth or tele-triage to decrease exposure to potential pathogens, increase the workforce, and allow for adaptive scheduling. These routes of health care delivery also provide the opportunity for immunocompromised or other at-risk physicians to participate in care more safely.8
  • Adding front-end treatment spaces to rapidly assess and discharge low-suspicion, low-acuity patients.

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

Front-end structure and process

Patients should be screened and triaged appropriately at the first point of contact with the health care system.9 The screening process should aim for high sensitivity to correctly identify as many high-risk patients as possible. Front-end triage should categorize patients into three categories ranging from a low to a moderate to a high likelihood of being infected. A front-end triage of patients using COVID-19 as an example is shown below:

COVID-19 is not suspected

  • Well-appearing patients with normal vital signs and no affirmative answers to screening questions
  • No concerning history, suspected exposure, or signs and symptoms
  • Can be triaged to the emergency department for further evaluation, to a rapid care area, or discharged directly, if appropriate

COVID-19 is considered — likely mild illness

  • Well-appearing patients who have a resting oxygen saturation greater than 93% on room air, who do not desaturate when ambulating, and who have a respiratory rate of fewer than 20 breaths per minute
  • May have a low-grade fever, a cough, malaise, rhinorrhea, or a sore throat
  • No concerning signs such as shortness of breath, difficulty breathing, increased respiratory symptoms (ie, sputum or hemoptysis), GI symptoms (ie, nausea, vomiting, or diarrhea), or changes in mental status9
  • Can be discharged home by a clinician in triage. Telehealth may be a good option for these patients. Appropriate screening and quality oversight are crucial in this cohort because some of these patients will have additional findings that warrant further evaluation at a higher level of care. A multidisciplinary approach that used similarly tiered screening to ensure close patient follow-up and that managed care transitions proved effective in some hospital systems’ responses during the pandemic.10

COVID-19 is suspected — high risk

  • Ill-appearing patients who answer in the affirmative to one or more of the illness triage questions
  • Have a resting oxygen saturation of 93% or less on room air or desaturate with ambulation; are older than 60 years; or have pre-existing medical conditions (eg, diabetes mellitus, hypertension, congestive heart failure, COPD, chronic kidney disease, an immunocompromised state), acute mental status changes, tachypnea, tachycardia, or hypotension
  • Need additional evaluation and stabilization. Ideally, they should enter through a designated entrance that is designed for patient and clinician safety and should then be guided to the appropriate area of the emergency department reserved for suspected high-risk and acutely decompensating COVID-19 patients.

For more information, see ACEP’s “COVID-19 ED Management Tool Now Available, Updated.”

Back-end processes

Back-end processes take place after entering the main emergency department. A modified emergency department process includes separating patients based on suspicion of infectious status and the level of care needed.

Ideally, the emergency department should be separated into the following three areas with physical barriers between them, if possible, and easily visualized designations and signage:

  1. Clean area: Low-suspicion COVID-19 and noninfectious pathology 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 who are not highly suspicious for COVID-19 but could be upgraded to an infectious classification. Ideally, the area with suspicion should be located between the clean and contaminated areas. Patients screened into the “COVID-19 is considered — likely mild illness” category go here. Patients who are not suspicious for COVID-19 who need a higher level of care, including potential resuscitation, can be seen in this location as well.
  3. Contaminated area: All patients with a high index of suspicion for COVID-19 (those who are screened into the “COVID-19 is 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 works well in emergency departments with multiple physician and APP shifts, it can be modified so that nurses and patients are separated into different sections, while physicians cover all areas. Physical barriers that require staff to navigate more between areas can slow the speed of care. Donning and doffing stations may need to be placed at appropriate entrances and exits for each area.

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 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 and clinicians in triage (or tents) and to isolate patients with respiratory symptoms away from others. Split cohorting 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 respiratory symptoms.11 Telemedicine visits are another split-cohorting method that prevents otherwise stable patients from having to leave their home.
  • Hospitals: Hospital isolation units and wards can be established to separate intermediate or low-suspicion patients as quickly as possible to reduce cross contamination and conserve much needed personal protective equipment (PPE).11
    • While test results are pending, persons under investigation should be isolated in their own individual patient rooms.
    • 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.


Using tents to screen patients and perform initial assessments is a valuable tool when triaging and separating COVID-19–suspected patients. Tents erected external to but near the emergency department reduce the volume of patients seen in the emergency department and decrease the potential exposure of non–COVID-19 patients and staff to infected patients. 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.

Tent use during the H1N1 pandemic decreased elopement rates (from 12.9% to 1.8%) and door-to-disposition time (from 282 to 152 minutes).12 During peak COVID-19 times, tent treatment areas decreased disposition times from 155 to 45 minutes.13,14

On arrival to the tent, patients should receive an initial screening. Patients who are too ill for tent triage or have COVID-19 symptoms should be taken to the higher-acuity, contaminated area and be cohorted for respiratory isolation. Patients who are well enough to be evaluated in the tent can be seen by a clinician on-site or via telehealth. Some patients can be safely discharged to receive “hospital-at-home” care (ie, supplemental oxygen, pulse oximeter, sphygmomanometer) and daily telemedicine visits or outpatient care. Patients discharged with hospital-at-home care should be educated on emergency department return precautions and how to use their equipment (including telemedicine calls). They should also have the ability to connect with EMS and should have scheduled follow-up care.

Patients should be given standard respiratory infection precautions (ie, surgical mask, appropriate spacing between patients, physical barriers for respiratory particles, negative-pressure or HEPA-filtered air circulation, etc). Staff safety includes PPE and, for those working in high-stress areas, full positive-pressure personnel suits and regular staff rotation to reduce fatigue and stress. 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.12

Surge planning

The use of Alternate Care Sites (ACSs) can be an important aspect of surge planning. ACSs are key to off-loading the impact of a patient volume that outweighs a health system’s capacity and capabilities.15 The US government developed resources on ACSs to help state, local, tribal, and territorial entities address potential shortages in medical facilities during the 2020 COVID-19 pandemic. These resources can be used for other federal agencies, states, or local jurisdictions to establish a similar capability.

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


COVID-19Surge is a spreadsheet-based tool that hospital administrators and public health officials used to estimate the surge in demand for hospital-based services during the COVID-19 pandemic. The tool produced estimates of the number of COVID-19 patients that needed to be hospitalized, the number that required ICU care, and the number that required ventilator support. The user could then compare those estimates with a hospital’s 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 supply and health care staffing shortages

When planning a surge response, COVID-19 projection data can assist with allocating resources, including staff, supplies, and space.16 Potential supply shortages can be identified early by keeping an inventory of equipment and referencing COVID-19 surge projection data. To mitigate health care staffing shortages, at a minimum, health care facilities should:

  • Ensure any COVID-19 vaccine requirements for health care workers are followed. Where none are applicable, encourage vaccination, including a booster dose, as recommended by the CDC (see the CDC’s “Return to Work Criteria for HCP with SARS-CoV-2 Infection”).
  • 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 (eg, community transmission levels).
  • Communicate with local health care coalitions and federal, state, and local public health partners (eg, public health emergency preparedness and response staff) to obtain additional health care workers (eg, hiring additional workers, recruiting retired workers, using students or volunteers) when needed.

Additionally, protecting staff from exposure to COVID-19 can mitigate health care staffing shortages.

  • Staff should be trained on proper PPE donning and doffing.
  • Patients, when able, should wear well-fitting source control masks while interacting with staff.
  • Staff should be reminded that in addition to potentially exposing patients, they could also be exposing their coworkers.
    • A respirator or well-fitting face mask should be worn even when they are in nonpatient care areas such as break rooms.
    • They should always practice physical distancing from coworkers.
    • If they must remove their respirator or well-fitting face mask to eat or drink, they should separate themselves from others.
    • They should self-monitor for symptoms and seek re-evaluation from the occupational health department if symptoms occur, recur, or worsen.

Additional information, including the CDC’s contingency and crisis capacity strategies, can be found in “Strategies to Mitigate Healthcare Personnel Staffing Shortages.”

Contingency capacity strategies to mitigate staffing shortages

Some strategies for mitigating staffing shortages include:

  • Canceling all nonessential procedures and visits.
  • Moving health care workers who work in closed areas to other areas of the facility to support other patient care activities. Facilities need to ensure that these workers have received appropriate orientation and training to work in the reassigned areas.
  • Addressing social factors like transportation and housing that may prevent health care workers from reporting to work. Adaptations may be needed for workers with underlying medical conditions or workers who live with someone with an underlying medical condition that puts them at high risk of severe infection.
  • Identifying additional health care workers who can work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of health care workers.
  • As appropriate, requesting that health care workers postpone elective time off from work. There should, however, be due consideration for health care workers’ mental health, recuperation, and caretaker responsibilities, which may differ substantially among staff.

UMS-JHM crisis standards of care interim guidelines

Disclaimer: The following resource has not been published or reviewed by ACEP and is meant to serve as an example for clinicians to use to help develop their own tools.

Although much has been written about crisis standards of care (CSC), the triggers that give a hospital a CSC status remain unclear. Teams from the University of Maryland (UMS) and Johns Hopkins Medicine (JHM) have developed interim guidance to allow some standardization for a CSC status across institutions. This guidance is based on the criteria that several hospitals in Maryland used to notify the state’s governor and the Centers for Medicare and Medicaid Services that they needed a CSC status.


This section is designed to address the challenges that hospitals may face, which, in turn, will define the standard of care applicable under challenging circumstances. Standards of care are determined by the circumstances under which health care staff are working and are defined by what is reasonable under the same or similar circumstances. What is reasonable operationally for a hospital without taxed resources is different from what is reasonable for a hospital facing significant resource challenges. Under conventional conditions, hospitals are not facing resource or other challenges and can provide care that is considered 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 is still functionally similar to conventional care (ie, contingency conditions). Crisis conditions exist when challenges to resources place such a burden on hospitals that they cannot adequately adapt and must modify their practice standards to provide care. The literature often refers to these modified practices as CSC.


As the COVID-19 pandemic affected Maryland, hospitals across the state acted urgently to build bed, equipment, and skilled caregiver capacity. However, as the pandemic ensued, Maryland faced more challenges with maintaining critical resources for hospitalized patients and had to consider implementing a CSC. Based on their experience, these Maryland hospitals were able to outline the indicators, triggers, and process for determining when a CSC should be implemented.

Indicator and trigger guidelines

Hospitals that implement CSC should have exhausted all efforts to resolve their resource deficiencies. Resolution efforts include transferring patients to other hospitals and recruiting or redeploying staff, equipment, or supplies from within a hospital system, from affiliated hospitals, or from hospitals throughout the state or region. Before implementing a CSC, hospitals should have reached their highest surge capacity, and hospitals within larger health systems should have leveraged all available system resources.

At least daily, hospitals should track potential CSC indicators involved in caring for patients. These indicators generally fall into three categories: census, staffing, and material resource availability. By tracking the data for these indicators, hospitals can determine when their demands exceed their resources and then consider implementing a CSC.


  • Census
    • Includes units or areas that were put in place to accommodate patient volume during a surge (ie, tents or temporary buildings)
      • Specialty areas, including the appropriate level of care for the areas listed below (eg, pediatrics, mother-baby)
      • ICU and CCU
      • Intermediate care units
      • Medical, surgical, acute care, and telemetry-capable units
      • Behavioral health units and emergency departments
      • Perioperative and procedural areas
      • Ambulatory areas
    • Includes any hospital boarders and their locations
    • Implementation of red and yellow resource alert status procedures for staffing and bed capacity
    • Operative schedule
      • At what percentage capacity is the operating room running?
      • Are elective, nonemergency surgeries being canceled?
      • What is the projected need for urgent and emergent operating room procedures?
  • Staffing
    • What is the health care clinician–to-patient ratio (for all applicable units, areas, and services)?
    • What is the stretch metric in staffing that applies to the operational service line (for all applicable services and areas)?
    • Are other critical disciplines affected?
      • Respiratory therapists
      • Radiology technicians
      • Pharmacists and pharmacy technicians
    • Who is doing what?
      • Has the hospital diverted nonessential operating room staff to supplement staff on other units?
      • Are students or volunteers available and allowed to assist in caregiving?
      • Has the hospital deployed retired or unlicensed personnel into its workforce?
      • Are there clinicians who can be granted emergency privileges?
    • Are direct care services and operations service teams at or above capacity?
      • Direct care services: pharmacy, care management, rehabilitation, respiratory therapy, and so on
      • Operations services: facilities, and so on
  • Material resource availability
    • Life-sustaining resources
      • Ventilators
      • Blood products
      • Dialysis machines
      • Extracorporeal membrane oxygenation (ECMO)
    • PPE
    • Non–life-sustaining yet necessary equipment (eg, feeding pumps, end-tidal CO2 monitors)
    • Medications (both COVID-19 specific and otherwise)


There are specific metrics to be monitored for triggering a CSC status. A hospital must demonstrate and document that it has at least three of the triggers listed below. Some of these metrics can trigger CSC implementation independently or in combination with other metrics. One of the triggers must include either 1, 2, or 3.

  1. At or above 50% of the emergency department acute bed capacity is occupied by hospital boarders for more than 12 hours and is expected to continue for over 24 hours;
  2. Urgent and emergent procedures or surgical cases are being delayed;
  3. Nursing ratios on a unit are increased above the locally set standard for greater than 12 hours and are expected to continue for at least 24 hours (example: ICU 1:3, intermediate care unit 1:4, medical-surgical unit 1:6, or the emergency department 1:4);
  4. Nonclinical staff are deployed to active patient care activities;
  5. Clinical staff are redeployed to specialty care units outside of their standard specialty;
  6. More nontraditional locations with fewer resources (eg, gases, suction, infection control) than would be available in the proper traditional care setting are being used;
  7. Clinically significant supply, drug, or equipment limitations alter the ability to maintain the standard of care and require allocation of lifesaving scarce resources (eg, ICU, ventilators, key medications, ECMO, dialysis, other respiratory support devices); or
  8. Health care infrastructure limitations impact the hospital’s ability to maintain standards of care (eg, facility degradation due to flood or fire, prolonged information technology or electric outage).

Process for implementing a CSC

CSC status should be implemented ethically and transparently. Based on specific pre-identified trigger thresholds, the hospital CEO, in consultation with the hospital incident command (HIC), has the authority to decide that the hospital needs to consider implementing a CSC and which resources warrant the implementation. That decision should be immediately communicated to the health system or hospital unified command (HUC) for final approval prior to implementation. The date and time that CSC begins and ends should be documented within the HIC structure and the HUC. In addition, the metrics and data to support an ongoing CSC should be reviewed daily.

Once the hospital has submitted the data that support its plan for CSC implementation, hospital leadership should work with regulatory and compliance units to ensure that state and federal notification requirements are met. If the state governor has not declared a state of emergency, any plans for CSC must be submitted to the state’s secretary of health prior to implementation — once the submission is made, approval from the secretary of state prior to implementation is unnecessary. However, the submission will need to be supported by documented data that reflect the triggering metrics of the CSC.

Certain administrative or routine tasks can also be modified when a CSC status is designated to a hospital. Such activities may include, but are not limited to:

  • Documentation;
  • Cosigning of orders; and
  • Certain routine checks (eg, checking ventilators every 2 hours as opposed to every 1 hour).

This process should also be communicated to the HUC and documented within the HIC structure. Communications should then be shared with hospital leaders, staff, frontline workers, and the community, as approved by the HUC.

Allocation of scarce resources

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

Termination of a CSC

In general, a CSC status is intended to be used for an extended period, as opposed to hours or one shift. This concept should be kept in mind as hospitals put their processes in place for triggering and rescinding a CSC status. For instance, a CSC status may be triggered on day 1 if certain equipment is unavailable and then resolved on day 2 once that equipment’s supply is restored. However, it may not be beneficial to rescind the CSC on day 2 unless the metrics demonstrate no risk of equipment scarcity for the next several days. Monitoring of staffing metrics for the near future should especially be considered before rescinding a CSC status based on staffing because staffing is particularly fluid.

The hospital is responsible for monitoring the criteria and rescinding their CSC status once it is no longer applicable. The hospital CEO, in consultation with the HIC and HUC, should immediately communicate any CSC rescission within the HIC structure and should document its date and time.

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

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

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

ACEP supported redeployment and utilization of ABP-boarded or ABP-eligible PEM physicians to meet patients’ increased demand for care during the COVID-19 pandemic. In a variety of hospital settings during the pandemic, pediatric physicians provided care above the typical age limits set for pediatrics and were instrumental in helping with the surge of patients who needed acute and prolonged care. ACEP appreciates the preparation and efforts implemented by pediatric and PEM clinicians in pediatric emergency departments and hospitals to meet surges in demand for care. These clinicians are also an important resource during mass-casualty events or other health emergencies that may overwhelm a hospital system.  


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  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. Hsieh A, Arena A, Oraha A, et al. Implementation of vertical split flow model for patient throughput at a community hospital emergency department. J Emerg Med. 2022 Oct;64(1):77-82. doi: 10.1016/j.jemermed.2022.10.007
  4. Garrett JS, Berry C, Wong H, Qin H, Kline JA. The effect of vertical split-flow patient management on emergency department throughput and efficiency. Am J Emerg Med. 2018 Sep;36(9):1581-1584. doi: 10.1016/j.ajem.2018.01.035
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  6. Rabinowitz HK, Paynter NP. The rural vs urban practice decision. JAMA. 2002 Jan 2;287(1):113. doi:10.1001/jama.287.1.113-JMS0102-7-1
  7. Michael SS, Bickley D, Bookman K, Zane R, Wiler JL. Emergency department front-end split-flow experience: 'physician in intake'. BMJ Open Qual. 2019 Nov 18;8(4):e000817.
  8. Health workers and administrators. WHO.
  9. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance. WHO. Published March 13, 2020.
  10. Landor M, Schroeder K, Thompson TAK, et al. Managing care transitions to the community during a pandemic. J Nurs Adm. 2020 Sep;50(9):438-441.
  11. Mitchell R, Banks C; authoring working party. Emergency departments and the COVID-19 pandemic: making the most of limited resources. Emerg Med J. 2020 May;37(5):258-259.
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  14. Orman BJ. COVID-19: triage tent logistics [audio podcast]. Hippo Education ERcast. March 2020.
  15. Bell SA, Krienke L, Quanstrom K, et al. Alternative care sites during the COVID-19 pandemic: policy implications for pandemic surge planning. Disaster Med Public Health Prep. 2021 Jul 23:1-3. doi: 10.1017/dmp.2021.241
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