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

As the COVID-19 pandemic progresses, staffing shortages will likely occur because of health care personnel (HCP) exposures, illness, or need to care for family members at home. Health care facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate them, including considerations for permitting HCP to return to work without meeting all return-to-work criteria above. According to the CDC, as part of this, asymptomatic HCP with a recognized COVID-19 exposure might be permitted to work in a crisis capacity strategy to address staffing shortages if they wear a face mask for source control for 14 days after the exposure. This time period is based on the current incubation period for COVID-19, which is 14 days.

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

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.