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
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.”
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.
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:
Any change in front-end processes should include a quality monitoring system.
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.
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.
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.
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.
According to the U.S. Food and Drug Administration (FDA), health care workers:
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.
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:
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
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.
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 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:>
Contingency Capacity Strategies to Mitigate Staffing Shortages
Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities.
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.
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.>
Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows:
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.>
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.
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.
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.
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”).
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.
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.
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:
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:
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.
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:
* 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)
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.”