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Analysis

6 Approaches to Managing Coronavirus Patient Surges in Emergency Departments

By Christopher Cheney  
   August 11, 2020

Emergency departments have developed strategies to handle coronavirus patient surges such as addressing limited space in their facilities.

Emergency department management and clinical care practices to cope with coronavirus disease 2019 (COVID-19) patient surges have evolved since the pandemic began, according to a recent journal article.

Particularly for the most seriously ill COVID-19 patients, emergency departments are an essential healthcare setting during the coronavirus pandemic. Given their key role, EDs need to function efficiently and effectively to save lives.

The recent journal article, which was published in Annals of Emergency Medicine, highlights six lessons learned that can help emergency departments rise to the challenges of addressing COVID-19 patient surges.

"The very novelty of COVID-19, in multiple senses—immunologic novelty for a population lacking herd immunity, clinical novelty in its diversity of presentations, and sociocultural novelty in that it has appeared amid nationwide tumult and institutional distrust—makes it a perfect storm. It has caught much of the United States unprepared. Yet despite the many uncertainties about COVID-19, emergency physicians have gained critical practical knowledge," the journal article's author wrote.

1. Hot zones and cold zones

To deal with a rush of COVID-19 patients, emergency departments should be divided into two areas, according to the journal article. A hot zone should be created for the assessment and treatment of patients who are suspected of having COVID-19 or influenza. A cold zone should be created for other patients.

A contributor to the journal article told HealthLeaders that having hot zones and cold zones in an emergency department generates two primary benefits during a COVID-19 patient surge.  

"On the patient side, one of the things that people are most afraid about during the COVID-19 pandemic is being infected. Therefore, having different areas where people with COVID-19 or people with suspicion of COVID-19 are handled creates physical separation and less likelihood that even casual contact could happen. It gives not only a measure of safety but also an enhanced appearance of safety for people coming into an ED," says Donald Yealy, MD, Department of Emergency Medicine chair at the University of Pittsburgh School of Medicine in Pittsburgh.

"On the provider side, having different areas where patients are placed either with or without suspicion of COVID-19 allows for more efficiency in staffing, more consistent care, and more protection of the patients and the providers," he says.

2. Rapid COVID-19 testing

The capability to test patients for COVID-19 in a timely manner is helpful in the ED setting, and it could be essential when the influenza season begins in the fall, the journal article says.

For emergency room clinicians, rapid COVID-19 testing is a desirable tool, Yealy says. "If you could get a test that was quick and retain the accuracy of the more standard viral tests, it would help us identify at the beginning of a hospitalization who has symptomatic and asymptomatic COVID-19."

3. Personal protective equipment

In emergency rooms, having adequate supplies of personal protective equipment (PPE) is crucial during a COVID-19 patient surge, the journal article says. "Ensuring adequate PPE and adapting facilities in ways that conserve this resource by reducing repeated donning and doffing will be essential to safeguard staff before waves of new cases again become overwhelming."

Yealy says four factors determine the availability of PPE: the production of PPE, the distribution of PPE, the intensity of cases, and the use of the equipment. For now, he is cautiously optimistic. "There is enough PPE even if the virus numbers increase. I don't anticipate that there will be widespread shortages again, but there could be individual facilities that could be under duress."

4. Alternatives to mechanical ventilation for COVID-19 patients

Both in terms of available resources and patient outcomes, placing COVID-19 patients on mechanical ventilation is problematic, and alternative treatments should be used when possible, the journal article says.

The approach to mechanical ventilation for seriously ill coronavirus patients has evolved significantly since the beginning of the pandemic, Yealy says.

"Early on, we felt that what was most key was to assist respiration by all means necessary, including endotracheal intubation and mechanical ventilation as early as possible because of the fear of profoundly low oxygen levels. We have now learned that haste to begin standard mechanical ventilation with an endotracheal tube may not serve patients well. Alternatives such as high-flow oxygen, prone positioning without intubation, and using other noninvasive ventilatory techniques can be quite helpful for an extended period," he says.

As is the case with any critical care therapy, expertise is important when proning coronavirus patients in the ED, Yealy says. "Proning is not something you can just learn on the fly. There are lots of things that can go wrong. So, you either have to have proning teams or you have to have within your staff subsets of people who understand how to do proning and are practiced at it."

5. ED space constraints

During a COVID-19 patient surge, EDs need to be creative in managing triage space such as erecting tents and other outdoor facilities, the journal article says.

Using tents to address ED space concerns is a good strategy under the proper circumstances, Yealy says.

"Tents are a reasonable alternative for the patients with the lower level of symptoms and acuity because they help provide care to very large numbers of patients if you have a physically restrained bricks-and-mortar environment. Obviously, outdoor triage and treatment facilities can be shackled by their location and the weather. In the far Northeast, those kinds of facilities would be a very difficult way to provide care in February. In the Southwest, those kinds of facilities could be the perfect way to provide care year-round."

For EDs in many areas of the country, repurposing existing bricks-and-mortar areas for clinical care such as conference rooms is an attractive option for managing limited space, he says.

6. Telemedicine

Utilizing telehealth capabilities can reduce the strain on EDs during a COVID-19 patient surge, the journal article says.

"It can help people with lower-level symptoms get the care and advice they need without having to come to the emergency department," Yealy says.

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

Emergency departments are playing a pivotal role in the response to the coronavirus pandemic.

In emergency departments, a primary strategy to cope with coronavirus patient surges is to create a "hot zone" for potentially infectious patients and a "cold zone" for other patients.

Using telemedicine to triage and treat low-acuity coronavirus patients can ease burdens in emergency departments during a patient surge.


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