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Emergency Department Clinical Operations During a Pandemic: Lessons Learned and Future Directions
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April 2021


Michael Redlener, MD, FAEMS
Associate Professor of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
Elyse Lavine, MD, FACEP
Associate Medical Director, Department of Emergency Medicine, Mount Sinai Morningside, New York, NY
Eric Legome, MD, FACEP
Professor and Chair, Department of Emergency Medicine, Mount Sinai West and Mount Sinai Morningside, Icahn School of Medicine, New York, NY

Peer Reviewer

Andy Jagoda, MD, FACEP
Professor and Chair Emeritus, Department of Emergency Medicine; Director, Center for Emergency Medicine Education and Research, Icahn School of Medicine at Mount Sinai, New York, NY
Jolion McGreevy, MD, MBE, MPH
Vice Chair for Emergency Operations, Mount Sinai Health System, New York, NY
Table of Contents

About This Issue

The COVID-19 pandemic brought together front-line medical professionals, operational experts, and scientists to share effective strategies and lessons learned during the most tumultuous medical event of our generation. As hospitals and health systems assess the challenges they have faced over the last year, it is essential that they adapt—and even re-imagine—healthcare delivery to address future waves, the next pandemic, or unanticipated new threats that may arise. This white paper, written by emergency physicians who served both clinically and administratively in New York City at the height of the 2020 COVID-19 crisis, is an effort to share lessons learned in pandemic planning and surge response, and to help better prepare our colleagues for the future.

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Table of Contents
  1. Overview
  2. Building on Modern Pandemic Response Literature
  3. Preparedness: A Key Part of the Pandemic Response Framework
    1. COVID-19 Spotlight 1: Preparedness for a Hidden Threat and Implications for Emergency Department Planning
    2. Leadership and Communication
    3. COVID-19 Spotlight 2: Providing Insight into Pandemic Practice
  4. Ensuring a Safe and Secure Environment for Patients and Emergency Department Staff
    1. Patient Screening
    2. COVID-19 Spotlight 3: Patient Screening
    3. COVID-19 Spotlight 4: Employee Screening
    4. Visitor Policies
    5. COVID-19 Spotlight 5: Visitors and Visitor Screening
    6. Distancing
    7. Personal Protective Equipment
    8. COVID-19 Spotlight 6: Personal Protective Equipment
    9. Improving Air Flow and Negative Pressure Space
    10. Emergency Department Endemic Unit Designation
    11. COVID-19 Spotlight 7: The Emergency Department as a COVID-Endemic Unit
    12. Radiology
    13. Environmental Services
    14. Electronic Medical Record
    15. Respiratory Intervention Practices
    16. Emergency Department-Based Telemedicine
    17. COVID-19 Spotlight 8: Telemedicine Innovation
  5. Emergency Department Surge Concept and Definitions
    1. Triggers and Initiation of Surge Plan
    2. Utilizing the Crisis Standard of Care Framework
    3. Elements of an Emergency Department Surge Plan
    4. Pandemic Surge Processes
    5. Surge Space
      1. Temporary Barriers
      2. Medical Tents
      3. Existing Surge Spaces and Alternative Care Sites
    6. COVID-19 Spotlight 9: EMTALA and Pandemic Response
      1. Permanent Infrastructure Upgrades
    7. Surge Resources
      1. Respiratory Equipment
      2. Surge Staffing
      3. Ancillary Staff Needs
  6. Clinical Policy Guidance
    1. Clinical Treatment and Algorithm Protocols
    2. COVID-19 Spotlight 10: Development of Clinical Guidelines
    3. Consult Policies
    4. COVID-19 Spotlight 11: Consultation Experience
  7. Admission Policies
    1. COVID-19 Spotlight 12: Admission Policies
    2. COVID-19 Spotlight 13: Disposition Criteria
    3. Palliative Care
    4. COVID-19 Spotlight 14: Using Palliative Care
    5. Crisis Standards of Care and Ethical Triage
  8. Finances and Fiscal Planning
    1. A Flexible Approach to Pandemic Finances
    2. Cost Increases
    3. Mental Health Considerations
    4. COVID-19 Spotlight 15: Fiscal Issues
    5. Protecting Vulnerable Staff and Sick Call Policies
  9. Putting it All Together
    1. Key Takeaway Points for Emergency Department Leadership During a Pandemic
  10. Tables and Figures
    1. Table 1. Screening Guidelines
    2. Table 2. Sample Tiered Visitor Policy
    3. Table 3. Surge Framework for the Emergency Department
    4. Figure 1. Sample Pandemic Triage Operations Algorithm
  11. References


The world's experience with COVID-19 has demonstrated that the current infrastructure and practice of emergency medicine are not designed to respond effectively to an ongoing and sustained pandemic.1

As of March 18, 2021, the United States saw over 29 million cases of COVID-19 and experienced over 535,000 deaths.2 Although there have been some relative successes with limiting the spread of COVID-19, the U.S. continued to see areas with growth in both total cases and hospitalized cases of COVID-19 and a corresponding influx of COVID-19 patients presenting to local emergency departments (EDs). As the epicenter of the early U.S. wave, New York City experienced a surge of COVID-19 patients that magnified the daily strain on regional ED capacity and operations. In addition to existing preparedness plans, from mid-February through April of 2020, clinical leadership at major health systems developed multiple “just-in-time” plans to ensure safety and clinical effectiveness during a period of significant medical uncertainty.3,4 In addition to learning key treatments, crucial knowledge was gained in reconceptualizing ED operations in response to a pandemic.

During the first wave of the pandemic, EDs experienced dramatic reductions in the numbers of non-COVID-19 patients.5 While this allowed for focus on treating COVID-19 patients, continued disease prevalence or recurrent waves of COVID-19 may bring a more mixed group of patients to EDs, so the lessons of infection prevention and segregation will be increasingly important in order to control nosocomial spread of all infectious disease. The response to pandemic surge conditions requires ongoing attention to clinical operations to keep patients and staff safe while providing effective and efficient ED care. In this report, we highlight concepts in surge and disaster planning and incorporate them into a generalizable response plan for pandemic conditions. Specific insights related to COVID-19 that were gained during this crisis are highlighted in COVID-19 Spotlight boxes.

Building on Modern Pandemic Response Literature

Over the last 25 years, outbreaks from H1N1 and H5N1 influenza, severe acute respiratory distress syndrome (SARS), Ebola, and other infectious diseases have sparked extensive recommendations for responding to emerging infectious disease.6-12 Within the ED, 3 major strategic areas of focus include: (1) infection prevention efforts; (2) surge planning; and (3) operational response to acute, ongoing, and unpredictable high patient volumes. The U.S. Centers for Disease Control and Prevention (CDC) and the Assistant Secretary for Preparedness and Response (ASPR) within U.S. Department of Health and Human Services (HHS) have developed useful tools to support hospital and health system preparedness, giving specific guidance about strategic planning for these prolonged or short-term surges.13,14 In 2011, Dugas et al highlighted key interventions and priorities in pandemic response put forth by a panel of 34 experts representing public health, disease surveillance, clinical medicine, ED operations, and hospital operations. Many of the direct ED recommendations were coordinated with hospitals, public health authorities, and regional planning authorities, as a comprehensive framework.15

Literature that was focused on clinical and operational interventions, innovations, and administrative process proliferated after the early period of the COVID-19 outbreak.3,16-20 Although the level of evidence for specific interventions to improve the safety and efficiency of hospitals and EDs during a pandemic is low, this literature—in conjunction with prior experience with infectious disease outbreaks—provides a framework for action. In developing this paper, we have taken our experiences as part of a large urban healthcare system with 8 acute care hospitals and incorporated best practices and promising interventions from around the U.S. and the world. This review will offer ideas and opportunities to optimize overall pandemic planning, as well as noting specific approaches to COVID-19 management.

Tables and Figures

Table 1. Screening Guidelines

Table 2. Sample Tiered Visitor Policy
Table 3. Surge Framework for the Emergency Department
Figure 1. Sample Pandemic Triage Operations Algorithm

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

  1. Mareiniss DP. The impending storm: COVID-19, pandemics and our overwhelmed emergency departments. Am J Emerg Med. 2020;38(6):1293-1294. DOI: 10.1016/j.ajem.2020.03.033
  2. U.S. Centers for Disease Control and Prevention. CDC COVID Data Tracker. Accessed March 22, 2021.
  3. Uppal A, Silvestri DM, Siegler M, et al. Critical care and emergency department response at the epicenter of the COVID-19 pandemic. Health Aff (Millwood). 2020;39(8):1443-1449. DOI: 10.1377/hlthaff.2020.00901
  4. Shah S, Majmudar K, Stein A, et al. Novel use of home pulse oximetry monitoring in COVID-19 patients discharged from the emergency department identifies need for hospitalization. Acad Emerg Med. 2020. DOI: 10.1111/acem.14053
  5. Hartnett KP, Kite-Powell A, DeVies J, et al. Impact of the COVID-19 pandemic on emergency department visits - United States, January 1, 2019-May 30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(23):699-704. DOI: 10.15585/mmwr.mm6923e1
  6. Nap RE, Andriessen MP, Meessen NE, et al. Pandemic influenza and hospital resources. Emerg Infect Dis. 2007;13(11):1714-1719. DOI: 10.3201/eid1311.070103
  7. Kao HY, Ko HY, Guo P, et al. Taiwan’s experience in hospital preparedness and response for emerging infectious diseases. Health Secur. 2017;15(2):175-184. DOI:10.1089/hs.2016.0105
  8. Singh SR, Coker R, Vrijhoef HJ, et al. Mapping infectious disease hospital surge threats to lessons learnt in Singapore: a systems analysis and development of a framework to inform how to DECIDE on planning and response strategies. BMC Health Serv Res. 2017;17(1):622. DOI: 10.1186/s12913-017-2552-1
  9. Foote M, Daver R, Quinn C. Using “mystery patient” drills to assess hospital Ebola preparedness in New York City, 2014-2015. Health Secur. 2017;15(5):500-508. DOI: 10.1089/hs.2016.0130
  10. Tham KY. An emergency department response to severe acute respiratory syndrome: a prototype response to bioterrorism. Ann Emerg Med. 2004;43(1):6-14. DOI: 10.1016/j.annemergmed.2003.08.005
  11. Iskander J, Strikas RA, Gensheimer KF, et al. Pandemic influenza planning, United States, 1978-2008. Emerg Infect Dis. 2013;19(6):879-885. DOI: 10.3201/eid1906.121478

Subscribe to get the full list of 57 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: COVID-19, operations, pandemic, New York, emergency department, ED, preparedness, load-balance, communication, screening, visitor, distancing, mask, PPE, negative pressure, endemic, EMR, electronic medical record, respiratory, telemedicine, surge, crisis standard of care, staffing, infrastructure, admission, disposition, palliative, fiscal

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