Emergency Department Clinical Operations During a Pandemic: Lessons Learned and Future Directions -
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
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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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.
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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
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
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