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10 Lessons for COVID-19 ED Operations

Ezenkwele, Ugo A. MD, MPH

doi: 10.1097/01.EEM.0000695564.59474.18
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    COVID-19
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    Mount Sinai Queens is a high-volume emergency department with an annual census of nearly 70,000. We anticipated a surge of patients coming into our ED after hearing information from China in early January, South Korea in February, and Italy in March. (WHO. Jan. 5, 2020; https://bit.ly/3fwalQf; BBC. Feb. 23, 2020; https://bbc.in/3bbcHAx; New York Times. March 21, 2020; https://nyti.ms/2YN2PL4.)

    Patients started coming in early March, and our peak was reached on April 6. We learned many lessons from our experience that may be helpful to others who have yet to see a surge.

    1. Capacity and Access: Creating surge space is not an ED-only solution. We initially developed surge capacity in the ED by using our waiting room. We quickly outgrew this space, and had to expand to the ambulatory care clinic and a tent. Operationalizing this was extremely fluid and involved a team of administrators, IT staff, pharmacists, housekeeping, emergency physicians and nurses, and ambulatory care clinicians.

    Operational inefficiencies had to be quickly recognized and redressed. ED tracking boards, for instance, were not accessible by the ambulatory care team, but we allowed immediate use so the ambulatory care team could place orders and document patient care.

    2. PPE: Availability of PPE was critical, and placing it in clinical care areas necessitated accessibility and accountability. Early on, staff from other parts of the hospital were coming to the ED and leaving with gowns, masks, and face shields, meaning PPE was not readily available when the ED staff needed it. Eventually, N95 masks and face shields were supervised and dispensed by the ED charge nurse. A PPE czar is also necessary to patrol the ED and ensure that staff and patients have appropriately donned (and doffed) protective gear.

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    3. Negative Pressure: Open resuscitation bays can contaminate equipment and staff during aerosolizing procedures. Engineering was able to convert our resuscitation bay into a negative pressure space by installing a HEPA filter and a negative-pressure exhaust system.

    4. Ventilators: Patient care is fluid and priorities can shift in the middle of a pandemic. We were initially concerned about running out of ventilators given the correspondence from our peers in Italy. (N Engl J Med. 2020 Mar 18; https://bit.ly/3bbdyBf.) Efforts were made to obtain more ventilators, and Mount Sinai even converted sleep apnea machines into ventilators. (Business Insider. April 7, 2020; https://bit.ly/3dvJPEC.) As the pandemic progressed, it became clear that using ventilators may be associated with even more mortality. (Reuters. April 23, 2020; https://reut.rs/3ciDfRP.) Fortunately, we never ran out of ventilators.

    This is more likely because we used nonmechanical ventilation, including continuous positive airway pressure, high-flow nasal oxygen, and even Ambu bags with a viral filter fashioned to deliver positive airway pressure while minimizing aerosolization. (EMCrit. March 27, 2020; https://bit.ly/2QU4ppB.)

    5. Aerosol-Reduction Covers: Aerosol-reduction covers and boxes are necessary to protect staff. Building them can be elegant, requiring an acrylic factory as initially described in Taiwan (FocusTaiwan. March 22, 2020; https://bit.ly/3b9IfXG), or as simple as the St. Louis aerosol-reduction cover requiring duct tape, clear sheets, measuring tape, and scissors. (Mercy Health System; https://bit.ly/2YNYuHg.) A crew of Girl Scouts in the community constructed nearly 100 plastic covers that we put into use.

    6. Telemedicine: This is not only useful for patient-clinician interactions but also for nursing and registration. In these instances, furloughed staff can be used. We used InTouch Health on iPads, which were placed in a tent of eight pods with a nurse assigned for direct patient care. Physician, nursing, and registration communication was carried out remotely using the devices.

    7. Oxygen Splitters and Tubing: As the oxygen requirements of our patients kept increasing, especially at the height of the pandemic, we became increasingly reliant on large tanks. Small canisters were rapidly depleted. Oxygen splitters were essential to allow more than one patient per tank. Extra-long tubing allowed us to keep pumps outside patient rooms so that nurses could minimize entries to titrate medications.

    8. Communicating with Family: Once visitors were restricted in the ED, the volume of calls from concerned family members grew exponentially. A communication tree was created with calls directed to specific numbers for pharmacy, laboratory, and family. Once implemented, call volume and holding time decreased substantially.

    9. Discharge: Patients being discharged need a home monitoring system for oxygen (a pulse oximeter) and a process for them to communicate with the health care staff. We used Precision Recovery, which was developed by a team of neurosurgeons and rehabilitation specialists. (Mt. Sinai; https://precisionrecovery.net.)

    10. Proning: It is well known that proning patients for hypoxemia and ARDS results in an oxygenation benefit. (Emerg Care J. 2018;14[1]; Chest. 2017;151[1]:215.) We operationalized it by forming a team of nurses and occasionally a respiratory tech who rounded on patients who were not intubated or who were on noninvasive ventilation. They proned eligible patients and checked oxygen levels on the tanks and replaced them if necessary.

    The current pandemic offered many lessons. Fortunately, the peak seems to be behind us, but a second wave may be coming when our state reopens.

    Dr. Ezenkweleis the chief of emergency medicine at Mount Sinai Queens and an associate professor of clinical emergency medicine at Icahn Mount Sinai School of Medicine. He is a councilor for the American College of Emergency Physicians and an oral board examiner for the American Board of Emergency Medicine.

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