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Special Report

Special Report

Lessons Learned in Clinical Adjustments at an ED at a COVID-19 Pandemic Epicenter

Davis, Frederick DO, MPH; Berman, Adam MD; Delgado, Manuel; Tang, Richard MD; Willis, Helena RN; Khaitov, Irina; Rudy, James; Adam, Christian; Mayorga, Rene; D'angelo, John MD; Becker, Lance MD; Kwon, Nancy MD

doi: 10.1097/01.EEM.0000731704.16512.4f
    COVID-19, coronavirus, pandemic
    COVID-19, coronavirus, pandemic:
    Figure 2. Floor Plan of the LIJMC ED

    COVID-19 was first identified in New York on March 1, and New York City and the surrounding metropolitan and suburban areas were quickly affected. The peak of confirmed infections for New York State was around April 14, deaths per day peaked on April 11, and the peak of hospital resource use of all beds was around April 9. (Institute for Health Metrics and Evaluation. https://bit.ly/3jbGE8z; New York State Department of Health COVID-19 Tracker. https://on.ny.gov/33ck7Ti.)

    Queens, one of the city's five boroughs, saw the highest number of confirmed COVID-19 cases of all of the boroughs in New York City. (New York State Department of Health COVID-19 Tracker. https://on.ny.gov/33ck7Ti; FiveThirtyEight.com. April 14, 2020; https://53eig.ht/345Gx8e.)

    Hospitals and emergency departments had to adjust their operations rapidly to care effectively for patients who had COVID-19. This was especially applicable in Queens because it was the epicenter of the pandemic in the state. Many hospitals and EDs not only had to adjust the space available to see patients, but increase clinical staffing to safely care for them. New York Gov. Andrew Cuomo also mandated an increase in hospital beds of at least 50 percent. (Democrat & Chronicle. April 1, 2020; https://bit.ly/3ijO9sZ.)

    After the peak of the initial wave of the pandemic, the number of COVID-19 cases and of hospitalized and intubated patients gradually declined. Many EDs saw a significant decrease in their daily volume to numbers that were lower than what they saw before COVID-19. These fluctuations in volume and the types of cases presenting to the ED resulted in the need for quick and rapid responses to adjust to the changes in volume. We also created operational changes in response to the pandemic at our large tertiary care academic hospital and ED at the epicenter of the outbreak. These responses included changes in staffing and the use of alternate care spaces.

    Figure 1.
    Figure 1.:
    Raw Numbers of Respiratory Cases Presenting to the ED

    Operational Methodology

    The Long Island Jewish Medical Center Emergency Department (LIJMC) is part of a 583-bed tertiary care academic center in Queens, New York. It is part of the Northwell Health system, and serves the greater New York metropolitan area and Long Island. In the midst of the pandemic, LIJMC cared for some of the highest acuity patients and experienced the highest volume of COVID-19 patients in New York State and even the nation.

    Pandemics historically have a second and even third wave, and here we describe the operational changes that occurred in the ED during the first wave so it can be a guide and adapted if there is a resurgence or during another outbreak, which is typical. (FiveThirtyEight.com. April 14, 2020; https://53eig.ht/345Gx8e; CDC. May 11, 2018; https://bit.ly/2SaKeDO.)

    We divided these changes into five phases: baseline (pre-COVID), ramp-up (early COVID), surge (peak COVID), de-escalation (after peak COVID), and recovery. These phases are identified by discrete dates and are based on the curve of COVID-19 cases that we experienced. Figure 1 shows the raw numbers of respiratory cases that presented to the LIJ ED.

    Baseline: Pre-COVID

    Before March 2, the LIJMC ED had the highest volume in the Northwell Health System, averaging approximately 278 adult patients per day. The ED has approximately 35,000 square feet of space with 52 licensed beds. It also has 12 licensed beds for the clinical decision unit (CDU). The emergency short stay unit (ESSU) is used as a holding unit for admitted patients until a bed can be secured in the hospital. It is also used as a flex unit to care for ED patients when there are surges of ED volume. (The layout of our ED can be seen in Figure 2.)

    Ramp Up: Early COVID

    From March 2 to March 22, the percentage of respiratory cases was rapidly increasing, 20 percent (60 patients) of cases on March 2 and 62 percent (147 patients) of cases on March 22. As the volume of patients with respiratory illnesses increased, we gradually converted areas of the ED to COVID and non-COVID areas to maximize efficiency and minimize the risk of transmission. Patients were bifurcated into high- and low-suspicion COVID-19 and into horizontal or vertical.

    Surging to Peak COVID

    We saw approximately 290 patients a day during this high-volume, high-acuity period from March 23 to April 10. Volume decreased after April 1. The average daily volume from April 2 to April 10 was 219 patients a day, a 21 percent decrease from pre-COVID volume.

    New challenges arose as we started to see more patients with higher acuity throughout March. Many admitted patients were boarding in the ED because of a lack of open inpatient beds, which resulted in long wait times. During this surge period, a large percentage of patients were high risk for COVID-19.

    To meet these increased demands for space and for the higher volume of patients with COVID-19, a low-acuity tent in the hospital lobby was set up and implemented on March 23. These were mostly ESI 4 and 5 patients.

    De-Escalation

    The average volume was 145 patients per day from April 11 to May 1, which was significantly less (a 48% decrease) than our pre-COVID volume. As the total volume and the volume of COVID-19/respiratory cases decreased during this period, processes and staff gradually reverted back to a new normal. We used the tent for the final time on April 11. ED spaces were gradually returning to their prior states in the reverse order of how they had progressed.

    Multidisciplinary Teamwork

    The culture created in our health system was a system response to the pandemic, and no individual, department, specialty, or hospital was alone in the response. This included clear and frequent communication and an organized approach to redeployment with the creation of a centralized project management team for redeployment.

    Communication: COVID-19 guidelines were changing daily, sometimes even multiple times a day, so clear and frequent communication was essential. In-person meetings were prohibited, so we used Microsoft Teams to conduct all meetings, which included hospital leadership, the Emergency Medicine Service Line (EMSL), and a daily ED faculty COVID Chat that focused on relaying information to staff and addressing any concerns they had.

    Centralized Project Management Team for Redeployment: The health system implemented a centralized project management team to organize redeployment efforts. The project management team identified all clinical staff whose areas were closed because of COVID-19 (non-emergency surgical cases were halted), and redeployed those clinicians to areas where they were needed, such as the ED, the ICUs, and the hospital medicine floors.

    ED Redesign

    As the COVID-19 pandemic progressed, we needed to redesign and change the utilization of hot and cold zones and alternate care sites rapidly, sometimes on a daily basis. It was also important for maintaining safety for staff and patients to have environmental services place HEPA filters throughout the department and provide terminal cleans for every room in the hot zones.

    Throughput: This was greatly affected by COVID-19 because patients needed to be cohorted and placed in hot zones; they were kept in single rooms as available. There was less space available because admitted patients holding in the ED could no longer be placed in the hallway. The tent assisted in reducing the length of stay.

    Predictive Modeling and Staffing Plans: To stay ahead of the curve and be prepared with enough staff, the ED worked with the hospital administration, the project managers for redeployment, and the hospital industrial engineers to provide potential plans based on volume and alternate care spaces.

    Innovations: Many innovations to care and operations occurred during the pandemic, and many more continue to be developed and implemented. Some of these included using a large portable UV light to assist with the terminal cleaning of rooms, on-site creation of plexiglass boxes to offer increased protection for staff during intubation, and on-site creation of plexiglass hubs where patients could be swabbed for coronavirus and staff members could be protected. There were also programmatic and IT innovations in the EMR to assist with the ED care and post-discharge care of patients affected by COVID-19.

    Recovery

    Recovery to normal operations since May 2 has been contingent on a new normal in the aftermath of the surge and de-escalation of the COVID-19 pandemic in our ED and hospital. ED volume remained lower as we entered the recovery phase. Some of the new operations that will be part of our new normal is cohorting all patients by their COVID status, which will be difficult once the ED volume returns to normal. COVID-19 screening is a part of triage for every patient with risk. During this recovery period and as the volume of COVID-19 patients decreased, triage processes were returned to pre-COVID ones with one area for walk-in patients to be triaged. All patients were masked, and we had the ability to send a patient to a single room to be evaluated quickly. Many of these factors will be critical to leading us to as full a recovery as possible.

    Every ED's volume, patients, and overall operations are unique, and the operational changes that occur during a crisis of the magnitude of the COVID-19 pandemic can relay lessons learned to all emergency departments and health systems. The lessons learned during the first wave of this pandemic will be invaluable if future waves occur, and will also be relevant for the response to other emerging infectious diseases. The operational responses that were needed at an ED at the epicenter of the pandemic are replicable at other EDs across the country and the globe.

    Dr. DavisandDr. Bermanare associate chairs of emergency medicine at Northwell Health, Long Island Jewish Medical Center (LIJMC), and assistant professors of emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Mr. Delgadois the senior administrative director of emergency medicine,Dr. Tangis an administrative fellow in emergency medicine, Ms. Willisis the senior administrative director of nursing of emergency medicine, Ms. Khaitovis the supervisor of the advanced clinical practitioners in emergency medicine, Mr. Rudyis the director of industrial engineering, andMr. Adamis the senior administrative manager of cardiothoracic surgery, all at LIJMC. Ms. Mayorgais the senior director of the Emergency Medicine Service Line for Northwell Health. Dr. D'Angelois the executive director of the Emergency Medicine Service Line for Northwell Health and an associate professor of emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. Beckeris the chair of emergency medicine at LIJMC and the chair of emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell. Dr. Kwonis the vice chair of emergency medicine at LIJMC and an associate professor of emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.

    Details and Data

    An unabridged version of this article with additional data and tables is available in our Breaking News blog at http://bit.ly/EMNNewsBlog.

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