Adapting Emergency Departments for the COVID-19 Surge

Grant M. Gallagher

A recent study contains a checklist for adapting the ED to a potential coronavirus case surge.

Over 1 million confirmed cases of the novel coronavirus have been reported. As cases rise and we eventually hit a peak, health care systems will be overwhelmed if they are not prepared.

There is a concept in disaster preparedness known as “sudden onset disaster mass casualty incidents” which surge response guidelines are designed around. The coronavirus disease 2019 (COVID-19) pandemic has undoubtedly introduced a surge in demand for medical services in key affected areas, but how much do these guidelines apply to present circumstances?

The investigators of a new study published in Disaster Medicine and Public Health Preparedness have applied the concept of sudden onset mass casualty incident surge capability to the process of expanding COVID-19 pandemic surge response. This has led to creating a checklist to guide emergency departments in their COVID-19 surge structural response.

The study authors reviewed available surge structural science literature to determine applications to the ongoing pandemic response.

Health care surge capacity was conceptualized in terms of a health system’s resilience.

“A resilient health care system must be able to limit and cope with stressors and events(absorptive capacity), to adapt itself toward external events (adaptive capacity), to forecast events and taking action to minimize effects (anticipatory capacity) and to change the structures and operations to better address results (transformative capacity),” the study authors wrote.

A difference the study authors identified between the existing literature on mass casualty incidents involves the need for precautions by health care staff. In the event of a natural disaster or terrorist attack, there is a quick peak of patients and the restrictions of a viral pandemic do not factor in.

However, in the COVID-19 pandemic, more people gradually continue to seek care over time. These patients must also be given special care in order to protect staff and non-COVID-19 patients alike. In this context, we’ve seen that many hospitals did not have the surge capacity necessary in relation to personal protective equipment or ventilators.

Recent sources the study team reviewed addressed the need to physically separate COVID-19 patients from other patients as much as possible, which isn’t a usual issue in other mass casualty events.

The authors reference a strategy undertaken by a hospital at the epicenter of the COVID-19 pandemic in Lodi, Italy.

“Their conventional management was to cohort patients based on their oxygen requirements and potential for aerosol (NIV treatment) as well as those placed on ventilators to maximize similar structure and space. As the ICU structure was filling up, they turned to the operative theater to increase their ventilator and monitoring space after the first days. While this required minimal investment of resources to reconfigure to limit exposure to staff and to have sufficient supplies, the team was identifying structures that could be adapted, repurposed with little creation to have space to manage the ventilator dependent patient,” the study authors explained.

The checklist that the study authors created includes a variety of helpful measures.

Firstly, the creation of a particular team focused on critical infrastructural recommendations is imperative.

Once that team creates projections on the likely COVID-19 patient load demands ahead, they can clearly lay out the challenges ahead and adapt accordingly.

Creating a pandemic adapted path to the emergency department at this point can be helpful in preventing the emergency department itself from becoming a vector for transmission that’s overwhelmed with patients who do not require detailed evaluation.

In Italy, external tent structures have become a key screening space. Droplet exposure has to be accounted for from the moment of the patient’s arrival in the parking lot.

Ideally, patients who call ahead should be instructed to notify staff of their arrival while still in the car, in order to obtain a surgical mask to limit droplet spread.

In order to make signage and instruction intuitive, planners can walk through the patient path to the tent or other intake structure and place information where they find it helpful.

The study authors note that ventilators and other machines may require different electrical outlets to avoid overloading any circuits, a potential challenge that is easy to overlook.

When patients are traveling to places like radiology departments, their path should be clearly marked for COVID-19 patients.

These, among other pieces of advice, could be essential to developing the best possible response in emergency departments likely to experience surges soon.