Procedures for patients who are best-served with medication nebulizers are most safely done outdoors, downwind of any building entrances and away from ED staff. This may require placing chairs in a weather-protected area, with an outlet for compressed air or medical oxygen to power the nebulizers.

Also consider if patients can be screened and managed virtually without provider contact. Virtual encounters and telemedicine opportunities are gaining popularity in emergency medicine.¹⁰

Remember, once providers have had contact with COVID-19 patients, they could infect other personnel and contaminate equipment including computers, phones, machines, and so forth. This supports the argument to use virtual care as much as possible and have medical scribes assist physicians. By doing this, the same people touching infected or high-risk patients as part of diagnostic or therapeutic care will not need to touch equipment.

We would be remiss to not include a word about “direct care” and “indirect care” of COVID-19 patients. Where PPE is being conserved, hospitals may employ a strategy to carefully segregate workers who contact patients directly from workers who do not. Using scribes in the emergency department lends itself to this workflow segregation.

COVID-19’s impact on ED volumes and acuity has been stunning. According to the Emergency Department Benchmarking Alliance, most of the more than 1,200 ED members sharing data have actually seen ED volume go down 40 percent since mid-March because patients have avoided the emergency department due to infection risk.^11,12

Acuity breakdown and admission rates are changing at some locations. Most do not think that the 40 percent drop will be maintained into summer because American emergency departments are the source for unscheduled health care and that demand will continue. This means ED leaders will need to consider staff and patient flow in their emergency departments from scratch and be informed by the data. The data can suggest the zones or service lines needed, their hours of operation, how many beds are designated, and how each area should be staffed.

Now more than ever, it is all about flow.

References

1. Coronavirus Disease 2019 (COVID-19). Cases, Data, Surveillance. Centers for Disease Control and Prevention website. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.html. Accessed May 21, 2020.
2. van der Linden C, Lindeboom R, van der Linden N, et al. Managing patient flow with triage streaming to identify patients for Dutch emergency nurse practitioners. Int Emerg Nurs. 2012;20(2):52-57.
3. Aksel G, Bildik F, Demircan A, et al. Effects of fast-track in a university emergency department through the National Emergency Department Overcrowding Study. J Pak Med Assoc. 2014;64(7):791-797.
4. Hwang CE, Lipman GS, Kane M. Effect of an emergency department fast track on Press-Ganey patient satisfaction scores. West J Emerg Med. 2015;16(1):34-38.
5. Arya R, Wei G, McCoy JV, et al. Decreasing length of stay in the emergency department with a split Emergency Severity Index 3 Patient Flow Model. Acad Emerg Med. 2013;20(11):1171-1179.
6. Soremekun OA, Shofer FS, Grasso D, et al. The effect of an emergency department dedicated midtrack on patient flow. Acad Emerg Med. 2014;21(4):434-439.
7. Coronavirus Disease 2019 (COVID-19). Symptoms. Centers for Disease Control and Prevention website. Available at: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html. Accessed May 21, 2020.
8. Coronavirus Disease 2019 (COVID-19). Infection Control Guidance. Centers for Disease Control and Prevention website. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed May 21, 2020.
9. Coronavirus Disease 2019 (COVID-19). Optimize PPE Supply. Centers for Disease Control and Prevention website. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Accessed May 21, 2020.
10. Izzo JA, Watson J, Bhat R, et al. Diagnostic accuracy of a rapid telemedicine encounter in the emergency department. Am J Emerg Med. 2018;36(11):2061-2063.
11. About Us. Emergency Department Benchmarking Alliance website. Available at: https://www.edbenchmarking.org/about-us. Accessed May 21, 2020.