1
Introduction
The COVID-19 pandemic has evoked dramatic global disruption as health and governmental
agencies struggle to manage this historic medical event. As of April 4, 2020, over
200 countries and territories have been affected, with over 1,000,000 cases and 60,000
deaths worldwide [1]. The United States currently is the country with the highest
prevalence of COVID-19 cases, with New York City (NYC) serving as the epicenter of
this pandemic [2].
Emergency medical services in NYC face unprecedented challenges in patient acuity,
bed management, and hospital operations, while experiencing high levels of provider
stress and fatigue. While robust literature on emergency medicine responses to natural
disasters and pandemics exists [3], the unique challenges of the pandemic in NYC will
likely be experienced by other emergency departments (EDs) across the country, as
the disease continues its anticipated trajectory. Here, we report an overview of our
experiences and response, as a NYC ED at the center of this pandemic.
The volume and acuity of suspected COVID-19 cases in our ED accelerated rapidly over
the course of four weeks. New York Presbyterian Hospital-Columbia encompasses an adult
and pediatric academic quaternary medical center, in addition to community sites in
upper Manhattan and Westchester, with a collective annual volume of approximately
250,000 visits. For the month of March, we have seen approximately 850 cases of COVID-19
with the majority arriving from March-15th-30thz. Faced with rapid acceleration of
volume and acuity, broad challenges have included: optimization of physical space
and staffing, the development of management strategies for high numbers of patients
requiring respiratory support, minimizing transmission risk to other patients and
healthcare staff, determining best strategies for redeployed non-emergency medicine
physicians and staff, and finally, frontline staff fatigue and well-being.
2
Strategies and general approaches
2.1
Taking a “comprehensive healthcare” approach
Our strategy included integration of ED, hospital, city, state, and national leadership
to coordinate the delivery of efficient care during this pandemic. With the support
of institutional leadership we orchestrated a multi-departmental response to the crisis.
To accommodate the anticipated ED volume and acuity, flexible approaches to staffing
from within and outside our ED were implemented. Due to low pediatric volumes and
cancellation of elective procedures/surgeries, we harnessed an influx of available
critical care beds, physicians, and support staff. We designated an incident commander
to help lead efforts and support clinical staff 24 h. In collaboration with the hospitalist
service, transfers of care (e.g. “sign out”) to admitting teams were done in the ED,
with redeployed off-service clinicians managing admitted patients to allow emergency
clinicians to treat new patients. In collaboration with ambulatory care providers,
“cough and cold” clinics were established outside of the ED to rapidly evaluate low
acuity patients with viral symptoms, helping to reduce ED volumes. In addition, they
performed a medical screening exam, facilitating transfer to specialty clinics for
isolated low acuity complaints (e.g. orthopedics, gynecology). Finally, patient bedding
was adjusted to reduce transmission risk, with suspected COVID-19 patients placed
into isolation rooms and positive cases cohorted together.
2.2
Coordinating care with other critical care services to optimize patient care and reduce
provider risk
The volume of patients requiring high-risk aerosolizing procedures during COVID-19
has been significant. Recognizing the high volume of emergent airways, we developed
protocols with the anesthesia service to assist with ED intubations that included
the use of HEPA viral filters and appropriate PPE. Additionally, a COVID-19 “SWAT”
team consisting of surgical chief residents and attendings was organized and available
to perform procedures such as central lines and arterial lines. Given the increased
need for difficult goals of care conversations, we involved palliative care, social
services, and ethics consultations early and often for critically ill patients, including
pre-intubation.
2.3
Consider remote/telemedicine opportunities for low acuity patients and follow-up care
Telemedicine has played a critical role in our COVID response, providing another pathway
for determining need for acute care, while also decreasing ED patient volume and potential
viral exposure. Telemedicine has also allowed us to extend our footprint of care into
the home, through a follow-up program involving video visits with oxygen concentrators
and pulse oximeters distributed to patients during their index ED visit.
2.4
Staff morale/health
Protecting healthcare workforce is paramount in fighting COVID-19. The concern for
illness, fatigue, low morale, and clinical error is high [4]. It is important to allow
for increased flexibility and surge staffing during this time period. We had a number
of support resources available, including mental health experts, spiritual care, virtual
wellness rounds, and frequent staff huddles. Concerns about exposure risk were high
amongst our providers, and an emphasis on PPE and supplies has been paramount.
The COVID-19 pandemic has placed immense burdens on healthcare systems globally. We
hope our early experiences in confronting the pandemic will provide valuable information
for other EDs and health care systems around the country during this ongoing crisis.
Grant
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