The novel coronavirus disease 2019 (COVID-19) pandemic has stretched many local, regional, and national healthcare systems to previously unimaginable limits. When the first case of COVID-19 in the United States was reported in Washington State,
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robust clinical guidance was still in its infancy, hospital operations largely adhered to models developed for prior infectious outbreaks (eg, HIV, Ebola), and previously reliable supply chains struggled to meet skyrocketing worldwide demands for personal protective equipment, ventilators, and other medical supplies.
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Widespread uncertainty and stress placed on health systems revealed variation in administrative and clinical practices across the country that seemed to evolve daily during the early stages of the pandemic's surge.
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In New York City, a region disproportionately impacted by COVID-19 cases and hospitalizations, the pandemic's impact was especially severe. As the city's public hospital system, the largest municipal health system in the country, New York City (NYC) Health + Hospitals was at the epicenter of the pandemic. As the disease concentrated in lower-income and immigrant communities where public hospitals are primary or sole providers of care, the pressure the surge of cases imposed on infrastructure, processes, and staff felt impossibly compounded. As described by Uppal et al,
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NYC Health + Hospitals spearheaded the response through a system command leadership structure, further establishing an emergency department action team comprised of system and local emergency department clinical leadership to orchestrate strategy and mobilize resources across the enterprise to meet real-time needs. Early priorities for the public system's emergency departments included protecting and communicating with frontline staff of our 11 emergency departments, prioritizing resources for those facilities most in need, and expanding clinical capacity and safely enhancing efficiency of emergency department operations.
As the pandemic's first surge subsided, COVID-19 cases in New York City gradually fell, and traffic to emergency departments by people without COVID-19 resumed, the lingering probability of subsequent surges has prompted the immediate need to translate lessons learned about how to best protect staff and patients into immediate infrastructure, material, technological, and process changes. These changes are more than just preparation for the second surge. We believe they will help fortify our system's readiness for the foreseeable “post-COVID-19, pre-vaccine” world; and our lessons learned from this process can help inform similar transformations elsewhere. To regain the trust of the community that has already demonstrated avoidance of potentially necessary medical care out of fear of infection, emergency departments and hospitals in the United States, especially those in areas most impacted by COVID-19, must deliver on thoughtful safeguards.
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At NYC Health + Hospitals, we assembled an interdisciplinary team spanning emergency medicine, emergency management, facilities development, supply chain, and information technology to guide system redesign planning and prioritization. Through a series of debriefs, assessments, and site walk-throughs with each hospital's executive and departmental leadership, we generated consensus on the following 10 strategies, organized under 3 overarching principles, to drive the transformation of our emergency care system.
Redesign Patient Flow to Manage Surge
1. Limit entry points by reducing the number of entrances. During the pandemic's surge, our hospitals necessarily restricted visitation policies and we limited building access to a dedicated set of designated entry points. To prevent against occult spread of COVID-19 moving forward, even as new cases temporarily wane, all patients and visitors will continue to be given masks to wear throughout their stay and educational materials on testing, tracing, and isolating for COVID-19. Other changes at entry points include temperature checks with infrared devices and symptom screening.
2. Provide the right level of care for the right patient. Historically, emergency departments have resourced around the ability to provide any range of necessary evaluations and treatments to stabilize and care for every patient who appears at their front door. The sheer volume and acuity of COVID-19 patients forced our emergency departments to move away from traditional nurse triage and waiting rooms and, instead, adopt new patient flow models by placing a clinician at point of entry. This sentinel provider performed a medical screening exam and could discharge low-risk, low-acuity patients with medical advice and patient education or, if appropriate, direct them to alternative care areas outside of the emergency department, such as an onsite COVID-19 testing space or urgent care clinic. Providers in and in front of triage were able to expedite diagnostics and treatment to reduce patient length of stay and emergency department census. To support patient navigation, the addition of strategically placed informational video screens helped direct patients to appropriate treatment areas. These patient flow changes kept emergency departments reserved for the sickest patients, reduced waiting room and emergency department occupancies, and provided low-acuity patients the appropriate level of care more efficiently and without unnecessary exposure to the virus. Moving forward, we intend to retain these models or, at least, plan staffing schedules to enable rapid switching back to this workflow to protect waiting rooms and emergency department census.
Incorporate New Distancing into Care Spaces
3. Apply design thinking to spaces to promote social distancing. While patient flow models aim to reduce waiting room and emergency department census, additional structural, spatial, and enhanced patient wayfinding changes can augment adherence to social distancing and minimize inadvertent and unrecognized disease spread. Starting in the waiting room, clear floor markers provide visual cues instructing patients where to stand to maintain appropriate distancing. Traditional waiting room seating configurations continue to be adjusted or replaced with spatially distanced chairs. Separate entrance paths into the emergency department from triage can be instituted based on the patient's likelihood of COVID-19 infection, which was determined at the point of triage based on symptoms and exposures.
4. Build physical barriers where distancing is not possible. While emergency department care spaces are designed to accommodate wide fluctuations in patient volume, social distancing within them is not always possible in moments of peak demand, when individual care areas require occupancy by multiple patients. To prevent droplet transmission of disease during these moments, plexiglass partitions were installed throughout the emergency department, including entrances, hospital police posts, registration desks, triage areas, nursing stations, and provider work areas. Patient care areas located in shared bays will be further divided using hard space dividers—instead of disposable or washable curtains—that are readily cleaned between patient use.
5. Leverage telemedicine technology as a communication modality. While our system has benefited from the growth of telemedicine to communicate virtually with patients in their homes, care spaces similarly will be outfitted with telecommunication technology to transform the nature of onsite care delivery.
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Starting with isolation rooms, video monitoring and communication devices will allow for virtual encounters to limit direct contact, avoiding unnecessary use of personal protective equipment and protecting staff who do not need to assess the patient at the bedside, including registration clerks, financial counselors, and social workers. In one emergency department, this same technology was used to screen patients at the entrance doors, allowing for rapid direction to the most appropriate area of the department. Furthermore, a more complete integration of biomedical devices into the enterprise electronic medical record will assist clinical staff with both remote monitoring and documentation of vital signs including oxygen saturation.
Reconstruct Spaces to Meet Clinical Needs
6. Designate hot and cold zones. Early experience during the pandemic universally demonstrated the impossibility of predicting who had COVID-19 based on simple screening techniques alone. Despite recently declining disease prevalence in New York City, the inability to detect all COVID-19 carriers without widely available, rapid point-of-care diagnostics means that having a 100% “COVID-free” area of the emergency department is likely to remain an unachievable ideal. Nevertheless, emergency departments will cohort patients based on degree of likelihood of COVID-19 infection, splitting emergency department layouts into separate zones that can alternate between either “hot” (higher COVID-19 likelihood) or “cold” (lower COVID-19 likelihood) based on local and regional epidemiological trends and care needs. Constructing temporary walls can address some structural limitations. Emergency departments with ample footprints can additionally designate a third “flex” area that can be flipped between “hot” and “cold,” as the situation demands.
7. Safeguard staff with proper anterooms and breakrooms. Makeshift anterooms assembled at the beginning of the pandemic's surge should now be formalized in the architecture of the post-COVID-19, pre-vaccine emergency department. Constructing strategically placed anterooms for designated hot zones ensures that clinical staff properly don and doff personal protective equipment to lower inadvertent spread of infection, rather than risk continuous wear across care areas. Similarly, recognizing that breakrooms are areas for possible infection if staff enter wearing contaminated protective equipment, the formal use of anterooms will help ensure safe practices for break areas.
8. Establish pathways for transporting lower risk patients. While cohorting patients based on their probability of COVID-19 infection will help minimize inadvertent virus spread within care areas, attention is also needed to patient paths of movement across these spaces. Establishing hot and cold zones alone is insufficient, as some patients require transport across areas to radiology or admission if hospitalized. Thoughtful planning and rerouting of standard transport pathways is essential to avoid exposures and contamination that would nullify gains from creating designated, risk-based clinical areas.
9. Reimagine oxygen supply and air flow designs. In several hospitals during the surge, patients occupied every conceivable care space, exceeding the capacity of wall-routed oxygen. To ensure adequate oxygenation support, trails of plastic tubing traced back from patients to a myriad of wall oxygen ports and portable canisters. Although no patient went without oxygen, ensuring adequacy of this plastic tubing network was resource intensive. As we prepare for a potential second surge, our system has focused on ensuring oxygen outlets are available throughout additional wall areas and finding additional creative ways to deliver oxygen to high-density patient populations as needed. For example, oxygen tubing lattices can be embedded in the ceiling, with the ability to drop oxygen connections to patients below, as needed, during an influx. Air flow is another important challenge. Additional patient rooms, and even entire pods, will need conversion to negative pressure, which will require careful planning and activation of appropriate air pressure relationships to maintain infection control between hot and cold zones.
10. Expand and equip observation space to increase capacity. During the surge, all available hospital space was rapidly converted into critical care or high-acuity inpatient floors, while some emergency departments continued to hold over 100 admitted patients waiting for inpatient space. To care for scores of patients without critical illness, but who still require further observation of their clinical course, emergency departments will need to develop additional surge observation space, properly equipped with the ability to provide supplemental oxygen and continue telemonitoring and treatment.
COVID-19 rapidly shifted the nature of how healthcare is delivered in the United States. As hospitals and health systems emerge from their initial surges, preparation for a “new normal” of delivering medical care will require continued coordination. Our work has benefited from close collaboration among many partners at both the local hospital and central system levels, with respective representation from clinical services, executive leadership, facilities development, supply chain, and information technology. The fostering of buy-in and commitment to walk through 11 emergency departments is what pushes this progress forward, and we would emphasize that a department leader cannot do this work alone. These 10 strategies from New York City's heavily impacted public hospital system are likely transferrable across geographic regions and patient populations to all hospitals and systems currently strengthening their preparations for subsequent surges. Over the long term, these efforts will make care delivery better, safer, and more efficient for patients and staff in the post-vaccine world as well. Together, emergency departments can continue to successfully meet the high standards demanded by COVID-19 and any future public health threats we may face.
