EXECUTIVE SUMMARY

New York hospital leaders warn colleagues to prepare for a rapid escalation of cases as soon as they see evidence of community spread of COVID-19. As of March 9, Stony Brook University Hospital had 15 persons under investigation (PUI) for COVID-19. By March 30, that number was 250. ED administrators note that of those PUI cases, they were discharging about 70% of patients, admitting about 27% to inpatient floors, and about 3% of ED patients went straight to the intensive care unit.

  • Stony Brook administrators note many of their staff members became ill with COVID-19 before they shifted their protocols to treat every patient who presents to the emergency department (ED) as if he or she has the coronavirus.
  • Many patients who presented to the ED with strokes, ST-elevation myocardial infarction, traumatic injuries, or even sprained ankles tested positive for COVID-19.
  • Administrators advise hospital leaders elsewhere to ensure all staff wear masks at all times and to employ telework solutions for any employees who can perform their jobs at home. Even clinicians who round as a group should wear masks and practice social distancing.
  • Managing the COVID-19 crisis is so complex that it can easily overwhelm one ED leader. Administrators advise colleagues to develop an infrastructure within the ED where different staff members can take charge of specific issues relating to personal protective equipment (PPE), staffing, testing, and the like.
  • ED personnel are leaving on their eye protection and N95 masks for their entire shifts. This has conserved a lot of PPE, but administrators also believe the practice has resulted in lower infection rates among staff on the front lines.

In the early stages of the COVID-19 outbreak, the emergency department (ED) at Stony Brook University Hospital in Stony Brook, NY, would screen presenting patients to see if they recently traveled to countries with known virus outbreaks. If yes, then staff members would place these patients in a negative pressure room and don personal protective equipment (PPE) to protect themselves.

However, such steps were not taken when people from the surrounding community came in with a cold. That was a mistake, according to Peter Viccellio, MD, FACEP, vice chair of the department of emergency medicine for Stony Brook University. Viccellio shared his experiences during an ED-focused briefing sponsored by the Patient-Centered Outcomes Research Institute (PCORI) on April 7.

Eventually, ED staff started protecting themselves from any patient who presented with symptoms of fever and cough, but that was a mistake, too. Viccellio urged other hospitals still awaiting an outbreak of COVID-19 in their communities to learn from the experiences of hospitals in New York state.

“With the very first case you see in your community, you really need to start treating everyone as a possible COVID-19 patient,” he stressed. “We have had trauma patients, strokes, STEMIs [ST-elevation myocardial infarction] ... all sorts of patients who have turned out to have COVID-19.”

Viccellio urged colleagues to imagine a trauma patient who also happened to be infected with COVID-19 was brought into their surgical intensive care unit (ICU). However, no one was treating that patient as if he or she was positive for the virus. That could lead to a unit-wide outbreak.

“You need to have [staff members at] your whole institution wearing masks at all times, washing their hands like crazy, eliminating visitors, and sending home any [employee] who can work from home rather than at the institution,” Viccellio advised. “A lot of our personnel who contracted COVID-19 contracted it during this early period when we thought we could pick and choose who we needed to worry about. You just simply can’t.”

There is no safe place or person. “If you round as a group, you should do social distancing, and you should be wearing masks,” Viccellio stressed.

All patients should wear a mask, even one who arrived with a sprained ankle. Furthermore, once the first case of COVID-19 happens, anticipate a forthcoming explosion of cases.

Eric Morley, MD, clinical director of the department of emergency medicine at Stony Brook University, concurred that EDs need to be prepared to ramp up quickly.

“On March 9, we had 15 persons under investigation [PUI]. On March 30, we had 250 PUIs [for the virus],” he explained during the April 7 PCORI briefing. “As the volume has gone up, we are learning that we are discharging about 70% of [PUI] patients home, admitting about 27% to the floors, and about 3% to the ICU.”

Unfortunately, a significant number of hospitalized patients with COVID-19 are requiring intubation and transfer to the ICU about two to three days into their course, Morley reported. “What we are left with is a very crowded hospital with a dramatically extended number of ICU requirements,” he added.

At Stony Brook University Hospital, peak demand seemed to hit around March 30. By early April, admissions were going down. For all adult patients, the ED is currently admitting about one-third of patients (about 40 to 50 patients per day). The adult volume ranges between 120 and 150 patients (both coronavirus-related and non-coronavirus-related) as of late April. For perspective, before the pandemic, the ED was seeing between 200 and 230 adult patients per day. “The main issue is that a lot of these patients who are intubated remain intubated for quite a long time, so we are not out of the woods in terms of our demand upstairs,” Morley shared.

While the hospital incident command center (HICC) worked well in helping the ED prepare for the pandemic-driven surge in patients, Morley noted that, in hindsight, he would have involved more people from the ED in that process sooner to help him stay on top of the many issues involved.

“There was quite a bit of information. I wish that earlier on I had organized several members of the team, different attendings who wanted to help, to be responsible for different parts,” he lamented.

For example, Morley eventually named one person to keep track of all the evolving guidance and institutional instructions regarding PPE. Another member was charged with tracking COVID-19 testing. These individuals were responsible for communicating about their respective areas to the ED at large as new information needed to be conveyed.

“Developing an infrastructure and getting people [involved] within your department is incredibly important, and something I would recommend early on,” Morley explained.

There is so much information arriving and complexity in managing the outbreak, all of which can easily overwhelm one person. “I got several of these people to join the daily HICC calls that we have so that I was not the only person to share information,” Morley said.

This added participation helps ensure the information shared is accurate and up to date. Also, should Morley contract the virus or otherwise become unavailable, he can be secure that someone is there to take charge. Within the ED, there is a daily meeting to discuss all aspects of the COVID-19 response, which Morley said has made managing the crisis easier. Typically, this meeting includes the lead physician assistant, nursing leadership, and several attending physicians.

“People may feel like their staff [members] don’t want to get involved, but it turns out that actually most of my colleagues want to be a part of it every day. I urge people to get that kind of infrastructure set up as early as possible,” Morley suggested. “Building [your] own incident command structure within the department is a critical action.”

Even before the HICC structure was put in place, Morley was working with hospital leadership to plan for an anticipated spike related to COVID-19. To a large degree, these early preparations have allowed the ED to function well, Morley added.

For instance, the 20-bed forward-triage area, which was assembled in the Stony Brook University parking lot about two days before clinicians started seeing a surge in COVID-19 patients, has worked as intended to ease congestion.

Staff members try to avoid conducting lab tests in this area, but there is portable chest X-ray capability. Generally, clinical personnel have seen 100 to 150 patients per day in that field tent, Morley reported.

Further, at this point, clinicians have largely dispensed with testing for influenza or respiratory syncytial virus, instead moving directly to testing for COVID-19.

“We have sent home about 95% of our patients from this area. About 3% to 4% have had rebound visits, but only a handful of these got admitted on their rebound visit. We think that it has been very successful,” Morley observed. “The last thing we want is to have 20 or 30 people sitting in our waiting room shoulder-to-shoulder. I don’t know how we would have [avoided] that without a forward-triage area.”

Morley’s advice to colleagues is to establish a plan for how and where to implement a forward-triage area. “If you don’t end up using it, that’s OK,” he said. “It has been a real lifesaver for us.”

One other way administrative leaders have facilitated patient flow in the ED is by acting early on to expand ICU capacity. “The maintenance team has been working night and day to create probably an additional 70 or 80 ICU-capable rooms in our hospital,” Morley noted. “We have very few ICU holds in the ED at this point.”

Frontline providers accustomed to dealing with influenza outbreaks where there is a gradual increase in patients need to understand the tempo is different with COVID-19. One cannot allow admitted patients to start accumulating in the ED, Viccellio stressed.

“That means that by tomorrow or the day after tomorrow you may have to open up another ICU or another inpatient unit,” he said. “You need to move very quickly in getting the walking wounded into another area so they don’t clog up the ED. But also, you cannot be boarding patients because in another day or two, you will no longer have an ED.” While clinicians still conduct bedside evaluations in the ED, every effort is made to minimize the number of times a clinician needs to enter a patient’s room.

“We created in the ED a video conferencing solution where there is an iPad in the room. We can connect to that iPad from a computer, another iPad, or a phone,” Viccellio explained. “We can talk directly with the patient from outside the room. Now, the nurse, the hospitalist, and a consultant can all converse with the patient remotely.”

The setup not only minimizes opportunities for exposure, it also saves a lot of PPE by making repeated visits to the patient’s room unnecessary, Viccellio observed. “The other nice aspect of this is that a hospitalist or consultant doesn’t even have to come to the ED; they can link into the patient’s room from virtually anywhere,” he added.

When it comes to PPE, with a few exceptions, ED personnel are leaving on their eye protection and N95 masks for their entire shifts, Morley noted.

“This has conserved a lot of PPE, but the more important component of that for the people who adhere to this [practice] is that we are seeing lower infection rates in our staff ... on the front lines,” he explained. “They are not touching their faces or their PPE over and over again. I think that ... is a really important concept, not removing your PPE.”

At the end of shifts, clinicians can place their N95 masks under an ultraviolet light to presumably kill any remnants of the virus.

However, the hospital has also just purchased a new piece of equipment that will be used to sterilize the masks using hydrogen peroxide gas, after which the masks will be returned to their original users. As with many other health systems, physicians from multiple specialties are caring for the crush of patients presenting with COVID-19.

Viccellio cautioned that such clinicians need to take steps to ensure they are equipped to provide appropriate care. “It’s not just retirees. If you have cardiologists or gastroenterologists who are called in to provide inpatient care for these patients, they need to get up to snuff,” he shared.

There are multiple resources that can assist in this process. Viccellio noted that the Society of Critical Care Medicine offers a wealth of additional COVID-19 educational resources. He also urged colleagues to check out the EMCrit Project resources or EM:RAP, which offer regular, updated guidance on how to take care of COVID-19 patients.

“Anyone [for whom] this is not their domain needs to really dive in and understand this disease,” Viccellio said. “The knowledge you may have as a physician about influenza does not necessarily crosswalk to the coronavirus. The patients are very different.”

Far from being a hindrance to the ED, the staff upstairs have done such a good job of freeing both inpatient and ICU beds that Morley has asked his team to start helping the inpatient staff manage their patients in the ED. “The concept needs to be that everybody needs to do exactly what it is they are asked, and to do as much as they possibly can to help their teams,” Morley explained. “I have never seen in any healthcare facility this level of teamwork and the ability to look past what [you] are normally expected to do and go above and beyond. I think that is what gets you through something like this.”