Hospitals located in communities that are not considered hotspots for COVID-19 are nonetheless seeing patients concerned that they have contracted the virus.
“We put up a tent right away. What you will see almost immediately, if you haven’t already, is that most of the volume involves people who want to rule out COVID-19. We developed segments just like we do in our ED [emergency department]: low acuity, medium acuity, and high acuity,” stated Karen Murrell, MD, ED director at Adventist Health Lodi Memorial Hospital in Lodi, CA, a community about 90 miles east of San Francisco.
Murrell shared her experiences as part of an ED-focused briefing sponsored by the Patient-Centered Outcomes Research Institute (PCORI) on April 7.
“People are greeted right away in their car as they drive up. We do their vital signs in the car. If they are stable with no hypoxia, and they are doing well, they are just going to be treated in the car,” Murrell explained.
She noted roughly 70% of patients presenting to the ED fall into this low-acuity group. Clinicians equipped with the appropriate personal protective equipment (PPE) interact with patients, but they do not provide complete medical exams if the patients show no signs of respiratory distress and their oxygenation is normal. “We are going to do [COVID-19] tests if we have them available. We will give patients standard discharge instructions,” Murrell added.
The tent is reserved for medium-acuity patients who may need a bit more care. “We set up portable X-ray machines just like [some hospitals] are doing in New York. We can do labs there, but they are probably not that much use at this point,” Murrell said. “Almost all of these patients get discharged. Then, we have preserved our ED for the higher-acuity patients who need more testing and more treatment.”
California initiated social distancing measures early in the outbreak. Murrell credits this step with producing lower ED volumes than expected. Still, she noted clinicians are treating every patient who presents as a patient under investigation (PUI) for the virus.
Murrell also noted that effective lines of communication with higher-ups have been hugely beneficial in keeping the ED running smoothly. “I function at a smaller place under a larger system,” Murrell noted. “This is your time if you have a smaller ED ... to really get your relationships with administration ready right now.”
For instance, Murrell said health system leaders have taken some of the load off the ED regarding logistics and staffing. “They have helped us with backup plans because [many non-emergency] physicians are not as busy as they normally are in the outpatient clinics. We canceled outpatient surgeries right away, so those doctors have been engaged to be backups for us,” she shared. “We also have a daily call with all physicians so everyone can be updated about what is going on at our site. We have this transparency of information that is really helpful to [easing] these huge fears among our clinicians. Everyone is on the same page and knows exactly what we are going to do every day.”
Murrell’s advice is to carefully anticipate what the needs will be at peak volume regarding both inpatient and intensive care unit (ICU) beds. “Right away, we converted one of our floors to something that could be upgraded to an additional ICU to prevent boarding [in the ED],” she said.
Further, Murrell noted that if colleagues can set up in-house testing, that can help boost flow from the ED into the hospital. “Patients who we thought would be admitted for CHF [congestive heart failure] exacerbations, COPD [chronic obstructive pulmonary disease], or other respiratory problems have all turned out to have COVID-19,” Murrell said. “Just assume people have [the virus] at this point.”