Table 1.

Amendments to ED operations during viral respiratory outbreaks.

Operation	Response considerations
Patient volume/triage	•Standardize ED admission criteria for patients with respiratory symptoms •Expand inpatient capacity: expedite discharges, cancel elective surgeries •Limit inflow by conducting initial patient evaluation via telemedicine •Triage low-risk patients with respiratory symptoms to an alternate site (medical tent) and high risk patients to a designated ED treatment space
Screening patients	•Screen via clinical and epidemiologic clues • Current guidelines for COVID-19 testing include individuals with fever and/or symptoms of acute respiratory illness who: ○ are already hospitalized ○ are at high risk for poor outcomes ○ have been in close contact to a COVID-19 patient or travelled to high risk geographic area within 14 days of their symptom onset
Cohorting patients	•Large healthcare systems can designate one hospital to be the primary hospital for infected patients • Geographically cohort patients with presumed or confirmed infection ○ Use long shifts and overtime hours to limit staff turnover in these units
Infection control and environmental changes	•Any patient with respiratory symptoms must wear a mask at all times • Current COVID-19 guidelines recommend any HCP performing an aerosol-generating procedure on a COVID-19 patient wear a fitted respirator mask with contact precaution and eye protection ○ Use negative-pressure rooms for such procedures • Establish new housekeeping protocols with Environmental Services (EVS) o Add EVS staff during times of peak room turnover
Screening/testing HCPs	• Current CDC guidelines for COVID-19 testing among HCPs: ○ Asymptomatic HCPs with low-risk exposures are able to work but should self-monitor with supervision for two weeks after last exposure ○ HCPs with medium/high risk exposures should undergo active monitoring, including restriction from work until 2 weeks after last exposure. •Implement a system to evaluate staff for fevers and/or respiratory symptoms prior to starting work •Any HCP with fever or respiratory symptoms should immediately self-isolate.
Staffing concerns	•Have additional staff backup on the schedule to cover •HCPs should have priority for rapid-turnaround testing
ED stocking and supply	•Obtain an appropriate supply of PPE and establish allocation procedures • Increase inhaler and spacer stock ○ Instruct EMS/ED staff to preferentially use inhaler treatments •Obtain additional stock of paralytics, induction agents, and medications for post-intubation sedation •Confirm Pyxis availability •Have disposable tape measurers for patient height and a wall reference with ideal body weights available to help establish appropriate initial ventilator settings
Radiology preparation	•Use portable radiographic equipment whenever possible •Establish satellite radiography centers and dedicated radiographic equipment •If a suspected patient must be transported to the radiology department, that individual must wear appropriate PPE throughout transport/encounter
Respiratory support	•COVID-19 patents are recommended for high-flow nasal cannula over NIPPV •Perform early endotracheal intubation when clinically indicated via video-guided laryngoscopy •Mechanical ventilation should be managed similarly to other patients with acute respiratory failure