Creating a COVID-19 surge clinic to offload the emergency department

The spread of COVID-19 has strained or overwhelmed emergency department (ED) capacity across the world. Facing an emerging COVID-19 outbreak in our city, we feared that the same situation could overwhelm our ED resources [1]. Therefore, we sought to create an area adjacent to our existing ED where patients not requiring emergency level care could be evaluated, tested for COVID-19, and safely discharged home. Here, we describe the creation and operation of a Surge Clinic in our indoor ambulance bay.

Our hospital is a large quaternary-care academic referral center and Level-1 trauma center. Our ED sees approximately 110,000 patients annually. Our ambulance bay normally accommodates seven ambulances and directly connects to the ED. It also contains a decontamination space.

The hospital's Department of Emergency Medicine (EM), Ambulatory Management (AM), the Department of Medicine (DOM), and the Center for Disaster Medicine (CDM) collaborated to develop the COVID-19 Surge Clinic. EM provided the physical space, guidance and infrastructure for triaging appropriate patients to the Clinic, and initial clinician staffing. AM directed much of the overall Clinic planning, identified clinical and administrative directors, and performed scheduling of patient appointments. The DOM provided second phase physician and nursing staff for the Clinic, established a referral system to direct outpatients to the Clinic, and drafted patient care guidelines. CDM provided strategic planning for the Clinic's interface with the COVID-response of the health system and facilitated infection control recommendations.

Transforming the ambulance bay into a functional Clinic required close and rapid collaboration with hospital leadership, the environmental services department, buildings and grounds staff, infection control experts, and a materials management team. Fig. 1 illustrates the resultant physical space and flow.

Fig. 1.

The physical set-up of the clinic with patent flow indicated by arrows. RN = Registered Nurse. APP = Advanced Practice Provider. MD = Medical Doctor. Pt = Patient.

Patients arrive to the Surge Clinic via one of two pathways. ~75% of patients have appointments scheduled through referrals from primary care offices, triage phone lines, or the hospital's occupational health service. These patients proceed directly to the Clinic on arrival without ED triage evaluation. The second source of patients (25%) are walk-ins to the ED are the second source of patients (25%). All patients arriving to the ED are given masks and evaluated by a greeter nurse who asks about COVID-related symptoms and uses specific criteria (developed collaboratively by the EM, AM, and DOM) based on symptoms and comorbidities to determine who is appropriate for the Clinic versus the ED. Those immediately excluded from clinic consideration include patients with chest pain, shortness of breath, or pre-syncope, as well as those with significant co-morbidities such as immunocompromising illness, significant pulmonary conditions, or any type of end-stage organ disease. Vital signs are obtained only if deemed necessary for assessing stability for the Clinic. All patients triaged to the Clinic receive a medical screening exam consistent with EMTALA requirements.

The Clinic registration desk is located 6 ft from the patient arrival area with a separating physical barrier, protecting registration personnel and limiting their needs for personal protective equipment (PPE). Appropriate PPE must always be worn by staff in all other Clinic areas. Waiting room chairs are separated by 6 ft and cleaned by environmental services staff between patients. The Clinic has four clinical spaces separated by temporary plastic walls and three portable restrooms with a handwashing station for patients. There is also a small discharge area. All patients are discharged with their tests pending and subsequently receive a phone call with results and guidance.

The waiting area and patient flow are monitored by a nurse. The evaluation spaces use a two-clinician model, generally a physician and advanced practice provider. One clinician performs the history and physical, including vital signs. The other documents the encounter and orders any needed laboratory testing while standing at a computer 6 ft away to minimize cross-contamination of surfaces and reduce unnecessary clinician exposure. The only tests available in the Clinic are Influenza/RSV, Strep, and COVID-19; a nurse collects specimens as ordered, and the patient is sent to the discharge area. The clinicians then clean their clinical area, doff their PPE, and re-don PPE in preparation for the next patient. This workflow minimizes the amount of PPE used per patient. In the discharge area, a nurse or nurse case manager provides education on in-home self-isolation and the plan of care, and provides the patient with a discharge packet including a mask for travel home and an additional mask in case the patient needs to return for further evaluation.

Over the first three weeks of operation, the Clinic saw a total of 2667 patients (average = 160 daily). Slightly more than 1% of patients required transfer to the ED for further testing or treatment (e.g., chest X-ray, nebulized medications, or intravenous fluids). The Clinic has become an essential component of our hospital's strategy to manage the volume of COVID-related cases our ED and physician practices are now seeing.

Prior presentations

None.

Author contributions

JJB developed the paper concept and drafted the manuscript. JJB, BJY, ES, AC, JB, KL, LH, MML, ASR, ITL, and PDB were all instrumental in the creation and operation of the Surge Clinic. PDB, ES, ITL, JB, and ASR provided critical revisions of the manuscript for important intellectual content.

Financial support

None.

Conflict of interest disclosure

JJB, BJY, ES, AC, JB, KL, LH, MML, ASR, ITL, and PDB report no conflicts of interest.