Emerging Success Against the COVID-19 Pandemic: Hospital Surge Capacity in Taiwan

To the Editor:

Surge capacity of emergency departments (EDs) is crucial to prevent health care worker infection and hospital collapse during the pandemic crisis.¹ Coronavirus disease 2019 (COVID-19) has shown higher interhuman contagious rates based on the absence of hallmark clinical presentations, higher transmissible capacity, and asymptomatic carriers that challenge hospital response capacity.²

After the severe acute respiratory syndrome epidemic, the Kaohsiung Medical University Hospital’s ED designed an indoor infection isolation area, including 2 negative-pressure isolation rooms and 2 isolation areas with an independent ventilation system and 4 beds each. Those facilities seemed to be appropriate during the early stage of the pandemic. However, in accordance with the worldwide outbreak and its clinical presentation,³ a huge influx of suspected cases of COVID-19 is expected, which might overwhelm the initial indoor setting, so we installed 10 well-ventilated single-room tents at outdoor parking lots immediately outside the ED entrance. Moreover, an outdoor concrete chemical decontamination area was turned into a radiograph room, personal protective equipment removal corridor, and shower service. High-risk patients with oxygen demand or critical conditions were transported to indoor infection isolation areas for any resuscitation support. Stable patients were led to individual tents. In response to the worldwide spread of COVID-19 and the presence of sporadic native cases in Taiwan,⁴ tent numbers were increased to 15, and enough time was allowed to build a modular house with 14 isolation rooms. A parking lot before the ED entrance is another key element that offers a buffer area for urgent-care tents and allows health care workers to engage with a predefined patient flow (Figure , A).

Figure.

Imaging of the ED. A, The outdoor tent area. B, The indoor infection isolation area and the subcompartmentalization idea. W, Medical waste stockroom; T, toilets with hospital sewage plant drainage; cQ, modular house; c1, outdoor single tents; c2, indoor isolation area; cT, pretriage; cP, personal protective equipment removal corridor; cX, radiograph room; c3, indoor negative-pressure rooms; →, patient flow.

Additionally, we implemented a reverse triage strategy⁵ to hasten the discharge of patients at low risk for adverse events and quarantine them at home through means of a simple but essential screening protocol (interview, chest radiograph, and swab collection). Audiovisual devices and acrylic shields were used to accelerate the interview process and provision of swab collection, respectively. Both measures also reduced the use of personal protective equipment.

During the global COVID-19 outbreak, we managed surge capacity by temporarily establishing outdoor individual tents that can rapidly expand and offer individual space for preventing infection during an ED stay. In total, there were 1,496 patients in tents and 270 in indoor isolation areas from January 22 to April 19, 2020. Three patients with COVID-19 and free of nosocomial infection were detected. However, massive community spread may threaten people with multiple comorbidities who require a large space with sophisticated medical devices. Thus, we proposed subcompartmentalizing the ED ventilation system to handle critical infected and noninfected patients (Figure, B). By integrating the original facility and tent area, along with seamless screening of patients and avoidance of rapid consumption of essential but scarce logistic inventory, we added proactive and dynamic strategies to enhance surge capacity, thereby preventing nosocomial transmission.