Table 1.

Checklist for ED pandemic workflow

	Situational awareness & perimeter defence	ED staff protection	Surge capacity management
ED Input	SYSTEM
	Workflow & protocols
	□ Is there a single entrance into the ED? □ Is there a screening criterion for all ED patients? (incorporating clinical and epidemiological features) □ Is the screening criteria kept up-to-date? □ Are there clear triage criteria (high suspect, intermediate suspect & non-suspect)	□ Is there a protocol for the type of PPE to be worn by screening, triage and ancillary staff? □ Do all patients have to wear masks? □ Are there safe-distancing measures for patients in waiting areas? □ Is there a contactless screening system?	□ Is there a workflow to re-direct well patients to alternative screening centres?
	Communication
	□ Is there a system to allow early alert of the 1st index case? □ Does the system alert new cluster pickups through the ED? □ Is there a platform for communication with pre-hospital ambulance system? □ Is there a platform for the ED surveillance team to communicate with the infectious disease team in the hospital? (e.g.: Command centre)	□ Are there clear instructions of PPE expectation in the different areas? □ Is there clear communication about staff movement between areas? □ Is there clear communication with patients and relatives about their movement within the different areas?	□ Is the ED able to communicate to the primary healthcare facility about changes in workflows to manage the input? □ Is there a platform to communicate with the hospital inpatient departments? □ Is the ED able to communicate workflow changes to the public?
	STAFF (Manpower/ Leadership/ Command teams/ Operational teams/ Working teams)
	□ Is there a designated ED surveillance team to monitor changes in screening criterion? □ Are there more experienced nursing staff at triage? □ Has security personnel been activated to restrict access into ED during outbreak period?	□ Have vulnerable staff members (e.g. pregnant or immunocompromised) been appropriately re-deployed to minimise exposure. □ Who is responsible for training staff for PPE (ED staff, augmented, ancillary)?	□ Are there plans for augmented manpower at screening area? □ Who trains the augmented staff for screening?
	SPACE (Infrastructure/ ED spaces/ Ward spaces)
	□ Do you have a screening area before triage? □ Are there separate triage areas for patients following screening into high suspect, intermediate suspect and non-suspect categories?	□ Can the spaces be reorganised to reduce exposure & movement of staff?	□ Is the IT system able to capture the patients’ data, to facilitate contact tracing? □ Is there IT support in expanded areas?
	SUPPLY (PPE/ Cleaning equipment/ Clinical management equipment)
	□ Are there any point of care test kits to facilitate screening process?	□ Is there adequate PPE for the different risks areas and does a reliable supply chain exist? □ Are masks provided for patients in waiting areas?	□ Are there standby equipment for areas that need to be expanded?
ED Throughput	SYSTEM
	Workflow & protocols
	□ Is the system able to limit movement of patients between the different suspect areas? □ Is the system able to monitor patients and staff movement between the different suspect areas? □ Is there a workflow for testing in the ED such that the cases can be labelled confirm infected rather than suspected?	□ Is there a strict area demarcation between the different COVID suspect areas? □ Are there regular PPE training & audits? □ Are there handwashing audits or equivalent? □ Is there a workflow for PPE during intubation? □ Is there a workflow for aerosol generating procedures? □ Is there a workflow for the cardiac arrest/ drowsy/ AMS patients?	□ Is there a workflow for high risk suspects with time sensitive conditions (AMI, stroke)? □ Is there a workflow for patients with respiratory symptoms? □ Is there a workflow for dying/palliative patients? □ Is there a workflow for patient intubation? □ Is a rapid diagnostic test being used for the outbreak? □ Is there a workflow with the radiologist to have reports out early? □ Is there a workflow with microbiology for early results? □ Is there a workflow for testing and sending well patients home?
	Communication
	□ Is there a platform to communicate patient workflow and management changes?	□ Are Instructions readily available on donning and doffing of PAPR? □ Is there a platform to communicate with infectious disease specialists within hospital? □ Are there considerations for patients in high risk areas to communicate with staff through portable electronic devices from their negative pressure/ isolation rooms?	□ How is the movement of patients within the ED communicated to ED staff? □ Is there a platform to communicate with radiologists and microbiologists to facilitate investigations done within ED?
	STAFF (Manpower/ Leadership/ Command teams/ Operational teams/ Working teams)
	□ Is there a system to reduce mixing between working teams? (e.g.: modular, team based or staff remaining in their allocated areas for a period of time?)	□ Are there measures to avoid placing the immunocompromised and the pregnant staff in intermediate and high suspect areas? □ Is there a self-monitoring system that allow staff to detect for early signs of infection (e.g.: temperature taking) and report in sick? □ What will be the workflow for the allied healthcare staff in ED? (e.g.: physiotherapy)	□ Is there augmented manpower at the various areas?
	SPACE (Infrastructure/ ED spaces/ Ward spaces)
	□ Is there geographical/ physical segregation between the patients of different risk categories? □ Are there negative pressure rooms in the high suspect areas? □ Is there adequate spacing between the patients in the intermediate and high suspect areas? □ How will radiology spaces be managed?	□ Are there shower facilities for staff? □ Is there adequate space in the pantry for staff to have their meals with physical distancing?	□ Is there a designated path for high and intermediate suspect cases to take to their respective investigation areas (e.g.: CT scan) □ Does the IT system allow the smooth flow of patient information from the screening to their inpatient or community notes?
	SUPPLY (PPE/ Cleaning equipment/ Clinical management equipment)
	□ Are there sufficient equipment for patients to rest on in the various areas without cross contamination risks?	□ Are there disposable/ hospital-based scrubs that staff can wear?	□ Are there alternative equipment for patient management during the outbreak (eg: spacer instead of nebuliser) □ Is there an established supply chain for drugs?
ED Output	SYSTEM
	Workflow & protocols
	□ Is there a workflow to determine disposition of the patients?	□ Are there PPE rules for the staff bringing high and intermediate suspect patients being brought to the ward? □ Is there a protocol to clear the route while bringing the patients up to the ward? □ Is there a workflow for interfacility transfer?	□ Is there a workflow to clear inpatient beds during a surge?
	Communication
	□ Is there a method of communicating patients’ ‘suspect status’ when admitting them to the ward? □ Is there a method of communicating patients’ status when doctors from other disciplines review patients in the ED?	□ Is there a good handover regarding patients’ suspect status when sending them to the ward?	□ Is there a platform to communicate with BMU during surges? □ Is there a platform to recall patients after they are d/c? (for contact tracing, information of results)
	STAFF (Manpower/ Leadership/ Command teams/ Operational teams/ Working teams)
	□ Is there adequate manpower in the holding areas?	□ Is the staff transporting the patient trained to wear appropriate PPE? □ Is the security clearing the route trained to wear appropriate PPE?	□ Is there augmented manpower at the holding areas? □ Is the adequate manpower to transport patients? □ Is there adequate manpower to carry out adequate cleaning of the intermediate and high suspect areas?
	SPACE (Infrastructure/ ED spaces/ Ward spaces)
	□ Is there adequate holding areas in the 3 suspect categories?	□ Is there adequate PPE for ancillary staff (Security, admin, porter)? □ Is there supply chain of decontamination substances?	□ Are there spaces that can be opened up during a surge to hold patients awaiting beds? □ Are there sufficient ICU beds and is are there escalation plans when ICU beds are full?
	SUPPLY (PPE/ Cleaning equipment/ Clinical management equipment)
	□ Are there rapid results test kits available to detect the infection and facilitate segregation during disposition? □ Is there adequate partitioning within the ED to keep patients of different risk profiles separated while awaiting disposition?	□ Is there adequate supplies for disposal of contaminated equipment?	□ Is there adequate transport equipment (e.g. wheelchair, trolley)