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. 2021 Sep 10;16(9):e0256982. doi: 10.1371/journal.pone.0256982

Preparations of Dutch emergency departments for the COVID-19 pandemic: A questionnaire-based study

Rory D O’Connor 1,*, Dennis G Barten 2, Gideon H P Latten 3
Editor: Robert Jeenchen Chen4
PMCID: PMC8432867  PMID: 34506521

Abstract

Background

The onset of the COVID-19 pandemic was characterized by rapid increases in Emergency department (ED) patient visits. EDs required an appropriate transformation. The main challenges were: adapting capacity to respond to surges in the number of patient visits, protection of high risk (frontline) staff and the segregation of suspect-COVID-19 patients. To date, only a few studies have assessed the nation-wide response of EDs to the COVID-19 pandemic. This study was designed to review the preparations of Dutch EDs during the initial phase of this public health crisis.

Methods

The study was designed as a nation-wide, cross-sectional, questionnaire-based study of Dutch hospital organizations having one or more EDs. One respondent completed the questionnaire for each hospital. The questionnaire was conducted between the first and the second COVID-19 wave in the Netherlands. It contained close-ended and open-ended questions on changes in ED infrastructure, ED workforce adaptions and the role of emergency physicians (EPs) in each hospital crisis management team.

Results

The questionnaire was completed by 58 respondents. This represented 80% of the total number of EDs. All respondents had made preparations in anticipation of a COVID-19 patient surge. Treatment capacity was expanded in 70% of EDs, with a median increase of 49% (IQR 33–73%). Suspect-COVID-19 was segregated from non-COVID-19 patients in 89% of EDs. Alternative locations (such as outpatient departments) were more often used to assess non-COVID-19 patients, than for suspect-COVID-19 patients. Staff was expanded in 82% of EDs. This largely concerned nursing staff. A formal role for Emergency Physicians (EPs) in the hospital’s crisis management team was reported by 94% of hospital organizations employing EPs.

Conclusion

All Dutch EDs responded to the COVID-19 pandemic in a very short time span despite much uncertainty. Preparations predominantly concerned expansion of treatment capacity and segregation of COVID-19 ED care. EPs played a prominent role, both in direct COVID-19 care and in the hospital crises management team. It is vital for EDs to adapt to community needs swiftly. The ability of EDs to respond to the pandemic varied considerably.

Introduction

Coronavirus disease 2019 (COVID-19), which emerged in Southeast China in December 2019, was declared a pandemic by the World Health Organization on March 11, 2020 [1]. As it spread rapidly around the globe, hospital emergency departments (EDs) braced for impact.

In the Netherlands, the first case of COVID-19 was identified on February 27, 2020 [2]. As of May 31, 2020, which can be considered the end of the first Dutch COVID-19 wave, there were 45,976 confirmed cases of infection (of which 11,674 were hospitalized) and 5,939 confirmed COVID-19 deaths [3]. It resulted in a national incidence of 264 cases per 100,000 inhabitants. The most affected region, situated in the south, registered an incidence of 501 compared to an incidence of 60 per 100,000 inhabitants for the least affected region in the north of the Netherlands.

Emergency medical services and hospital EDs are viewed as public health services that are responsible for the initial medical response to any type of disaster, both in the short and long term [4]. In contrast to sudden-onset events, large-scale infectious outbreaks typically require a prolonged, sustained response [4, 5]. The current COVID-19 pandemic was initially characterized by rapidly increasing patient hospital contacts. A swift overhaul of several aspects of ED preparations in Dutch hospitals was imperative [6, 7]. Challenges mainly concerned surge capacity, frontline staff (staff at high risk of infection during initial contact with patients) protection and the segregation of suspect-COVID-19 patients [8–11].

To date, few studies have assessed nation-wide ED ability to cope with the COVID-19 pandemic. A French questionnaire-based study, conducted during an early stage of the pandemic (March 7 to March 11, 2020), revealed that EDs were poorly prepared [12]. A similar study from India, limited to academic EDs, showed that 90% of hospitals had developed specific COVID-19 triage systems and that almost 80% established dedicated areas for suspect-COVID-19 patients. However, it also revealed that the level of preparation of EDs varied widely. The authors stated that an individualized coping strategy for each ED which considers baseline needs and available resources is superior to a blanket strategy applied to all EDs. Although this claim seems sensible, evidence is scant [13].

Whilst clinical and intensive care unit (ICU) capacity for COVID-19 in Dutch hospitals were closely monitored and controlled through a national body (Landelijk Coördinatiecentrum Patiënten Spreiding), there was no guidance on the surge capacity management of EDs [6]. Consequently, hospitals largely restructured the organization of their EDs on an individual basis. This study aimed to form an overview of preparations that were taken in Dutch EDs during the initial phase of the COVID-19 pandemic. In addition, it aimed to explore the role of Dutch emergency physicians (EPs) in the hospitals’ crisis management teams.

Methods

Setting

The Dutch healthcare system is modern. It has an effective primary care system and a finely meshed network of specialized acute and critical care facilities. This network includes 82 EDs (Fig 1), which are located within 71 hospital organizations. 10 of these hospital organizations have multiple ED locations. The EDs serve the Dutch population of 17.4 million people. On average an individual ED is attended by 22,500 patients per year, of whom 17% are self-referrals [14].

Fig 1. Emergency departments in the Netherlands (June 2020) [15].

Fig 1

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Pink circle: Opened 24 hours, 7 days a week. Yellow square: Opened day and evening, 7 days a week.

Study design

This study was designed as a nation-wide, cross-sectional, questionnaire-based study of Dutch hospital organizations with one or more EDs. For each hospital one respondent, either an EP or an ED manager, received an invitation to participate by email on July 29, 2020. The Netherlands Society of Emergency Physicians distributed the invitations. It has a database of all Dutch EDs. Contact details remained anonymous to the researchers in compliance with laws for the protection of personal information.

If a respondent did not complete the questionnaire, a reminder was sent every fortnight. The questionnaire could be completed until September 30, 2020. Respondents were requested to complete the questionnaire on behalf of the hospital in which they practiced. When a hospital had multiple EDs, the questionnaire facilitated provision of information on all EDs.

The questionnaire contained 15 close-ended questions (dichotomous and multiple-choice) and 2 open-ended questions. Broadly, all these questions covered 3 topics: changes in ED infrastructure, alterations in ED workforce and the role of EPs in the hospital’s crisis organization. A Dutch and an English version of the questionnaire is supplied as S1 and S2 Files. Crowding was defined as described by Asplin et al. [16].

Statistical analysis

All analyses were performed with SPSS version 26 (SPSS Inc., Chicago, USA). Continuous data were reported as means with standard deviation (SD) or as medians with interquartile ranges (IQR). Categorical data were reported as absolute numbers and as valid percentages (to correct for missing data).

All data was collected anonymously. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines was used for reporting this observational study [17]. The Medical Ethics Committee Zuyderland & Zuyd concluded that the rules of the Medical Research Involving Human Subjects Act (WMO in Dutch) do not apply to this study (METCZ20200130). The study was registered in the Netherlands Trial Register (Trial number NL8818).

Results

The questionnaire was completed on behalf of 66 (80%) out of 82 EDs (Table 1). These EDs served 58 (82%) out of 71 hospital organizations, as eight hospital organizations had multiple ED locations. Prior to the COVID-19 pandemic, the majority of the EDs had an annual attendance of less than 30.000 patients per year. 86% of EDs were staffed by EPs.

Table 1. Baseline ED characteristics.

EDs (n = 66)* EDs that did not respond (n = 16)*
Annual attendance
        <20,000 patients 19 (28%)
        20,000–25,000 patients 17 (25%)
        25,000–30,000 patients 13 (19%)
        30,000–35,000 patients 8 (12%)
        35,000–40,000 patients 3 (4%)
        >40,000 patients 6 (9%)
Staffed by EPs 57 (86%) 10 (63%)
Preparations made for COVID-19 pandemic 66 (100%)
Incidence** in region where ED is situated
        < 100 6 (9%) 1 (6%)
        100–200 13 (20%) 2 (13%)
        200–300 20 (30%) 8 (50%)
        300–400 21 (32%) 5 (31%)
        > 400 6 (9%) 0
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Abbreviations: ED–emergency department, EPs–emergency physicians.

* Data are presented as n (%).

** COVID-19 cases per 100.000 as of May 31, 2020 [3].

The majority of EDs were situated in regions with 100 to 400 COVID-19 cases per 100,000 inhabitants This was the case for EDs that completed the questionnaire (82%) and EDs that did not respond (94%). The 16 EDs that did not respond were localized in different regions throughout the Netherlands and included university, teaching and peripheral hospitals [3].

All participating EDs had made preparations in anticipation to a surge of COVID-19 patients. The date when these preparations were completed varied between February 24 and April 1, 2020 (Median: 16 March 2020; IQR: 11–21 March 2020).

Changes in ED infrastructure

Before the COVID-19 pandemic, the median number of ED treatment spaces was 17 (IQR 12–21) (Table 2). Treatment capacity was expanded in 46 (70%) EDs. The median number of additional treatment spaces was 8 (IQR 4–10). This is a median increase of 49% (IQR 33–73%).

Table 2. Changes in ED infrastructure.

EDs (n = 66)* Number of Spaces (IQR)*
Number of treatment spaces was increased during pandemic 46 (70%)
- Pre-pandemic treatment spaces 17 (12–21)
- Additional treatment spaces 8 (4–10)
Number of treatment spaces was not increased during pandemic 20 (30%)
            Reasons for not increasing treatment spaces:
            ○Logistical alterations to usual ED practice 10 (15%)
            ○non-COVID-19 ED 4 (6%)
            ○Expansion not feasible 3 (4%)
            ○Other 3 (4%)
COVID-19 ED care was segregated from non-COVID-19 ED care 59 (90)
            Location of COVID-19 ED care
                - Original ED only 39 (59%)
                - Original ED and other location 14 (21%)
                - Other location only 7 (11%)
                Location of non-COVID-19 ED care
                - Original ED only 25 (38%)
                - Original ED and other location 27 (41%)
                - Other location only 7 (11%)
                Screening for COVID-19 before ED entry performed with
                - Symptom-based screening list only 43 (65%)
                - Symptom-based screening list and radiological imaging (Chest X-ray or CT) 13 (20%)
                - Chest CT only 1 (2%)
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ED–emergency department.

* Data are presented as median (IQR), or n (%).

Reasons for not increasing the ED area included: a previous reduction of ED utilization for several logistic alterations (15%), the ED being designated as a non-COVID-19 ED (6%), and the inability to expand ED treatment spaces due to isolation measures demanding more space per patient (4.5%).

Logistic alterations to standard practice included: the redirection of less urgent ED visits, such as minor traumatic injuries, to outpatient departments in 42 (63%) EDs and 12 (18%) EDs actually effectuated a faster admission process to hospital wards and intensive care units. The latter resulted in a shortened length of stay in the ED.

Suspect-COVID-19 patients were segregated from non-COVID-19 patients in 59 (89%) EDs. In the majority (59%) of EDs, this was organized within the original ED allotted area. Alternative locations used by the remaining EDs can be found in S1 Table. In most (75%) EDs, a symptom-based checklist alone was used to assign a suspicion of COVID-19 infection.

In 46 (79%) hospital organizations, one or more of the measures implemented for the pandemic were intended as permanent (S2 Table). These included improved infection prevention in 13 (22%), improved interdisciplinary collaboration in 13 (22%), permanent adjustments to segregate infectious patients in 10 (17%) and permanent redirection of less urgent patients in 8 (14%) hospital organizations.

Alterations in ED workforce

In 54 (82%) EDs the workforce was modified (Table 3). Nursing staff was expanded by redeploying, both additional specialized ED nurses (53%), and nursing staff from other departments (61%) took part. A large variety of physicians took part directly in COVID-19 ED care. Emergency medicine (86%), internal medicine (85%) and pulmonology (82%) were involved most frequent. In 21 (32%) EDs, the additional workforce consisted of nurses and physicians only. In the remaining 45 (68%) EDs other medical disciplines were also deployed.

Table 3. Alterations in ED workforce.

EDs*
Expansion of nursing staff 54 (82%)
Additional ED nurses 35 (53%)
Additional non-ED nurses 40 (61%)
Specialties involved in ED COVID-19 care
- Emergency medicine 57 (86%)
- Internal medicine 56 (85%)
- Pulmonology 54 (82%)
- Anesthesiology 26 (40%)
- Geriatrics 24 (36%)
- Surgery 23 (35%)
- Neurology 22 (33%)
- Cardiology 20 (30%)
- Pediatrics 20 (30%)
- Gastroenterology 16 (24%)
- Orthopedics 14 (21%)
- Otolaryngology/ENT 12 (18%)
- Urology 12 (18%)
- Dermatology 6 (9%)
- Primary care 6 (9%)
- Plastic surgery 6 (9%)
- Rheumatology 5 (8%)
- Gynecology 4 (6%)
- Other 18 (27%)
Other disciplines 44 (67%)
- Medical interns 17 (26%)
- Physician assistants 15 (23%)
- Doctor’s assistants 15 (23%)
- Surgery assistants 14 (21%)
- Anesthetic nurses 9 (14%)
- Orthopedic practitioner 9 (14%)
- Other** 7 (11%)
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ED–emergency department, ENT–ear nose throat.

* Data are presented as n (%).

** Volunteers, medical students.

Role of EPs in the crisis organization

At 49 (85%) hospital organizations EPs were employed. In these hospital organizations EPs were directly involved in the assessment and treatment of COVID-19 patients. They had an additional coordinating role in the ED in 43 (88%) and they were involved in triage or segregation of suspect-COVID-19 patients in 40 (82%) hospital organizations. A formal role of EPs in the hospital’s crisis management team was reported in 46 (94%) hospital organizations. An EP was member of the strategic crisis team in 19 (39%) and of the operational crisis management team in 32 (65%) hospital organizations.

Crowding

The majority (52%) of hospital organizations experienced no crowding during the first COVID-19 surge [16]. Occasional crowding was reported by 24 (41%). Four (7%) hospital organizations experienced crowding multiple times a week.

Discussion

This questionnaire-based study aimed to provide an overview of preparations of Dutch EDs for the initial phase of the COVID-19 pandemic. With a high response rate of 80% of EDs, the results are representative for the majority of Dutch EDs.

All participating EDs made preparations for a surge in COVID-19 patients. Treatment capacity area was increased in almost 70% of the participating EDs, with a median increase in treatment spaces of 50%. Suspect-COVID-19 patients were segregated from non-COVID-19 patients in 89% of EDs. The ED workforce was expanded in 82% of EDs. EPs were directly involved in the care for COVID-19 patients in all EDs and they had a prominent role in the hospital crisis management team in 94%.

The COVID-19 pandemic obliged EDs to make drastic organizational changes in a very short time span. It was then unclear for EDs if they would be adequately compliant for the requirements of the pandemic or if they were even necessary [8]. There is national Dutch guidance on clinical and ICU capacity [6]. Remarkably, however there was then no consensus or general advice on ED capacity. This is reflected by the differences found between responding EDs in this study.

Some standardization of EDs may be indeed desirable. Nonetheless most EDs planned their surge response both individually and to their satisfaction. The majority reported only occasional or no crowding. In this perspective, it is important to acknowledge that ED surge capacity planning should take individual hospital characteristics into consideration. Indeed, improvisation can be important, even when there are national guidelines. During the first wave of the COVID-19 pandemic, regions within the Netherlands differed considerably with regards to COVID-19 infection rates. This may have influenced the workload of some EDs. It could in part explain the differences between ED pandemic approaches.

The COVID-19 pandemic may have changed ED care forever and some adaptions in EDs have become permanent. E-health applications have flourished and there is more focus on securing optimal care at the correct institution [18]. Not all patient categories need ED care, but may continue to receive safe and efficient care at another location.

Furthermore, this public health crisis has shown the importance of a strong emergency and critical care system. A certain degree of overcapacity may be pivotal for an effective response. As this pandemic is ongoing, surge capacity models that allow some flexibility may be the most useful [7, 9, 19]. Hospital capacity is dynamic and highly dependent on the occupancy of available resources [20]. When the pressure on ED care is lower, capacity could be used for non-urgent care and vice versa. This way, EDs could comply timely with community demands.

Close collaboration within EDs has always been of vital importance. As shown by our results, virtually all medical disciplines were deployed in the EDs during the pandemic. Although this survey did not examine the quality of inter-disciplinary collaboration, multiple respondents greatly valued the unique situation where all kinds of disciplines worked closely together. It may not come as a surprise that EPs, internists, and pulmonologists were involved in COVID-19 ED care. However, EPs also played an important role in ED coordination and triage. Furthermore, EPs played a vital role in the hospitals’ crisis management teams. This emphasizes the necessity of the inclusion of experienced staff members working specifically in the ED.

As outbreaks of novel infectious diseases share similar characteristics, the results of this study may also relate to other future pandemics. Usually, little is known about the pathophysiology, symptomatology, and contagiousness of the disease. The lack of knowledge compels EDs to have a low threshold for isolating patients who might be contagious. EDs should therefore invest in isolation capacity. Furthermore, pandemics may result in high numbers of patients who require emergency care, which underlines the need for health care systems to have sufficient surge capacity. Finally, alterations of usual care, such as the redirection of low-acuity ED patients to outpatient departments, may help to alleviate the pressure on EDs during future pandemics.

This study does have limitations. Firstly, this was a retrospective questionnaire-based study filled in by one respondent per ED. Researchers were unaware who the anonymous respondents were and did not know the extent of their involvement in the hospital’s crisis management team. Also, the extent to which respondents were aware of the issues of care at their own hospital was not clear. Furthermore, a non-responder bias could exist, though the response rate was high and the regional COVID-19 rates of the EDs without a response were similar to the participating EDs. Lastly, patients’ self-report could have affected the validity of responses.

Globally emergency services were used less frequently during the pandemic [21]. This phenomenon is not yet completely understood. However, it may have protected many EDs from overcrowding despite their maintenance of full non-COVID-19 ED care. The pandemic approaches of these EDs may not be as successful in other crisis situations. Finally, the results of this study may not apply to EDs in some healthcare systems. This is the case in those without a strong primary care system functioning as gatekeepers for the EDs. In the Netherlands, a relatively large proportion of ED patients (82%) is referred by a general practitioner or by emergency medical services [14].

Conclusion

This study showed that all Dutch EDs made preparations for COVID-19 in a short time span and despite many uncertainties. Preparations primarily included the expansion of treatment capacity and the segregation of COVID-19 care. EPs had a prominent role, both in direct patient COVID-19 ED care and in the crisis management teams of hospitals. It is vital for EDs to be able to adapt in response to community requirements. The ability of ED’s to achieve this during the pandemic varied considerably.

Supporting information

S1 File. Questionnaire English.

(DOCX)

Click here for additional data file. (19.7KB, docx)
S2 File. Questionnaire Dutch.

(DOCX)

Click here for additional data file. (18.6KB, docx)
S1 Table. Alternative locations of emergency care.

(DOCX)

Click here for additional data file. (17.1KB, docx)
S2 Table. Measures intended as permanent

(DOCX)

Click here for additional data file. (15KB, docx)
S1 Dataset. Emergency departments.

(XLSX)

Click here for additional data file. (24KB, xlsx)
S2 Dataset. Hospital organisations.

(XLSX)

Click here for additional data file. (17.5KB, xlsx)

Acknowledgments

We would like to thank all participating EDs for their participation in this study. We also want to thank the Dutch Society of Emergency Physicians for its support in distributing the questionnaire.

Collaborators

L.M. Esteve Cuevas, M.L. Ridderikhof, dr W.A.M.H. Thijssen, R.R. Pigge, N.E. Mullaart-Jansen, R.J.C.G. Verdonschot, V. Brown, G. van Woerden, E.L. Janssens, B.Y.M. van der Kolk, B. de Groot, F. Derkx-Verhagen, W.P. Poortvliet, H. Lameijer, Y. Schoon, J. Holkenborg, L.E. Kerkvliet, M.S.A. de la Fosse, E. ter Avest, MD, PhD., K. Azijli, S. Postma, J.M. van Lieshout, B. Vlaming, C. Kok, M. Maltha, R. Lulf, R.J.L. Boden, A.E. Boendermaker, J.L.P. Kuijten, J.L. van der Meer, K. van den Broek, L. Jansen, M.J. Meijer, T.B. Nanlohij, D.J.R. Keereweer, A.G. Pol, T.J. Oosterveld-Bonsma, J.M. Huttenhuis, G.B. Spijkers, J. Jaspers.

Abbreviations

EP

Emergency physician

ED

Emergency department

ICU

Intensive care unit

IQR

Interquartile Range

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Robert Jeenchen Chen

2 Jul 2021

PONE-D-21-12869

Preparations of Dutch emergency departments for the COVID-19 pandemic: a questionnaire-based study.

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1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In their manuscript, O'Connor et al describe the results of a questionnaire filled out by individuals involved in the management of Dutch emergency departments, specifically on the preparations involved during the first wave of the COVID-19 epidemic. The questionnaire is thorough and the response rate high given the circumstances. Although the results are solely descriptive, they do offer interesting perspective on ED preparations. There are some limitations worth addressing.

One major limitation of this study is that the reader is given little information as to who the respondents were and in what capacity they served during the COVID crisis. The authors state these individuals “may also have been the most involved professionals in crisis management in these EDs” (ln 206-207) without giving any evidence to the support this. Did a manager give the questionnaire to someone else to fill out? Were respondents aware of all the issues of care at the hospital? Self-report could affect the validity of responses, which needs to be addressed clearly as a limitation.

The authors then claim that this sample is representative for all Dutch ED (ln 169). How can the authors infer this? Are they able to compare characteristics of those who did versus did not response? Were there certain hospital characteristics associated with non-response (i.e. hospital density, timing of the first wave, burden of the epidemic)? This needs to be clearer.

The authors also conclude substantial heterogeneity in response (ln 43, ln 178-9), but which statistic is this based on? The increase in treatment capacity is likely dependent on several hospital level factors (hence the variation) and it seems that the hospitals had good reasons not to increase capacity. The rest of the statistics suggest fairly common strategies, with some departures due to sensible reasons. More specific discussion on these aspects is needed.

If the authors wanted to be more thorough, they could choose two or three important outcomes, gather hospital level covariates and responses to certain questions and perform a risk factor analysis. This could give more insight into the sources of the variation observed.

It was surprising to see that the date of finalization varied so much (ln 120). Could the authors give the distribution of these dates (i.e. median and 25 75th%tile)? And what were the reasons why some of the centers were delayed until May 2020 (which was practically the end of the first wave in the Netherlands)?

Finally, as the second/third wave of the Netherlands is coming to an end, how do these results relate to future epidemics? Any particular reflections?

Minor comments:

- Abstract. Information on the unit of analysis (i.e. one respondent per ED) and the total number of respondents needs to be reported.

- ln 35. “Alternative” should be defined here.

- ln 58. How are EDs “community-based resources”? Suggest a more appropriate term.

- ln 69. Is this supposed to be a separate paragraph?

- ln 72-73. Agree, but this claim is supported by what evidence?

- ln 75. Which body? RIVM? NVZ? NVSHA? Ref 6 only refers to the Amsterdam region.

- ln 139. Maintained for an unspecified amount of time?

- Table 2 & 3. Was n the same for all statistics presented?

- Table 2. Do the options under “No increase in treatment spaces” pertain to all respondents? Or those who did not increase treatment spaces? Needs to be clear.

- ln 162, ln 180. Not sure if this really is “crowding”. In the Dutch version, the authors explicitly asked if there was a shortage in personnel. Is this directly linked to crowding? Or because a large proportion of personnel became sick? The terms should be closer to the questions asked.

- ln 199-200. Is this based on personal feedback?

- ln 212. How does primary care help here? Were the majority of hospitalized patients referred to by the general practitioner in the Netherlands?

General comment:

- The authors should have the manuscript double-checked with a native speaker. There are some Dutchisms that crop up from time to time (e.g. the double subordinate clause on lns 72-73, “therewith” on ln 132, “plaster technician” in Table 3) or awkward phrasing (e.g. “hospitals’ crisis organizations” on ln 79, “contagious patient categories” on ln 141).

Reviewer #2: The authors describe a questionnaire-based study on changes in ED infrastructure, ED workforce adaptions and the role of emergency physicians in the hopsital’s crisis organization during the first wave of the COVID-19 pandemic in the Netherlands. All responding hospital organizations made preparations for a surge in COVID-19 patients to the ED.

Minor comments

* The authors got response from 66 of the 83 Dutch emergency departments. Percentages are presented in one decimal throughout the manuscript. Given the denominator (number of EDs), it would be more appropriate to only present integers without decimals.

* Abstract. Please consider to also mention the number of responding EDs and/or total number of Dutch EDs, next to the response rate, in the abstract.

* Methods-Study design, lines 91-92. Please consider changing ‘This was designed as’ into ‘This study was designed as’.

* Results-Changes in ED infrastructure, lines 139-142. Please add ‘in’ between ‘patient categories’ and ‘8 (13.8%)’.

* Discussion, lines 167-169. The authors state here that the results are representative because of the high response rate of 80%. I agree that it is an adequate response rate. Nevertheless, is it for example possible that no response was obtained from one or more regions or academic versus non-academic hospital organizations which could have affected the representativeness?

**********

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Reviewer #1: No

Reviewer #2: No

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PLoS One. 2021 Sep 10;16(9):e0256982. doi: 10.1371/journal.pone.0256982.r002

Author response to Decision Letter 0

4 Aug 2021

Response to reviewers’ comments:

Reviewer #1: In their manuscript, O'Connor et al describe the results of a questionnaire filled out by individuals involved in the management of Dutch emergency departments, specifically on the preparations involved during the first wave of the COVID-19 epidemic. The questionnaire is thorough and the response rate high given the circumstances. Although the results are solely descriptive, they do offer interesting perspective on ED preparations. There are some limitations worth addressing.

1. One major limitation of this study is that the reader is given little information as to who the respondents were and in what capacity they served during the COVID crisis. The authors state these individuals “may also have been the most involved professionals in crisis management in these EDs” (ln 206-207) without giving any evidence to the support this. Did a manager give the questionnaire to someone else to fill out? Were respondents aware of all the issues of care at the hospital? Self-report could affect the validity of responses, which needs to be addressed clearly as a limitation.

First, I want to thank both reviewers for their efforts to review the article.

We agree that this point should be addressed. In the revised manuscript in the method section we have clarified that respondents were anonymous to the researchers. (lines 97-99) Furthermore, the discussion section is adapted according to the suggestions of the reviewer to highlight the limitation. (lines 230-231)

2. The authors then claim that this sample is representative for all Dutch ED (ln 169). How can the authors infer this? Are they able to compare characteristics of those who did versus did not response? Were there certain hospital characteristics associated with non-response (i.e. hospital density, timing of the first wave, burden of the epidemic)? This needs to be clearer.

We agree with the reviewer that the characteristics of EDs that did not respond would clarify to which extent the sample is representative for all Dutch EDs. We have therefore addressed the different characteristics the reviewer has suggested.

First, we added “The 16 EDs that did not respond were localized in different regions throughout the Netherlands and included university, teaching and peripheral hospitals.” (lines 125 – 126) and adjusted our claim in the discussion section to: ‘… the majority of …’ to the claim. (lines 183-184).

Second, concerning the timing of the first wave, we have reason to believe that this was similar for both EDs that did and did not respond, since the EDs in both groups were spread throughout the country. We also added this information in the results section. (lines 125 – 126)

Third, we added the regional incidence for all ED locations as of 31 May 2020, to table 1. (lines 129-133)

This data is publicly available in the COVID-19 dataset from the Dutch National Institute for Public Health and the Environment. We have provided a histogram in the rebuttal letter to give insight in the regional incidence of COVID-19 of EDs that did and did not respond.

Upon analyzing the EDs that did not respond to the questionnaire, we discovered that one ED was closed as of January 2020, before COVID-19 reached the Netherlands. We therefore adjusted the total number of EDs from 83 to 82 in the introduction and results section. (line 87)

Histogram comparing participating EDs to EDs without a response regarding regional COVID-19 incidence

3. The authors also conclude substantial heterogeneity in response (ln 43, ln 178-9), but which statistic is this based on? The increase in treatment capacity is likely dependent on several hospital level factors (hence the variation) and it seems that the hospitals had good reasons not to increase capacity. The rest of the statistics suggest fairly common strategies, with some departures due to sensible reasons. More specific discussion on these aspects is needed.

We agree that the term ‘heterogeneity’ may have suggested the use of a statistic. We doubt whether a statistic exists that would be able to adequately measure heterogeneity in our population. We have therefore changed the section mentioned to: “This is reflected by the differences found between responding hospitals in this study”. (Line 194)

It must also be noted that we discuss this further in the section following this sentence. As stated in our manuscript as well, we agree that hospitals may have had good reasons not to increase capacity. (lines 195 – 202)

4. If the authors wanted to be more thorough, they could choose two or three important outcomes, gather hospital level covariates and responses to certain questions and perform a risk factor analysis. This could give more insight into the sources of the variation observed.

In our opinion, a risk factor analysis was not part of the primary research question. To be able to perform such an analysis, several extra parameters would have to be gathered. As our study was meant to be a descriptive study regarding the changes in ED infrastructure, ED workforce adaptations and the role of emergency physicians in the COVID crisis, we would like to refrain from performing such an additional analysis. We agree that offering additional explanations would indeed be interesting.

5. It was surprising to see that the date of finalization varied so much (ln 120). Could the authors give the distribution of these dates (i.e. median and 25 75th%tile)? And what were the reasons why some of the centers were delayed until May 2020 (which was practically the end of the first wave in the Netherlands)?

We are thankful for this clever observation. After revising the data we discovered that the answer of 2 hospitals (finalization in May) probably had an erroneous answer in the questionnaire, because nearly all hospitals made changes to their ED infrastructure between the end of February and the end of March. The first wave was indeed practically the end of the first wave in the Netherlands. We have contacted these two EDs by telephone (emergency physician on duty) and they both provided dates in March (12 and 23 March, respectively). These dates were adjusted in the data set. We now also provide the distribution of the dates. The sentence was changed into: “The date when these preparations were completed varied between February 24 and April 1, 2020 (Median: 16 March 2020; IQR: 11 - 21 March 2020). (127 - 129)

6. Finally, as the second/third wave of the Netherlands is coming to an end, how do these results relate to future epidemics? Any particular reflections?

We agree with the reviewer that the results of our study may also relate to future pandemics. We have added a paragraph with particular reflections in the discussion section: “As outbreaks of novel infectious diseases share similar characteristics, the results of this study may also relate to other future pandemics. Usually, little is known about the pathophysiology, symptomatology, and contagiousness of the disease. The lack of knowledge compels EDs to have a low threshold for isolating patients who might be contagious. EDs should therefore invest in isolation capacity. Furthermore, pandemics may result in high numbers of patients who require emergency care, which underlines the need for health care systems to have sufficient surge capacity. Finally, alterations of usual care, such as the redirection of low-acuity ED patients to outpatient departments, may help to alleviate the pressure on EDs during future pandemics.” (lines: 221 - 228)

Minor comments:

7. Abstract. Information on the unit of analysis (i.e. one respondent per ED) and the total number of respondents needs to be reported.

We added the information according to your suggestion. (lines 26 and 31)

8. ln 35. “Alternative” should be defined here.

“Such as outpatient departments” was added to the sentence. (lines 34-35)

9. ln 58. How are EDs “community-based resources”? Suggest a more appropriate term.

The term was replaced by “public health services”(line 61)

10. ln 69. Is this supposed to be a separate paragraph?

This was adjusted, as the reviewer correctly pointed out, the segment is part of the same paragraph. (lines 71 - 72)

11. ln 72-73. Agree, but this claim is supported by what evidence? (Gideon)

Considering the claim mentioned, we agree with the reviewer that it is poorly substantiated by the authors in the article we cited (Claim: “an individualized strategy for ED preparedness that considers baseline needs and available resources is superior to a blanket strategy for all EDs.”). We therefore added “Although this claim seems sensible, evidence is scant.” (lines 75-76)

12. ln 75. Which body? RIVM? NVZ? NVSHA? Ref 6 only refers to the Amsterdam region.

This national body was the Landelijk Coördinatiecentrum Patiënten Spreiding. This was added to the text between brackets. (lines 78–79)

13. ln 139. Maintained for an unspecified amount of time?

There was indeed no specified amount of time. The text has been adjusted. (lines 150-151)

14. Table 2 & 3. Was n the same for all statistics presented?

Percentages were recalculated and were adjusted when they did not correspond to the following: % = n (value) / n (total). An additional column was added to table 2 for “treatment places”. (lines 155-157 and 165-168)

15. Table 2. Do the options under “No increase in treatment spaces” pertain to all respondents? Or those who did not increase treatment spaces? Needs to be clear.

We adjusted table 2 according to the comments of the reviewer: “No increase in treatment spaces” was changed to “Number of treatment spaces was not increased during pandemic”. We also added “Reasons for not increasing treatment spaces:” and adjusted the indentation of the specific segment. Indentation of “Location of COVID-19 ED care”, “Location of non-COVID-19 ED care” and “Screening for COVID-19 before ED entry performed with” was also adjusted for clarity. (lines 155-157)

16. ln 162, ln 180. Not sure if this really is “crowding”. In the Dutch version, the authors explicitly asked if there was a shortage in personnel. Is this directly linked to crowding? Or because a large proportion of personnel became sick? The terms should be closer to the questions asked. (Gideon)

We agree with the reviewer that the English translation does not correspond to the question asked. We therefore adjusted the English Question 16 to:

“In the spring of 2020, during the peak of the pandemic in the Netherlands, was there a moment (or moments) when the capacity of the ED was insufficient?”. (Supplemental file 1, question 16)

The comment regarding “crowding” made us realize we had not been clear which definition of ED crowding we referred to, as there have been multiple definitions in the past. To be clear to the reader which definition we use, we added “as described by Asplin et al.” to lines 176-177 and added the reference. This definition: “A situation in which the identified need for emergency services outstrips available resources in the ED.” is widely used in literature and corresponds to question 16.

17. ln 199-200. Is this based on personal feedback?

This was not based on personal feedback. As shown in Supplemental file 4, 9 respondents intended to maintain the improved interdisciplinary collaboration and 2 respondents the improved transmural collaboration.

18. ln 212. How does primary care help here? Were the majority of hospitalized patients referred to by the general practitioner in the Netherlands?

The majority of patients who present to Dutch EDs are referred by general practitioners or emergency medical services. We have added a sentence to make this clearer: “In the Netherlands, a relatively large proportion of ED patients (82%) is referred by a general practitioner or by emergency medical services.” (241-242)

General comment:

19. The authors should have the manuscript double-checked with a native speaker. There are some Dutchisms that crop up from time to time (e.g. the double subordinate clause on lns 72-73, “therewith” on ln 132, “plaster technician” in Table 3) or awkward phrasing (e.g. “hospitals’ crisis organizations” on ln 79, “contagious patient categories” on ln 141).

The whole manuscript was double-checked by a native speaker and alterations were made accordingly.

The Dutchisms mentioned by the reviewer were also adjusted:

The double subordinate clause was addressed. (Lines 74-75)

“therewith shortening ED length of stay which” Was changed to: “The latter resulted in a shortened length of stay in the ED.” (144-145)

“hospitals’ crisis organizations” was altered to hospital’s crisis management team. (line 175)

“Plaster technician” was replaced by “orthopedic practitioner” (Table 2 lines 155-157). This was also corrected in the English version of the questionnaire (supplemental file 1) and the dataset.

Reviewer #2: The authors describe a questionnaire-based study on changes in ED infrastructure, ED workforce adaptions and the role of emergency physicians in the hopsital’s crisis organization during the first wave of the COVID-19 pandemic in the Netherlands. All responding hospital organizations made preparations for a surge in COVID-19 patients to the ED.

Minor comments

20. The authors got response from 66 of the 83 Dutch emergency departments. Percentages are presented in one decimal throughout the manuscript. Given the denominator (number of EDs), it would be more appropriate to only present integers without decimals.

We agree with the reviewer and adjusted the percentages regarding number of EDs throughout the manuscript so only integers without decimals are presented.

21. Abstract. Please consider to also mention the number of responding EDs and/or total number of Dutch EDs, next to the response rate, in the abstract.

We added ”The questionnaire was completed by 58 respondents, covering” to the abstract so the number of responding EDs is mentioned next to the response rate. (line 31)

22. Methods-Study design, lines 91-92. Please consider changing ‘This was designed as’ into ‘This study was designed as’.

We adjusted the sentence according to the comment. (line 94)

23. Results-Changes in ED infrastructure, lines 139-142. Please add ‘in’ between ‘patient categories’ and ‘8 (13.8%)’.

We adjusted the sentence according to the comment. (line 153)

24. Discussion, lines 167-169. The authors state here that the results are representative because of the high response rate of 80%. I agree that it is an adequate response rate. Nevertheless, is it for example possible that no response was obtained from one or more regions or academic versus non-academic hospital organizations which could have affected the representativeness?

We agree with the reviewer that this claim deserves attention. As we responded to reviewer 1, we added characteristics of EDs that did not respond to the results (lines 125 -126) table 1 in the results (lines 129-133). We also adjusted our claim accordingly (182 – 184).

Attachment

Submitted filename: Response to Reviewers_updated.docx

Click here for additional data file. (32.4KB, docx)

Decision Letter 1

Robert Jeenchen Chen

10 Aug 2021

PONE-D-21-12869R1

Preparations of Dutch emergency departments for the COVID-19 pandemic: a questionnaire-based study.

PLOS ONE

Dear Dr. O'Connor,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please revise accordingly.

Please submit your revised manuscript by Sep 24 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Robert Jeenchen Chen, MD, MPH

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The responses are clear and I thank the authors for incorporating many of my suggestions.

Two very minor issues:

- "Plaster technicians" is still in Table 3.

- ln 178. The definition of crowding should be mentioned in the methods, not here.

Reviewer #2: (No Response)

**********

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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PLoS One. 2021 Sep 10;16(9):e0256982. doi: 10.1371/journal.pone.0256982.r004

Author response to Decision Letter 1

17 Aug 2021

Journal requirements:

1. Reference list:

The reference list was reviewed and minor adjustments to the style were made to meet PLOS requirements. None of the references were removed or retracted.

Response to reviewers’ comments:

We would like to thank the reviewers for their thoughtful comments and efforts towards improving our manuscript. The minor issues were adjusted according to their suggestions.

Reviewer #1: The responses are clear and I thank the authors for incorporating many of my suggestions. Two very minor issues:

• "Plaster technicians" is still in Table 3.

‘Plaster technician’ was alterered to ’Orthopedic practitioner’

• ln 178. The definition of crowding should be mentioned in the methods, not here.

The sentence was moved to lines 107-108 of the methods.

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file. (18.1KB, docx)

Decision Letter 2

Robert Jeenchen Chen

20 Aug 2021

Preparations of Dutch emergency departments for the COVID-19 pandemic: a questionnaire-based study.

PONE-D-21-12869R2

Dear Dr. O'Connor,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Robert Jeenchen Chen, MD, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

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Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

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Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

6. Review Comments to the Author

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Reviewer #1: (No Response)

Reviewer #2: (No Response)

**********

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Reviewer #1: No

Reviewer #2: No

Acceptance letter

Robert Jeenchen Chen

31 Aug 2021

PONE-D-21-12869R2

Preparations of Dutch emergency departments for the COVID-19 pandemic: a questionnaire-based study.

Dear Dr. O'Connor:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Robert Jeenchen Chen

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 File. Questionnaire English.

    (DOCX)

    Click here for additional data file. (19.7KB, docx)
    S2 File. Questionnaire Dutch.

    (DOCX)

    Click here for additional data file. (18.6KB, docx)
    S1 Table. Alternative locations of emergency care.

    (DOCX)

    Click here for additional data file. (17.1KB, docx)
    S2 Table. Measures intended as permanent

    (DOCX)

    Click here for additional data file. (15KB, docx)
    S1 Dataset. Emergency departments.

    (XLSX)

    Click here for additional data file. (24KB, xlsx)
    S2 Dataset. Hospital organisations.

    (XLSX)

    Click here for additional data file. (17.5KB, xlsx)
    Attachment

    Submitted filename: Response to Reviewers_updated.docx

    Click here for additional data file. (32.4KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    Click here for additional data file. (18.1KB, docx)

    Data Availability Statement

    All relevant data are within the manuscript and its Supporting Information files.

    Articles from PLoS ONE are provided here courtesy of PLOS

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