COVID-19 Preparedness for ED Leaders Webinar
Presented March 26, 2020, by ICEP President Ernest Wang, MD, FACEP
Thanks to all who joined us for President Ernest Wang, MD, FACEP’s discussion sharing his experiences and data leading a large 4-hospital ED system through the evolving outbreak.
(Click icon bottom right to watch Fullscreen)
The 2020 Emerging Global Pandemic and the Role of Emergency Physicians
From ICEP President Dr. Ernest Wang:
On February 29, 2020, the Illinois Department of Health announced that another Illinois resident has tested positive for coronavirus. The positive test results will have to be confirmed by the U.S. Centers for Disease Control and Prevention lab. The patient is hospitalized in isolation and CDC protocols have been implemented. This is the third case identified in the state of Illinois.(1)
It is no understatement that the evolving COVID-19 outbreak has captured the attention of the world as the number one medical story of 2020. With the first two documented cases in the U.S. surfacing in Illinois, and the first case of human-to-human spread, our state quickly became the center of national scrutiny. Fortunately, both patients have recovered and released from home isolation(2) and no healthcare workers contracted the virus.(3)
As of March 1, 2020, the disease has affected at least 87,137 people affected with the majority (79,968) of cases still centered in Hubei province in mainland China. Over 7,100 individuals in over 50 countries have also contracted the disease, with the largest outbreaks in South Korea, Italy, Iran, Japan, and aboard the cruise ship Diamond Princess.(4)
ICEP is working to keep the emergency medicine community of Illinois informed about COVID-19 as new information about the epidemic emerges. ICEP represents more than 1400 physicians who practice emergency medicine in our state, including most EMS medical directors.
ICEP has been in contact with and stands ready to assist IDPH in preparing our members to handle the arrival of patients in our EDs.
Dial 1-800-889-3931 or email DPH.SICK@ILLINOIS.GOV to have all your COVID-19 questions answered.
- The global exposure rate is changing daily. Updated information is available at the World Health Organization website (5) and the Centers for Disease Control (6)
- We have to cast a wider net. Community spread in the US has been documented in California and Washington state. Clinical criteria and epidemiological risk accounting for community spread have been updated to include “Fever with severe acute lower respiratory illness (e.g., pneumonia, ARDS) requiring hospitalization and without alternative explanatory diagnosis (e.g., influenza) AND No source of exposure has been identified.”(7)
- The first U.S. mortality, the first healthcare worker affected, and the first possible outbreak in a long-term care facility attributed to COVID-19 have occurred.(8)
- Most cases are mild. 81% with an overall case-fatality rate of 2.3%.(9)
- Older patients (>70 years) and individuals with chronic diseases (cardiovascular, diabetes, chronic respiratory, hypertension, and cancer) are at higher risk of severe or critical illness.(9)
- PPE is important. The Chinese Center for Disease Control and Prevention reported that 3.8% of the 44,672 confirmed cases were affected health care workers. Of these cases, 63% were in Wuhan, where the outbreak started.(9)
- If it does show up, it will likely show up unannounced.(10) This leaves front line personnel (registration staff, triage nurses, ED nurses, and physicians) with limited time to take countermeasures to quarantine suspected patients.
- Exposure will impact your frontline staff. Over 120 healthcare workers at UC Davis are currently under self-quarantine and monitoring due to potential exposure to the one COVID-19 case that presented there.(11)
- Keep calm and wash your hands. It’s not the flu. (12) In terms of disease morbidity and mortality, influenza continues to have significantly more impact in the U.S. with over 29 million affected individuals, 280,000 hospitalizations, and 16,000 deaths (105 pediatric).
Note: At the time of publication of this page, 2 deaths have occurred in the United States, both in Washington state.
There is much we don’t currently know and that adds to our national anxiety. Can the virus be contained? What will the course of this illness be? Will it become more or less virulent? These cannot be answered definitively at this point in time.
However, a much more important and actionable question that we can ask as is:
How many people actually are affected in our local area? In our region? In the state of Illinois? In the U.S.?
If we don’t know the true number of positive patients, asymptomatic or symptomatic, then we cannot know the true prevalence of the disease in our communities, nor can we estimate the true case fatality rate.
What is our preparedness at the state, municipal, and local level?
This topic is constantly evolving as we learn more. Connect with the relevant organizations using the Resource Links below.
When can we return to work if we treat a COVD-19 patient?
Although the current recommendation is two weeks of isolation and temperature monitoring and two negative tests, there are indications that the virus can resurface in individuals who have previously tested negative, turning these individuals into carriers.(13)
Spend your energy preparing rather than panicking.
Devote your clinical bandwidth to preparing and protecting your staff and yourselves for the next wave of COVID-19 patients. We have to manage what is truly under our control.
Take the following steps to ensure that your ED is as prepared as possible to deal with a suspected case of COVID-19:
- Identify a local leader at the institutional level (i.e. infection control, emergency preparedness) and in the ED.
- Create open and fluid communication channels to allow for rapid communication both internally and externally.
- Ensure timely communication with the Illinois Department of Public Health regarding any persons under investigation.
- Create a plan for your frontline staff (registration, triage, nurses, APPS, and ED physicians) for how you will identify and rapidly isolate a suspected case.
- Create safeguards to prevent patient exposure in the waiting room, in the ED, and in the hospital.
- Simulate and drill the plan to ensure that you identify gaps and latent operational threats. Are you ready for the first case? Do all of your staff have the knowledge and skills needed to safely manage a COVID-19 patient without significant forewarning?
- Consider embedding a best practice alert in your EHR that triggers at triage.
- Create a patient testing protocol. Where will the patient be tested (i.e. ED vs designated isolation inpatient rooms)? Who are the designated individuals who will manage the patient? Only essential personnel should come into direct contact with patients.
- Create ED patient management protocols for ALL categories of patients – mild, severe, and critical – including those requiring intubation and mechanical ventilation.
- Create a plan for supply chain management. Ensuring adequate PPE including N95 masks, surgical masks, gowns, gloves, and PaPR equipment is essential to protect ED staff. There will likely be disruptions in supply due to production and demand.
- Consider utilizing telehealth capabilities for remote evaluation. This can limit exposure and PPE use.
- Have a written visitor policy
- Effective immediately, the following restrictions have been implemented to protect patients, visitors and staff:
- Visitors under the age of 18 will not be permitted; exceptions can be made on a case-by-case basis at the discretion of the bedside care team
- The number of visitors will be limited to two per patient at any one time
- Promote compliance with Hand Hygiene and Respiratory Hygiene/Cough Etiquette
- Visitors with symptoms of acute respiratory illness (including fever, cough, and sore throat) are advised to not visit patients in the hospital
- Symptomatic visitors who wish to enter a patient room are required to wear a mask and should be instructed on the importance of hand hygiene
- Visitors are strongly advised to receive influenza vaccination to prevent infection of themselves and reduce the possibility of transmission to others
- Create a patient isolation and transport plan to ensure safe transport of patients to dedicated inpatient units. Identify how many negative airflow rooms you have in your ED and your facility.
- Create a staff post-exposure plan. How you will manage staff after treating a COVID-19 patient or who have sustained potential low, medium, or high-risk exposure?
Finally, it is important to keep this outbreak in perspective. The spread of the coronavirus in a pandemic fashion does not correlate with increasing lethality. Current indications are that preparedness and basic protective measures are effective. What is clear is that ED physicians need to take proactive steps to work with their hospitals and health systems to ensure that the systems and processes are in place to best protect staff and patients. Your expertise, commitment, and courage taking care of any and all emergencies 24/7/365 sets you apart in the medical professions and I applaud and thank each and every one of you for your service.
Illinois Department of Public Health
COVID-19 Home (updated Mondays, Wednesdays, and Fridays)
World Health Organization
I would like to finish with advice from Dr. Tedros Adhanom Ghebreyesus, WHO Director-General:
February 28, 2020
Dr. Tedros Adhanom Ghebreyesus, Director-General
“…there are 10 basic things that you should know.
First, as we keep saying, clean your hands regularly with an alcohol-based hand rub, or wash them with soap and water.
Touching your face after touching contaminated surfaces or sick people is one of the ways the virus can be transmitted. By cleaning your hands, you can reduce your risk.
Second, clean surfaces regularly with disinfectant – for example kitchen benches and work desks.
Third, educate yourself about COVID-19. Make sure your information comes from reliable sources – your local or national public health agency, the WHO website, or your local health professional. Everyone should know the symptoms – for most people, it starts with a fever and a dry cough, not a runny nose. Most people will have mild disease and get better without needing any special care.
Fourth, avoid traveling if you have a fever or cough, and if you become sick while on a flight, inform the crew immediately. Once you get home, make contact with a health professional and tell them about where you have been.
Fifth, if you cough or sneeze, do it into your sleeve, or use a tissue. Dispose of the tissue immediately into a closed rubbish bin, and then clean your hands.
Sixth, if you are over 60 years old, or if you have an underlying condition like cardiovascular disease, a respiratory condition or diabetes, you have a higher risk of developing severe disease. You may wish to take extra precautions to avoid crowded areas, or places where you might interact with people who are sick.
Seventh, for everyone, if you feel unwell, stay at home and call your doctor or local health professional. He or she will ask some questions about your symptoms, where you have been and who you have had contact with.
This will help to make sure you get the right advice, are directed to the right health facility, and will prevent you from infecting others.
Eighth, if you are sick, stay at home, and eat and sleep separately from your family, use different utensils and cutlery to eat.
Ninth, if you develop shortness of breath, call your doctor and seek care immediately.
And tenth, it’s normal and understandable to feel anxious, especially if you live in a country or community that has been affected. Find out what you can do in your community. Discuss how to stay safe with your workplace, school or place of worship.
Together, we are powerful. Containment starts with you.
Our greatest enemy right now is not the virus itself. It’s fear, rumours and stigma.
And our greatest assets are facts, reason and solidarity.”(14)
ICEP will be working to provide access to information and resources to help you in your efforts to take care of these patients if and when they arrive at your door. Updates will be posted here at ICEP.org as well as sent directly to your email and posted on ICEP’s Facebook and Twitter.
With gratitude and respect,
Ernest Wang, MD, FACEP
President, Illinois College of Emergency Physicians
- Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. Published online February 24, 2020. doi:10.1001/jama.2020.2648 https://jamanetwork.com/journals/jama/fullarticle/2762130.
- Livingston E, Bucher K, Rekito A. Coronavirus Disease 2019 and Influenza. JAMA. Published online February 26, 2020. doi:10.1001/jama.2020.2633. https://jamanetwork.com/journals/jama/fullarticle/2762386
- Lan L, Xu D, Ye G, et al. Positive RT-PCR Test Results in Patients Recovered From COVID-19. JAMA. Published online February 27, 2020. doi:10.1001/jama.2020.2783. https://jamanetwork.com/journals/jama/fullarticle/2762452?guestAccessKey=7820e619-cb79-425d-8f8e-73410994ca93&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=022720