key: cord-0753918-ovhvqh41
authors: Garra, Gregory; Gupta, Sanjey; Ferrante, Steven; Apterbach, William
title: Dedicated area within the emergency department versus an outside dedicated area for evaluation and management of suspected coronavirus disease 2019
date: 2020-11-01
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12288
sha: a79e0578b4f685bbc48bb070d16f8b475181386b
doc_id: 753918
cord_uid: ovhvqh41

BACKGROUND: The circumstances of the coronavirus disease 2019 pandemic necessitated an alternate operations strategy for efficient patient management. Alternate care sites were a viable option for managing emergency department (ED) surge in previous epidemics and disasters. OBJECTIVE: This study describes the development of an alternate care site and evaluates efficiency by comparing key performance indicators between an ad hoc nested respiratory evaluation unit (NRU) within the ED and an alternate care site outside the ED. METHODS: This was a cohort study of 2 care models in the same ED during 2 different time periods. As coronavirus disease 2019 surged in March 2020, potential treat‐and‐release patients with fever or respiratory symptoms were triaged to a dedicated ED area (NRU). As ED volume grew, these low‐acuity patients were triaged to an ACS. We compared ED length of stay, elopement, and left without being evaluated rates and ED recidivism between the 2 care models: NRU patients presented to the ED from March 16, 2020, to March 31, 2020, and ACS patients presented from April 1, 2020, to April 15, 2020. Continuous variables were compared using independent t test or Mann‐Whitney test. Categorical variables were compared using χ(2) test. RESULTS: There were 414 NRU patients and 146 alternate care site patients with no significant differences in sex or age. The mean ED length of stay was shorter for alternate care site patients: 155 versus 45 minutes (P < 0.01). Elopement and left without being evaluated rates were higher in the NRU. There was no significant difference in ED recidivism between groups: 10% versus 6% (P = 0.15). CONCLUSIONS: An alternate care site provided an efficient resource for the evaluation of patients with fever or respiratory symptoms during the coronavirus disease 2019 pandemic.

Surge capacity has been defined as a healthcare system's ability to rapidly expand normal services to meet increased demand in the event of large-scale public health emergencies or disasters. 1 Surge census is strongly associated with delays in patient evaluation, increased emergency department (ED) length of stay (LOS), and increased elopement from the ED. There are 3 essential components that contribute to surge capacity: staff, equipment, and structure (both physical and management infrastructure). 1 The American College of Emergency Physicians recommends healthcare facilities and systems plan for contingency capacity by developing alternate care sites during large-scale public health emergencies. 2 The use of alternate care sites during a surge has been previously reported [3] [4] [5] and is recommended by the Centers for Disease Control and Prevention. 6 The first confirmed case of severe acute respiratory syndrome coronavirus 2 in the United States was identified on January 15, 2020. 7 Disseminated community spread rapidly followed with amplification of cases in New Orleans, Detroit, Chicago, and New York City. 8 Similar to other respiratory virus epidemics, the circumstances of coronavirus disease 2019 (COVID-19) necessitated modifications to triage and management of ED patients in an efficient manner.

This study evaluates the efficiency of an alternate care site during the COVID-19 surge by comparing key performance indicators between a nested respiratory evaluation unit (NRU) within the ED and an alternate care site located outside but close in proximity to the ED.

A surge in patients with respiratory complaints began in March 2020.

In an attempt to cohort low-acuity patients presenting to the ED during the COVID-19 pandemic, we initially earmarked 5 single-occupancy rooms for non-toxic-appearing patients with fever or respiratory symp- Both the NRU and alternate care site functioned as treat-andrelease screening units. Workup was limited to nasal swabbing.

Patients identified as having more serious disease or suspicion of an alternate diagnosis were retriaged to another area of the ED for care.

The ED triage process was not altered during the COVID-19 surge.

After a quick registration to generate an EMR, the ED triage nurse completed a rapid assessment that included vital sings, pulse oximetry, travel screening, and assignment of an Emergency Severity Index 

There was a total of 5401 ED visits during the time intervals captured in this report; 3227 during the NRU period and 2174 in the alternate care site period. There were significant differences in the proportions of ESI levels between periods, with a higher acuity of illness and a smaller proportion of treat-and-release patients in the alternate care site interval compared with the NRU interval (Table 1) .

There were 414 patients triaged to the NRU and 146 patients triaged to the alternate care site. There was no significant difference in sex or age between groups. There were significant differences in the ESI distributions between intervals. Comparison of key ED performance metrics between the NRU and ACS patients is listed in Table 2 .

Overall, the mean ED LOS decreased from 155 minutes in the NRU to 45 minutes in the alternate care site (P < 0.01). The ED LOS for each acuity level was significantly different between groups. The rates of elopement and left without being evaluated were higher in the NRU. There was no significant difference in the overall ED revisit rate between groups; 10% versus 6% (P = 0.15). There was no significant difference in the number of patients admitted to the hospital on return visit from the NRU and alternate care site.

There are several limitations to the current report. 

We created an alternate care site outside of the ED for the evalua- Lama et al 10 found a significantly higher mortality rate among patients with non-specific interstitial pneumonia who experienced a fall in oxygen saturation ≤88% during a 6-minute walk test. Our exertional pulse oximetry test was performed on a different population of patients for a shorter length of time; however, it simulated the conditions a patient would experience upon discharge and provided an opportunity to educate patient about the disease process and his or her current symptoms.

An alternate care site staffed by emergency personnel provided an efficient resource for the evaluation of patients with fever or flu-like symptoms during the COVID-19 pandemic as demonstrated by shorter ED LOS and fewer ED return visits.

Surge capacity for healthcare systems: a conceptual framework

American College of Emergency Physicians American College of Emergency Physicians. Health care system surge capacity recognition, preparedness and response

Use of tent for screening during H1N1 pandemic: impact on quality and cost of care

A rapid medical screening process improves emergency department patient flow during surge associated with novel H1N influenza virus

Going viral: adapting to pediatric surge during the H1N1 pandemic

Consideration for alternate care sites infection prevention and control considerations for alternate care sites

First case of 2019 novel coronavirus in the United States

COVID-19), cases in the US

The walking capacity assessment in the respiratory patient

Prognostic value of desaturation during a 6-minute walk test in idiopathic interstitial pneumonia

The authors declare no conflict of interest.

Gregory Garra contributed to the conceptualization, methodology, writing, original draft preparation, and formal analysis. Sanjey Gupta contributed to the conceptualization, writing, reviewing, and editing.Steven Ferrante contributed to writing, reviewing, and editing. William Apterbach contributed to writing, reviewing, and editing.