A Global Survey of Emergency Department Responses to the COVID-19 Pandemic

Prashant Mahajan, MD, MPH, MBA; Chong Shu-Ling, MD, MBBS, MRCPCH, MCI, MPH; Camilo Gutierrez, MD; Emily White, MS; Benjamin A.Y. Cher, MS; Elizabeth Freiheit, PhD; Apoorva Belle, MA, MHA; EMERGE NETWORK; Johanna Kaartinen, MD, PhD; Vijaya Arun Kumar, MD, MPH; Paul M. Middleton, MD; Chip Jin Ng, MD; Daniel Osei-Kwame, MBChB; Dominik Roth, MD, PhD; Tej Prakash Sinja, MBBS, MS; Sagar Galwankar, BBS, DNB, MPH; Michele Nypaver, MD; Nathan Kuppermann, MD, MPH; Ulf EKelund, MD, PhD

Disclosures

Western J Emerg Med. 2021;22(5):1037-1044.

Abstract and Introduction

Abstract

Introduction: Emergency departments (ED) globally are addressing the coronavirus disease 2019 (COVID-19) pandemic with varying degrees of success. We leveraged the 17-country, Emergency Medicine Education & Research by Global Experts (EMERGE) network and non-EMERGE ED contacts to understand ED emergency preparedness and practices globally when combating the COVID-19 pandemic.

Methods: We electronically surveyed EMERGE and non-EMERGE EDs from April 3–June 1, 2020 on ED capacity, pandemic preparedness plans, triage methods, staffing, supplies, and communication practices. The survey was available in English, Mandarin Chinese, and Spanish to optimize participation. We analyzed survey responses using descriptive statistics.

Results: 74/129 (57%) EDs from 28 countries in all six World Health Organization global regions responded. Most EDs were in Asia (49%), followed by North America (28%), and Europe (14%). Nearly all EDs (97%) developed and implemented protocols for screening, testing, and treating patients with suspected COVID-19 infections. Sixty percent responded that provider staffing/back-up plans were ineffective. Many sites (47/74, 64%) reported staff missing work due to possible illness with the highest provider proportion of COVID-19 exposures and infections among nurses.

Conclusion: Despite having disaster plans in place, ED pandemic preparedness and response continue to be a challenge. Global emergency research networks are vital for generating and disseminating large-scale event data, which is particularly important during a pandemic.

Introduction

Emergency departments (ED) globally are on the front lines in addressing the COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Most EDs have disaster preparedness plans in place for health system responses to large-scale disasters, including infectious disease outbreaks. However, infectious disease pandemics pose a unique challenge due to their infrequency and the extended period over which they may occur.

The incomplete and evolving knowledge of a novel pathogen limits early preparations for resource needs during a pandemic and predisposes individuals and communities to poor health outcomes. Critical evaluation of the global response to the 2009 H1N1 influenza pandemic identified substantial variability and poorly conceived or even absent preparedness plans in many emergency care systems.^[1] This missed opportunity to implement successful disaster response plans prior to the following major infectious outbreak highlights the need to study global ED responses and healthcare system preparedness on a continuous basis.^[2,3] With the ongoing COVID-19 pandemic, knowledge regarding presentation, prognosis, and response to therapies continues to evolve. It is imperative for data, lessons learned, and successful approaches used by EDs with a high pandemic burden to be made rapidly and reliably available to those in earlier stages.

Emergency medicine networks are valuable for collection of data supporting research, administrative, and educational goals and can potentially be leveraged to collate and disseminate experiences from disasters.^[4] Emergency Medicine Education & Research by Global Experts (EMERGE) is a newly developed network of 26 EDs across 17 countries and six continents whose goal is to improve the care of acutely ill and injured patients by garnering the collective experiences of its member EDs.^[5,6]

In this study we sought to leverage the EMERGE network and establish collaborations with non-EMERGE EDs to determine global ED preparedness for COVID-19 and, specifically, to identify successful processes and protocols that may be adopted and/or adapted by other EDs to improve patient outcomes.

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Table 1. Strengths and weaknesses reported from the pandemic/disaster plans.
	Strengths	Weaknesses
Communication	Communication with large number of employees, interdepartmental communication, ongoing patient/physician communication, telecommunication, health care workers' communication with government	Failure in communicating logistics
Triage	ED triage tents, pre-triage bed reassignment, creating different zones for triage based on symptoms presented	Time-consuming efforts to organize the triage plans
Testing	Creating mobile testing unit, drive-through testing units	Testing capacity was low, slow process of government approval of in-house rapid testing, difficulty in obtaining official confirmation for the need for testing, long wait time for test results, bedside equipment shortage
Supplies	Resource allocation was conducted adequately, gradually increased supplies	Difficulty in mobilization of resource, PPE shortage faced at initial stages of the pandemic, planning to secure additional PPE was a slow process
Space	Creating separate areas for patients with COVID-19 like symptoms, creating field hospitals and dedicated COVID-19 centers, creating tents, halting elective procedures, and creating space for COVID-19 patients	Creation of surge capacity for the possibility of large volume of patients with respiratory distress
Staff	Staff pooling into categories to replace staff in critical areas, smooth communication and coordination, efficient training, interdepartment training, cooperation with medical students and other health care workers, and great staff well-being initiatives	Staffing mobilization, hesitancy of certain healthcare workers, mixing staff schedule to work on all zones simultaneously, no clear direction for sick healthcare workers

ED, emergency department; COVID-19, coronavirus disease 2019; PPE, personal protection equipment.

Table 2. COVID-19 screening criteria used in participating EMERGE and non-EMERGE emergency departments.
Fever	72 (97%)
Signs/Symptoms of lower respiratory illness (cough, difficulty breathing)	71 (96%)
Close contact with a confirmed case of COVID-19	66 (89%)
Travel to affected areas	66 (89%)
Signs/Symptoms of upper respiratory illness (runny nose, sore throat)	63 (85%)
Close contact with a suspected case of COVID-19	59 (80%)
Timely relation to a possible contact (ie, 14 days)	53 (72%)
Healthcare worker	40 (54%)
Signs/Symptoms of gastrointestinal illness (vomiting, diarrhea)	36 (49%)
Nonspecific symptoms (malaise, myalgias, headache)	32 (43%)
Immunocompromised	25 (34%)

EMERGE, Emergency Medicine Education & Research by Global Experts; COVID-19, coronavirus disease 2019.

Table 3. Innovations reported and developed in response to COVID-19 across participating EMERGE* and non-EMERGE emergency departments.
Communication	• Robots for communication • Tele-consultation • Developed vernacular language standees • Dedicated call center facility (Run by medical & nursing students & doctors) • Using Zoom meeting to interact with patients regarding clinic visits, questions, etc. • Conducting community awareness sessions
Triage	• Teletriage system • App-based screening • Triage truck • Designated COVID-19 center manned by ACE team • Screening area with a Decon shower facility • Formulated a ventilator triage protocol based on a scoring system devised from existing literature
Test	• Sampling booths • Door-to-door screening for all people in the community • Drive-through swab for COVID-19 • Results available within 90 minutes for high urgency needs and number of high urgency tests is limited to 15/day • Biofire testing for patients requiring admission with results in 4–12 hours • Mobile vehicle for testing
PPE	• Ultraviolet sterilization of N95 masks • Locally designed Intubation box • Reusable ultraviolet sterilization of N95s, masks, and gowns • Disposable aerosol box for airway management • 3-D printer face shields and 3-D printed face masks. Visors used instead of masks • Use of short-sleeved gowns instead of long sleeves due to the shortage
Area	• Isolated areas, fever clinic and COVID-19 tents • Field hospitals • Flu-screening isolation facility for staff employed in COVID-19 ward • Ambulance hall rebuilt into extra patient rooms • Negative pressure room • ED restructured into zones
Staff	• Pre-triage screening station manned by non-medical ED staff • EMCREWS team managed by a consultant (attending) working remotely • Pooling of rotation forming the ACE team • Hired medical students • Hospital infection committee for training and certifying HCWs and allied staff in donning and doffing • Fever clinics with volunteers helping in segregation and providing PPE
Other	• Provide shelter options for COVID-19 positive patients • Creation of SARI cubicle • Closure of AC ducts • Use of separate lifts/elevators

3-D, three dimensional; Decon, decontamination; COVID-19, coronavirus 2019; ED, emergency department; SARI, severe acute respiratory infection; AC, air conditioner; Biofire, Biofire Diagnostics: Syndromic Infectious Disease Diagnostics (Salt Lake City, UT) ACE, anesthesia, critical care, and emergency medicine; HCW, healthcare workers; PPE, personal protective equipment.

Authors and Disclosures

Prashant Mahajan, MD, MPH, MBA*, Chong Shu-Ling, MD, MBBS, MRCPCH, MCI, MPH^†, Camilo Gutierrez, MD^‡, Emily White, MS^§, Benjamin A.Y. Cher, MS^¶, Elizabeth Freiheit, PhD^§, Apoorva Belle, MA, MHA^||, EMERGE NETWORK^#, Johanna Kaartinen, MD, PhD*, Vijaya Arun Kumar, MD, MPH^†, Paul M. Middleton, MD^‡, Chip Jin Ng, MD^§, Daniel Osei-Kwame, MBChB^¶, Dominik Roth, MD, PhD^||, Tej Prakash Sinja, MBBS, MS^#, Sagar Galwankar, BBS, DNB, MPH**, Michele Nypaver, MD^††, Nathan Kuppermann, MD, MPH^‡‡ and Ulf EKelund, MD, PhD^§§

*University of Michigan, Departments of Emergency Medicine and Pediatrics, Ann Arbor, Michigan
^†KK Women's and Children's Hospital, Department of Emergency Medicine, Singapore
^‡George Washington University School of Medicine and Health Sciences, Departments of Emergency Medicine and Pediatrics, Washington, District of Columbia
^§University of Michigan, SABER, Ann Arbor, Michigan
^¶University of Michigan Medical School, Ann Arbor, Michigan
^||University of Michigan EMERGE, Department of Emergency Medicine, Ann Arbor, Michigan
^#See supplemental file for full authorship
*University of Helsinki/Helsinki University Hospital, Department of Emergency Medicine and Services, Helsinki, Finland
^†Wayne State University, Department of Emergency Medicine, Detroit, Michigan
^‡South Western Emergency Research Institute, Department of Emergency Medicine, Liverpool, England
^§Chang Gung Memorial Hospital, Department of Emergency Medicine, Taoyuan City, Taiwan
^para;Komfo Anokye Teaching Hospital, Department of Emergency Medicine, Kumasi, Ghana
^||Medical University of Vienna, Department of Emergency Medicine, Vienna, Austria
^#All India Institute of Medical Sciences, Department of Emergency Medicine, New Delhi, India
**Sarasota Memorial Hospital, Department of Emergency Medicine, Sarasota, Florida
^††University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
^‡‡University of California, Davis School of Medicine, Departments of Emergency Medicine and Pediatrics, Davis, California
^§§Skane University at Lund, Department of Emergency Medicine, Lund, Sweden

Address for Correspondence
Prashant Mahajan, MD, MPH, MBA, University of Michigan, Department of Emergency Medicine, 1540 E Hospital Drive CW 2–737, Ann Arbor, Michigan 48109. Email: pmahajan@med.umich.edu.

Conflicts of Interest
By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.