SARS changes the ED paradigm

How the pandemic spread of COVID-19 affected children's traumatology in Italy: changes of numbers, anatomical locations, and severity

BACKGROUND

The study aim was to share our experience in hospital reorganization and management of pediatric traumatology in the early stage of COVID-19 pandemic. We centralized pediatric traumatology supposing a reduction of ER admissions, with increased severity of conditions, and a change in fracture patterns; consequently, we reorganized our structure. The COVID-19 epidemic in Europe has seen Italy as the first focus starting from February 21, 2020. Lombardy has been the most affected area. The initial NHS approach determined a high percentage of hospital admissions that led to early overload of hospitals, and we had to reorganize our structure to face the emergency.

METHODS

We retrospectively evaluated the admission and treatment data to observe the epidemiological evolution of pediatric trauma during the lockdown ordinance and compared them with the same period in 2019.

RESULTS

We found a reduction of 78% pediatric visits in the ER but no decrease in the number of pediatric fractures. We found a rate of pediatric fractures increased by 21.62%: the upper limb fractures being the most representative.

CONCLUSIONS

Our expectations were confirmed. We believe that the reorganization and the guidelines by us designed have been effective to spare resources and subtract the pediatric traumatology load from those hospitals dealing with an unexpected number of critical COVID-19 patients. Even if we experienced a significant reduction of pediatric admissions to our trauma ER, the presence of a determined number of fractures justifies the necessity of a specialized hub to collect all pediatric fractures.

NYU-EDA in modelling the effect of COVID-19 on patient volumes in a Finnish emergency department

BACKGROUND

Emergency departments (EDs) worldwide have been in the epicentre of the novel coronavirus disease (COVID-19). However, the impact of the pandemic and national emergency measures on the number of non-COVID-19 presentations and the assessed acuity of those presentations remain uncertain.

METHODS

We acquired a retrospective cohort containing all ED visits in a Finnish secondary care hospital during years 2018, 2019 and 2020. We compared the number of presentations in 2020 during the national state of emergency, i.e. from March 16 to June 11, with numbers from 2018 and 2019. Presentations were stratified using localized New York University Emergency Department Algorithm (NYU-EDA) to evaluate changes in presentations with different acuity levels.

RESULTS

A total of 27,526 presentations were observed. Compared to previous two years, total daily presentations were reduced by 23% (from 113 to 87, p < .001). In NYU-EDA classes, Non-Emergent visits were reduced the most by 42% (from 18 to 10, p < .001). Emergent presentations were reduced by 19 to 28% depending on the subgroup (p < .001). Number of injuries were reduced by 25% (from 27 to 20, p < .001). The NYU-EDA distribution changed statistically significantly with 4% point reduction in Non-Emergent visits (from 16 to 12%, p < .001) and 0.9% point increase in Alcohol-related visits (from 1.6 to 2.5%, p < .001).

CONCLUSIONS

We observed a significant reduction in total ED visits in the course of national state of emergency. Presentations were reduced in most of the NYU-EDA groups irrespective of the assessed acuity. A compensatory increase in presentations was not observed in the course of the 3 month lockdown. This implies either reduction in overall morbidity caused by decreased societal activity or widespread unwillingness to seek required medical advice.

The Impact of the COVID 19 Pandemic on Emergency Department Attendance: What Seems To Be Keeping the Patients Away?

During outbreaks such as severe acute respiratory syndrome and COVID 19, many Emergency Departments across the world had a reduction in the general attendance, including the attendance of more serious and critical diagnoses. Here, the author shares the numbers seen at Singapore General Hospital, the largest public hospital in Singapore during the period of February to June 2020. The reduction ranged from 13% to 28% compared to the same period in 2019, before the outbreak. Patient and healthcare system-related factors which may have caused these observations are discussed. The author also puts forth the Behavioral Immune System and Response mechanism as a possible explanation for patients staying away from the hospitals during the outbreak.

Dynamic emergency department response to the evolving COVID-19 pandemic: the experience of a tertiary hospital in Singapore

The coronavirus disease 2019 (COVID‐19) pandemic has placed large stressors on emergency departments (EDs) worldwide. As the pandemic progressed, EDs faced changing patient epidemiology and numbers. Our ED needed to rapidly transform to deal with the risk of COVID‐19. Having limited floor space, we opted for a phased, dynamic response that allowed us to adapt the ED multiple times as the epidemiology of the pandemic evolved. The principles behind our response include guiding ED operations with data, enhancing infection control practices, and being prepared to transform areas of the ED to care for different groups of patients. Our experience can serve to guide other EDs in planning their response to surge capacity and ED operations during such pandemics.

The Attend Study: A Retrospective Observational Study of Emergency Department Attendances During the Early Stages of the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease-19 (COVID-19) pandemic was associated with a large reduction in the number of attendances at emergency departments (EDs) in March 2020 in the United Kingdom (UK). We sought to identify which patient groups attended EDs least.

METHODS

Single-centre before and after study. We used routine administrative data from March 2020 and compared this to a composite control of March 2019 and February 2020.  Results: Mean daily attendance fell by 30% from 342 patients per day in the composite control months to 242 patients per day in March 2020. Reductions in attendance were seen in almost all patient groups but were greatest in patients with injuries, those referred by another clinician, those arriving at the weekend, and in patients who received no investigations. Multivariate analysis revealed that the proportion of patients who were admitted to hospital fell, despite the patients being sicker, older, needing more investigations, and more likely to arrive by ambulance.

DISCUSSION

The reduction in ED attendances seen in the early phases of the UK pandemic occurred in all patient groups, but was greatest in the lower acuity patients. Reasons for this are complex and likely to be multifactorial.

Emergency department 'outbreak rostering' to meet challenges of COVID-19

The COVID-19 outbreak has posed unique challenges to the emergency department rostering. Additional infection control, the possibility of quarantine of staff and minimising contact among staff have significant impact on the work of doctors in the emergency department. Infection of a single healthcare worker may require quarantine of close contacts at work. This may thus affect a potentially large number of staff. As such, we developed an Outbreak Response Roster. This Outbreak Response Roster had fixed teams of doctors working in rotation, each team that staff the emergency department in turn. Members within teams remained constant and were near equally balanced in terms of manpower and seniority of doctors. Each team worked fixed 12 hours shifts with as no overlapping of staff or staggering of shifts. Handovers between shifts were kept as brief as possible. All these were measures to limit interactions among healthcare workers. With the implementation of the roster, measures were also taken to bolster the psychological wellness of healthcare workers. With face-to-face contact limited, we also had to maintain clear, open channels for communication through technology and continue educating residents through innovative means.

Recommended Modifications and Applications of the Hospital Emergency Incident Command System for Hospital Emergency Management

The Hospital Emergency Incident Command System (Hospital Emergency Incident Command System), nowin its third edition, has emerged asa popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the Hospital Emergency Incident Command System in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (Severe Acute Respiratory Syndrome) outbreaks in eastern Asia and Toronto, Canada.

Several modifications of the Hospital Emergency Incident Command System are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the Hospital Emergency Incident Command System to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in chemical, biological, radiological, nuclear emergencies; (3) new unit leaders in theOperations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, anddependents in terrorismrelated emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types ofpatients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems.

New uses of the Hospital Emergency Incident Command System in hospital emergency management also are recommended, including: (1) the adoption of the Hospital Emergency Incident Command System as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the Hospital Emergency Incident Command System not only to healthcare facilities, but also to healthcare systems.

Finally, three levels of healthcare worker competencies in the Hospital Emergency Incident Command Systemare suggested: (1) basic understanding of the Hospital Emergency Incident Command System for all hospital healthcare workers; (2) advanced understanding and proficiency in the Hospital Emergency Incident Command Systemfor hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the Hospital Emergency Incident Command System ad hoc from existing healthcare workers in resource-deficient settings. The Hospital Emergency Incident Command System should be viewed asa work in progress that will mature as additional challenges arise and ashospitals gain further experience with its use.

An intervention to improve compliance with transmission precautions for influenza in the emergency department: successes and challenges

Background: Concern with the potential for hospital-based transmission of influenza has come to the forefront due to emergency department (ED) crowding and the novel H1N1 pandemic. Compliance with infection control guidelines for influenza in the ED is generally unknown, and effective yet low-resource training is needed to educate staff on the importance of decreasing the potential for ED transmission of the virus. Objectives: This study evaluates compliance with patient assignment and transport precautions for influenza in an urban ED before and after implementation of electronic reminders. Methods: We included patients with a diagnosis of influenza for two consecutive influenza seasons, and retrospectively collected limited patient encounter data on patient location, transport, and compliance with assignment and transport precautions for both years. For the second influenza season we sent monthly reminders to all ED providers via the electronic medical record (EMR), explaining the importance and proper use of infection control precautions in patients with suspected influenza. Compliance between the two seasons was compared using descriptive statistics and chi-squared analysis. Results: Overall compliance with infection control precautions was poor, but increased with the use of electronic reminders from 29% to 45% (p = 0.015). Compliance with precautions for patients moved to the hallway or Radiology increased from 7% to 24% (p = 0.001). Conclusions: The EMR may be a useful tool for improving compliance with transmission-based precautions by implementing reminders on order sets and informational mailings, and by tracking compliance. Future study should be undertaken to determine the most effective interventions to prevent ED transmission of influenza.

Stockpile of personal protective equipment in hospital settings: preparedness for influenza pandemics

BACKGROUND

Personal protective equipment (PPE) is known to be a crucial means of preventing influenza pandemics; however, the amount of PPE that should be stored in hospital settings has been unclear.

OBJECTIVES

The purpose of this paper is to propose a PPE calculation system to help hospitals to decide their PPE stockpile.

METHODS

We searched influenza guidelines from a number of countries and research papers on protective devices and infectious diseases. The PPE calculation system included factors such as the influenza pandemic period, risk classification by health care workers (HCW) type, and the type and number of PPE for a HCW per day.

RESULTS

We concluded that 4 sets of PPE (N95 respirators, double gloves, gowns, and goggles) per day should be prepared for HCWs in a high-risk group. Similarly, 2 sets of appropriate PPE, depending on the risk level, are required for medium- and low-risk groups. In addition, 2 surgical masks are required for every worker and inpatient and 1 for each outpatient. The PPE stockpile should be prepared to cover at least an 8-week pandemic.

CONCLUSION

Purchasing a PPE stockpile requires a sizable budget. The PPE calculation system in this paper will hopefully support hospitals in deciding their PPE stockpile.

A model "go-kit" for use at Strategic National Stockpile Points of Dispensing

The Strategic National Stockpile (SNS) is a national repository of pharmaceuticals and other medical supplies forseeably needed during a medical disaster. In the event of SNS deployment, state and local public health authorities must be prepared to receive, distribute, and dispense the materials. We propose a cache of supplies, termed the "POD go-kit," prepared in advance and locally available prior to the establishment of Points of Dispensing (POD) for SNS material. Characteristics of the preassembled go-kit are its multiplicity of use, ease of storage and transportation, minimal redundancy with SNS material, and packaging in a manner consistent with POD function. The POD go-kit is assembled into 4 separate "subkits": administrative supplies, patient routing supplies, dispensing supplies, and POD staff protection supplies. Incorporating existing practices from the SNS Listserv, this article itemizes the contents of the POD go-kit and its subkits and provides a rationale for its packaging. The Division of Strategic National Stockpile (DSNS) has not certified the proposed "POD go-kit" as a standardized POD go-kit.

Communicable respiratory threats in the ED: tuberculosis, influenza, SARS, and other aerosolized infections

Respiratory infections are the most common communicable infectious diseases. EDs are the front line for patients with respiratory infections because of their acute nature and because the ED is the principal site of health care for those at highest risk. These diseases include influenza, tuberculosis, and measles, together accounting for 25% of infectious causes of death worldwide. These are emerging and biothreat agents that follow the same route of transmission, such as pneumonic plague. We discuss epidemiology, pathogenesis, diagnosis, and treatment of each agent. Emphasis is on the ED's role as a public health prevention arena, with attention to education and disease prevention, early identification of disease in patients at risk, and reduction of illnesses.

Declining emergency department visits and costs during the severe acute respiratory syndrome (SARS) outbreak

Background

The immediate and long-term impact of severe acute respiratory syndrome (SARS) outbreak on emergency department (ED) visits and hospital expenditures for these visits has not been thoroughly investigated. The objectives of this retrospective observational study investigated the impact of SARS outbreak on ED visits and the cost of these visits in a designated SARS medical center.

Methods

Data related to the total number of ED visits and their costs were collected for the SARS epidemic period in 2003 and the same period in the preceding year in 2002. Data collected included total number of ED visits, services provided, triage categories, and total expenditures for all patients. Data for before and during the outbreak were retrieved and compared.

Results

At the peak of the SARS epidemic, the reduction in daily ED visits reached 51.6% of pre-epidemic numbers (p < 0.01). In pediatric, trauma and non-trauma patients, the maximum mean decreases in number of visits were 80.0% (p < 0.01), 57.6% (p < 0.01) and 40.8% (p < 0.01), respectively. In triage 1, 2 and 3 patients, the maximum mean decreases were 18.1% (p < 0.01), 55.9% (p < 0.01) and 53.7% (p < 0.01), respectively. The maximum decrease in total costs was 37.7% (p < 0.01). The maximum mean costs per patient increased 35.9% (p < 0.01). The proportions of increases in mean costs for each patient were attributed to laboratory investigations (31.4%), radiography (21.9%) and medications (29.5%).

Conclusion

The SARS outbreak resulted in a marked reduction in the number of ED visits which persisted for 3 months after the end of the epidemic. Total cost of treating individual patients showed a simultaneous marked increase, while overall operational costs in the ED showed a marked decrease. The increased total cost for each patient was attributed to the increased number of diagnostic procedures to screen for possible SARS in the ED.