COVID-19: resetting ED care

Postpandemic Evaluation of the Eco-Efficiency of Personal Protective Equipment Against COVID-19 in Emergency Departments: Proposal for a Mixed Methods Study

BACKGROUND

The COVID-19 pandemic has had a profound impact on emergency department (ED) care in Canada and around the world. To prevent transmission of COVID-19, personal protective equipment (PPE) was required for all ED care providers in contact with suspected cases. With mass vaccination and improvements in several infection prevention components, our hypothesis is that the risks of transmission of COVID-19 will be significantly reduced and that current PPE use will have economic and ecological consequences that exceed its anticipated benefits. Evidence is needed to evaluate PPE use so that recommendations can ensure the clinical, economic, and environmental efficiency (ie, eco-efficiency) of its use.

OBJECTIVE

To support the development of recommendations for the eco-efficient use of PPE, our research objectives are to (1) estimate the clinical effectiveness (reduced transmission, hospitalizations, mortality, and work absenteeism) of PPE against COVID-19 for health care workers; (2) estimate the financial cost of using PPE in the ED for the management of suspected or confirmed COVID-19 patients; and (3) estimate the ecological footprint of PPE use against COVID-19 in the ED.

METHODS

We will conduct a mixed method study to evaluate the eco-efficiency of PPE use in the 5 EDs of the CHU de Québec-Université Laval (Québec, Canada). To achieve our goals, the project will include four phases: systematic review of the literature to assess the clinical effectiveness of PPE (objective 1; phase 1); cost estimation of PPE use in the ED using a time-driven activity-based costing method (objective 2; phase 2); ecological footprint estimation of PPE use using a life cycle assessment approach (objective 3; phase 3); and cost-consequence analysis and focus groups (integration of objectives 1 to 3; phase 4).

RESULTS

The first 3 phases have started. The results of these phases will be available in 2023. Phase 4 will begin in 2023 and results will be available in 2024.

CONCLUSIONS

While the benefits of PPE use are likely to diminish as health care workers' immunity increases, it is important to assess its economic and ecological impacts to develop recommendations to guide its eco-efficient use.

TRIAL REGISTRATION

PROSPERO CRD42022302598; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=302598.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50682.

Operational Status of Isolation Rooms in Emergency Departments and Patient Concentration in Higher-Level Emergency Departments in Daegu Metropolitan City and Neighboring Provinces, South Korea, during the COVID-19 Pandemic

BACKGROUND

In a pandemic situation such as the one of the COVID-19 pandemic, nosocomial transmissions attempted to be prevented by initially classifying them in triage. Therefore, emergency departments (EDs) installed isolation rooms at their entrance. Additionally, a system for pre-emptive quarantine at the triage stage was established nationwide for patients with COVID-19-related symptoms.

METHODS

Data were retrospectively collected from 28,609 patients who visited the regional emergency medical center of Yeungnam University Hospital in Daegu Metropolitan City in 2021. The study population was divided into experimental and control groups comprising patients with and without COVID-19-related symptoms, respectively. The difference in the percentage of patients visiting from outside the city was investigated between the two groups. The critically ill patient (CP) ratio was analyzed in the experimental group to verify the appropriateness of visiting a higher-level ED and was further divided into sub-regions to determine their reason for visiting an ED beyond their residential region.

RESULTS

Most lower-level EDs did not have isolation rooms. About 20.1% and 17.3% of patients in the experimental and control groups visited a higher-level ED with an isolation room beyond their residential region, respectively. The absence of an isolation room in the ED in their residential region was one reason for traveling beyond their residential region, with an odds ratio of 4.44 (95% confidence interval: 0.53-8.35).

CONCLUSION

In the process of implementing the "pre-emptive quarantine" system, it was revealed that the cooperation of the lower-level EDs was not effective during the implementation of the "pre-emptive quarantine" system. Consequently, a higher number of patients with COVID-19-related symptoms had to locate an ED with an isolation room and travel a longer distance than general patients. The participation of more EDs is required.

The Rapid Development of Virtual Care Tools in Response to COVID-19: Case Studies in Three Australian Health Services

BACKGROUND

News of the impact of COVID-19 around the world delivered a brief opportunity for Australian health services to plan new ways of delivering care to large numbers of people while maintaining staff safety through greater physical separation. The rapid pivot to telemedicine and virtual care provided immediate and longer term benefits; however, such rapid-cycle development also created risks.

OBJECTIVE

The aim of this study was to understand the sociotechnical aspects of the rapid-cycle development of seven different COVID-19 virtual care tools, and to identify enablers, barriers, and risks at three health services in Victoria, Australia.

METHODS

A qualitative, embedded, multiple case study design was adopted. Researchers from three health services collaborated with university researchers who were independent from those health services to gather and analyze structured interview data from key people involved in either clinical or technical aspects of designing and deploying seven different virtual care tools.

RESULTS

The overall objectives of each health service reflected the international requirements for managing large numbers of patients safely but remotely and for protecting staff. However, the governance, digital maturity, and specific use cases at each institution shaped the methodology and specific outcomes required. Dependence on key individuals and their domain knowledge within an existing governance framework generally enabled rapid deployment, but sometimes posed barriers. Existing relationships with technical service developers enabled strong solutions, which in some cases were highly scalable. Conventional project methodologies such as steering committees, scope, budget control, tight functional specification, consumer engagement and codesign, universal accessibility, and postimplementation evaluation were ignored almost universally in this environment.

CONCLUSIONS

These three health services took a variety of approaches to the rapid-cycle development of virtual care tools to meet their urgent needs for triaging and remote monitoring during the first year of the COVID-19 pandemic. Their experiences provided insights into many social and technical barriers and enablers to the development of virtual care tools. If these are addressed proactively, they will improve clinical governance and technical management of future virtual care. Some changes can be made within individual health services, while others entail health system policy reforms. Enhancing the environment for virtual care tool design and implementation now will yield returns not only during future health emergencies but also in many more routine care settings.

Adverse events and preventive measures related to COVID-19 vaccines

The coronavirus disease 2019 (COVID-19) vaccines are categorized according to the manufacturing technique, including mRNA vaccines and adenovirus vector vaccines. According to previous studies, the reported efficacy of the COVID-19 vaccine is excellent regardless of the type of vaccine, and the majority of studies have shown similar results for safety. Most of the adverse reactions after vaccination were mild or moderate grade, and severe reactions were reported in a very small proportion. However, the adverse reactions that might occur after nationwide vaccinations can contribute to crowding of emergency departments, and this can further lead to significant obstacles to providing necessary treatment for life-threatening conditions. Therefore, as emergency physicians, we would like to present some concerns and suggestions to prevent these predictable problems.

Operationalizing a Pandemic-Ready, Telemedicine-Enabled Drive-Through and Walk-In Coronavirus Disease Garage Care System as an Alternative Care Area: A Novel Approach in Pandemic Management

OBJECTIVE

Emergency departments face unforeseen surges in patients classified as low acuity during pandemics such as the coronavirus disease pandemic. Streamlining patient flow using telemedicine in an alternative care area can reduce crowding and promote physical distancing between patients and clinicians, thus limiting personal protective equipment use. This quality improvement project describes critical elements and processes in the operationalization of a telemedicine-enabled drive-through and walk-in garage care system to improve ED throughput and conserve personal protective equipment during 3 coronavirus disease surges in 2020.

METHODS

Standardized workflows were established for the operationalization of the telemedicine-enabled drive-through and walk-in garage care system for patients presenting with respiratory illness as quality improvement during disaster. Statistical control charts present interrupted time series data on the ED length of stay and personal protective equipment use in the week before and after deployment in March, July, and November 2020.

RESULTS

Physical space, technology infrastructure, equipment, and staff workflows were critical to the operationalization of the telemedicine-enabled drive-through and walk-in garage care system. On average, the ED length of stay decreased 17%, from 4.24 hours during the week before opening to 3.54 hours during the telemedicine-enabled drive-through and walk-in garage care system operation. There was an estimated 25% to 41% reduction in personal protective equipment use during this time.

CONCLUSION

Lessons learned from this telemedicine-enabled alternative care area implementation can be used for disaster preparedness and management in the ED setting to reduce crowding, improve throughput, and conserve personal protective equipment during a pandemic.

Facilitating Test Status Information Communication in the Time of COVID-19

The Coronavirus 2019 pandemic has strained nearly every aspect of pathology practice, including preanalytic, analytic, and postanalytic processes. Much of the challenges result from high demand for limited severe acute respiratory syndrome coronavirus 2 testing capacity, a resource required to facilitate patient flow throughout the hospital system and society at large. At our institution, this led to unprecedented increases in inquiries from providers to laboratory staff relating to the expected time to result for their patients. The demand was great enough to require redeployment of staff to handle the laboratory call volume. Although these data are available in our laboratory information system, the data do not interface to our electronic health record system. We developed systems using the R statistical programming language that abstract the necessary data regarding severe acute respiratory syndrome coronavirus 2 polymerase chain reaction testing from our lab system in real time, store it, and present it to clinicians for on demand querying. These data have been accessed over 2500 times by over 100 distinct users. Median length of each user session is approximately 4.9 minutes. Because our lab information system does not persistently store tracking information while our system does, we have been able to iteratively recalculate time to result values for each tracking stop as workflows have changed over time. Facility with informatics and programming concepts coupled with clinical understanding have allowed us to swiftly develop and iterate on applications which provide efficiency gains, allowing laboratory resources to focus on generating test results for our patients.

Impact of patient isolation on emergency department length of stay: A retrospective cohort study using the Registry for Emergency Care

Objective

The number of patients with suspected COVID‐19 presenting to Australian EDs continues to impose a burden on healthcare services. Isolation is an important aspect of infection prevention and control, but has been associated with undesirable consequences among hospital inpatients. The aim of the present study was to determine if isolation is associated with an increased length of stay (LOS) in the ED.

Methods

The Registry for Emergency Care Project is a prospective cohort study with a series of nested sub‐studies. The present study was a retrospective analysis of adult patients allocated an Australasian Triage Scale category of 1 or 2 who presented to a tertiary ED between 18 and 31 May 2020. The primary outcome was ED LOS. Regression methods were used to determine the independent association between ED isolation and LOS.

Results

There were 447 patients who met inclusion criteria, of which 123 (28%) were managed in isolation. The median (interquartile range) ED LOS was 259 (210–377) min for the isolation group and 204 (126–297) min for the non‐isolation group, a difference in median ED LOS of 55 min (P < 0.001). Isolation was independently associated with a 23% increase in ED LOS (P = 0.002) and doubled the odds of an ED stay of more than 4 h (adjusted odds ratio 2.2 [1.4–3.4], P = 0.001).

Conclusion

Consistent with the anecdotal experience of Australian ED clinicians, the present study demonstrated an increased ED LOS for patients managed in isolation. Enhanced infection prevention and control precautions will be required during and beyond the current pandemic, creating significant ongoing challenges for emergency care systems.