The COVID-19 pandemic will continue to stretch hospital capacity globally, with local responses varying according to community impact and the limitations of workforce, infrastructure, and other resources. Emergency physicians must remain vigilant in assessing and managing possible or known positive COVID-19 patients attending emergency departments (EDs), regardless of community case numbers.

COVID-19 has seen rapid changes in EDs and within the healthcare system more generally. The challenge of delivering safe, timely, and effective patient-centred care under these circumstances presents opportunities for community-building, better communication, and system reform. Such innovation should be informed by universal principles of care that apply to all workplaces:

  • No patient emergency should compromise the safety of the healthcare workforce. It is unreasonable to expect healthcare workers to operate in overcrowded and under-resourced environments, while simultaneously operationalising rapidly changing models of patient care, maintaining rigorous infection control requirements, and embracing ever-evolving complexity in patient care delivery. Allowing this situation to continue is harmful for patients and clinicians; and will lead to lower efficiency, more staff burnout, and increased infections.
  • Emergency departments should have clear processes to identify and isolate patients who may be a source of disease transmission, with all patients to be considered as potentially infectious during high rates of community transmission. It is essential that the hospital executive, and other specialities, share accountability for managing patient flow at all times. In the COVID-19 era, and in its aftermath, there must be zero tolerance for hospitals having to operate beyond capacity, patients waiting in overcrowded EDs, and routine ambulance ramping / off-stretcher delays.
  • Planning for increased numbers of patients requiring critical care is important. Hospitals and health services should have holistic pandemic plans that encompass organisational and systemic responses, and that include but are not restricted to emergency and critical care areas. There should be agreed trigger points for EDs to switch to disaster triage. Emergency medicine clinicians should be consulted in this process, and hospital incident management teams should be informed by predetermined and graduated whole-of-hospital responses. 
  • Appropriate and judicious use of personal protective equipment (PPE) is paramount. Exposure to COVID-19 occurs in three principal ways (1) inhalation of very fine respiratory droplets and aerosol particles, (2) deposition of respiratory droplets and particles on exposed mucous membranes in the mouth, nose, or eye by direct splashes and sprays, and (3) touching mucous membranes with hands that have been soiled either directly by virus-containing respiratory fluids or indirectly by touching surfaces with virus on them. 
  • All healthcare workers providing direct patient care, or working within the patient/client zone for individuals with suspected or confirmed COVID-19, should have access to P2/N95 respirators. N95 or equivalent respirators will only provide airborne protection if they are properly fitted to the individual’s face – therefore preventing unfiltered air being drawn inside the mask. Those delivering care to suspected or confirmed COVID-19 patients should be identified, fit-tested and supplied with appropriately fitting masks at the point of clinical care.
  • Emergency departments across Australia and Aotearoa New Zealand must strive to provide culturally safe, equitable access to care for vulnerable groups, in particular older persons, Aboriginal and Torres Strait Islander peoples, and Māori. These patients are at risk of increased disease severity and death from COVID-19. ACEM acknowledges that vulnerable groups currently experience health outcomes that are avoidable and unjust. The COVID-19 pandemic has likely exacerbated such inequities and biases, partly through reduced access in other key areas of care. Equitable and transparent decision making is vital and should incorporate local community perspectives.
  • Despite the challenges that the COVID-19 pandemic presents, it is a unique opportunity to optimise the delivery of patient care, and to put patient and staff safety first. Successful models of care that have been developed during the pandemic must be considered for implementation as standard practice so that, and as appropriate, patients can minimise their time in or totally avoid the ED.

Many EDs have introduced new safety processes. These include regular ‘safety huddles’ to review infection control processes, streamlined pathways for common ED presentations, novel and expanded community-based and ‘virtual’ substitutive care programs, and enhanced staff training and wellbeing. Patient safety and system co-ordination are key principles in re-thinking ED function and design to provide patient-centred safe care.