The New Normal ED – Living with COVID-19

EDs are faced with sustaining additional requirements to maintain patient, staff and public safety in the context of COVID-19. Ongoing Personal Protective Equipment (PPE) availability and utilisation for both patients and staff will be required long term. Additional capacity and redundancy to manage infections in staff and associated the isolation measures are required (see Workforce and Wellbeing section).

Given the required increased vigilance and workload, it is unsustainable for emergency clinicians to work in an overcrowded and under-resourced environment. Allowing this to continue is harmful for patients and clinicians and will lead to lower efficiency, staff burnout and increasing infections (see ACEM’s Access Block statement). It is essential that there is a shared awareness and accountability from other specialties and executives to manage patient flow.  There can be no tolerance for the previous situation of over-capacity hospitals, overcrowded EDs and ramped ambulances in the COVID era.

The pandemic is a unique opportunity to optimise the delivery of patient care to put patient and staff safety first. The successful models of care that have been developed to date in the pandemic must now be reviewed and implemented as standard practice, so that where appropriate, patients can minimise their time in or avoid the ED. Many EDs have introduced new safety processes, including regular ‘safety huddles’ to review infection control processes, streamlined pathways for common ED presentations, introduced and expanded community-based and “virtual” substitutive care programs, and enhanced the focus on staff training and wellbeing (see Workforce and Wellbeing section). Patient safety and system co-ordination are key principles in re-thinking ED function and design to provide patient-centred, safe care.

Every ED will need to develop a framework to address key priorities in the New Normal ED as we contend with the pandemic:

• ED design (see ED Design Layout section).
• Protocols for appropriate reception, testing, pre-screening, and cohorting of patients (see Triage and Reception of Patients section).
• Personal Protective Equipment (PPE) - appropriate to each pandemic stage according to community prevalence (see Personal and Protective Equipment section).
• Streamlined pathways for common ED presentations to minimise overcrowding, including expedited admission processes and escalation strategies if delays or capacity is reached.
• Staffing, training and a focus on staff wellbeing (see Workforce and Wellbeing section)
• Public health messaging regarding the role of an ED.

Every ED will need to reconsider its physical organisation considering the infection risk of COVID-19. Specific considerations include:

• Waiting room design to ensure appropriate physical distancing between all patients and support people in waiting areas, including 1.5m or greater between people and a maximum of 1 person per 4 square metres.
• Physical distancing between patients in treatment areas.
• Physical distancing between staff at workstations and break areas.
• Appropriate signage to support physical distancing.
• A suitable area to screen all ED presentations on arrival for COVID-19 symptoms and risk factors.
• Use of masks for staff, patients and visitors to minimise infection risk in areas of community transmission. Masks can be used as an adjunct when maximal occupancy is being reached in non-infectious areas.
• Cleaning and disinfecting of high touch surfaces regularly.
• Meetings held via video conferencing, telephone or in suitably spaced areas. Outdoor meetings may be required.
• Restriction of visitor numbers and duration of stay.
• Adequate ventilation of the ED.
• A suitable number of negative pressure isolation rooms and single rooms.
• Review of resuscitation bays for infection control considerations including storage, protected entry and exit, and communication strategies between staff who are inside and outside the room.

We recommend:

1. Each health service must develop pathways to manage possible and known COVID-19 patients, with staffing and physical resources to maximise patient and staff safety. We recommend that EDs review their processes for the reception and management of ED patients:
   • Are unable to provide an accurate history, and therefore cannot have their risk of COVID-19 infection assessed; or
   • May require an aerosol generating procedure (see ED Design Layout section Table 1). In general, a safe approach is to use the same precautions (including PPE) as for patients with suspected and confirmed COVID-19
2. Adaptation of models of care that enhance patient flow and avoid access block. This includes:
   • streamlined pathways for common ED presentations. Inpatient admissions should be expedited, with ED consultants having admitting rights for inpatient areas, and inpatient teams undertaking admissions on the wards. Robust hospital escalation strategies are required for when EDs reach capacity.
   • maintenance of critical illness pathways (for example STEMI, trauma, stroke, febrile neutropaenia) that are efficient and safe.
   • diversion of non-essential attendances to virtual models or to other providers.
3. Implementation of new access measures that go beyond the four-hour (National Emergency Access Target (NEAT); Australia) or six-hour (Shorter Stays in Emergency Departments (SSED); New Zealand) targets to reduce overcrowding and promote good quality care. Such measures need to be across the whole healthcare system and should be incentivised at the local and jurisdictional levels. These include access measures for separate disposition streams (discharges, transfers, Short Stay Unit and inpatient admissions).

We recommend:

1. Crowding of patients, visitors and staff in the ED waiting room, corridors and treatment spaces is unacceptable. Physical distancing requirements must be maintained in all working and waiting areas, including ambulance ramping/ awaiting offload areas. Waiting room occupancy needs to be measured and managed. Innovative strategies are required to allow geographically remote waiting and electronic call back where appropriate.  Breaches of safe capacity should be built into hospital wide escalation responses.
2. Ramping (delayed ambulance offload) of unscreened patient cohorts is never acceptable. This mixes possible COVID-19 patients with other potentially vulnerable patients and risks patient, staff and community harm and fatalities (see Triage and Reception of Patients section).
3. Health systems require capacity to deal with surges in ED infectious presentations and local outbreaks, through well supported and implemented escalation policies.
4. ED facility design is reviewed to incorporate enhanced numbers of negative pressure isolation rooms and single rooms, appropriate waiting area design with adequate spacing, ventilation and signage and other environmental infection prevention and control mechanisms as a priority.
5. Funding and implementation of IT and environmental redesign solutions to facilitate safe access of staff and relatives to support patients regardless of infectious status.

We recommend:

1. Providing support and creating accountability in healthcare networks for regional, rural and remote EDs, including the sharing of resources and workforce, and the use of telehealth and virtual models, and retrieval repatriation services.
2. Continual development of and investment in community, telehealth and virtual models of care for patients accessing hospital care, including Virtual EDs, Residential Aged Care Facility (RACF) acute care support programs, Hospital in the Home (HITH) services, Outpatient Services, primary care and other providers. These programs may involve emergency clinicians but must be independent models of care with dedicated funding and resources.
3. Public messaging from Health Departments and Networks continue to ensure that seriously ill patients feel confident to present to EDs but also articulate the alternative community-based services that can be accessed for less urgent healthcare needs.
4. Adoption of measures to collect, analyse and optimise patient safety data for Emergency patients across their healthcare journey. Healthcare systems should monitor the impact of system changes to identify and respond to unintended consequences, such as delayed access to time-critical interventions, iatrogenic complications, ED and inpatient length of stay and increased mortality.
5. Governance structures which allow clinician engagement and input to ensure rapid implementation of improved models of care based on evolving evidence.
6. Funding structures that incentivise positive patient experience and outcomes rather than solely incentivising activity.

We recommend:

1. Increased access to community-based care for chronic disease management with sustainable case coordination and streamlined access to reviews with specialists as required.
2. Increased access to community-based care for minor illness and injury presentations.
3. A community solution for care, housing and ‘home’ isolation options for people experiencing homelessness and those facing housing insecurity, including those living in poverty and overcrowded households. 
4. A community strategy for care of vulnerable patients including older patients, those with mental health issues, and those with disabilities who are reliant on home carers to access healthcare, while as much as possible enabling the goal of people safely remaining in their own homes.

The following resources were used in the preparation of this section:

• Australasian College for Emergency Medicine (ACEM). Policy on standard terminology (P02). Melbourne: ACEM; 2014. [Link]
• Australasian College for Emergency Medicine (ACEM). Emergency department design guidelines (G15). Melbourne: ACEM; 2014. [Link]
• Australasian College for Emergency Medicine Emergency Events Register. [Link]
• Staib A and Small N. Emergency medicine's COVID future: Facing the triple challenge after flattening the curve. Emerg. Med. Australas. 2020. doi.10.1111/1742-6723.13566. [Link]
• Chu DK et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet. 2020. 395(10242):1973-1987. [Link]
• Skinner C. At a time of looming crisis, a vision for health system transformation. Croakey, January 2020. [Link]
• Javidan et al. Report from the Emergency Department Crowding and Access Block Task Force. International Federation for Emergency Medicine, June 2020. [Link]

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources. The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.