ACEM - Pandemic Planning

In Aotearoa New Zealand, this section should be read in conjunction with the New Zealand Pandemic Action Plan [Link].

In Australia, this section should be read in conjunction with Federal, State and Territory Plans:

Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) [Link]
ACT [Link]
New South Wales [Link]
Northern Territory [Link]
Queensland [Link]
Tasmania [Link]
Victoria [Link]
Western Australia [Link]

We recommend the following:

That ED leadership are actively involved with the Hospital Incident Management Team (HIMT), or equivalent, which should have been activated during the Preparedness / Standby phase of pandemic planning (Australia) or the Keep it out/ Stamp it Out (Aotearoa New Zealand) phase of pandemic planning. Active involvement of the ED in the HIMT and broader hospital planning, through direct membership or consultation, will facilitate collaboration with all areas of the hospital, which is essential for the complete and integrated, whole-of-hospital response to a pandemic.
That the hospital pandemic plan is consistent with state and federal guidelines and that, where possible, these plans are used without modification.
That the hospital pandemic plan should include all aspects of the standard Health Incident Management Plan. These will have differing titles in different jurisdictions but should include:
- Command, Coordination, Control.
- Planning, including structural elements and staffing required for different stages of pandemic response.
- Recovery.
- Communications (both external and internal).
- Operations (business as usual plus pandemic response including clinical protocols, infection control).
- Logistics (supplies and workforce).
- Intelligence (data gathering).
- Investigation.
- Finance.
The ED should not duplicate activities undertaken by the HIMT, but should provide input to ensure the plan fulfils the needs of the ED and its patients, whilst supporting the rest of the healthcare sector in managing the pandemic.
FACEMs should develop clinical guidelines in conjunction with relevant colleagues, including infection control, to ensure a consistent approach to patient care.
Code Brown should not be the primary response to a pandemic. Unlike a mass casualty event, time is available and should be used for planning and preparation, in order to avoid or delay the need for a Code Brown response. If Code Brown is used, there should be a clear, defined benefit over and above that of the hospital’s pandemic plan.
EDs have a robust system to cope with sick leave due to exposed staff having to be isolated, so that the department is still able to cope with the workload.
ED leaders advocate for the development of co-ordinated systems across different healthcare networks for the provision of staff in the event of localised workforce depletion
ED leaders advocate for the continued ability to provide clinical resources to services reliant on a FIFO medical workforce or which State cross borders

We align with the following resources:

Australian Government, Emergency Response Plan for Communicable Disease Incidents of National Significance: National Arrangements. [Link]
Australian Department of Health National Communicable Diseases Plan. [Link]
Management of Respiratory Disease Outbreaks: including Severe Influenza, Pandemic Influenza and Emerging Respiratory Illness. Australasian College for Emergency Medicine [Link]
United States Centers for Disease Control and Prevention Checklist for Health Services. [Link]

This document should be read in conjunction with relevant ACEM standards, including:

G26 Guidelines for reducing the spread of communicable infectious disease in the emergency department. [Link]

Measures to decrease ED demand
We recommend:
1. Health services develop clear agreement with external stakeholders and ambulance services regarding transport and reception of patients (especially special populations such as frail older persons).
2. Hospitals develop procedures to defer patients to alternative health services (for example, private hospitals) or defer time of presentation (for example, electives).
3. Hospitals redeploy non-ED staff (within their scope of practice) to assess acute, low risk COVID-19 patients outside the ED (for example, in clinics, in the community or on wards).
4. Hospitals support early redirection of patients seeking public health screening with mild respiratory symptoms to screening clinics (see below), which are located away from pandemic hospitals wherever possible.
5. Hospitals improve telehealth support for a range of clinical services.
6. Use of pre-existing social and traditional media avenues (for example, mobile apps) to inform patients of appropriate use of emergency services.
7. Other specialties urgently develop processes for patients to be reviewed without transit through the ED.
8. Algorithms of pre-hospital services are redirected away from the ED (for example, 13 Health).
9. Hospital in the home (HITH) units develop scalable models of care ranging from simple home monitoring to complex virtual whole hospitals, including guidelines for home or special health accommodation (including isolation hotels and hotel quarantine) management for management, escalation of care and direct admission pathways, including co-ordination with transport services.
We advocate for clinical care to occur in the most suitable setting – at home, in special health accommodation, aged care or hospitals – where safe and appropriate. This will vary between jurisdictions but aims to provide the safest and most compassionate care, whilst avoiding disease transmission and overwhelming hospital systems.
Measures to increase ED capacity
Optimising patient flow through the ED to inpatient service or to discharge will increase the ED capacity and ability to cope through the pandemic. With the bushfire crisis and now COVID-19, maldistribution of the emergency workforce to rural and regional centres has been problematic.

We recommend:
1. Urgent measures are required to increase ED staff, equipment and treatment spaces in the short term, and for maintenance of these for the duration of the pandemic and recovery. Resources need to include suitable temporary or permanent spaces for both patient care and staff facilities, that allow physical distancing.
2. Health services actively increase work hours of existing staff for those willing to do so who are not full time and recruit additional healthcare staff in the short term. Critical care staff should be encouraged to remain where their skills are most valuable and be compensated for appropriately, rather than being employed/ redeployed to other settings.
3. Health services utilise other non-ED staff in the low risk COVID-ED for suitable cases (for example, orthopaedic registrars for limb injuries, gynaecology registrars for early pregnancy bleeding).
4. Health services consider changing or increasing the footprint of EDs and short stay units to meet demand. Separate short stay and ED areas as required for confirmed and suspected infected patients. Confirmed and where possible high-risk cases should be placed in single rooms and additional spaces should be constructed with this in mind.
5. Health services optimise patient flow, to decreased access block, in preparation for increased presentations. Data system prediction models should be used. This is especially important for ICU and respiratory cases.
6. Tertiary paediatric hospitals take paediatric presentations away from other hospitals in order to increase capacity to treat unwell adults in those hospitals.
Measures to maintain healthcare system flow
The response to COVID-19 must be considered a health system response with a shared responsibility to staff, patients and risk. As such, guidelines and protocols should consider colleagues in other professions, departments, networks, societies and colleges.

We recommend:
1. That ‘hub’ hospitals maintain their support of, and accountability to, surrounding smaller facilities although specifics of that support will change with each pandemic phase.
2. There are agreed methods of medical evacuation of COVID-19 and non-COVID-19 patients from hub hospitals back to smaller facilities or community services.
3. Improved communication between hospitals and health services and key community services including RACFs and primary care.
4. Collaboration with private hospitals and other healthcare facilities.
5. Non-essential education and clinical support time is re-purposed to contribute to the pandemic response. With the increasing duration of the pandemic these activities should be recommenced in COVID-safe manners to ensure ongoing education of the workforce and maintenance of other activities, which support safe patient care, such as quality assurance activities.
6. That health services assess their capacity to provide non-critical elective surgery during the pandemic and consider screening processes
7. That health services assess their capacity to provide non-critical outpatient clinics during the pandemic, both directly and via Telehealth
8. Escalation to hospital management or public health unit if there are obstacles to transfer of care on the basis of infection-control concerns.
9. That cross-border provision of medical care continues or is replaced by state based services in the event of border closures
10. Sub-specialty hospitals eg plastics, cardiac, should develop guidelines for the transfer of patients where specialist services at one hospital close, with aims to minimise transits through EDs
Measures to improve communication
We advocate for the following:
1. A single ‘point of truth’ for rapid communication and dissemination of reliable clinical information that applies at state and national levels.
2. Coordination and clear lines of communication in critical care networks at a local, regional, state-wide and national level, and for messages to be consistent between states and federal governments wherever possible
3. Agreed clinical pathways and thresholds for intervention are shared between all critical care services.
4. Agreed referral and communication (including telehealth) pathways between rural, regional and larger metropolitan sites.
5. Agreed communication pathways between frontline clinicians and governance networks to inform of rapidly changing policy.
6. Hospitals should consider their internal communication strategies that may include COVID-huddles for staff, electronic messages, apps and use of hospital intranets
7. Agreed public and private healthcare network communication strategies to coordinate response.
Section disclaimer

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

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.

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