Challenge of COVID-19 crisis managed by emergency department of a big tertiary centre in Saudi Arabia.

BACKGROUND: The Kingdom of Saudi Arabia was hit hard by the COVID-19 pandemic wave. King Faisal Specialist Hospital and Research Centre, Riyadh dealt with the crisis in a proactive way with the emergency department (ED) playing a pivotal role. PATIENTS AND METHODS: We searched the international literature to review the processes adopted by healthcare institutions and also used our experience of managing a previous epidemic to devise safe processes for our ED patients.
RESULTS: The interventions done by ED, led to safer patient care, avoidance of unnecessary admissions, reduced risk of cross infection and enhanced staff safety.
CONCLUSIONS: Integrated ED processes helped streamline Covid-19 patients.

Introduction

COVID-19 was first reported on December 31, 2019 in China. The Kingdom of Saudi Arabia (KSA) had its first confirmed case on March 2, 2020 [1]. It was declared a pandemic by World Health Organization (WHO) on March 11, 2020. As of June 8, 2020, there are a total of 6,799,713 confirmed cases with 377,388 deaths in 216 countries. KSA has reported 98,869 confirmed cases with 676 deaths [2] as of this writing.

Majority of the world’s advanced emergency systems got quickly overwhelmed to a breaking point with the COVID-19 crisis [3]. The overcrowded emergency departments (EDs) ran the risk of succumbing with these highly infectious patients [4].

Various emergency strategies were adopted worldwide to cope with this major disaster [[5], [6], [7]]. Our ED adopted measures aligned with the international recommendations. Our objective was to search the medical literature to look for specific emergency processes implemented internationally and to share the steps taken by our ED to deal with the COVID-19 crisis.

Search strategy

We searched the US National library website (NCBI) with the underlying search strategy using keywords (covid, emergency department, steps, and processes). We retrieved 724 articles, of which 25 were relevant to our question, after reading their abstracts. We went through the full text of the selected articles, which are included as references.

“covid [All Fields] AND (“emergency service, hospital"[MeSH Terms] OR (“emergency"[All Fields] AND “service"[All Fields] AND “hospital"[All Fields]) OR “hospital emergency service"[All Fields] OR (“emergency"[All Fields] AND “department"[All Fields]) OR “emergency department"[All Fields]) AND process [All Fields] AND steps [All Fields]”

ED steps and processes in response to COVID-19

King Faisal Specialist Hospital and Research Centre is the largest tertiary care center in KSA, treating the highest number of cancer and transplant patients. Its ED is consequently geared up for managing advanced sepsis, in complex clinical scenarios. It was at the forefront of managing the lethal "Middle East Respiratory Syndrome" (MERS CoV-1) from 2012 to 2016, which originated in KSA [6]. Continuing from its lessons learnt from that smaller epidemic, it bolstered itself to deal with the monstrous Covid-19 challenge. The following were the key steps taken by our ED in the wake of COVID-19 pandemic:

Screening at the ED entrances

All the entrances leading to the Emergency Medical Services (EMS) building were manned by nurse assistants, screening all entering personnel. They checked temperature with non-touch devices, provided surgical masks, and hand sanitization.

Covid safety measures in the ED waiting room

Posters and electronic monitors displayed the audiovisual safety information. Seating arrangement was altered according to the “social distancing principles.” A separate respiratory seating area was designated in the waiting room. Number of patient attendants were limited to one.

Prehospital staff

The hospital ambulance staff were provided simulated training about the recognition of symptoms, structured pre-alerts and transfer of a suspected COVID-19 case to ED. The ambulances were advised to strictly follow recommended disinfection procedures during transport.

Decontamination tent outside ED

In preparation for a mass presentation of COVID-19 cases, a tent was erected to screen patients outside the ED premises. This tent had portable oxygen supply and facility to take diagnostic swabs.

Front end ED screening area

All new patients were screened for infectious disease before booking at the registration desk. Severe Acute Respiratory Index (SARI)was used to risk stratify patients (Fig. 1). The patients scoring high on this accredited tool were transferred to the negative pressure cubicles, which had direct access through the screening area.

Fig. 1

Adult SARI tool.

Suspected patients at triage

Experienced triage nurses were deployed to immediately cordon a suspected case, slipping the screening net. They were immediately allocated an appropriate clinical space and brought to the attention of the ED physician.

Clinical space allocation

ED allocated four purpose built negative pressure rooms for COVID-19 patients. Other cubicles were also equipped with portable “HEPA-filters.” The examination cubicles displayed airborne precautions on their doors and instructed the healthcare provider to use appropriate protective gear, before entering.

Respiratory diagnostic and treatment area

Eleven cubicles, outside the main ED were equipped and designated “respiratory screening area,” where suspected COVID-19 ambulatory patients were transferred through a safe route for diagnostic tests. Their disposition was based on clinical symptomatology with majority of them discharged home, pending COVID-19 test results.

Provision of rapid PCR testing for COVID-19 patients in ER

The turnaround time for this test was kept at 70 min. This was meant for quick transfer of admitted patients to their inpatient beds from ED, provided their test was negative. The positive patients were sent to the designated COVID-19 hospital wing, under a dedicated team. Point of Care Diagnostic Testing (POCT) for COVID-19 was also validated for ED. The chest X-rays were organized within the examination cubicles and one CT scanner was dedicated for COVID-19 patients only.

ED staff

All staff were fit tested in house, for N95 respirator masks or “Powered Air Purifying Respirators” (PARP). The shortage of the N95 masks was also predicted and controlled distribution of these masks was initially triggered. The N95 masks within the department were kept for the ED staff and the specialties were encouraged to bring their own masks from their local areas. Staff instructions to wear suitable protective gear during aerosol procedures were clearly displayed, outside the ED cubicles. These protective processes were also discussed in the daily staff huddles. Suspected ED staff were prioritized for COVID-19 screening. Any affected expatriate staff were isolated in a designated housing complex.

ED physicians

Our consultant-based ED helped organize on floor simulations for the junior physicians and allied staff. There were joint ED and ICU endotracheal intubation drills in the designated cubicles. A modified cardiopulmonary resuscitation protocol was also rehearsed for COVID-19 patients. ED consultants completed an online critical training course for “non-ICU physicians” in preparation for “hospital surge plan” (Fig. 2). As the COVID-19 patient numbers soared, the asymptomatic patients and the ones with minor symptoms were advised to isolate at home. A dedicated COVID-19 virtual shift was launched for that purpose, where a dedicated ED consultant spoke to the COVID-19 positive patients discharged from ED in the last 12 h. They triaged them based on their symptomatology. With buildup of another clinical team for this role, the responsibility of this physician was changed to provide consultations for sick COVID-19 patients only (Fig. 3).

Fig. 2

Adult EM COVID-19 Surge plan DEM.

Fig. 3

COVID-19 reporting MD

Miscellaneous steps

ED consultants’ discretion was used to allow attendants, with the COVID-19 positive patients.

Security presence was heightened to stop any untoward occurrences, due to movement restrictions.

ED coordinators (nonclinical managers) were kept available on the floor to answer any questions from the patient’s relatives.

ED covid meetings/webinars

A separate weekly staff online meeting was set up by the ED chairman for raising awareness and discussing strategies and ideas to manage the constantly changing situation. There were also regular COVID-19 updates from the hospital management.

Steps to reduce COVID-19 patient numbers in ED

Patient awareness

After the declaration of COVID-19 as a pandemic, the ED patient numbers started to increase with the “fear factor.” Later on, with the online public awareness campaign through media, the Ministry of Health (MOH) website and imposition of curfew significantly decreased the ED patient number (Fig. 4).

Fig. 4

DEM monthly total volume.

Drive through Covid-19 testing

The stable patients and employees were screened through this process, bypassing ED.

Start of virtual clinics

The hospital cancelled all the scheduled outpatient clinics, for a period of two months. This measure decreased ED influx in two ways. It stopped the inward flow from clinics to ED (e.g., admitted patients sent due to the lack of hospital beds). The telephonic consults also increased patients’ awareness, that face to face clinical encounter is not always required.

Access to clinic hotline

Hospital patients were given direct phone access of their relevant primary clinic to discuss nonemergent issues.

Establishment of Covid-19 clinic

This was established to follow up daily the COVID-19 patients who were considered suitable for home isolation.

Designated Covid-19 hospital wing

This was a geographically segregated area, well suited to accommodate and manage the COVID-19 patients, who needed inpatient treatment. It also had a secluded ICU for the patients needing ventilatory care. The COVID-19 patients being observed at home could directly be transported to their allocated bed, if their clinical condition worsened.

Dedicated microbiologist and infectious disease consultant

This was to provide expert advice particularly to the frontline staff, expedite diagnostic tests, and treatment decisions.

Discussion

COVID-19 is a serious life-threatening condition. It has a relative lower mortality than MERS CoV-1 (10% vs 34.4%), but much higher transmissibility [7,8]. Both conditions also share the same mode of transmission. We applied the principles learnt from MERS CoV-1 for managing the COVID-19 crisis. Successful previous experiences, go a long way in managing surges [9].

“Major disaster plan” in ED, triggers a joint institutional response to a mass incident [10,11]. COVID-19 crisis, not only triggered a response on disaster footings, but also led to a major transformation in the existing hospital emergency systems [[12], [13], [14]]. A “command & control center” was based next to our ED, which was guided by the “COVID-19 task force” made up of key players from each department. All major departments broke barriers and made collaborative plans to help improve ED patient flow. This joint approach, in mass casualty situations translates to a successful outcome [14,15].

ED modified its “Cardio-Pulmonary Resuscitation” (CPR) and other emergency procedures for COVID-19 patients, based on international recommendations. The modified plans took into consideration, the risk of droplet & air borne transmission caused by this disease; e.g. decision of early endotracheal intubation without initial bag and mask ventilation. Adopting evidence based clinical practices reduces risk of transmitting infection [16,17].

We took a proactive approach of screening all our ED patients for COVID-19 who presented with fever, because of their high vulnerability. We implemented a joint standard operating procedure (SOP), whereby the patients’ admission by the specialties would not be delayed, once the “decision to admit” was made by the ED. Anticipatory approach, through learning of the disease pattern, can help tailor a proportionate response [18,19].

Our ED’s patient mortality stayed unchanged, with no recorded COVID-19-related safety incident, during the crisis period. This could be because of ED preparedness, the involvement of most senior physicians, robust transfer process and the ready availability of inpatient beds. The ED boarding was significantly decreased with the above processes, which had a positive impact on patients’ mortality [20].

The availability of skillful ED workforce is vital in managing major disasters [21].

The successful screening, appropriate space allocation, barrier nursing, rapid testing, and treatment helped save lives.

ED protected its workforce by giving them clear protocols, personal protective equipment, regular drills, and daily updates about the dynamic situation [22]. As a result, majority of the ED staff were found to be in compliance with the departmental SOPs on weekly audits.

Our institution tailored its strategy, according to changing circumstances. The hospital “command and control” center kept the ED situation at the heart of its planning. This helped decant ED effectively and any sudden patient influx was dealt with efficiently. The priorities set by leaders and managing the health system can have a major impact in controlling surge [23].

COVID-19 has changed ED staff behaviors. It has inducted habits of safe distancing, regular hand hygiene, and the use of personal protective equipment. It has also created the sense of mental and physical preparedness for any similar eventuality.

EDs’ resilience, commitment, and an integrated approach helped fight this new challenge. These good practices helped slow down the propagation of COVID-19, which is likely to stay with us over the coming months and years [24].

Limitations

These processes were implemented in the ED of a big tertiary center, with a peculiar case mix, which may not apply to smaller EDs.

Conclusions

Effective ED processes go a long way in managing any crisis situation. There should always be thoughtful planning and an integrated approach in managing a challenging situation like COVID-19. The process and practices adopted by the Emergency staff can be helpful for any similar future situations.

Ethical statement

The article has been written keeping in mind all the international ethical requirements.

Declaration of competing interest

The authors declare that they have no conflicts of interests.