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Table 1 Checklist for ED pandemic workflow

From: A conceptual framework for Emergency department design in a pandemic

  Situational awareness & perimeter defence ED staff protection Surge capacity management
ED Input SYSTEM
Workflow & protocols
□ Is there a single entrance into the ED?
□ Is there a screening criterion for all ED patients? (incorporating clinical and epidemiological features)
□ Is the screening criteria kept up-to-date?
□ Are there clear triage criteria (high suspect, intermediate suspect & non-suspect)
□ Is there a protocol for the type of PPE to be worn by screening, triage and ancillary staff?
□ Do all patients have to wear masks?
□ Are there safe-distancing measures for patients in waiting areas?
□ Is there a contactless screening system?
□ Is there a workflow to re-direct well patients to alternative screening centres?
Communication
□ Is there a system to allow early alert of the 1st index case?
□ Does the system alert new cluster pickups through the ED?
□ Is there a platform for communication with pre-hospital ambulance system?
□ Is there a platform for the ED surveillance team to communicate with the infectious disease team in the hospital? (e.g.: Command centre)
□ Are there clear instructions of PPE expectation in the different areas?
□ Is there clear communication about staff movement between areas?
□ Is there clear communication with patients and relatives about their movement within the different areas?
□ Is the ED able to communicate to the primary healthcare facility about changes in workflows to manage the input?
□ Is there a platform to communicate with the hospital inpatient departments?
□ Is the ED able to communicate workflow changes to the public?
STAFF (Manpower/ Leadership/ Command teams/ Operational teams/ Working teams)
□ Is there a designated ED surveillance team to monitor changes in screening criterion?
□ Are there more experienced nursing staff at triage?
□ Has security personnel been activated to restrict access into ED during outbreak period?
□ Have vulnerable staff members (e.g. pregnant or immunocompromised) been appropriately re-deployed to minimise exposure.
□ Who is responsible for training staff for PPE (ED staff, augmented, ancillary)?
□ Are there plans for augmented manpower at screening area?
□ Who trains the augmented staff for screening?
SPACE (Infrastructure/ ED spaces/ Ward spaces)
□ Do you have a screening area before triage?
□ Are there separate triage areas for patients following screening into high suspect, intermediate suspect and non-suspect categories?
□ Can the spaces be reorganised to reduce exposure & movement of staff? □ Is the IT system able to capture the patients’ data, to facilitate contact tracing?
□ Is there IT support in expanded areas?
SUPPLY (PPE/ Cleaning equipment/ Clinical management equipment)
□ Are there any point of care test kits to facilitate screening process? □ Is there adequate PPE for the different risks areas and does a reliable supply chain exist?
□ Are masks provided for patients in waiting areas?
□ Are there standby equipment for areas that need to be expanded?
ED Throughput SYSTEM
Workflow & protocols
□ Is the system able to limit movement of patients between the different suspect areas?
□ Is the system able to monitor patients and staff movement between the different suspect areas?
□ Is there a workflow for testing in the ED such that the cases can be labelled confirm infected rather than suspected?
□ Is there a strict area demarcation between the different COVID suspect areas?
□ Are there regular PPE training & audits?
□ Are there handwashing audits or equivalent?
□ Is there a workflow for PPE during intubation?
□ Is there a workflow for aerosol generating procedures?
□ Is there a workflow for the cardiac arrest/ drowsy/ AMS patients?
□ Is there a workflow for high risk suspects with time sensitive conditions (AMI, stroke)?
□ Is there a workflow for patients with respiratory symptoms?
□ Is there a workflow for dying/palliative patients?
□ Is there a workflow for patient intubation?
□ Is a rapid diagnostic test being used for the outbreak?
□ Is there a workflow with the radiologist to have reports out early?
□ Is there a workflow with microbiology for early results?
□ Is there a workflow for testing and sending well patients home?
Communication
□ Is there a platform to communicate patient workflow and management changes? □ Are Instructions readily available on donning and doffing of PAPR?
□ Is there a platform to communicate with infectious disease specialists within hospital?
□ Are there considerations for patients in high risk areas to communicate with staff through portable electronic devices from their negative pressure/ isolation rooms?
□ How is the movement of patients within the ED communicated to ED staff?
□ Is there a platform to communicate with radiologists and microbiologists to facilitate investigations done within ED?
STAFF (Manpower/ Leadership/ Command teams/ Operational teams/ Working teams)
□ Is there a system to reduce mixing between working teams? (e.g.: modular, team based or staff remaining in their allocated areas for a period of time?) □ Are there measures to avoid placing the immunocompromised and the pregnant staff in intermediate and high suspect areas?
□ Is there a self-monitoring system that allow staff to detect for early signs of infection (e.g.: temperature taking) and report in sick?
□ What will be the workflow for the allied healthcare staff in ED? (e.g.: physiotherapy)
□ Is there augmented manpower at the various areas?
SPACE (Infrastructure/ ED spaces/ Ward spaces)
□ Is there geographical/ physical segregation between the patients of different risk categories?
□ Are there negative pressure rooms in the high suspect areas?
□ Is there adequate spacing between the patients in the intermediate and high suspect areas?
□ How will radiology spaces be managed?
□ Are there shower facilities for staff?
□ Is there adequate space in the pantry for staff to have their meals with physical distancing?
□ Is there a designated path for high and intermediate suspect cases to take to their respective investigation areas (e.g.: CT scan)
□ Does the IT system allow the smooth flow of patient information from the screening to their inpatient or community notes?
SUPPLY (PPE/ Cleaning equipment/ Clinical management equipment)
□ Are there sufficient equipment for patients to rest on in the various areas without cross contamination risks? □ Are there disposable/ hospital-based scrubs that staff can wear? □ Are there alternative equipment for patient management during the outbreak (eg: spacer instead of nebuliser)
□ Is there an established supply chain for drugs?
ED Output SYSTEM
Workflow & protocols
□ Is there a workflow to determine disposition of the patients? □ Are there PPE rules for the staff bringing high and intermediate suspect patients being brought to the ward?
□ Is there a protocol to clear the route while bringing the patients up to the ward?
□ Is there a workflow for interfacility transfer?
□ Is there a workflow to clear inpatient beds during a surge?
Communication
□ Is there a method of communicating patients’ ‘suspect status’ when admitting them to the ward?
□ Is there a method of communicating patients’ status when doctors from other disciplines review patients in the ED?
□ Is there a good handover regarding patients’ suspect status when sending them to the ward? □ Is there a platform to communicate with BMU during surges?
□ Is there a platform to recall patients after they are d/c? (for contact tracing, information of results)
STAFF (Manpower/ Leadership/ Command teams/ Operational teams/ Working teams)
□ Is there adequate manpower in the holding areas? □ Is the staff transporting the patient trained to wear appropriate PPE?
□ Is the security clearing the route trained to wear appropriate PPE?
□ Is there augmented manpower at the holding areas?
□ Is the adequate manpower to transport patients?
□ Is there adequate manpower to carry out adequate cleaning of the intermediate and high suspect areas?
SPACE (Infrastructure/ ED spaces/ Ward spaces)
□ Is there adequate holding areas in the 3 suspect categories? □ Is there adequate PPE for ancillary staff (Security, admin, porter)?
□ Is there supply chain of decontamination substances?
□ Are there spaces that can be opened up during a surge to hold patients awaiting beds?
□ Are there sufficient ICU beds and is are there escalation plans when ICU beds are full?
SUPPLY (PPE/ Cleaning equipment/ Clinical management equipment)
□ Are there rapid results test kits available to detect the infection and facilitate segregation during disposition?
□ Is there adequate partitioning within the ED to keep patients of different risk profiles separated while awaiting disposition?
□ Is there adequate supplies for disposal of contaminated equipment? □ Is there adequate transport equipment (e.g. wheelchair, trolley)