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801 DB # 1: How can health care facilities manage PPE supplies during the COVID-19 pandemic?Forum

Since January 2020 Elsevier has created a COVID-19 resource centre with
free information in English and Mandarin on the novel coronavirus COVID19. The COVID-19 resource centre is hosted on Elsevier Connect, the
company’s public news and information website.
Elsevier hereby grants permission to make all its COVID-19-related
research that is available on the COVID-19 resource centre – including this
research content – immediately available in PubMed Central and other
publicly funded repositories, such as the WHO COVID database with rights
for unrestricted research re-use and analyses in any form or by any means
with acknowledgement of the original source. These permissions are
granted for free by Elsevier for as long as the COVID-19 resource centre
remains active.
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Contents lists available at ScienceDirect
Disease-a-Month
journal homepage: http://www.elsevier.com/locate/disamonth
COVID – 19 case study in emergency medicine
preparedness and response: from personal
protective equipment to delivery of care
Brenna Leiker, MS, PA-C, Katherine Wise, MSN, APN-CNP∗
NorthShore University HealthSystem, Jane R Perlman NP/PA Fellows 2019-2020, Division of Emergency Medicine,
Evanston, IL, United States
“May you live in interesting times”.English expression of Purported Chinese Curse
Introduction
In late 2019, a novel new virus appeared in China with reports of a cluster of pneumonia
cases in the large city of Wuhan. Current epidemiological theories trace the virus’s first appearance to a seafood market in the city. It is there the virus was thought to have passed from
animals to humans. Hundreds and then thousands of Chinese nationals developed high fevers,
body aches, and pneumonia-like symptoms. Testing to determine cause revealed it wasn’t SARS,
the coronavirus that spread around the country in 2002, or the deadly Middle East Respiratory
Syndrome, MERS; nor was it influenza, bird flu, or the adenoviruses that cause respiratory symptoms.49 All this was unfolding just before China’s biggest holiday, Spring Festival, a time when
hundreds of millions of Chinese travel to celebrate and be with family.20
Over the ensuing months, this new coronavirus spread across the globe. By February 11, 2020,
this virus was given an official name severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) by the International Committee on Taxonomy of Viruses. On that day the World Health
Organization announced the official name of the virus, there were 42,708 confirmed cases reported in China and 1017 deaths in that country, mostly in Wuhan’s Hubei province. Outside of
China, there were 393 reported cases in 24 countries and 1 death.69 In the months following
that day, many millions have gotten sick and hundreds of thousands have died. As for nomenclature, the illness that this virus causes became synonymous with the virus itself: COVID 19.

Corresponding author.
E-mail addresses: kwise@northshore.org, bleiker@northshore.org (K. Wise).
https://doi.org/10.1016/j.disamonth.2020.101060
0011-5029/© 2020 Elsevier Inc. All rights reserved.
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In the United States, the first COVID case was reported on January 21, 2020.31 In the weeks
that followed, an additional 53 cases were reported and many public health officials hoped the
viral spread was limited but containment measures were haphazard and based on a rapidly developing knowledge base about viral transmission. The federal government barred entry of most
foreign nationals with recent travel to China, but not US residents who had been to China. Little
viral testing was available or done to screen people entering the US. Given low official numbers
of cases that month, social gatherings were not restricted. Voluntary self-quarantine measures
and hand hygiene recommendations were the mainstays of response at that time.42
By late February, reports of positive cases outside of China with no recent travel history indicated a rise in community transmission and hinted at pandemic spread. Cruise ships were
particularly vulnerable to the spread of COVID with their crowded common areas, travel to new
areas, and limited medical resources.53 Italy and Iran were also seeing a rapid increase in cases,
foreshadowing the effects of widespread transmission and prompting concerns over upcoming
holiday and religious pilgrimage travel.32
On February 29th, authorities in Seattle reported the first American death from COVID; later
reports indicated the earliest COVID death in the United States was in early February in Santa
Clara County in the San Francisco Bay area.66 Ongoing community spread, attendance at professional and social events, introduction into facilities and settings prone to amplification, and
the lack of viral testing contributed to rapid increase in transmission in March in the United
States. Large social events such as Mardi Gras, spring break vacation travels, and attendance at
international professional conferences were held as planned. Directly linked increases in cases
related to events like these prompted state-led restrictions in gatherings and travel.6 A funeral
in Albany, Georgia was attended by more than 100 people. Later, Dougherty County, Georgia,
the small rural county that includes Albany, reported the highest cumulative incidence of COVID
(1630/10 0,0 0 0) in the country at the time.65 Areas particularly impacted at this time were longterm care facilities and high-density urban areas. Other factors increasing COVID spread included
confluence with influenza and pneumonia season, continued importation of virus from other areas via travel, and undetected transmission among presymptomatic or asymptomatic individuals.
By mid-March, transmission had become widespread and state and federally mandated measures to contain spread and protect health care capacity were initiated. Federal travel bans expanded to include Italy, South Korea and many European countries. Nearly all states were under some form of stay-at-home orders with closures of school and nonessential workplaces and
cancellation of sporting events and all group gatherings to try to “flatten the curve.” Most lockdowns began between late March and early April. California was the first state to issue lockdown
orders on March 19th, following the lead of San Francisco three days prior.58 Restrictions on international travel were put in place, and a No Sail Order from the Director of the CDC was issued
on March 14th, suspending travel on US waters.65 On March 26th, the United States became the
country hardest hit in the world by coronavirus with 81,321 confirmed infections.51 That trend
continues today.
COVID in Illinois
Spread of coronavirus and the challenges inherent in pandemic circumstances were similar in
the state of Illinois. Its index case was the second detected case in the United States: a woman
traveling from Wuhan, China in mid-January who returned home to Illinois and was hospitalized
a week later with pneumonia.7 Her spouse tested positive as well the following week which was
the first recorded case of local transmission in the United States.26 Early screening and positive
cases in Illinois were connected to travel histories such as recent travel to high risk areas as
with Illinois’ first case or recent travel on a cruise ship.36
Nationally, retrospective analysis of surveillance data from this time period suggests that limited community transmission likely began by early February after initial importation from travelers from China and Europe.43 This could not be tracked until late February to early March via
emergency department syndromic surveillance data as evidenced by an increase in emergency
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
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Fig. 1. Percentage of emergency department (ED) visits for COVID-19–like illness (CLI),∗ in 14 counties†,§ (three in California and Washington [A]; four in Illinois, Louisiana, Massachusetts, and Michigan [B]; and seven in New York [C]) —
National Syndromic Surveillance System,¶ February 1–April 7, 2020. Source: https://www.cdc.gov/mmwr/volumes/69/wr/
mm6922e1.htm?s_cid=mm6922e1_w#F1_down
Legend:
Abbreviation: COVID-19 = coronavirus disease 2019.

Fever and cough or shortness of breath or difficulty breathing or presence of a coronavirus diagnostic code.
† California: Santa Clara County; Washington: King County, Snohomish County; Illinois: Cook County; Louisiana: Orleans
Parish; Massachusetts: Middlesex County; Michigan: Wayne County; New York: Bronx County, Kings County, Nassau
County, New York County, Richmond County, Queens County, Westchester County.
§ King County, Washington includes Seattle; Cook County, Illinois includes Chicago and many of its suburbs; Wayne
County, Michigan includes Detroit and many of its suburbs; Orleans Parish includes New Orleans; Kings County (Brooklyn), Queens County (Queens), Bronx County (Bronx), Richmond County (Staten Island), and New York County (Manhattan) are all within New York City.
¶ From the subset of emergency departments in each county that participates in the National Syndromic Surveillance
Program.
department visits for COVID-like illness demonstrated increased incidence (Fig. 1). This data represents a critical indicator, given limitations in widespread testing at that time.
By March 10th, the first cases of coronavirus were being reported not only outside Cook
County but also in individuals with no identifiable risk factors such as recent travel or known
sick contacts.37 Retrospective analyses have confirmed the deadly nature of community transmission like the above case in Albany, Georgia: Chicago Department of Public Health (CDPH)
investigated a large, multi-family cluster of COVID positives and presumed positive cases. This
cluster investigation and tracing demonstrated transmission to non-household contacts and family gatherings after one index patient attended funeral events that triggered a chain of transmission that included 15 other confirmed and probable cases of COVID and ultimately three
deaths.25
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
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Long term care facilities (LTCF) became a particular area of focus and monitoring. The first
resident of an Illinois long term care facility that tested positive during this time spurred testing of the entire facility and resulted in 21 positive cases including 17 residents and 4 staff
members, confirming the fears of public health officials both of the inherent risky nature of
congregate living and the vulnerability of congregate living residents.38 Increased guidance from
IDPH for nursing homes included restrictions on all visitors, volunteers, and non-essential health
care personnel (e.g., barbers), cancellation of group activities and communal dining, and active
symptom monitoring for both residents and staff. As one congregate living resident summarized
during his emergency room visit at the time: “I haven’t been allowed to leave my room and they
bring all my meals to my door and leave it there. My family can’t visit me.”
By the time that Illinois Governor Pritzker issued stay-at-home orders on March 21st, Illinois
had 585 confirmed cases across 25 counties, including 163 recently diagnosed new cases and
a death toll of five.39 The directive prohibited socializing in-person with people outside your
household and gatherings larger than 10 people. Playgrounds were closed and selective green
spaces were used with 6 feet of social distancing. Only essential travel was permitted and essential services continued. At the time, Illinois was joining California, New York and Connecticut,
states with three of the largest cities in the country, to enforce strict sheltering measures. Illinois remains one the states with stricter sheltering measures in the country and subsequent
reopening guidelines currently.
COVID in the emergency department
The approach to the coronavirus pandemic in our emergency department focused on identification and isolation of infected individuals, adequate protection of staff, reporting of positive cases to the health department, effective treatment, and education of patients and families. Protocols for triaging, use of PPE (personal protective equipment), environmental services
and cleaning, even the types of tests we ordered were adjusted to maximize protection. Use of
telemedicine technologies helped mitigate risk and exposure. Care for these patients was pared
down to the most essential personnel to minimize staff exposure, especially given a worst case
scenario that predicted temporary loss of staff due to illness and quarantining. Staff was reallocated to essential areas such as the ED, ICU, home health, and nursing homes to help test
and care for COVID patients. Other staff were recruited from outpatient areas with less volume
to assist in the ED in anticipation of higher volumes and unanticipated staff absences due to
illness.
The physical space of the emergency room was re-evaluated to best triage and isolate COVID
patients. Protocols for cleaning and sanitizing rooms and common diagnostic areas (radiology, CT
scanners) were formulated to balance the need to turnover spaces efficiently but safely. A trauma
or stroke patient cannot be imaged in a CT scanner that just minutes before accommodated a
confirmed COVID positive patient, so protocol for use and cleaning had to be developed. These
were but a few of the many challenges that pandemic conditions present to an emergency room
and to a hospital.
The NorthShore University HealthSystem (NorthShore) had to be dynamic, informed, and innovative in its approach in order to provide effective care with minimal risk of exposure to
both patients and staff. NorthShore is headquartered in Evanston, IL and includes 5 hospitals–
Evanston, Skokie, Glenbrook, Highland Park and Swedish–on the north side of Chicago and its
suburbs. These ED’s are busy–seeing a combined total of over 170,0 0 0 visits annually.34 The integrated nature of the hospital system means that NorthShore can be dynamic and responsive
to the needs of the community while also having the resources to be effective.
Advanced Practice Practitioner (APPs) is a term used to represent Physician Assistants and
Nurse Practitioners. APP’s have traditionally been widely used in the NorthShore system and
are utilized in a variety of clinical areas from outpatient to inpatient roles. APP’s are used in
nearly every service area, evaluating patients, ordering tests, formulating treatment plans, and
educating and advising patients and families. The NorthShore ED APP group consists of 31 fullPlease cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
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time, part-time, and resource team APP’s. We work all the ED pavilions in both fast track and
main room areas. APP’s assist by seeing patients alongside and in addition to the physicians,
dispersing responsibilities and providing more complete care. With the advent of COVID, we
have worked to adjust our role along with the rest of the ER team. APP’s within NorthShore
have had to alter their usual role to adapt to COVID, many temporarily relocating to the ED,
Immediate Care, inpatient floor, ICU, and as part of the nursing home testing outreach team.
APP’s who participated in these roles were able to alleviate the demand placed on these departments and provide access to on-site testing. APP’s in the Immediate Cares have played a
crucial part in caring for COVID patients and providing access to testing within their clinical
sites. APP’s in the ICU have been critical in helping fill the gaps where additional staff where
needed to care for COVID patients, make calls to update family members, and provide input for
treatment protocols. We, the authors of this article, work as APP’s within the NorthShore emergency department. The following is a detailed description of our perspective on how NorthShore,
one hospital system in the US, adapted to respond to the demands of the COVID pandemic. In
writing this paper, we interviewed people across the system to help capture some of the changes
our hospital system underwent to respond to COVID.
Hospital communication during COVID
Communication throughout the COVID response faced many challenges and growing pains.
The landscape of understanding and response to the virus changed so radically over this year
that clear and constant communication was vital for healthcare workers. Challenges arose with
social distancing and sheltering at home guidelines restricting large meetings that posed a threat
of transmission,yet it was essential to maintain a clear understanding of clinical and operational
guidelines to ensure safe and effective care.
These efforts occurred on many levels. Early on, NorthShore set up an online COVID resource
center to update staff. The site was divided into protocols, updates, and specific service line
guidelines (such as surgery, vascular lab, or psychiatry admissions). Also included in updates and
education were common procedures performed in caring for COVID patients such as intubation,
donning and doffing protocols, updated testing guidelines, and proper nasopharyngeal swabbing
technique.
NorthShore’s internal COVID website also included the most recent recording of the weekly
physician update for the hospital system. These meetings were conducted by COVID response
team leaders in the NorthShore system who drew on their expertise in their clinical areas to
update and educate physicians across the system and other NorthShore employees on particular aspects of COVID and NorthShore’s response to the pandemic. Representatives included
NorthShore’s leaders including Dr. Mahalakshmi Halasyamani, Chief Quality and Transformation
Officer, Dr. Tom Hensing, Chief Quality Officer, and Dr. Kamaljit Singh, Director of Microbiology
and Infectious Diseases Research. Each offered updates including testing and laboratory data,
hospital protocols, and clinical research trials. The weekly meeting also offered a forum for addressing meeting attendees’ questions, some of which were particular to their own specialty but
also arose from general curiosity about NorthShore’s COVID response.
NorthShore’s CART (COVID Analytics Research Team) maintained a real time data resource accessible through Epic, NorthShore’s electronic medical record system. This page included current
operational COVID census within the hospital system as well as total testing outcomes. Through
the hard work of this team, data was analyzed by age, end outcome, and other markers. More
recently, CART has begun analyzing and presenting early data from NorthShore’s COVID antibody
testing.
Within the ED, our division chief Dr. Ernest Wang hosted bi-weekly call-in meetings open to
physicians, APP’s, nurses and ED staff. Those meetings focused on ED workflow and covered a
variety of topics. He also invited feedback and discussion as well as contributions from directors of each of the individual ER locations. Given the information deluge that has characterized
COVID, physicians in our group worked hard to stay up-to-date themselves and shared important
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
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information within the ED group using group chat platforms. It seemed like nearly daily there
were important new understandings of COVID and our team worked hard to share, interpret,
and discuss this information. Our ED APP manager, Sue Bednar, APN, also held call-in meetings
to field questions and concerns as well as sent out regular email updates. All these efforts were
appreciated by staff because shared knowledge is important not only for personal safety but also
for efficient and effective patient care.
With our group trying to stay informed on ED workflows in several different ED pavilions, it
was important that we received guidance and information from one central source. Sue Bednar,
Dr. Wang, and all the other physician leaders in our group worked tirelessly to keep us safe
and informed. Their work ensured that we felt calm and prepared for challenging shifts, that
we understood PPE use and rationale and ED testing and treatment protocols, and that we had
knowledge of current areas of stress in the system and measures to address these challenges and
bottlenecks in daily workflow. All this reinforced the message that we were valued members of
the organization.
PPE use and availability
As the first case of COVID was confirmed in the United States in January, hospitals, clinics,
and essential businesses across America started to think about how they were going to protect their employees. There was scarcity of equipment like standard surgical masks, N95 masks,
and gloves for not only essential businesses but the general public as many rushed to protect
themselves and their loved ones. In addition, hospitals needed to ensure that they had sufficient
gowns, face shields, shoe coverings, and hair coverings so healthcare workers could safely do
their jobs, not just in the days but also the weeks and months to come. Having adequate PPE
and training proved to be the most important means of enforcing workplace safety and preventing viral transmission to healthcare workers. Reports of high healthcare worker infection rates
out of countries badly hit by COVID like China and Italy, worried healthcare workers in the US.75
Hospital employees everywhere were questioning if their employers had the resources to protect them as the number of COVID cases grew and if the PPE would be effective. Surrounding
communities stepped up to help by donating any extra PPE they had. Despite shortages elsewhere, NorthShore has been fortunate to be able to provide adequate PPE for all employees that
came in contact with COVID patients.
Prior to the COVID pandemic, most employees hadn’t worn N95 masks often and most hadn’t
been recently fit tested for proper N95 mask size. At each NorthShore hospital, fit testing was
offered as hundreds of employees lined up to be refitted for appropriate sizing of N95 masks.
As the months progressed, employees were retested for appropriate fit as the hospital ran out
of certain sizes of N95 masks and alternatives were provided.
In addition to the need for N95 mask fit testing, NorthShore had to also reeducate employees on proper use of PPE. On March 11th, NorthShore released their first statement regarding
PPE use, drawing from WHO (World Health Organization) and CDC (Center for Disease Control) guidelines. NorthShore recommended full PPE when caring for confirmed COVID or PUIs in
Immediate Care, ED, and hospitalized settings. NorthShore also had to address concerns of improper PPE donning and doffing procedures that could inadvertently expose staff: Kang et al.44
demonstrated that healthcare personnel contaminated themselves in almost 80 percent of videotaped PPE simulations. This was especially apparent during the Ebola virus outbreaks from 2014
to 2016.46 , 23 In early March 2020, there were concerns about PPE shortages that created a tension between appropriate use and unnecessary waste. CDC guidelines at the time did not recommend wearing masks when not around COVID patients, nor did they recommend masks for
people without symptoms. It goes without saying that we all felt confused about PPE usage and
what resulted were inconsistent practices within hospitals and also between hospitals.
By mid-April every employee and visitor was required to be screened by taking temperatures
and answering questions about symptoms or exposure prior to entering any NorthShore facility.
With a negative screen, everyone entering the hospital was given a mask to wear throughout
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their visit. Distribution of masks was limited initially in efforts to preserve supply, but as the
hospital recognized the difficulty of socially distancing at work to prevent spread of infection,
universal masking became standard. As of early June, NorthShore’s positivity rate among employees is 13 percent, an improvement since enforcing universal masking and eye protection. It’s
unclear how many of these positive employees contracted COVID at work or at home, but the
decrease in positivity rate is a testament to the effectiveness of proper implementation of PPE.
As NorthShore was able to increase COVID testing, PPE protocols became more regulated. Full
PPE was required when interacting with patients with confirmed or suspected COVID including
N95 mask, goggles or face shield, hair covering, plastic or cloth gown, and gloves. NorthShore
and ED management worked hard to disseminate instructions on when and how to properly use
PPE via handouts, emails, and videos. This was especially important for employees that needed
to review how to use a PAPR and proper decontamination after performing an aerosolizing procedure like intubations (Fig. 2). Patients considered PUIs were flagged by the triage nurse and
placed in a room with both contact and airborne precaution signs on the door, indicating need
for full PPE. Patients that were not flagged as PUIs were not placed on COVID precautions, and
providers interacting with these patients were only required to use standard precautions and a
surgical mask.
Other ways in which NorthShore worked to protect its staff working directly with COVID patients was offering the opportunity to shower at work post-shift and providing hospital-issued
scrubs for shift use rather than wearing personal scrubs that must be laundered at home. Although robust literature about the use of hospital-issued scrubs to minimize exposure is lacking,
most experts don’t believe laundering scrubs at home poses an infection control problem. Regardless, Neysa P. Ernst, RN, MSN, a nurse manager in the Biocontainment Unit at Johns Hopkins
School of Nursing notes “COVID-19 is so novel that ‘psychological safety’ is extremely important… For many frontline providers, changing in and out, and wearing hospital-laundered scrubs
reduces concerns about bringing COVID home.”21 Although hospital scrub use was put up as optional to use at first, quickly all ED employees took advantage of this opportunity to prevent the
spread of COVID to home.
In addition to what was provided by NorthShore, ED employees also shared amongst themselves strategies for mask storage and eye protection, shoe changing/storage, and social distancing precautions. When N95 mask resources were limited, it became routine to wear a surgical
mask over the N95 to further prevent contamination of valuable N95 masks. A few physicians
and APP’s referred to evidence published online regarding use of UV light or moist oven heat
to decontaminate materials, some even buying personal portable UV lights to use on masks between patients.8 Items that were once kept at desks in the ED were now confined to a locker,
phones were kept in plastic bags, and hair kept in scrub caps to prevent exposure. Providers
also referenced online resources that discussed strategies to prevent contamination at work and
home through FOAM (Free Open Access Meducation) online resources like EMCRIT, EMRAP, and
Emergency Medicine Cases.
From the beginning, NorthShore collaborated with employees to align with CDC recommendations, preserve resources, and create an environment in which employees felt safe and supported. 9 Each hospital employee also had to take into account their own level of comfort, some
going so far as to isolate themselves from their family completely, sleeping in separate houses
or hotel rooms at the height of the pandemic. When it came down to it, COVID presented many
new challenges that hospitals across the nation will continue to navigate as we move through
the pandemic.
Testing and admission criteria
As we learned more about the nature of the virus and the reality of an imminent pandemic set in, America scrambled to find a widely available means of diagnosing COVID. In midFebruary, Illinois became the first state in the United States to use a nasopharyngeal swab to test
for COVID.35 According to the FDA, the sensitivity of the COVID rt-PCR test is 95% with a speciPlease cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
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Fig. 2. Donning and Doffing PPE and PAPR.
ficity of 100%, but Illinois was only producing about 12 swabs a day for the entire state.30 , 48 .
At that time, testing was extremely restricted and controlled entirely by the state which posed
difficulties in both meeting the community’s testing needs as well as incorporating testing into
hospital protocols.
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
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The rapidly changing recommendations for COVID testing in Illinois were reflected at
NorthShore as we struggled to keep up with the daily changes in testing supplies, requirements
and best use. On January 21st, NorthShore released their first statement regarding screening of
patients under investigation (PUIs) including symptoms of cough, shortness of breath, and/or
fever with either recent travel in China or contact with a COVID positive patient within the
past 14 days. This was in accordance with CDC guidelines. Initially, tests were only available
by request from the IDPH, leaving NorthShore dependent on state guidelines and resources for
testing.
When caring for a PUI patient, providers were advised to isolate the patient in a negative
pressure room, wear PPE, and contact NorthShore Infection Control for further guidance. Additionally, the guidelines for PUI’s identification continually expanded to match viral spread
throughout the world and our local community. By early March, PUI’s were considered to be
those with cough, shortness of breath, and fever and had recently returned from Italy, Korea,
Iran, or China, or patients who had come in contact with a known positive person in the past
14 days. While there were many cases already confirmed in California and Washington State and
the first few COVID cases emerging within Chicago, PUIs at this time continued to be limited.
Recognizing the danger of limited testing, in late February the FDA relaxed policies regulating development of COVID testing kits to help achieve more rapid testing capacity nationally.24
This was in response to the CDC’s failure to develop a test under the emergency use authorization granted by the FDA that prohibited other laboratories from having the same freedom
to fast track testing products. The CDC’s initial test was distributed among states but problems
with state testing sites and reagents yielded equivocal and unreliable test results.64 At a time
when the government was unable to provide adequate tests with prompt results, hospital systems across the nation were faced with the task of developing their own test as quickly as
possible. By March 12th, NorthShore became the first local community hospital in the Chicago
area to develop their own test for COVID with the capacity to run 400 tests daily. NorthShore’s
24 to 48 h test turnaround time was impressive, given this was during a time when much of
the rest of the country’s COVID testing took almost two weeks to result.
COVID also emerged in the midst of the influenza season, further complicating the approach
to a diagnosis. Testing protocols early on mandated ruling out flu/RSV prior to initiating a COVID
test and halting further viral testing with a positive influenza/RSV swab. At that time, the possibility of co-infection of COVID with other respiratory viruses was thought to be unlikely. To
simplify testing protocol, ED providers were given a flowsheet on how to approach patients
with respiratory symptoms (Fig. 4). By late March, the decision was made to remove flu/RSV
testing. The flu/RSV test was set up with a reflex to test for COVID if negative. By late March,
the majority of the flu-RSV tests had resulted as negative, while many were reflexively resulting
positive for COVID (Fig. 3). It was determined that continuing to test for flu/RSV was a misuse
of resources, and it would be best if the step was eliminated from the protocol.
By mid-March the screening criteria for COVID was expanded to include patients with recent
travel to Japan and anywhere in western Europe, domestic travel to the cities of Seattle, Boston,
San Francisco, Los Angeles, New York City and the surrounding suburbs, or patients that had
attended large gatherings such as conferences or sporting events in the past 14 days. This came
at a time when the virus continued to spread within the community. In an article published
in The Daily Northwestern “there were 55 confirmed cases in Evanston. 1865 Illinois residents
have tested positive for the virus, and 26 have died as of Thursday (03/26) at 2:30 p.m., according to the state’s Coronavirus (COVID-19) Response webpage.”29 Despite the virus’s rapid
spread, NorthShore and IDPH worked to match the testing protocol with the demand within the
community.
By early April, COVID had spread widely within the NorthShore population, significantly
impacting surrounding nursing homes, independent living facilities, and other congregate living arrangements. Eventually, community spread was so prominent and recent national or international travel rarer that history of travel became less emphasized in testing criteria. As
NorthShore further increased their ability to perform in-house testing and we learned more
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Fig. 3. Respiratory Virus Testing from December 2019 to June 2020.
about the virus, the threshold for COVID testing continued to be lowered. The testing criteria
as of April 11th is listed below:
Cough, shortness of breath, and lower respiratory symptoms
Unexplained hypoxemia (discordant exam)
Fever/chills and no alternate diagnosis
Myalgias
Anosmia/ageusia
GI symptoms including N/V/D
Radiologic findings consistent with COVID (i.e. ground glass interstitial infiltrates)
Admission from nursing home w/ or w/o known positive cases
Known positive contact within the past 14 days
New onset of severe headache
New onset of labs suspicious for COVID infection: leukopenia, atypical lymphocytes of lymphopenia,
thrombocytopenia, and elevated LFTs
Although the screening criteria is much the same as of time of writing in early June, it continues to expand as more discoveries are made and findings disseminated across the globe.
There seems to be a clear relation between COVID and vascular findings, with a study published on May 21st showing that alveolar capillary microthrombi were 9 times as prevalent
in patients with COVID as in patients with influenza.1 A COVID patient’s initial presentation
may be a catastrophic vascular event such as a stroke, mandating changes to stroke care that
included early COVID screening to protect staff.16 Another example lies in pediatric populations frequently seen in the ED: the last few months, there have been minimal findings in
the young otherwise healthy population, with a death rate of essentially 0% in those ages
0–17 in the Chicago area.62 However, as of late May, NorthShore pediatricians have alerted
providers of COVID-induced Kawasaki syndrome as well as Multisystem Inflammatory Syndrome
in Children.28 Along with COVID toes, limb ischemia, and COVID-induced hepatitis, clinicians
are still in the process of discovering the full effects of this virus and the symptoms that align
with it.
COVID disposition from the ED
Management of COVID patients from the ED requires complex decision-making and coordination. NorthShore’s protocols took advantage of its unique systems-based and multi-hospital set
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11
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response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
2020.101060
Fig. 4. ED Fever and Respiratory Symptoms Algorithm from 03/15/2020
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up in its management of COVID patients. Patients that were stable enough to go home were notified of their results via phone call or online medical record portal. Their discharge instructions
included strict self-quarantining while waiting the 24 to 48 h for test results but this was only
a small inconvenience compared to test turnaround times of up to two weeks in other parts of
the United States.
For patients who required inpatient admission, several factors in their presentation were
taken into consideration. Need for admission mostly weighed on the patient’s vital signs, specifically tachypnea and SpO2 on room air as well as the need for supplemental oxygen. Providers
also took into account radiographic findings, medical history, living situation, and other significant test findings.
Biomarkers for COVID were included in the work up and were used to help predict a positive
test or severity of illness including CRP, LDH, hepatic enzymes, and the presence of leukopenia
or lymphopenia. For example, a patient with a CRP of greater than 200, a chest x-ray with infiltrates consistent with COVID, and a marginal oxygen saturation were much more likely to be
admitted to the hospital than someone without these findings. In addition, these inflammatory
biomarkers were helpful while waiting for the results of a COVID PCR test to assist in inpatient
placement.
Determining the disposition of a COVID patient or PUI required a reevaluation of the admission process. Aside from patients that were considered stable enough to be discharged to
quarantine at home, NorthShore had to create a protocol for patients too sick to be discharged
that utilized the unique systems-based approach to COVID. Two of the four NorthShore hospitals offered a COVID floor and ICU: Evanston and Glenbrook Hospitals. Anyone who was swabbed
for COVID was then admitted to a COVID floor or ICU as they awaited the results of their test.
Skokie Hospital was no longer admitting patients as pre-pandemic, during its transition to becoming primarily an orthopedic facility. The fourth NorthShore pavilion, Highland Park, was designated as COVID-free and would admit only patients non-concerning for COVID. All COVID rule
out cases were transferred to either Glenbrook or Evanston Hospital. With a negative test result,
these patients were immediately transferred to a non COVID floor. While initially Glenbrook admitted both COVID and non COVID patients, eventually the hospital was chosen as the COVID
only hospital and all other patients were transferred to one of the two other admitting hospitals. Glenbrook’s choice to be the main COVID hospital was logical, given the layout of the newer
emergency room as it was built with the potential to become completely negative pressure. This
made it easier for the ICU to overflow into the ED rooms at Glenbrook as they reached capacity
in the inpatient areas. Therefore, the majority of the ICU patients were transferred to Glenbrook
for admission.
By the end of March an inpatient COVID hospitalist team was formed to determine which
patients being admitted required testing and to manage the COVID rule-out and known positive patients on the inpatient side. With this new team, the ED physician or APP discussed the
patient with the COVID hospitalist first and the need for testing. Once the hospitalist agreed
to admit the patient, the ED provider could place the order for the COVID test and the patient
would be admitted to the COVID team either at Evanston or Glenbrook.
The COVID hospitalist served an important role when placing patients in the appropriate setting was more important than ever. ED providers worked in collaboration with the hospitalist
to determine which patients needed to be tested for COVID. It was the physician’s responsibility
to protect both the inpatient population and the patient to be admitted from unnecessary exposure in the interim before the results of the COVID test were known. Ultimately, they were the
ones who made the testing and admission decisions. For example, consider the admission of an
elderly patient with a history of COPD, lung cancer and new respiratory symptoms. Admission
to a unit with COVID positive patients puts that patient at risk for infection but admission to a
general med surg floor can risk exposure of other patients if he does have COVID. It was important to have a team in charge of determining what was best for the patient under review, other
patients in the hospital, and the staff caring for them. As the rapid antigen test becomes more
accessible the admission process will continue to change.
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Rapid antigen swab
On May 8th, the Food and Drug Administration granted Emergency Use Authorization to the
nation’s first antigen test, the Sofia SARS Antigen FIA.24 NorthShore’s utilization of the Cepheid
Xpert Xpress rapid antigen test, made it possible to know if a patient is COVID positive in a
matter of 30 min as opposed to the 8 to 24 h it would take with the regular COVID PCR test.11
The addition of the antigen rapid COVID swab changed the admission process further by
making it easier to rule out COVID in patients where the diagnosis was unclear or wasn’t the
primary admission diagnosis. This was for patients that had not had a known positive COVID
exposure, had a history of living at a congregate living facility with positive cases, or didn’t
have lab markers or chest x-ray or CT findings consistent with COVID. For patients who had
symptoms consistent with possible COVID but the diagnosis was in question, the rapid test was
able to provide a direction for admission within an hour.
By late May, hospitals struggled to maintain an adequate supply of the antigen tests. This
meant COVID Hospitalists and ED providers had to work together to determine which cases
would benefit the most by using a rapid test. The admission protocol continues to change as
NorthShore works to obtain a consistent supply of rapid antigen tests.
The decision to intubate
The COVID pandemic forced the ED to face a troubling dilemma: how to deliver oxygen and
respiratory support to a COVID-positive patient or PUI in respiratory distress without placing
unnecessary risk to the patient or placing staff at increased risk of exposure.
Decisions to intubate are never taken lightly but factors like the high patient mortality rates
of COVID patients once intubated and the potential staff exposure during intubation also were
now being taken into consideration.
Additionally, conventional means of oxygen delivery and treatments for respiratory distress
such as noninvasive positive pressure ventilation (NPPV) modalities like BIPAP, high flow oxygen devices, and nebulized albuterol treatments became questionably dangerous tactics in a
world where transmission was measured by aerosolization, degree of exposure and distance
from source.
Reports out of China and Italy, other countries hard hit by coronavirus, were also alarming
in the high proportions of health care workers testing positive for coronavirus, presumably due
to occupational exposure.13 , 75 The rationale behind early intubation was perceived to be giving
the patient necessary ventilator support and also protecting staff from unnecessary airborne and
droplet exposure due to the closed nature of the ventilator system.
There has been an evolving understanding of the precise mechanism by which COVID is
spread such that we lacked consensus as to whether COVID is a droplet or airborne spread disease.59 This is where the term “aerosol generating procedure” gained new weight due to the
increased risk of exposure to health care workers within the vicinity of the patient during these
events, especially with prior evidence of increased viral particle spread with other viruses like
influenza.67 These events include: coughing, sneezing, NPPV with poorly fitting masks, nebulized medications via simple mask, bag mask ventilation, CPR prior to intubation, and tracheal
suctioning. All of these events could be part of treatment for a severely hypoxic COVID patient.
Early in the pandemic in the US, providers approached the problem of respiratory support
based on experiences of other countries hit hard by the pandemic.
Experiences from Italy advised early intubation to provide support for the hypoxic patient in
ways that avoided the typical aerosol generating strategies like high flow oxygen and NPPV and
to prevent a chaotic emergency intubation that can unnecessarily expose staff.4 Early on, we
treated COVID like acute respiratory distress syndrome (ARDS) and mechanical ventilation was
one of the mainstays of treatment.
This approach was supported by reports from China expressing concern that delayed intubation led to worse outcomes.52 Even transfer to another area of the hospital with the potential
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exposure to staff during transport and the safety of patient and staff during inter-hospital transport become important when considering intubation: can a patient safely be transported to the
proper intensive care unit without being intubated first?
Meng et al.52 emphasizes “timely, but not premature, intubation” but, early on, we lacked the
evidence and experience with COVID to make these decisions. At times, the decision to intubate
was clear: hypoxemia, tachypnea, work of breathing, increased fatigue, radiographic findings of
severe illness, agitation and altered mental status and rate of clinical deterioration made intubation a necessary intervention.
Yet the knowledge that once a COVID patient is placed on a ventilator, their mortality rate
rises significantly also weighed heavily on the decision: many studies quote mortality rates of
50 to 90% after intubation for COVID-related respiratory distress.70 , 61 , 3
As one ER/ICU doctor stated in an April interview with the New York Times: “You have a
disease that you don’t understand, that is very deadly… with patients that are scared and staff
that are scared… and on top of that, it does not appear that we have a good treatment strategy
other than a ventilator. We are not sure when to put a breathing tube in … the crux of it is we
don’t want to put a breathing tube in to someone who doesn’t need it knowing there’s a 70%
chance they will die and we don’t want to not put it in to someone too late.”57
Over the months of the epidemic, experience has given medicine a different, if still smallcohort and case-based, understanding of COVID’s effects on the lungs and body. Despite continued debate and more updated contributions to the discussion, understanding that COVID affects
lungs differently has grown.
The phenomenon of the “happy hypoxemic” puzzled many: many COVID patients were presenting with hypoxia without other markers of respiratory distress such as shortness of breath,
tachypnea and fatigue. After intubation, these hypoxic patients weren’t displaying the decreased
lung compliance of ARDS and instead showed a pure hypoxemia without stiffness or evidence of
end organ damage.50 Clinicians began to consider other strategies than intubation such as high
flow oxygen delivery devices and awake or self proning.
Many providers noted that these hypoxic patients actually did not “tire out” and require dangerous “crash intubations” and instead slowly improved over time. Others noted these patients
became more hypoxic without signs of distress but then noted worsening bradycardia and cardiac arrest.60 Another physician noted a story of “a patient satting 61% room air with a heart rate
of 135, and tachypneic. He was talking and sitting up, signing consent to let us take pictures. We
proned him and started high-flow. 2 h later, his sats were in the 90s”.60
All these stories are anecdotes, stories of a single or small number of patients; medicine is
based on large volume, evidence-based strategies. As one ICU doctor summarized for the New
York Times in April: “Within the last two weeks, what has been unacceptable has become very
acceptable. Some of these patients don’t need to be intubated. You watch them carefully, you
make sure their oxygenation is adequate and they can recover.”57 As another contributor stated
about his experience with COVID in an emergency medicine blog post: “The patient will teach
us about the disease, but we have to really listen and watch to see how he responds to treatments”.60 This is the predicament of changing knowledge and treatment recommendations for
intubation and oxygen support over the COVID pandemic.
The intubation process
As a potentially highly transmissible aerosol generating procedure (AGP), the intubation process was reevaluated and standardized in the ED. Close proximity to the patient’s airway, necessity of removing the patient’s mask to intubate, coughing and vomiting, and patient agitation
from hypoxia and respiratory distress are but a few of many potential modes of transmission.4
In addition, physicians had to become comfortable with intubating adeptly while wearing bulky
PAPR devices and using intubation equipment and barriers that often changed glottic views and
required different techniques. In a situation where swift action means limited exposure for the
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Fig. 5. Safe Airway Society COVID Airway Management.
intubator and the staff in the room, it was important that physicians felt comfortable with the
new protocols.
Dr. Joanna Davidson organized several in-situ simulation training sessions to help staff get
comfortable with new COVID protocols. At each NorthShore ED pavilion, she created simulation
scenarios involving both intubation and cardiac arrest of a mannequin substitute for a COVID
patient that increased physician, nurse, respiratory therapy, and other ED staff familiarity and
comfort. Her work allowed staff to practice unfamiliar tasks, gain muscle memory and facilitate experiential learning and teamwork. Topics included PPE donning and doffing, intubation
protocols, communication barriers, and equipment organization. She also sought to standardize
protocols across the four ED pavilions as well as identify and remedy knowledge gaps to ensure
staff and patient safety.
Intubation protocols were standardized and reviewed for safety of both staff and patient. Intubations were performed in negative pressure rooms with doors closed. All staff in the room
wore PPE advised for AGP’s: undergloves, PAPR devices covering head and shoulders, gown or
bunny suit, overgloves.2 The donning and doffing of PPE dictated proper layering to maximize
protection.10 Roles were pared down to essential personnel only in the room to minimize exposure: one intubator, one respiratory therapist to assist and manage the ventilator, and one
nurse to administer medications and monitor vital signs during the procedure (Fig. 5). Early on,
it was recommended that the most experienced physician intubate to minimize attempts and
exposure.2 Supply lists were standardized including a specialized COVID intubation tray with
equipment and a disposable medication bag with rapid sequence intubation medications. Equipment had to be readily available and in a convenient location in the ER.
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Fig. 6. NorthShore COVID Intubation Tray Set Up
The intubation tray was equipped for both video laryngoscopy and also alternative scenarios such as direct laryngoscopy and airway adjuncts like laryngeal mask airways.2 As well, the
medication bag was securely stored and contained the most commonly used medications for
intubation such as sedation for example propofol and etomidate, paralytic agents including succinylcholine and rocuronium and vasopressors. By having all agents in one bag, you can ensure
that medications are quickly available in a high stress, time sensitive situation (Fig. 6).
Communication during these procedures inside a closed, negative airflow room was critical
not only between staff in the room wearing PPE but also between those in the room and staff
outside the room. Over the months that we cared for patients, staff utilized many resources
including hands free phones on speaker settings as well as secure chat messaging within our
EMR. Even simple communication like hand signals and writing on glass doors with markers
helped overcome some barriers and allowed staff to quickly communicate a need for additional
supplies or assistance.
The intubation process itself also became more standardized to minimize or eliminate minor
aerosolizing steps such as ventilating the patient using a bag valve mask (BVM) or the patient
coughing without a surgical mask in place with the intubator or other staff nearby. These recommendations came both from guiding societies’ general recommendations and also from shared
knowledge in emergency medicine practice during this time.2 , 63 Use of viral filters in line with
BVM minimized exposure if bagging was done peri-intubation. Often bagging was not done in
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Fig. 7.
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“V-E” grip for BVM. Source: Safe Airway Society.
favor of passive oxygenation. Disconnection of oxygen delivery circuits was done with knowledge of where the viral filter was in the system and using the filter as a protective layer. Even
the traditional “C-E” technique of bag valve mask use in BLS training was re-evaluated to emphasize improved mask seal and prevent aerosolization (Fig. 7). Certain groups recommended an
alternative vice (V-E) grip to maximize face mask seal and minimize gas leak after induction.4
In other cases, preoxygenation was done by passive strategies only such as nasal cannula.
Rapid sequence intubation was preferred using therapeutic doses of longer acting paralytic
agents such as rocuronium to prevent coughing and vomiting during intubation as well as prolonged time to start sedative medications to minimize vent intolerance and optimize patient
comfort. Even wait times from administration of paralytic medication to intubation pass were
advised to be a 60 s window to maximize paralytic medication effects. Videolaryngoscope intubations with indirect visualization using a video screen view (such as CMAC or Glidescope)
were preferred over direct visualization to increase the intubator distance from the patient’s
face. After placement, inflation of the cuff of the endotracheal tube prior to administering the
first ventilated breath via BVM provided a seal to further prevent aerosolization.12 Viral filters
were also applied to ventilator tubing prior to initiating mechanical ventilation.
Other potential situations were considered as part of intubation protocols. Increased oral
secretions could be managed by administering atropine prior to intubation due to the risk of
aerosolization by oral suctioning. Some physicians elected to use an “aerosol box,” a clear hard
plastic box placed around the patient’s face to protect the intubator from aerosolized particles.5
Every step of an already detailed intubation process was examined for risk. This careful preparation ensured that both patients and staff were kept safe during this life-saving procedure.
Other modes of oxygen delivery
As our experience and understanding of COVID patients increased, our treatment strategies
evolved as well. With less early intubation, we pursued oxygen delivery strategies with minimal
risk of transmission and staff exposure.
ED physician Dr. Ben Feinzimer researched aerosolization risk and alternative oxygenation
strategies and formulated new algorithms for respiratory distress for all 4 ED pavilions. We
learned that some previously prohibited strategies were not as risky as previously implied. Simple nasal cannula at 1–6 L per minute with a surgical mask in place supported many patients.
When this was not enough support, NorthShore algorithms suggested a non-rebreather (NRB)
mask at 15 L be placed over the nasal cannula, also with surgical mask cover over the NRB
mask (Fig. 8).
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Fig. 8. NorthShore COVID-19 Respiratory Distress Algorithm.
When greater support than a nasal cannula at 6 L was required, we initially were turning to
intubation as the next intervention given the need to avoid aerosolizing forces of NPPV such
as BIPAP. Over time and learning lessons from the pandemic over the past few months, we
began utilizing other forms of oxygen delivery such as the Heated High Flow Nasal Cannula
(HHFNC). If not already in a negative pressure room, these patients were moved and HHFNC
therapy was initiated. This device has larger bore nasal prongs and tubing that delivers highvelocity nasal insufflation that flushes the anatomical dead space of the upper airway, thereby
creating a fresh, oxygenated, CO2-depleted gas reservoir that facilitates both oxygenation and
ventilation. 71 Titrations of the device involve both liter flow rate (40 to 60 liters per minute)
and fraction of inspired oxygen (Fi02) management.
By flushing the upper airway of carbon dioxide-filled expiratory gasses and replacing it with
warmed, humidified, highly concentrated oxygen, the HHFNC can noninvasively support a hypoxic and hypercarbic patient. The device can also assist with work of breathing by providing
positive end expiratory pressure to maintain alveolar and airway opening. A patient who continues to have tachypnea and increased work of breathing despite conventional nasal cannula
or NRB oxygen delivery often experienced decreased work of breathing after transitioning to
HHFNC. Small studies using HHFNC showed decreased mortality and intubation rates.72
The device also protects against mucosal damage to the upper nasopharyngeal space by
warming and humidifying gas even at high oxygen concentrations. The combination of positive pressure and high concentration of inspired oxygen means that it offers more support than
the conventional nasal cannula. Studies have found that it is noninferior to NPPV.18 In addition,
HHFNC is often better tolerated than NPPV by the patient as they can talk, drink and eat while
wearing the cannula which cannot be done easily with NPPV. This becomes especially important
when you’re anticipating days to weeks of oxygen support while the patient recovers.
Lastly, early expert opinion that questioned the aerosolization of these modalities such as
HHFNC and NPPV and associated exposure of staff has been found to not be as significant as
initially thought. Modifications were made to NPPV devices like BIPAP to ensure good interface
fitting and tubing that does not create widespread dispersion of exhaled air73 . Several studies
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show that droplet dispersion rates are actually much lower than initially feared and the addition
of a surgical mask over the oxygen device also minimizes viral spread. 33 , 47 Concern about CO2
trapping behind the mask worn on the patient’s face can be significantly offset by increasing
the amount of gas liter flow of the HHFNC to increase CO2 washout as well as continuous CO2
monitoring. NPPV like BIPAP has gained greater acceptance in treatment of hypoxia in COVID
patients.
Oxygen saturation
Oxygen saturation goals have also been debated over the last few months. With the goal of
end organ damage in mind, many “happy hypoxemic” patients confounded typical measures of
end organ perfusion.
New strategies of targeting Sp02 goals of >80% with careful monitoring of other measures
of respiratory distress such as work of breathing, fatigue, and altered mental status have been
successfully utilized both in the emergency room and in the inpatient setting. Clinical trajectory was also an important measure of level of intervention: a patient with a rapidly increasing
oxygen requirement over the hours they were monitored in the ED often required more interventions including intubation over a patient with a stable oxygen requirement. Tobin68 points
out the complexity of assessing respiratory status, noting that an increased respiratory rate does
not in itself indicate distress; instead, respiratory muscle use, sensation of air hunger, or fatigue
can be more accurate measures (p. 1319).
He also points out that hypoxia does not equate to end organ damage: evidence of endorgan damage is difficult to demonstrate in patients with PaO2 above 40 mm Hg (equivalent to
oxygen saturation of 75%) in patients with adequate oxygen carrying capacity and cardiac output
(p. 1320). This more detailed understanding allows emergency medicine clinicians to avoid knee
jerk responses to hypoxia without taking into consideration other measures of respiratory status.
Prone positioning
Another strategy to improve oxygenation in these patients included use of prone positioning
to improve oxygenation. Previous studies have shown prone positioning in severe ARDS intubated patients improved oxygenation but had not been recommended in mild to moderate disease and in non-intubated patients.56 One small study of early prone positioning combined with
HHFNC or NPPV in ARDS (not COVID positive) patients showed improvement in oxygenation
which was hypothesized to help avoid intubation.17 Prone positioning decreases lung compression by displacing the weight of the heart and mediastinum off the lungs, allowing for greater
aeration. It also supports more homogenous ventilation as evidenced by more homogenous distribution of transpulmonary pressures in the ventral-to-dorsal axis.27 This theoretically can improve VQ mismatch and alveolar recruitment.
Contrary to prone positioning in an intubated patient, self or awake proning of a nonintubated patient requires less staff and less risk as long as the patient is cooperative, protecting
their airway, and keeping the surgical mask in place. This may also mobilize secretions and allow for greater airway clearance. Some expert opinion even notes shifting of position from side
to side rather than proning can make a difference in oxygenation, yet all of these suggestions
are purely anecdotal.22 When we are practicing at the bleeding edge of a viral pandemic that
didn’t exist 6 months ago, practitioners are often forced to work with less than robust data sets.
Infection prevention and environmental services in ED
Infection prevention and control are cornerstones to a pandemic response. COVID dramatically changed the nature of infection prevention and control both within the hospital setting as
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well as in the community. Testing delays meant PUI-related care required precious and at times
scarce PPE just as much as confirmed positive patient care. As well, room turnover and equipment use related to COVID had to be carefully considered in order to balance urgent need with
safety and minimal exposure. This was important not only to support staff trust and feelings of
safety but also to guarantee safety to our patients as well.
Efficient treatment room turnover in the ED even during non-COVID times is paramount to
smooth ED throughput. With COVID, many questions arose regarding this workflow and how
to protect not only direct care staff and the next patient using the room but also the environmental services staff tasked with cleaning the room. CDC guidance about when to enter a
room after the patient has vacated takes into account ventilated air exchanges to remove potentially infectious particles, also known as air changes per hour (ACHs).7,76 NorthShore was in
line with these national recommendations as increased inpatient volume has stressed workflows
in areas with direct COVID patient care. ACHs and room type (standard versus negative airflow
room) were evaluated and Environmental Services protocols followed the time recommendation
for the number of ACH’s required to ensure 99.9% removal of potentially infectious particles in
that room. In a standard ED patient room, this was 70 min; in an airborne isolation room with
negative airflow, this wait time to enter and clean was reduced to 35 min due to the increased
rate of ACHs. While this slowed room turnover, it assured that patients and staff were protected
from viral transmission.
As well, these protocols were applied to common areas such as radiology. These protocols
became particularly important when considering areas like CT scanners which must be available at a moment’s notice for trauma or stroke patients. A CT scanner goes “out of commission”
for several hours after scanning a COVID positive patient due to the cleaning process of equipment and room. This can be disastrous for a critically ill patient presenting with massive trauma
or stroke. Our radiology technologists worked tirelessly to ensure adherence to these infection
control guidelines while also preserving as efficient workflow as possible.
Measures to limit movement of patients through the hospital were also adopted. Two view
PA and lateral chest x-rays were deferred in favor of portable AP chest x-rays that could be done
in the patients’ rooms.41 In addition, NorthShore’s radiology technologists utilized innovative
techniques to limit PPE use and staff exposure: the portable x-ray unit was placed outside the
patient room with the tube directed through the glass of the isolation room window. The AP
chest x-ray that is shot through the glass is of diagnostic quality. As part of modifications to
workflows developed during the 2014 Ebola outbreak, the University of Washington showed that
this can be done through wire-reinforced glass, through opened metal venetian-style blinds, and
even 10 to 15 feet away from the patient across an isolation antechamber room into an isolation
room.54 The patient is placed upright in the bed or in a wheelchair and a staff member (often
a PPE-clad nurse) in the room places the double-bagged x-ray cassette behind the patient just
prior to the x-ray. After the x-ray is done, the only equipment decontamination required is the
cassette. Using this technique, PPE is reduced, less equipment decontamination is required and
staff exposure is reduced.
Physicians and staff in the ED sought to minimize exposure without compromising patient
care. Providers used cell phones and iPads to update patients and clarify treatment plans and
also minimize the number of times the provider entered the room. In return, patients appreciated the ease of communication.
Use and management of the physical space of the ED
By early March, NorthShore anticipated that many areas of its healthcare system would be
stressed by the pandemic. NorthShore worked both with state and national authorities to analyze data and trends to best anticipate needs of the community. It was anticipated early on that
screening and testing would be an integral part of the services we could provide the community.
This could include any patient from a “walking well” who had mild symptoms or a history of
exposure or travel to a critically ill and hypoxic patient. NorthShore had to be prepared to hanPlease cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
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dle extremely high volume and variety, triaging effectively and moving patients through spaces
that kept them safe but also served their needs.
Early on, discussions on how to convert spaces to isolate, evaluate, and test “walking well”
populations centered on providing excellent care isolated from other patients in the department.
Two hospitals, Evanston and Northbrook, began building out areas in the ambulance bay to create a space distant from the main ED rooms but convenient for staff to operate. While the space
was being built, well-appearing patients with stable vital signs were evaluated by staff in a tent
adjacent to the Evanston ED to best isolate potential COVID positive patients. Within weeks, this
quickly expanded to a physical space encompassing the entire ambulance bay at Evanston Hospital that could manage dozens of patients at once. Patients were socially distanced in both triage
and evaluation areas of this part of the COVID bay. The area included computers, phone lines,
portable bathrooms, even an area for chest x-rays. Data analytics was crucial at this time, often
working to analyze how well these patients appeared and what level of care required: testing,
interventions, hospital admission versus discharge home from ED, etc.
Using this data, NorthShore was able to see that most of the patients tested were well
enough to go home with strict isolation protocols and that only a small percentage required
further evaluation or hospital admission. APP’s were extremely helpful in the triage of these patients in this COVID tent space. Adequate staffing of these areas often required additional staff
and many APP’s from other areas of the hospital system stepped in to help. The decrease in
surgeries and outpatient visits allowed NorthShore to increase resources in areas stressed by the
pandemic such as the ED. These APP’s were quickly trained to work in areas directly treating
COVID patients including triage, evaluation, and testing. An APP could evaluate a patient presenting to the COVID bay for COVID testing and help determine whether further evaluation was
needed: for example, a patient complaining of shortness of breath and fevers but also reporting
leg swelling would need more resources than the test space could provide. For those patients
requiring further evaluation in the ED, transfer into a negative airflow room in the main area
using proper PPE and isolation protocols was done.
Despite the constant possibility of a patient needing more testing and intervention than the
COVID bay could provide, the majority of the patients seen in this area were well served by the
dedicated resources and testing done there. These patients were triaged, tested and educated on
self-quarantine measures and symptoms to seek medical care prior to discharge from the ED. So
much so that the decision has been made at this time to keep these areas open and prepared
for other potential surges in cases later this year.
The immediate cares of NorthShore
The Immediate Cares (IC) of NorthShore were integral to NorthShore’s COVID response and
one of the most heavily utilized resources for COVID testing in the community. The Immediate Cares were re-designed to accommodate large volumes of mildly ill patients with symptoms
of COVID. A combination of a online COVID portal for triaging patient complaints, nurse phone
lines, telehealth visits, drive thru testing, and designated Immediate Care testing sites enabled
the NorthShore system to meet the needs of the community while also ensuring that other
areas of the system, such as the emergency department or primary care offices were not overwhelmed. Their efforts were an incredible success at triaging and addressing these populations
who were able to manage their COVID illness in an outpatient setting or at home.
Early on, certain IC’s were chosen to be dedicated COVID testing centers. These sites were
chosen both for their location in the community as well as their physical separation from clinical areas seeing non infected patients such as primary care offices. Many of these sites took
over adjoining family and internal medicine offices to increase the quantity of treatment rooms
given the necessary time it took to turn over rooms related to ventilation and cleaning protocols
similar to inpatient environmental services protocols. Through these modifications, a 4-room immediate care setting very quickly became a 25-room COVID-focused testing center. With these
modifications, one IC location saw and tested up to 200 patients daily in its busiest weeks.
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
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By dedicating staff and space to COVID testing, IC staff quickly became proficient in PPE protocols and testing. Fewer IC staff across the system were exposed to COVID given the efforts to
triage patients and direct them to designated testing centers. This contributed to their extremely
low COVID testing positivity rates among staff. With less staffing hours lost to illness and greater
staff comfort and confidence in COVID management, patients also received the best quality care.
Of course, the occasional walk-in patient with COVID-like symptoms was seen in an IC outside
these four dedicated IC’s, but even these scenarios were tightly protocolized. These scenarios
included instructions to patients directing them to one of the designated IC testing sites or immediate rooming of patients to minimize time the patient is in a common waiting area, use of
telephones in room to complete registration by staff outside the room, and use of proper PPE to
protect staff at that site.
One of the many striking aspects of IC triage algorithms is the acknowledgement of the early
period of COVID illness when PCR testing was more likely to yield false negative results. These
algorithms advise a “watch and wait” approach if a patient is in the first three days of symptoms
and managing their symptoms safely. Similar approaches were also applied to patients presenting without symptoms but with positive exposures. Studies have shown a high false negative
rate if a patient is tested too early due to a variety of factors.45 This results in missed diagnosis,
false reassurance given to patients, in appropriate discontinuation of self-isolation protocols, and
waste of valuable COVID testing swabs.
Similarly, clinically severe or worsening conditions were addressed effectively. Red flag symptoms such as fevers combined with shortness of breath, resting or ambulatory hypoxia or chest
pain had much different workflows than an asymptomatic patient with concern for exposure.
The good working relationship between the IC’s and ED’s of NorthShore facilitated seamless
communication about the patient’s condition and work up thus far: patients forwarded to the
ED could be addressed promptly. The goal of medical workflows is to get the patient the most
appropriate care by the most expeditious route possible: the IC was an excellent example of
this effort. Based on the presence or absence of symptoms, duration of symptoms, and history
of comorbidity or pregnancy, a patient could be adeptly directed to monitor symptoms at home
with close follow up, towards drive thru testing with minimal exposure of all parties, or to an
IC visit, an OB visit if pregnant, or the ED.
Conclusion
As of early June, there are over 7 million documented cases of COVID worldwide. Approximately 2 million of those were diagnosed within the United States, which far outweighs the
amount of cases in any other country in the world. Illinois continues to rank high among all
states for COVID cases, with nearly 130,0 0 0 positive cases so far.14 Daily positive cases continue
to oscillate in frequency over the past few weeks but the general trend has been a decline since
early May. Illinois has begun the process of ‘Phase Three’ of reopening Chicago and the state,
which includes the opening of non-essential businesses like restaurants (outdoor dining only),
personal services (barbershops and salons), and retail.15 Throughout this process, health officials
continue to stress the importance of hand hygiene, mask use, and social distancing to prevent
the occurrence of a surge in cases. The number of positive cases within the NorthShore system
nears 8720 patients with nearly a 24% positive rate of the total 36,347 tested.77 As part of the
reopening plan, NorthShore has begun to reinstate certain outpatient/non-emergent services.
Emergency department visits within Illinois for shortness of breath, COVID-like illness, and
pneumonia continue to decline daily40 . This figure has been compiled from Illinois’ Syndromic
Surveillance System and shows a decreasing percentage of visits to the emergency department for a chief complaint of pneumonia, COVID-like illness, or shortness of breath (Fig. 9).
NorthShore’s own ED census decreased over the early months of the pandemic, mirroring national trends in emergency rooms. As the state has started reopening, emergency department
volumes for non-COVID complaints as a whole have begun to steadily climb as tensions abate.
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.
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Fig. 9. IDPH COVID-19 Syndromic Surveillance Daily Percentage of Emergency Department Visits.
Source: Source: https://www.dph.illinois.gov/covid19/syndromic-surveillance on June 21, 2020.
Immediate Care Clinics continue to be a vital component of the ongoing battle with COVID,
with nearly 25,500 COVID SuperSite ICC visits and 6900 drive thru visits to date. They continue
to utilize their APPs to triage patients, complete telehealth visits, and see patients in the clinic.
As we move further into the summer, ICCs will reevaluate the distribution of resources and
continue to adjust to demand.
NorthShore is processing thousands of RT-PCR tests a day, accommodating testing for several
other non-NorthShore affiliated clinics and hospitals. NorthShore continues to follow a similar
testing criteria as what was established in April, but have begun to expand testing to asymptomatic individuals with positive exposure, pre-surgical candidates, and labor and delivery. The
hospital system continues to struggle with achieving reliable supply of rapid antigen tests. As
NorthShore is able to secure a steady supply, the admission protocol is likely to evolve once
again.
PPE supply continues to remain adequate in most areas of the country as many companies
have ramped up PPE production. ED personnel continue to wear full PPE for every PUI and confirmed positive, although the number of these encounters have steadily decreased in frequency.
We continue to use hospital-provided scrubs every day, wear a surgical mask through our entire
shift, and pass through temperature and symptom screening every day. We continue to participate in bi-weekly ED COVID conferences and weekly NorthShore COVID physician updates.
Although the number of patients requiring this isolation has significantly decreased, the tents
remain open in anticipation of another possible surge. As Chicago moves into subsequent phases
of reopening, it’s impossible to know if cases will spike. In the meantime, the tents stay open to
accept stable patients that present for testing. In addition, NorthShore services like SNF COVID
Swab teams continue to operate in congregate living facilities to evaluate and test symptomatic
patients. As well, outpatient areas like primary care offices continue to do what they can to
support their patients and keep them out of the emergency room and the hospital. Physicians,
APP’s, nurses, and office staff have triaged countless phone calls, telemedicine messages, and in
person visits to keep patients as healthy and able as possible.
NorthShore continues to adjust screening criteria, admission protocols, and staffing as we
learn more about the virus and attempt to prepare. However, changes are happening at a rapid
rate and it’s difficult to predict what the future will bring. As we move into the summer months,
there are many factors that will affect transmission with the possibility of warmer weather making a difference. A study out of Mount Auburn Hospital found that, “while the rate of virus
transmission may slow down as the maximum daily temperature rises to around 50° (F), the
effects of temperature rise beyond that don’t seem to be significant.” This indicates that it is unlikely that disease transmission will slow dramatically in the summer months from the increase
in temperature alone.55 The study also found that the transmission rate is highest in months
where the temperature is below thirty degrees Fahrenheit, meaning the rate of positive COVID
Please cite this article as: B. Leiker and K. Wise, COVID – 19 case study in emergency medicine preparedness and
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cases will most likely increase as we move back into fall and winter. This will coincide with increased rates of several other respiratory viruses, including influenza and RSV, and we will need
to consider to possibility of co-infection.74 This challenge will allow us to reconsider how we
approach triage and testing for respiratory complaints.
In the meantime, NorthShore has started to provide ‘COVID Kits’ to positive patients that are
able to remain at home or those that have been discharged after admission. This kit includes
masks, hand sanitizer, gloves, and most importantly–a pulse oximeter. Patients are given the
ability to monitor their oxygen levels at home. This will help catch the “happy hypoxic” patients
who have low oxygen saturation but don’t feel short of breath enough to present to the ED
themselves. Catching these patients early would theoretically prevent patients from presenting
to the ED when their pulse oximeter is dangerously low with significant respiratory distress. The
positive patients are followed by a designated outpatient team until their infection has cleared.
This is an indispensable resource to those that don’t have a primary care doctor to turn to when
questions arise.
With resources like antibody testing coming into play, we question when we will be able to
achieve herd immunity to COVID. As of late May, only a small portion of the population has
built up antibodies to the virus. Antibody testing has given us the ability to detect a history of
the virus in those that may have been asymptomatic. In the area hit hardest by the pandemic
within the United States, New York City, only 19.9% of the population has positive antibody status. In order to achieve herd immunity, it is necessary that 70 percent of the population show
positive antibody status. “This implies that over 200 million Americans would have to get infected to reach this threshold. Even if the current pace of the COVID pandemic continues in the
United States – with over 25,0 0 0 confirmed cases a day – it will be well into 2021 before we
reach herd immunity. If current daily death rates continue, over half a million Americans would
be dead from COVID by that time”.19 Attaining significant herd immunity would play a huge
role in slowing down transmission rates. The majority of the Chicago area population remains
susceptible to the virus, but according to the data collected by NorthShore’s team, around 5.17%
of the NorthShore population has positive antibody status. This is a far cry from the 70% necessary for herd immunity, but immunity status can perhaps be improved with the availability of
an effective vaccination.
We continue to learn more about the virus as we search for ways to slow its spread and
effectively treat its complications. Many of the changes already made are likely here to stay,
but the circumstances will almost certainly evolve as we navigate 2020 and another respiratory
virus season. This article sought to describe one ED’s response to the pandemic, given changing
understanding of both the disease, its spread, and its complications. We understand that our
experience is different from other ED’s nationally and internationally in staffing, utilization of
APP’s, social demographics, and resources. We believe that knowledge sharing is key to effective
action and hope that this article is both informative and interesting. As we move forward, we
approach reopening with caution and reiterate the importance of safe social distancing and mask
usage. NorthShore’s ED team remains vigilant and prepared to take on whatever the future may
bring.
Acknowledgments
We’d like to thank all the people who participated in interviews and contributed to the writing of this article including Sue Bednar, APN, Ali Ruiz, PA-C, Pam Walsh, PA-C, Kurt Ortwig, APN,
Olga Amusina, DNP, ACNP, Mary Lavin, RN, Jessica Folk, MD, Joanna Davidson, MD, Ben Feinzimer, MD, Gulia LaBellarte, APN–CNP, Mia Donoghue, APN–CNP, and Jeffery Graff, MD
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