Amarissa Alya Tsabita

18/425487/KU/20536
Group 3 - PD IUP 2018

TIMBUL Block D.1 Scenario 5

• What is ER setting in COVID-19 pandemic era?

Since the onset of the COVID pandemic, there have been rapid changes to processes in ERs
and the healthcare system. ER clinicians will need to maintain vigilance over the long term
in order to assess and manage the large numbers of possible or known positive COVID-19
patients attending ERs, regardless of community case numbers. ER patients require
infection control and physical distancing measures to prevent disease transmission to other
patients and staff. With ongoing outbreaks, chaotic and overcrowded ERs are a grave risk
to patients, visitors and staff.

As a general principle, all patients should be considered as potentially infectious. Some will
present with atypical symptoms (especially children and older persons), such that they fall
outside of case definition criteria. For this reason, clinicians should exercise a high degree
of suspicion and vigilance at all times.

Figure 1. Example of a simple risk stratification system

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

It is recommended that all waiting areas:

1. Are of sufficient size to ensure appropriate physical distancing between all patients
and support people, including 1.5m or greater between people and a maximum of 1
person per 4 square meters.
2. Include appropriate signage in support of physical distancing.
3. Are regularly cleaned and disinfected, with particular attention to high touch
surfaces.

Depending on the physical infrastructure of the ER, it may be desirable to have a separate
waiting area for patients who meet COVID-19 case definition criteria and will subsequently
be allocated to a high-risk zone. In the interests of patient safety, all patients in the waiting
area should remain within view of the triage nurse.

Patients meeting case definition criteria should be streamed into a dedicated ‘high-risk’
treatment zone within the ER with immediate isolation from other waiting patients.

It is recommended that any high-risk zone is:

1. Clearly demarcated, with a minimum number of entry and exit points and designated
areas for staff to don and doff PPE.
2. Described using neutral language, such as a ‘hot’ or ‘red’ zone.
3. Staffed by a team of dedicated clinicians separate from those looking after low-risk
patients.

It is recommended that staff working in this high-risk zone:

1. Wear appropriate PPE at all times.
2. Are not permitted to bring food into this or any other clinical area.
3. Take regular, planned breaks to preserve health and wellbeing, especially in the setting
of continuous PPE use.

Wherever possible, patients with suspected COVID-19 should be separated from those with
confirmed infection. This requires a dynamic approach to flow and bed management.

The hierarchy of isolated treatment spaces is summarised in Figure 3 below. While patients
with suspected or confirmed COVID-19 should ideally be managed in a negative pressure
room, this may not be feasible as patient numbers escalate.

It may be necessary for the ER to utilize temporary spaces for the care of patients. This is
not an ideal solution, but is a safer option than crowding within the ER.

We recommend that, if an expansion of the ER footprint is required, ERs select an area that
is in close proximity to the main department and can be rapidly fitted out to meet ER design
standards (to the extent that is possible). Outpatient clinics and day treatment areas often
represent a good option.

In exceptional circumstances, the use of temporary structures (such as tents and marquees)
may be required. These areas should be set up using the same design and infection control
principles discussed above.
References
Mitchell, R. and Banks, C. (2020) ‘Emergency departments and the COVID-19 pandemic:
making the most of limited resources’, Emergency Medicine Journal, 37(5), p. 258.
doi:10.1136/emermed-2020-209660.

Covid19.go.id. 2021. PANDUAN TEKNIS PELAYANAN RUMAH SAKIT PADA MASA

ADAPTASI KEBIASAAN BARU. [online] Available at:
<https://covid19.go.id/storage/app/media/Protokol/2020/November/panduan-teknis-
pelayanan-rumah-sakit-pada-masa-adaptasi-kebiasaan-baru-02-11-2020.pdf> [Accessed 26
September 2021].

Penn Medicine. 2020. Is It Safe to Go to the Emergency Room During the COVID-19
Pandemic?. [online] Available at: <https://www.pennmedicine.org/updates/blogs/health-and-
wellness/2020/august/is-the-emergency-room-safe-during-the-pandemic> [Accessed 26
September 2021].