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ARTICLE IN PRESS

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Disease-a-Month xxx (xxxx) xxx

Contents lists available at ScienceDirect

Disease-a-Month

journal homepage: 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 appear-

ance 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 symp-

toms. 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 (SARS-

CoV-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 re-

ported 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 nomen-

clature, the illness that this virus causes became synonymous with the virus itself: COVID 19.

∗ Corresponding author.

E-mail addresses: [email protected] , [email protected] (K. Wise).

https://doi.org/10.1016/j.disamonth.2020.101060

0011-5029/© 2020 Elsevier Inc. All rights reserved.

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.

2020.101060

2 B. Leiker and K. Wise / Disease-a-Month xxx (xxxx) xxx

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In the United States, the first COVID case was reported on January 21, 2020. 31 In the weeks

hat followed, an additional 53 cases were reported and many public health officials hoped the

iral spread was limited but containment measures were haphazard and based on a rapidly de-

eloping knowledge base about viral transmission. The federal government barred entry of most

oreign nationals with recent travel to China, but not US residents who had been to China. Little

iral testing was available or done to screen people entering the US. Given low official numbers

f cases that month, social gatherings were not restricted. Voluntary self-quarantine measures

nd 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 in-

icated a rise in community transmission and hinted at pandemic spread. Cruise ships were

articularly vulnerable to the spread of COVID with their crowded common areas, travel to new

reas, and limited medical resources. 53 Italy and Iran were also seeing a rapid increase in cases,

oreshadowing the effects of widespread transmission and prompting concerns over upcoming

oliday and religious pilgrimage travel. 32

On February 29th, authorities in Seattle reported the first American death from COVID; later

eports indicated the earliest COVID death in the United States was in early February in Santa

lara County in the San Francisco Bay area. 66 Ongoing community spread, attendance at pro-

essional and social events, introduction into facilities and settings prone to amplification, and

he lack of viral testing contributed to rapid increase in transmission in March in the United

tates. Large social events such as Mardi Gras, spring break vacation travels, and attendance at

nternational professional conferences were held as planned. Directly linked increases in cases

elated to events like these prompted state-led restrictions in gatherings and travel. 6 A funeral

n Albany, Georgia was attended by more than 100 people. Later, Dougherty County, Georgia,

he 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 long-

erm care facilities and high-density urban areas. Other factors increasing COVID spread included

onfluence with influenza and pneumonia season, continued importation of virus from other ar-

as via travel, and undetected transmission among presymptomatic or asymptomatic individuals.

By mid-March, transmission had become widespread and state and federally mandated mea-

ures to contain spread and protect health care capacity were initiated. Federal travel bans ex-

anded to include Italy, South Korea and many European countries. Nearly all states were un-

er some form of stay-at-home orders with closures of school and nonessential workplaces and

ancellation of sporting events and all group gatherings to try to “flatten the curve.” Most lock-

owns began between late March and early April. California was the first state to issue lockdown

rders on March 19th, following the lead of San Francisco three days prior. 58 Restrictions on in-

ernational travel were put in place, and a No Sail Order from the Director of the CDC was issued

n March 14th, suspending travel on US waters. 65 On March 26th, the United States became the

ountry hardest hit in the world by coronavirus with 81,321 confirmed infections. 51 That trend

ontinues today.

OVID in Illinois

Spread of coronavirus and the challenges inherent in pandemic circumstances were similar in

he state of Illinois. Its index case was the second detected case in the United States: a woman

raveling from Wuhan, China in mid-January who returned home to Illinois and was hospitalized

week later with pneumonia. 7 Her spouse tested positive as well the following week which was

he first recorded case of local transmission in the United States. 26 Early screening and positive

ases in Illinois were connected to travel histories such as recent travel to high risk areas as

ith Illinois’ first case or recent travel on a cruise ship. 36

Nationally, retrospective analysis of surveillance data from this time period suggests that lim-

ted community transmission likely began by early February after initial importation from trav-

lers from China and Europe. 43 This could not be tracked until late February to early March via

mergency 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.

2020.101060

B. Leiker and K. Wise / Disease-a-Month xxx (xxxx) xxx 3

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Fig. 1. Percentage of emergency department (ED) visits for COVID-19–like illness (CLI), ∗ in 14 counties † ,§ (three in Cal-

ifornia 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 (Brook-

lyn), Queens County (Queens), Bronx County (Bronx), Richmond County (Staten Island), and New York County (Manhat-

tan) 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 rep-

resents 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 trans-

mission 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 fam-

ily gatherings after one index patient attended funeral events that triggered a chain of trans-

mission 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

response: from personal protective equipment to delivery of care, Disease-a-Month, https://doi.org/10.1016/j.disamonth.

2020.101060

4 B. Leiker and K. Wise / Disease-a-Month xxx (xxxx) xxx

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Long term care facilities (LTCF) became a particular area of focus and monitoring. The first

esident of an Illinois long term care facility that tested positive during this time spurred test-

ng of the entire facility and resulted in 21 positive cases including 17 residents and 4 staff

embers, confirming the fears of public health officials both of the inherent risky nature of

ongregate living and the vulnerability of congregate living residents. 38 Increased guidance from

DPH for nursing homes included restrictions on all visitors, volunteers, and non-essential health

are personnel (e.g., barbers), cancellation of group activities and communal dining, and active

ymptom monitoring for both residents and staff. As one congregate living resident summarized

uring his emergency room visit at the time: “I haven’t been allowed to leave my room and they

ring 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

ad 585 confirmed cases across 25 counties, including 163 recently diagnosed new cases and

death toll of five. 39 The directive prohibited socializing in-person with people outside your

ousehold and gatherings larger than 10 people. Playgrounds were closed and selective green

paces were used with 6 feet of social distancing. Only essential travel was permitted and es-

ential services continued. At the time, Illinois was joining California, New York and Connecticut,

tates with three of the largest cities in the country, to enforce strict sheltering measures. Illi-

ois remains one the states with stricter sheltering measures in the country and subsequent

eopening guidelines currently.

OVID in the emergency department

The approach to the coronavirus pandemic in our emergency department focused on iden-

ification and isolation of infected individuals, adequate protection of staff, reporting of posi-

ive cases to the health department, effective treatment, and education of patients and fami-

ies. Protocols for triaging, use of PPE (personal protective equipment), environmental services

nd cleaning, even the types of tests we ordered were adjusted to maximize protection. Use of

elemedicine technologies helped mitigate risk and exposure. Care for these patients was pared

own to the most essential personnel to minimize staff exposure, especially given a worst case

cenario that predicted temporary loss of staff due to illness and quarantining. Staff was re-

llocated to essential areas such as the ED, ICU, home health, and nursing homes to help test

nd care for COVID patients. Other staff were recruited from outpatient areas with less volume

o assist in the ED in anticipation of higher volumes and unanticipated staff absences due to

llness.

The physical space of the emergency room was re-evaluated to best triage and isolate COVID

atients. Protocols for cleaning and sanitizing rooms and common diagnostic areas (radiology, CT

canners) were formulated to balance the need to turnover spaces efficiently but safely. A trauma

r stroke patient cannot be imaged in a CT scanner that just minutes before accommodated a

onfirmed COVID positive patient, so protocol for use and cleaning had to be developed. These

ere but a few of the many challenges that pandemic conditions present to an emergency room

nd to a hospital.

The NorthShore University HealthSystem (NorthShore) had to be dynamic, informed, and in-

ovative in its approach in order to provide effective care with minimal risk of exposure to

oth patients and staff. NorthShore is headquartered in Evanston, IL and includes 5 hospitals–

vanston, Skokie, Glenbrook, Highland Park and Swedish–on the north side of Chicago and its

uburbs. These ED’s are busy–seeing a combined total of over 170,0 0 0 visits annually. 34 The in-

egrated nature of the hospital system means that NorthShore can be dynamic and responsive

o 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

urse Practitioners. APP’s have traditionally been widely used in the NorthShore system and

re utilized in a variety of clinical areas from outpatient to inpatient roles. APP’s are used in

early every service area, evaluating patients, ordering tests, formulating treatment plans, and

ducating and advising patients and families. The NorthShore ED APP group consists of 31 full-

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.

2020.101060

B. Leiker and K. Wise / Disease-a-Month xxx (xxxx) xxx 5

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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 de-

partments 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 emer-

gency 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 effort s 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 partic-

ular 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 ad-

dressing 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 ac-

cessible 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

recent

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