Impact of a Novel Emergency Department Forward Treatment Area During the New York City COVID-19 Surge.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused a disproportionate number of patients to seek emergency care at hospitals in New York City (NYC) during the initial crisis. Our urban emergency department (ED), a member of the NYC public hospital system had to process the increased volume while also differentiating our patients' critical needs. We established a forward treatment area (FTA) directly in front of the ED to accomplish these goals from March 23-April 16, 2020. METHODS: A clinical greeter evaluated patients 18 years and older who presented to the walk-in entrance of the ED where they were screened for COVID-19-like complaints. If they did not appear critically ill and could ambulate they were directed into the FTA. Clinical and non-clinical staff worked in concert to register, evaluate, and process patients with either a disposition of directly home or into the ED for further care. RESULTS: A total of 634 patients were seen in the FTA from March 23-April 16, 2020. Of the 634 patients evaluated, 135 (21%) were referred into the ED for further evaluation, of whom 81 (12.7% of the total) were admitted. These patients were disproportionately male (91 into the ED and 63 admitted) and tended to have a higher heart rate (105.4 vs 93.7), a higher respiratory rate (21.5 vs 18.1), and lower oxygen saturation (93.9% vs 97.8%). CONCLUSION: A forward treatment area is an effective method to rapidly screen and process an increased volume of COVID-19 patients when resources are limited. This treatment area helped decompress the ED by being rapidly deployable and effectively screening patients for safe discharge home.

Intubation outcomes and practice trends during the initial New York SARS-COV-19 surge at an academic, level 1 trauma, urban emergency department.

OBJECTIVES: The goal of this study was to describe outcomes and associated characteristics of patients who were intubated during the initial (3/2020-4/2020) New York City surge of the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, during which time we were confronted by an unknown and unprecedented respiratory distress syndrome with extremely high degrees of morbidity and mortality. Our secondary aim was to analyze our physician's rapidly evolving approaches to COVID-19 airway management. METHODS: A retrospective cohort analysis of all patients intubated at two emergency departments (EDs) for COVID-19 suspected respiratory failure. In addition, a survey was done to analyze clinician airway management trends and attitudes as they evolved during that period. RESULTS: Ninety-five patients met inclusion criteria for the study. Primary outcomes looked at the spectrum of mortality outcomes ranging from died on arrival (DOA) to the ED, died in the ED (DED), died an inpatient (DIH), and survival to discharge. Overall mortalitywas 71.6% with an average age of 62.7 years. Female sex, as a demographic, was associated with higher rates of survival to discharge at 42.3% when compared to males at 23.2% (P < 0.001). Mean age was 70.8 years DOA, 65.6 years DED, 62.9 years DIH, and 60.0 years for survivors (P = 0.0037). Initial lactate levels were 8.15 mmol/L DED, 3.56 mmol/L DIH, and 2.61 mmol/L survivors (P < 0.0001). Initial creatinine levels were 3.38 mg/dL DED, 1.94 mg/dL DIH, and 1.77 mg/dL survivors (P = 0.0073). D-dimer levels were 7520.5 ng/mL DED, 5932.4 ng/mL DIH, and 1133.9 ng/mL survivors (P = 0.0045). Physician survey respondents reported high levels (69%) of laryngeal edema and prolonged post intubation hypoxia (>50% of time) and >80% remained concerned for their safety. There was a dramatic shift from early (73% of time) to late intubation strategies (67% of time) or non-invasive approaches (28% of time) as the first surge of the pandemic evolved. CONCLUSION: Our findings demonstrate that several demographic, clinical and laboratory parameters correlated with mortality in our cohort of patients intubated during the initial phase of the COVID-19 pandemic. These included male sex, advanced age, high levels of initial lactic acidosis, elevated D-dimer, and chronic kidney disease/acute kidney injury. In contrast, presenting respiratory characteristics were not correlated with mortality. In addition, our findings demonstrate that physician attitudes and strategies related to COVID-19 airway management evolved significantly and rapidly over the initial phase of the pandemic.