While the COVID-19 pandemic has impacted every corner of healthcare, emergency departments have been at the eye of the storm. In early 2020, well before the new coronavirus had reached the East Bay, emergency department leaders at Alta Bates Summit Medical Center, Eden Medical Center and Sutter Delta Medical Center began preparing their facilities and teams for a potential influx of COVID-19 patients.
As a small hospital, we benefited from being part of the Sutter Health network
Working closely with Sutter Health Emergency Management System (SHEMS), they reconfigured spaces, implemented new protocols, distributed personal protective equipment and galvanized teams to manage the virus as safely and effectively as possible. But along with accommodating COVID-19 patients, EDs had to remain ready to treat heart attacks, strokes and other serious illnesses and injuries, none of which stop during a global pandemic.
Executing so many changes while upholding a high level of care and ensuring patient, physician and staff safety was no easy feat. It took immense ingenuity, coordination, nimbleness and a fierce determination to continue offering our East Bay communities world-class care close to home.
“This was like nothing we’d ever experienced before,” says Ronn Berrol, M.D., medical director of the emergency department at ABSMC in Oakland. “It was a scary and exhausting time, but it was also so gratifying to see everyone understanding their role and working together to provide excellent care to our community. I give Sutter Health a lot of credit for taking the initiative to learn and make resources available, to prepare for the worst and have full capacity available.”
Because COVID-19 is a virulent airborne pathogen, the East Bay EDs had to strategically reengineer patient rooms, triage areas and waiting areas to minimize viral spread—and do so rapidly.
“From the get-go, it was about isolating and separating patients,” says Josh Sheridan, M.D., medical director of the Sutter Delta ED. “We erected physical barriers to create hot and cold zones and moved triage outside at times. We had to figure out exactly where potential COVID-19 patients needed to go in order to limit the spread.”
ABSMC and Eden also erected outdoor tents, which provide better airflow and more space for social distancing. “Initially, we thought the tents would be for treating patients, but we ended up needing more waiting space for patients with COVID-19 symptoms,” says Nathalie Coeller, M.D., medical director of emergency and trauma services at Eden.
Eden also used screens provided by philanthropy to carve out safe treatment stations in the lobby. “Until we could determine whether or not a patient had COVID-19, we treated them like they did,” Dr. Coeller says. “This helped save our staff in the emergency department and greater hospital from getting ill.”
To care for patients with severe respiratory or gastrointestinal symptoms, the EDs transformed additional rooms to negative airflow, ideal for managing contagious diseases. “Our engineers looked at the hospital in ways they hadn’t before, and within 48 hours, they’d created an eight-bed unit that had the safest air in the entire hospital,” Dr. Berrol says. “By engineering better negative-pressure airflow, we were able to reduce room turnover times from one hour to 15 minutes.”
This type of innovative thinking allowed emergency care teams to treat all patients comfortably and safely as they gained more insights about the disease. “We were being overly cautious at first because there were so many unknowns,” Dr. Berrol says. “Now we know we can be more efficient in using our space while not increasing the risk to patients or staff—but we had to learn that first.”
Learning in Real Time
When the first COVID-19 cases emerged in the East Bay, in late February and early March 2020, treatment protocols hadn’t yet been established. Emergency care providers had to learn as they went, which took persistence, creativity and collaboration.
Meanwhile, SHEMS consistently kept ED leadership abreast of new learnings. “As a small hospital, we benefited from being part of the Sutter Health network,” Dr. Sheridan says. “SHEMS took the lead, which helped us keep up with the latest recommendations and determine how to solve situations that arose locally.”
The ED medical directors at ABSMC, Eden and Sutter Delta also communicated constantly. “We used our collective knowledge within Sutter, asking one another ‘What is your experience? How are you being creative? What are you telling your doctors and nurses?’” Dr. Berrol says. “One doctor from Sutter Delta who’d volunteered in a New York COVID-19 unit came back and told us what he saw and what that facility did so we could adapt our PPE, cleaning procedures and so on.”
With information changing by the hour, teams had to remain nimble.
“As we were learning how best to care for COVID-19, we had the benefit of having Jeffrey Silvers, M.D., medical director of infectious disease for Sutter Health, based at Eden,” Dr. Coeller says. “He helped us pivot quickly when new information came in about science and symptoms so we could keep everyone safe.”
Continuous refinement of COVID-19 care also enabled physicians and staff to treat other emergencies more effectively. “We learned techniques to keep COVID-19 patients off ventilators and out of intensive care,” Dr. Berrol says. “Understanding the right care for each COVID-19 patient left more capacity to provide the right care for other emergency patients.”
Though the East Bay EDs were prepared, coronavirus cases didn’t surge right away. “We have the benefit of being in the Bay Area, with a very progressive public health system that didn’t deny that COVID-19 was coming,” Dr. Berrol says.
“Because we were the first counties to lock down, we canceled elective procedures and hospitals began working together, we saw less of a bump in cases than many other places that were inundated early, such as New York.”
The East Bay experienced its first real spike last summer. “But by that time, we’d learned enough about using PPE, separating patients with different risk factors and treating COVID-19 to protect staff and patients,” Dr. Berrol says. “ When our caseload increased, we were in a great position to meet the challenge.”
Although case numbers dropped back down in the early fall, they soared to new heights shortly after Thanksgiving. The percentage of severely ill cases also increased. With double the COVID-19 patients in December as during the summertime surge, ABSMC maxed out its intensive care unit capacity.
But again, by applying their learnings from the past several months, “we could provide excellent care even more efficiently and safely for the second surge,” Dr. Berrol says. This preparation allowed hospitals to continue elective surgeries and keep rehabilitation units open during the December influx, thereby maintaining vital services for the community.
New Year, New Call to Action
Moving into 2021, COVID-19 incidence stabilized and vaccinations began, signaling hope for the pandemic’s end and easing some of the pressure felt by emergency care clinicians. Yet the teams have remained vigilant, knowing the virus is still present and new variants can spread rapidly.
“We’ve had enough spikes over the last year that if another one occurs, we are prepared,” Dr. Sheridan says. “I hope that with vaccine rollouts, the worst is behind us and things will get better. But the only way that can happen is with widespread vaccination and continued masking, social distancing and handwashing.”
Although the ED leaders are happy to see fewer COVID-19 cases, they are concerned that their overall patient volumes remain down, just as they are nationwide. This is because many people are putting off care or neglecting to seek it altogether, fearing they could contract the virus in a busy ED or be separated from loved ones. As a result, those coming in for care tend to be very sick.
“Unfortunately, patients coming in for issues other than COVID-19 have been waiting too long,” Dr. Sheridan says. “I’ve heard too many stories of people staying at home for three or four days with concerning chest pain.” By the time these patients do come in, he adds, they’re at much higher risk of poor outcomes or disability. Some never make it to the ED—they die at home.
“There is still a lot of fear out there, and we understand that,” Dr. Berrol says. “But our role is to help differentiate chest pain caused by a heart issue versus a muscle strain. If you think you’re having an emergency, we are prepared to give you safe care.”
That’s the message all three leaders want to impress upon the community: If you are sick or hurt, come to the emergency department. You will be treated safely—and likely fare much better than if you delay or don’t seek care.