Rethinking ED waiting rooms in response to COVID-19

For many people, seeking emergency care typically involves waiting in a crowded room before being treated. Wait times for emergency services generally average from 24 to nearly 50 minutes nationally, depending on the department’s size.

But in the COVID-19 era, social distancing precautions mean not asking patients to wait in a packed emergency department.

As a result, health systems across the country are taking on the challenge of redesigning their EDs as well as rethinking their operations to keep patients safe. And rather than completely gutting and rebuilding, which is costly, most providers are thinking creatively to rework their existing spaces to reduce crowding of patients and family members.

Health systems “are really thinking clearly about their EDs—the entrances, the access (and) COVID-19 waiting,” said Catherine Gow, principal of health facilities planning at Francis Cauffman Architects.

Common practices include spacing chairs in waiting areas at least 6 feet apart and restricting visitors to avoid crowding, both of which have been deployed at University Hospitals based in Cleveland.

“You don’t want people to walk through the door, see a crowded ED, and walk out. That is the worst-case scenario,” said Dr. Jessica Goldstein, medical director of the system’s emergency medicine quality network.

Throughout the pandemic, it’s been easy for University Hospitals to maintain sparsely populated waiting areas due to low volumes, but patients are starting to return to the EDs. The volumes across the system’s 12 EDs are at 80% of pre-COVID-19 levels—slightly higher than trends nationally with hospitals reporting ED volumes are at 75% of pre-COVID levels. Research shows ED volumes have been slower to rebound compared with outpatient and inpatient volumes.

Like most hospitals, University Hospitals screens each patient upon entrance for COVID-19 symptoms. Those suspected to have COVID-19 are immediately bedded, and if that’s not possible, they’re led to a separate waiting area. Depending on the size of the hospital’s ED space, the designated waiting area might be a closed-off room or a section of a single waiting room separated by makeshift physical barriers to isolate suspected COVID patients.

The frequency of cleaning the waiting areas has also increased since COVID-19 with the environmental service team routinely wiping down chairs and other high-touch surfaces. New filtration systems were also installed to more efficiently scrub the air while patients wait.

“COVID-19 has offered us an opportunity to do something we do well: rethink limited resources,” said Dr. Robert Hughes, assistant medical director of the ED at University Hospitals’ Cleveland Medical Center.

And to avoid jammed waiting rooms, University Hospitals has set up tents in its parking lots to triage less-urgent cases. The tents are staffed with an advanced practitioner and nurse who can provide a full medical exam. For patients who arrive by car and have a cellphone, the nurse tells them to wait in their vehicles and they’ll receive a call or text when an exam room is ready. Nurses have been using a similar process for patients’ families and friends to keep them informed.

“A lot of times waiting room safety is a function of how efficiently you can keep the room clear,” Hughes said. “A lot of these initiatives have been a function of rapid patient transit to areas, which has created a safer waiting room.”

Unlike other hospitals, ED volumes at Lexington (Neb.) Regional Health Center, a critical-access hospital with 25 beds, have stayed consistent with pre-COVID levels, said CEO Leslie Marsh. The hospital has about 300 ED visits a month and although it experienced a surge of COVID cases in April, the hospital has continued to treat typical cases like heart attacks, strokes and car accidents.

“We are right off a major highway, so we do see trauma,” Marsh said.

To combat a crowded waiting room, which was common before COVID-19 because of visitors, patients are only allowed one visitor. Furthermore, there is now only one entrance for ED walk-ins, and patients must be buzzed in. A nurse meets them immediately upon entering, and they are then screened for COVID-19 symptoms and go through triage. The area is closed to other patients.

Marsh said this helps staff “know what they are dealing with” sooner and has helped manage ED throughput and operations.

Health systems face a extra layer of complexity if they deal with a number of patients who don’t have the option of waiting in a car. It isn’t ideal for a patient to wait outside if they can’t be immediately placed in an exam room and chairs in the waiting area are full given social distancing restrictions and weather conditions. Health systems are thinking through that problem by creating more space.

Rush University Medical Center in Chicago gets a fair number of patients who arrive at the ED via public transportation, and some even walk. Like University Hospitals, Rush isn’t now facing an overcrowded waiting area because the pandemic has lowered ED volumes, but leadership is planning for a potentially busy flu season.

In such a situation, Rush will take advantage of its pavilion space directly adjacent to the ED, said Dr. Paul Casey, the system’s acting chief medical officer. 

“We can make it a treatment area,” he said. “Now is the time to plan for that.”

The open space was designed so more beds can be added in a crisis such as a mass casualty event. Rush at one point set up beds in the pavilion during the first few months of the pandemic and treated about 20 patients there, Casey said. Rush also has additional space on a separate floor where family members of ED patients can wait.

But some older hospitals don’t have the option to add space, such as Henry Ford Hospital in Detroit, which is over 100 years old.

The physical structure “just isn’t capable of really being manipulated or moderated to facilitate social distancing practices, so we have had to be innovative in that regard,” Dr. John Deledda, chair of emergency medicine at the system.

Similar to Rush, Henry Ford gets patients who walk to the ED or take public transportation. Its ED volumes have been low, but Deledda said the system will roll out tents in parking lots if needed during the flu season.

Henry Ford set up tents in its parking lots to triage COVID-19 patients during the area’s pandemic peak in March and April. Tents were also used as waiting areas.

The tents were taken down recently as Michigan sees its COVID-19 cases drop, but they are ready to be deployed at any time, Deledda said.

A downside to the tents is the lack of appeal for patients. “Rolling past and seeing the hospital look like a refugee camp doesn’t exactly project a sense of, ‘It’s safe here,’ ” Deledda said.

In addition to using tents at some of its sites, Mount Sinai Health System in New York has added virtual technology to triage ED patients quickly. Similar to other urban hospitals, Mount Sinai gets patients who walk or take public transportation to its EDs.

Rather than a triage nurse assessing a patient, a clinician does it virtually, allowing tests and medications to be ordered before the patient is in a bed and sees the bedside physician, which improves ED throughput and length of stay.

“This changes (the patient’s) experience and maybe even their outcomes, but certainly their turnaround times,” said Dr. Brendan Carr, Mount Sinai’s chair of emergency medicine.

Similarly to other systems across the country, Mount Sinai is seeing lower ED volumes, hovering around 70% to 80% compared with pre-COVID levels. This is largely because COVID-19 cases are down significantly but also because people who can leave the city during summer months usually do and the business district is now much quieter, Carr said. Even so, he said, Mount Sinai is always prepared for a surge of cases.

Henry Ford leaders are thinking about how to handle a potential patient surge during flu season as well. A challenge will be the ability to quickly distinguish COVID-19 patients from those with flu so they aren’t mistakenly grouped together. The symptoms of both viruses are fairly similar. To combat that, Henry Ford would like to be able to rapidly test patients for both COVID-19 and the flu accurately. Right now, Henry Ford can test a patient for COVID-19 and get the results back within two hours.

“We have to be pretty spot-on when it comes to diagnosis before we think about (grouping) patients,” Deledda said. “We are going to have to concentrate on isolation practices.”

Health system leaders are hopeful that ED volumes won’t return to overcrowding levels thanks to the increased use of telehealth. About 4% of ED visits are considered non-urgent, according to the most recent data from the Centers for Disease Control and Prevention, but there is also research suggesting about 30% of ED visits from chronically ill patients are unnecessary, leading to $8.3 billion in additional costs for the industry.

Perhaps fewer people will view the ED as their first option, Casey said, because now “people have realized they want more on-demand care.”