Exterior ED Expansion: Temporary Open-Air Care Space

In the 2003 SARS outbreak, inefficient ventilation contributed to increased viral spread. ^{Reference Li, Leung and Tang11} In response, hospitals in Hong Kong utilized natural ventilation in patient wards. ^{Reference Qian, Li, Seto, Ching, Ching and Sun12} Building on this knowledge, temporary open-air care spaces were created by repurposing the ambulance bay (Image 1A). This additional space facilitated patient grouping, improved ventilation, and increased patient distancing to minimize disease transmission risk.

Figure 1.

Physical space modifications in response to COVID. 1A–1B: External and internal depiction of temporary open-air care spaces in ED ambulance bay. 1C: temporary construction panels added to existing curtained ED treatment rooms. 1D: secondary negative airflow annex ED waiting room repurposed from unused facility space. 1E: schematic of patient flow from immediate screening at ED waiting room entrance to open-air care space.

Using the ambulance bay as an open-air care space obviated the need for ventilation construction. To ensure safety while maintaining open airflow, the ambulance bay was partitioned by repurposing commercially available temporary construction panels (Image 1B). Each partitioned care space was equipped with documentation computers, testing supplies and sanitation materials, and PPE donning and doffing stations were installed at the staff entrance. The overall construction of this care space occurred in less than 4 days, costing approximately $75000. Due to the nature of the materials used for the creation of this space, this care space can be easily constructed and deconstructed as needed. Staffing costs were similar to other areas of the ED, but overall costs were partially mitigated by staff restructuring within other care spaces.

Physicians, advanced practice providers, nurses, and ED assistants all staff this care space. They don PPE and enter the open-air care space via a separate staff hallway. All patients presenting to the ED (approximately 250 patients per day) were screened for potential treatment in this care space. Well-appearing patients suspected to have COVID-19 are identified at the waiting room entrance, masked, and walked outside to the care space. This outdoor walkway prevents these patients from moving through the ED. Upon assessment in the open-air care space, testing for COVID-19 and/or chest radiography is performed as indicated, and the patient is dispositioned. Patients who require further evaluation and potential admission enter through the ambulance bay, where they are immediately placed in a closed-door room (Image 1E). Patients were often discharged prior to the results of their COVID-19 test, and results were called by a designated follow up health care team.

The creation of an open-air care space has successfully decreased stress on the existing ED. Over 30 days, this space was able to treat over 900 total patients (˜ 30 patients per day), which represented 15% of daily volumes. At peak volumes, over 70 patients were seen between 10 AM and 8 PM, the operational hours of this space. Overall, this space increased ED capacity while maintaining compliance with infection control guidelines, consolidating PPE, and improving care efficiency for low acuity patients with suspected COVID-19.

Creating Additional Neutral Airflow Rooms

It was infeasible to convert the entire ED to negative airflow rooms, therefore, all curtained open treatment rooms were retrofitted with temporary construction panels with doors costing approximately $20000 (Image 1C). This provided a physical barrier between providers and patients, creating neutral airflow rooms. These doors included a clear window, facilitating patient monitoring while maintaining appropriate isolation. Each door took less than 2 hours to attach, and the ED was refitted in less than 1 day. These installations increased neutral airflow room capacity by greater than 35% without disrupting the operational flow of the ED during construction.

Addition of Secondary Waiting Room: Annex and Chairs

The existing negative airflow waiting room was re-designed to comply with current CDC guidelines of 6 feet of separation. However, this redesign decreased waiting room capacity substantially (from 30 to 12) necessitating the creation of a second negative airflow annex waiting room. This occurred through the conversion of dead-space in the facility not adjacent to the ED over 1-week costing approximately $150000 (Image 1D). While the location for this annex waiting area is suboptimal and will require additional staffing, the benefits from an infection control perspective made this an intervention worth pursuing. Should volumes increase beyond the capacity allotted by the enclosed rooms, these waiting rooms can be split into care spaces.