A day in the ER: Perspectives from Advocate Aurora providers on the frontline

What is it really like to work in the emergency department during the COVID-19 pandemic?

While people and industries around the world are in a state of lockdown, hospital workers have been working non-stop for weeks developing new solutions, processes and workstreams to care for COVID-19 patients.

As innovators look for the best ways to support those workers, it’s difficult to gauge exactly where help is needed without understanding the daily challenges they face.

In a recent webinar, MATTER CEO Steven Collens interviewed four healthcare professionals from emergency departments and intensive care units throughout the Advocate Aurora Health system to learn more about what they have been seeing and experiencing day to day on the frontline.

The panelists included:

• Ellen Bollino, RN, nursing director of emergency and critical care services at Advocate Aurora South Suburban
• Ross Asher Kalman, MD, physician at Advocate Health Care
• Ron Lawton, MD, director of emergency medicine for Advocate Illinois Hospitals
• Carrie Mendoza, MD, ED, physician at Advocate Illinois Masonic, Advocate Trinity and Advocate South Suburban

You can watch the full webinar recording at matter.health/live. Here are several of the key challenges and insights these providers shared. Responses have been edited slightly for length and clarity.

The ED lives in the unexpected, but there was still a serious learning curve.

Carrie: “Something that we in emergency medicine are always prepared for is the unexpected. Post-9/11, and during various other public health emergencies, we always have been trained to look out for the ‘zebras.’ So to some degree it’s part of our mindset.

“But the enormity of this problem — and the fact that it has encompassed all of society — is of a whole different magnitude than we’re used to. Initially, it was definitely scary in terms of not clearly understanding the transmission rate and the degree to which we needed to protect ourselves on a shift. Once we got that down, it’s actually been a very organized calm environment for us. I think this experience has shown that we can have great faith in the way the hospital and our emergency teams can get organized very quickly.”

Ellen: “To Carrie’s point, the ED lives in the unexpected. We’re used to it and we adapt to it, but for the ICU teams, this is a little bit different. They’re used to already having algorithms in place. The care of intubated COVID-19 patients is challenging and they’re on the ventilators for a long time. So it takes a toll.

“Another one of the challenges is that, from an emergency preparedness perspective, our plans have always relied heavily on the CDC and the health organizations to help us manage. And they quickly became overwhelmed and we had to figure it out on our own. I think that we’ve done an excellent job of that, and we’ve learned and adapted quickly, but the planning that was put in place initially really didn’t work for these symptoms and this virus.”

COVID-19 symptoms manifest in a variety of ways.

Ross: “What’s making it so difficult is that, at this point you really don’t know who has COVID-19 symptoms and who doesn’t. There’s so much about this disease that we don’t know — and that’s reflected in how the guidelines and recommendations from our local governments and our health organizations are changing all the time.

“What we thought was the textbook presentation of this disease was cough, fever and shortness of breath combined with travel history. But as we’re all seeing more patients, there are really unusual presentations like vomiting and diarrhea, patients with altered mental status or patients with chest pain and elevated cardiac enzymes — which we would often attribute to something else, maybe not a viral illness. We’re really seeing a wide variety of presentations, and as a consequence, we’ve had to take almost automatic universal precautions — because truly, there’s no textbook case.

“It’s also been a challenge to predict who is going to do well when they get the disease and who is not going to do well…we just don’t have the data, knowledge or understanding to predict outcomes.”

“We’re really seeing a wide variety of presentations, and as a consequence, we’ve had to take almost automatic universal precautions — because truly, there’s no textbook case.” - Ross Kalman

Providers need to consume information constantly to keep pace.

Ross: “Treatment recommendations are truly changing from day to day and from week to week — we’ve seen a back-and-forth with different experimental therapies or antibiotics that might have some anti-inflammatory or antiviral activity. The data on these is just not clear and equivocal at best.

“One other thing we’re thinking dramatically differently about is ventilation. We’re learning as countries that are ahead of us — like South Korea and Italy — are producing some really good data that maybe early ventilation is not the best thing. So now there’s an urge to do alternatives to ventilation like non-mechanical ventilation, BiPAP, CPAP, or just means of keeping people awake and not putting a breathing tube down. That method has been much more successful because we’re learning that once a patient does require intubation, their morbidity and mortality significantly increases. So anything we can do, even if it’s to keep someone off of a ventilator for a couple of days is dramatic and really helpful.”

“A couple of months ago, information would have to be circulated through primary literature starting out in journals and filtering down. That process takes months to years to go through peer-reviewed journals. Now, we really have a much more urgent need for information.”

Ron: “This has been one of our greatest challenges: Information is changing daily. At one point I would say it was even changing hourly. It has been a challenge to get the latest information out to all of the frontline staff. One thing that we did at Advocate Aurora is set up a central website that has all of our documents around COVID-19 including treatment information, appropriate PPE, testing standards, guidelines for staff to stay safe at home, etc. In addition, we have daily emails that come out from various levels of leadership with the latest information. We’ve been having daily phone calls with leaders across the system to disseminate information. So it has been a great challenge, but we’re using a number of different modalities to do it.”

Supply shortages are unpredictable — and reach beyond just PPE.

Ellen: “The logistics of healthcare supply is based on a predictability model — so the lack of predictability as it relates to this pandemic has been really challenging. We’ve also needed things that you wouldn’t necessarily think about even beyond PPE. For example, in the ICU, providers are using extension tubing so that the IV pumps can be outside the room so that if the pump beeps or if they need to make an adjustment to the medication, they don’t have to go into the room. So then we started to run out of tubing…every day it’s a different supply that we’re looking to procure. As part of a very large organization, we’ve been able to get those supplies in quickly, but it’s something that we have to look at every day, seven days a week, 24 hours a day.”

“The logistics of healthcare supply is based on a predictability model — so the lack of predictability as it relates to this pandemic has been really challenging.” - Ellen Bollino

PPE requirements affect how providers care for patients.

Carrie: “We are all completely covered in PPE during the entire shift because every patient is pretty much presumed to have COVID-19. We have come up with a system to try and limit our times going into the room, whether it’s talking to the patient from the doorway, or working with the nurses to decide on what the plan is in terms of medications and therapeutics so they can limit the times they have to go in the room.”

Ross: “We’re used to examining people and being close to them — maybe holding a patient’s hand, putting your stethoscope on their chest, examining someone’s abdomen — and it’s all changed. You walk into a room and you’re covered in PPE, which automatically creates a distance between you and the patient. If you’re working with a child, that can be especially intimidating for them to watch this zombie-like creature come in covered with PPE. Things have completely changed in terms of our interactions with patients.”

“We’re used to examining people and being close to them — maybe holding a patient’s hand, putting your stethoscope on their chest, examining someone’s abdomen — and it’s all changed.” - Ross Kalman

Limited access to testing has affected decision making for both inpatients and outpatients.

Ellen: “When we have a patient who is COVID-19 negative and they’re an inpatient, they have to be in a private room, because the specificity of the testing isn’t enough that we would feel comfortable putting them with a patient who doesn’t have COVID-19. For patients who are COVID-19 positive, they can be cohorted in semi-private rooms.

“We get 30 rapid tests a day at our site, so we still don’t really have the capacity to test patients who are likely going to be discharged from the emergency department. We do have the testing to help a physician decide whether to send a patient home or not if they have mild symptoms, but a lot of risk factors. We are also able to test patients getting surgical procedures and moms who are delivering babies.

“So we do have tests, but we don’t have as many as I think the physicians would like in terms of giving those patients with mild symptoms an answer as to whether they’re going to infect their family members or not. That’s been a challenging message for our providers to communicate.”

For staff without emergency experience, the transition to COVID-19 units has been difficult.

Ellen: “Very early on, we identified nurses who may be working in non-emergency settings but have emergency experience, so we did get that help in the ED pretty quickly. The ICU has been a little more challenging. Again, one of the benefits of nurses with emergency experience is that they’re adaptable. They’re used to taking care of patients across the age spectrum from babies to elderly, and from someone who might have a broken ankle to someone who is having a heart attack. The nurses and other areas are not as used to that variance.

“For the nurses we pulled in from other procedural areas, which weren’t as busy, we developed some training for them and it has increased the productivity of our nurses to a certain degree — but it also increases their stress level in terms of making sure that the new staff have everything they need and have the knowledge and the skill to be able to take care of patients.”

Ross: “Emergency medicine by nature is stressful — we always say ‘controlled chaos’ and this is no exception. But in emergency medicine, we do talk a lot about provider wellness and burnout. I think, more than ever, it is increasingly important to prevent burnout, which is something we talk about a lot now, but has always been an issue in emergency medicine cause we’re very vulnerable to it.”

COVID-19 has changed the way systems see telehealth.

Carrie: “There’s been a more robust response from primary care and the hospital system at large to really look at what the role of telehealth is in terms of helping to triage patients away from the ER if they don’t need to be there — and empowering primary care physicians to be able to connect with their patients and answer their questions.

“Part of the ER’s function in the healthcare system before COVID-19 — and it’ll still be afterward — is that we are the safety net of the system and we’re the place that’s open 24/7 after the doctor’s office or urgent care is closed. Putting strong telehealth processes in place for primary care has helped to decrease some of the unnecessary emergency department visits that we were seeing early on. A lot of these changes were able to happen because at the federal level, they loosened up telehealth restrictions, which physicians have wanted for so long.”

“There’s been a more robust response from primary care and the hospital system at large to really look at what the role of telehealth is in terms of helping to triage patients away from the ER if they don’t need to be there.” -Carrie Mendoza

As the curve flattens, it’s important to examine learning opportunities at the system level.

Ron: “We’ve been asking ourselves, what good has come out of this? We never want to let a crisis go to waste. We have seen a lot of wins come from this and we want to take a good look at those and also take note of what we were doing in the past that we found out we really don’t need to do anymore. What are the new things we’re doing that have made a positive impact? We’re fortunately at a time where the curve is flattening and we can start to look at those longer-term questions at a system level.

“You know, memories sometimes can be a little short. We went through this to a lesser degree with Ebola and made a lot of plans around having PPE, donning and doffing, etc — and some of that stuck with us and we were able to kind of dust off the manuals for COVID-19, but those manuals were maybe not as much as they should have been. Now, we’re asking ourselves, how do we document this? How do we ensure that all of the lessons learned and all of the work from the last few weeks isn’t lost for the future?

“One of the most remarkable and surprising things has been the response from our communities — they’ve been able to take the lockdown seriously and really help flatten the curve. We made all the plans to be overwhelmed — we built tents at every one of our emergency departments, ready for an onslaught of patients. And due to the collaboration of these communities, doing everything possible to prevent that surge, we’re actually in a position where we haven’t needed to use our tents that much. Our volumes are surprisingly low in our emergency departments. When I say low though, we’re seeing less of the lower acuity patients, but we’re still seeing very, very sick patients. So volumes are down, but our acuity is certainly up.”

“One of the most remarkable and surprising things has been the response from our communities — they’ve been able to take the lockdown seriously and really help flatten the curve.” - Ron Lawton

Want to learn from more experts about how to navigate COVID-19? On May 6, Evive CEO Prashant Srivastava will join us to share what he learned leading a startup through the 2008 recession. RSVP here.