How Coronavirus Will Tax Already Overcrowded U.S. Emergency Departments

The novel coronavirus (COVID-19) is already having far-reaching effects on our nation. The stock market has taken a historic plunge from its all-time high. Major entertainment and sporting events have been canceled. I recently took a cross-country flight from Maryland to Oregon have not seen this many empty seats on a plane in a very long time.

While other public venues may be empty, emergency departments will likely get very busy. All indications are that we are at the beginning of an outbreak, with many more cases to come. Already crowded emergency departments will only become more so. Go to many EDs on any given day, and the wait to be seen can take hours. Add 10 percent more volume from the coronavirus, and it will get a lot worse.

Stratifying coronavirus patients

Coronavirus patients will include the very ill (those who are actually at risk of dying), those who think they are dying (think “man-flu”), and the worried well (those who are worried that they may get it). Add to that the demand for testing. Unlike the flu, where many of us get it but don’t bother to get tested, I suspect that anyone with a respiratory infection will want to know if he or she has COVID-19.

This is a rapidly evolving clinical situation, but evidence to date suggests that most patients infected with COVID-19—about 80 percent—will have mild symptoms. Thus, most of the patients coming to the emergency department will be able to go home. Interestingly, this is similar to the discharge rate at many community emergency departments. Yet, we are challenged to manage this outpatient population daily.

The problem is that most emergency departments don’t have an efficiently designed intake system and run out of beds every day. What’s needed is a system where the sick are quickly identified and separated from the not-sick. One where the sick get bedded quickly and the not-sick only get a bed for the time needed for proper assessment and treatment, saving valuable bed capacity for those patients who clearly need it.

Unfortunately, the time to implement a new intake system is not in the middle of a pandemic crisis. Hospitals will come up with temporary solutions like tents to cohort potential COVID-19 patients. It’s hard to believe that in a health care system as sophisticated as that in the United States that we will be treating patients in tents! But the reality is that the collective “we” have not addressed the increasing volume and complexity of patients coming to emergency departments over the past 15 years.

Building a new intake system takes some time and effort, but more than anything else, it takes commitment: Commitment to hard work to eliminate patient waiting time. Just like fad diets don’t work for sustainable weight loss, fad throughput initiatives don’t work either. True demand-to-capacity matching looking at both volume and acuity and utilizing queuing theory principals is required, along with identifying inefficiencies using Lean and eliminating bottlenecks using the theory of constraints. And lastly, deploying effect change management strategies to get people to work together to make the patient and health care professional experience better.

Joe Twanmoh is an emergency physician.

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