Table 1 Checklist for ED pandemic workflow

ED Input

□ Is there a single entrance into the ED?

□ Is there a screening criterion for all ED patients? (incorporating clinical and epidemiological features)

□ Is the screening criteria kept up-to-date?

□ Are there clear triage criteria (high suspect, intermediate suspect & non-suspect)

□ Is there a protocol for the type of PPE to be worn by screening, triage and ancillary staff?

□ Do all patients have to wear masks?

□ Are there safe-distancing measures for patients in waiting areas?

□ Is there a contactless screening system?

□ Is there a workflow to re-direct well patients to alternative screening centres?

□ Is there a system to allow early alert of the 1st index case?

□ Does the system alert new cluster pickups through the ED?

□ Is there a platform for communication with pre-hospital ambulance system?

□ Is there a platform for the ED surveillance team to communicate with the infectious disease team in the hospital? (e.g.: Command centre)

□ Are there clear instructions of PPE expectation in the different areas?

□ Is there clear communication about staff movement between areas?

□ Is there clear communication with patients and relatives about their movement within the different areas?

□ Is the ED able to communicate to the primary healthcare facility about changes in workflows to manage the input?

□ Is there a platform to communicate with the hospital inpatient departments?

□ Is the ED able to communicate workflow changes to the public?

□ Is there a designated ED surveillance team to monitor changes in screening criterion?

□ Are there more experienced nursing staff at triage?

□ Has security personnel been activated to restrict access into ED during outbreak period?

□ Have vulnerable staff members (e.g. pregnant or immunocompromised) been appropriately re-deployed to minimise exposure.

□ Who is responsible for training staff for PPE (ED staff, augmented, ancillary)?

□ Are there plans for augmented manpower at screening area?

□ Who trains the augmented staff for screening?

□ Do you have a screening area before triage?

□ Are there separate triage areas for patients following screening into high suspect, intermediate suspect and non-suspect categories?

□ Can the spaces be reorganised to reduce exposure & movement of staff?

□ Is the IT system able to capture the patients’ data, to facilitate contact tracing?

□ Is there IT support in expanded areas?

□ Are there any point of care test kits to facilitate screening process?

□ Is there adequate PPE for the different risks areas and does a reliable supply chain exist?

□ Are masks provided for patients in waiting areas?

□ Are there standby equipment for areas that need to be expanded?

ED Throughput

□ Is the system able to limit movement of patients between the different suspect areas?

□ Is the system able to monitor patients and staff movement between the different suspect areas?

□ Is there a workflow for testing in the ED such that the cases can be labelled confirm infected rather than suspected?

□ Is there a strict area demarcation between the different COVID suspect areas?

□ Are there regular PPE training & audits?

□ Are there handwashing audits or equivalent?

□ Is there a workflow for PPE during intubation?

□ Is there a workflow for aerosol generating procedures?

□ Is there a workflow for the cardiac arrest/ drowsy/ AMS patients?

□ Is there a workflow for high risk suspects with time sensitive conditions (AMI, stroke)?

□ Is there a workflow for patients with respiratory symptoms?

□ Is there a workflow for dying/palliative patients?

□ Is there a workflow for patient intubation?

□ Is a rapid diagnostic test being used for the outbreak?

□ Is there a workflow with the radiologist to have reports out early?

□ Is there a workflow with microbiology for early results?

□ Is there a workflow for testing and sending well patients home?

□ Is there a platform to communicate patient workflow and management changes?

□ Are Instructions readily available on donning and doffing of PAPR?

□ Is there a platform to communicate with infectious disease specialists within hospital?

□ Are there considerations for patients in high risk areas to communicate with staff through portable electronic devices from their negative pressure/ isolation rooms?

□ How is the movement of patients within the ED communicated to ED staff?

□ Is there a platform to communicate with radiologists and microbiologists to facilitate investigations done within ED?

□ Is there a system to reduce mixing between working teams? (e.g.: modular, team based or staff remaining in their allocated areas for a period of time?)

□ Are there measures to avoid placing the immunocompromised and the pregnant staff in intermediate and high suspect areas?

□ Is there a self-monitoring system that allow staff to detect for early signs of infection (e.g.: temperature taking) and report in sick?

□ What will be the workflow for the allied healthcare staff in ED? (e.g.: physiotherapy)

□ Is there augmented manpower at the various areas?

□ Is there geographical/ physical segregation between the patients of different risk categories?

□ Are there negative pressure rooms in the high suspect areas?

□ Is there adequate spacing between the patients in the intermediate and high suspect areas?

□ How will radiology spaces be managed?

□ Are there shower facilities for staff?

□ Is there adequate space in the pantry for staff to have their meals with physical distancing?

□ Is there a designated path for high and intermediate suspect cases to take to their respective investigation areas (e.g.: CT scan)

□ Does the IT system allow the smooth flow of patient information from the screening to their inpatient or community notes?

□ Are there sufficient equipment for patients to rest on in the various areas without cross contamination risks?

□ Are there disposable/ hospital-based scrubs that staff can wear?

□ Are there alternative equipment for patient management during the outbreak (eg: spacer instead of nebuliser)

□ Is there an established supply chain for drugs?

ED Output

□ Is there a workflow to determine disposition of the patients?

□ Are there PPE rules for the staff bringing high and intermediate suspect patients being brought to the ward?

□ Is there a protocol to clear the route while bringing the patients up to the ward?

□ Is there a workflow for interfacility transfer?

□ Is there a workflow to clear inpatient beds during a surge?

□ Is there a method of communicating patients’ ‘suspect status’ when admitting them to the ward?

□ Is there a method of communicating patients’ status when doctors from other disciplines review patients in the ED?

□ Is there a good handover regarding patients’ suspect status when sending them to the ward?

□ Is there a platform to communicate with BMU during surges?

□ Is there a platform to recall patients after they are d/c? (for contact tracing, information of results)

□ Is there adequate manpower in the holding areas?

□ Is the staff transporting the patient trained to wear appropriate PPE?

□ Is the security clearing the route trained to wear appropriate PPE?

□ Is there augmented manpower at the holding areas?

□ Is the adequate manpower to transport patients?

□ Is there adequate manpower to carry out adequate cleaning of the intermediate and high suspect areas?

□ Is there adequate holding areas in the 3 suspect categories?

□ Is there adequate PPE for ancillary staff (Security, admin, porter)?

□ Is there supply chain of decontamination substances?

□ Are there spaces that can be opened up during a surge to hold patients awaiting beds?

□ Are there sufficient ICU beds and is are there escalation plans when ICU beds are full?

□ Are there rapid results test kits available to detect the infection and facilitate segregation during disposition?

□ Is there adequate partitioning within the ED to keep patients of different risk profiles separated while awaiting disposition?

□ Is there adequate supplies for disposal of contaminated equipment?

□ Is there adequate transport equipment (e.g. wheelchair, trolley)