Violent circumstances and a global threat to epidemics and pandemics reflect the necessity of preparing emergency departments (ED) for disasters. With ongoing Novel CoronaVirus emergency once again International, state, and local government entities have realized the importance of hospitals, particularly emergency departments (EDs), in planning for such events.

Responding to any disaster outbreak demands presence of mind, but most of all, it requires a unified effort involving the entire medical community. The (Emergency Department) ED environment presents its own unique set of variables. Owing to the diverse mixture of often non-specific signs and symptoms, a high risk of exposure from resuscitative and other invasive procedures, and the EDs vital role in limiting transmission by maintaining a high index of suspicion, high-risk quarantine patients, and strictly adhering to clearly defined infection control measures. In many instances, ED acts as a safety net as well as a port of entry to healthcare access.

Therefore, in addition to hospital protocols, EDs should possess their own policy guidelines, tailored specifically for application in an ED setting.

This should comprise of the following

1. Basic, important information on the clinical characteristics of the epidemic (or pandemic) outbreak and its initial management.

2. Definitions of alert levels and their respective responses

3. Criteria for isolation and transfer to designated hospitals.

4. Physical infrastructure and equipping of the department to receive, manage and arrange for the appropriate disposition of potentially infected patients

5. A preparatory model for ED staff about education and training, audits, exercises, surveillance, prophylaxis (if available) and stockpiling.

6. A daily or weekly update on the situation in the region where ED is situated. For example, situation report Novel coronavirus (2019-nCoV) situation is available at http://who.maps.arcgis.com/apps/opsdashboard/index.html#/c88e37cfc43b4ed3baf977d77e4a0667

EDs ideally shouldn't wait for an outbreak to trigger the implementation of infection control measures. Instead, all Emergency Departments should be prepared with their basic infection control measures which carry the potential to be further enhanced if the world moved any

closer to a pandemic situation. The steps which should be instituted as primary measures include:

- screening of all patients at the entrance of the ED to identify those who would prone or more at risk of having a communicable infectious illness

- isolation of all such patients screened as infectious in a separate department with an independent ventilation system

- usage of basic Personal Protective Equipment (viz surgical mask, hospital scrubs) when attending to potentially infectious patients

- usage of alcohol rubs before and after attending to any patient

The department of ED during a pandemic mainly requires three focus areas:

- implementation of control measures strictly within the ED

- management of the capacity matrix, which involves the organization of hospital facilities, equipment and manpower

- maintenance of an effective communications network within the ED and its parent hospital, between local hospitals and national/international health authorities

Implementation of and strict adherence to control measures within the ED

The most important element in this scenario will be Fever screening, which consists of the following:

Rapid temperature measurement of all patients coming to the ED ideally by use of forehead digital Infrared thermometer for babies and adults with color-coded fever guidance.

Completion of the fever-screening questionnaire. The questionnaire should have the following components:

i. Patient ID

ii. Temperature measurement

iii. History of fever documentation

iv. Travel history documentation especially to areas of current flu infection

v. Contact history documentation

vi. Documentation of related symptoms of flu

vii. Particulars of accompanying persons, including contact particulars

The patients who do not clear the screening test are to be sent to the 'Fever Zone' of the ED. This further aids in distinguishing febrile and potentially infectious cases from other patients. The fever zone is the area where all patients with fever, positive contact history and history of travel to infected communities and those with similar symptoms. The zone should have facilities for full triage, patient registration and management of ambulant and trolley-based patients. Several observation beds will also be useful in this zone. Furthermore, this zone will require its own X-Ray facility, patient toilet and separate access to a discharge pharmacy.

The fever zone is also supposed to have an independent ventilation system. While air entering the fever portion may come from the same source, viz. re-circulated air from the rest of the hospital (mixed with fresh air), the effluent air from these fever zones should be channeled out of the ED. It should be directed into the external air after being passed through suitable bacterial/viral filters (e.g. HEPA filters) and ultraviolet radiated zones. Such air should not be re-circulated to cool air-conditioning systems.

Early implementation of preventive measures to limit the transmission of disease: These should be implemented in all areas of the Emergency Department, irrespective of them being a fever zone or a non-fever zone. Such precautionary measures indicate a high standard of hygienic practices needed for staff that comes into contact with patients.

The staff should wash their hands either with soap and water or use alcohol-based hand rubs. Furthermore, to maximise the effectiveness of hand-hygiene, all staff should not prevent wearing any wristwatch, jewelry or hand-accessories.

Handwash/rub is also recommended:

i. Between patient contacts

ii. Before donning or after removing protective apparel

iii. After contact with any respiratory secretions

iv. After removing the mask.

v. Before leaving the isolation area

vi. Before touching personal items

vii. Before meal breaks

Management of the capacity matrix

Staff rostering to fixed composite teams with any or slight mixing between teams should be paid attention to. This optimises team integrity and minimises losses to the department as a result of one member falling sick by the prevailing disease. It also simplifies contact tracing activities within the department.

Backing up the department with extra staff will have to be done in proportion with the increased need for outbreak-associated logistics such as PPE, disposable gowns, eye goggles and Positive Airway Pressured Respirators. Stockpiles for these should be identified and tied up with the hospital’s materials Management Department.

Maintenance of an effective communications network

Preparing training pamphlets, slides and short manuals for staff training have immense value in that they can be used repeatedly. On-site displays on infection control procedures will have immense value for staff education to function in times of disease outbreak.

A pandemic situation is also an extremely stressful period for the staff of the Emergency Department. To maximize morale and daily attendance communication from departmental leadership regularly, welfare activities and provision of scope for frequent debriefs, and feedback are all issues that need to be managed carefully and sensitively.

In extreme situations, Emergency Departments or hospitals may not be enough to handle a huge influx of suspected patients. Alternate care sites that can be established quickly are Stadiums, Schools, Community Halls; provided the hospital or healthcare authorities have prior planning and logistic arrangements.

One of the most significant impediments to pandemic preparedness is the tendency to believe that it can be accomplished merely by the completion of a written plan. We have now clearly realized that pandemic planning is an illusion unless: it is based on valid assumptions about human behavior, incorporates an inter-organizational perspective, is tied to resources, and is known and accepted by the stakeholders.