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RCEM Guidance – Key questions for clinical leads to prepare their departments for winter – November 2020

We have recently seen a sustained and serious rise in COVID-19 cases in the UK. The following questions are intended to help the clinical lead of an emergency department prepare for winter.

1. Do you know the maximum safe occupancy of your ED, and is it already crowded?
a. Work through the latest RCEM guidance with your executive and operational teams

2. Is your organisation prepared?
a. The hospital surge plan should include triggers based on community and hospital levels of disease, side room /COVID stream capacity, ICU capacity, staff sickness and acute bed occupancy.
b. The ED surge plan should include triggers based on community and hospital levels of disease, cubicle / COVID stream capacity, spaces safe for AGPs, and staff sickness.
i. Do you have sustainable resilience plans to support any increases in staff sickness or staffing requirements?
ii. Can you always have a free resuscitation room space? Is there an escalation plan that supports this?
c. Staff redeployment to acute areas, including EDs, may be needed.
i. Many EDs now have increased floor space, multiple clinical areas (on site and off site) with the same levels of staff. This is unsustainable and safe long-term ED staffing will need to be

3. Does your ED triage process screen patients for potential infectious diseases?
a. Have you considered how your screening process might need to change as community incidence of COVID increases?
b. Are there important local factors that might change the way you screen? Do you have local populations at particular risk?

4. Have you embedded safe IPC procedures across your whole department, including social distancing in clinical areas, waiting areas, and rest and office areas?
a. Do your staff know how to use PPE properly?

i. An RCEM staff survey conducted early in the pandemic found that staff from minority backgrounds had received less training in PPE.
ii. Make sure new and temporary staff are PPE trained.

5. Do your staff know how to care for a critically unwell patients whilst maintaining IPC?
a. This includes understanding when level 3 PPE should be used, where patients should be treated, and rehearsing relevant scenarios.
b. Are staff trained to safely care for the following scenarios: cardiac arrest, major trauma, severe respiratory failure and rapid sequence intubation?

6. Do you have up to date guidance for the clinical management of COVID available for all staff?
a. Which patients should be admitted?
b. Which patients should get dexamethasone and anticoagulants?
c. How do you manage hypoxic patients?

7. Does everyone in the organisation agree on the use of swabbing?
a. Who needs swabbing, where and when?
b. Which sort of swab should be used for which group of patients?
c. Who is responsible for chasing and acting upon the results? This is particularly relevant for discharged patients and should not routinely be the responsibility of the Emergency Medicine Service.
d. What are your arrangements to ensure that patients awaiting swab results are not remaining in the ED?

8. How are you assessing, advising and protecting staff who are at increased risk from COVID (including combinations of ethnicity, age, obesity and comorbidity)?
a. Are your risk assessments up to date and does your advice take account of increasing community incidence?

9. How do you communicate to staff?
a. Do you reach all staff members?
b. Which ways work best for each group?

10. How are you supporting your staff?
a. Is everyone clear on the sickness rules? (When to quarantine? How to get hold of Occupational Health?)
b. Staff who were shielding in the first phase of the pandemic may now be back in the department – how are they supported?
c. Are staff who are unable to do face to face work included in departmental planning and communications and allocated nonclinical work that enables them to contribute to the department in a worthwhile manner and so feel valued?
d. Do you have an active wellbeing team, and if so, are they engaged?
e. Do your staff have adequate and safe (and socially distanced) rest areas?
f. Are you rotating staff through areas requiring higher levels of PPE?
g. Are staff taking adequate leave to recover? Have the rules about carrying leave over in 2021-22 been explained?

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