18 The Impact And Efficiency Of Medical Screening Exams In Forward Treatment Areas At NYC Public Hospitals During The Initial COVID-19 Surge

Background: New York City (NYC) experienced a dramatic surge of infections with the novel SARS-CoV-2 virus in March 2020. The rapid increase in patients presenting to emergency departments (EDs) necessitated a change in intake processes in contrast to prior emergency response protocols outfitted for single day or short-term disasters. To adapt to the increased demands on patient flow, NYC Health and Hospitals (NYC H+H) established a rapid medical screening evaluation (MSE) process in each of its eleven-member public hospitals. Each hospital created its own treatment areas to perform their MSE. Some hospitals created a Forward Treatment Area (FTA) external to the ED to evaluate and disposition patients prior to entering the ED. Methods: Five of the eleven hospitals created external FTAs to perform rapid MSEs in accordance with EMTALA and make disposition decisions before patients physically entered the ED. Patients 18 years and older were screened in the FTA and either sent into the main ED for further evaluation or discharged home. Some sites directed patients to an alternate care site where they could receive COVID-19 testing (very limited availability) and/or receive further information about COVID-19. Three hospitals utilized paper-based MSE, and two used an Electronic Medical Record (EMR)-based approach. Paper logs and EMR charts were reviewed using a standardized data extraction template. In addition, patients discharged from the FTA were contacted by a follow-up phone call, and a structured interview was used to capture additional data regarding their subsequent clinical course. Chi-square and Fischer’s exact test were used to compare paper- and EMR-based MSE. Results: Across the five EDs, a total of 3,335 patients were evaluated in their respective FTAs. Of these patients, 970 (29.1%) were referred for further evaluation into the ED, of which 203 (20.9% of the subset) were hospitalized and nineteen (2.0%) died. Of 2,302 patients discharged directly from the FTA, 182 (7.9% of the subset) returned to the ED within seven days, resulting in 42 (1.8%) hospitalizations and seven (0.3%) deaths. The facilities using an EMR-based approach discharged proportionally more patients from their FTA (81.9% vs 65.3%, p < 0.001), had similar seven-day return visit rates (9.3% vs 7.1%, p = 0.055) and similar mortality rates (0.49% vs 0.20%, p = 0.251). Conclusion: An MSE in an FTA is a highly effective process to disposition patients safely in a high patient volume situation. Differences exist in paper-based vs EMR-based approaches, suggesting EMR-based MSEs provide better data and greater effectiveness. This would suggest that prioritizing a standardized EMR-based MSE should be considered in future circumstances.