ACEP COVID-19 Field Guide

Editor: Etch Shaheen, MD, FACEP

Authors: Michael Baker; Kevin Curtis; Aditi Joshi; Etch Shaheen; and Brian Skow 

Contributors: Jeffrey Davis, ACEP Director of Regulatory Affairs; and the ACEP Telehealth Section

1. Goals, resources, challenges, and troubleshooting: Determine what resources are available, what goals you are trying to accomplish, and what stands in the way of accomplishing those goals. Figure out solutions as problems arise, but be realistic. Use the 80/20 rule: If you meet 80% of the goal, that is not bad.
1. What resources do you have available to you?
1. The number of physician or nonphysician providers (NPPs) during a shift, in your group, or on call; as well as
2. Outsourced vendors.
2. What are you trying to accomplish?
1. Keeping people at remote locations; 
2. Avoiding transmission of COVID-19 or other contagious diseases;
3. Performing triage in a waiting room directly next to an appropriate site;
4. Performing triage and initiating workups as early as possible; and/or
5. Improving metrics (eg, D2D, LWOT, LOS).
3. What are your challenges?
1. Legal restrictions (eg, licensing);
2. Regulatory restrictions;
3. Organizations;
4. Staff buy-in; and/or
5. Leadership buy-in.
4. What are the solutions?
1. Empowering staff to be flexible;
2. Using common sense;
3. Exercising good judgment;
4. Not being afraid to make mistakes;
5. Being willing to try something new, re-evaluate frequently (eg, immediately, hourly, daily), adjust accordingly, and then repeat;
6. Waiving regulations or standard rules (eg, making exceptions), such as:
1. Allowing the CEO or medical staff to grant emergency privileges;
2. Improving the flow out of the emergency department;
1. Using surgery suites as ICU rooms, if ICU is full;
2. Using ventilators for two patients; and/or 
3. Allowing holds on the floor in halls instead of in emergency department halls;
7. Keeping it simple; and/or
8. Communicating.
2. Technology, hardware, and software — determining what equipment or service to use: Under ordinary circumstances, HIPAA and/or other regulatory requirements must be met. During this crisis, HIPAA requirements have been lifted for telemedicine, tele-EM, and tele-triage. Technology may be the easiest component because there are many companies that offer the “connection” and many products that perform quality audio and video interactions that are sufficient for a quality evaluation.
1. For the quickest implementation:
1. Consider the simplest-to-use, least complicated product;
2. Consider platforms like Zoom, Polycom/Cisco, and Skype;
3. Consider what is common to many or what people already know how to use (eg, Skype);
4. Don’t delay because you want a “cart” or tele-triage setup with peripherals (eg, stethoscope);
5. Don’t delay because of a desire to be HIPAA compliant; desperate times call for desperate measures;
6. Certainly, use HIPAA-compliant software if you are already using it or this doesn’t cause a delay; but
7. Theoretically, start within minutes.
2. For the long term:
1. Figure out how to comply with HIPAA requirements;
2. Consider all the bells and whistles, such as:
1. Larger platform companies; and 
2. Fancy equipment; and
3. Look into specific tele-triage software (eg, EMOpti).
3. Anticipate unexpected problems, such as:
1. Hardware issues — have a backup plan (eg, iPhone, FaceTime);
2. Software issues — have IT available;
3. Staff-related issues;
4. Patient-related issues; and
5. Other miscellaneous issues.
3. Charting
1. Consider purchasing software that integrates the EMR with a tele-triage platform, which:
1. Can be a more expensive option; or
2. May cause delays in implementation (eg, weeks, months); and
2. Consider using an existing EMR as a separate screen and log-in because it has:
1. No additional cost, you are already using it, or you already have the hardware; or
2. No time delay will be necessary because it is immediately available.
4. Pathways and workflows
1. Make them as user friendly and simple as possible with:
1. Scripting;
2. Complaint-driven options;
3. Templates; and
4. Diagrams of flow design;
2. Place colored tape on the floor so that patients can follow to designated destinations;
3. Make them intuitive; and 
4. Use evidence-based or established guidelines (eg, the CDC’s guidelines for testing).
5. Manpower, staffing, and backup staff
1. Consider:
1. Current emergency department physicians and NPPs on duty;
2. Emergency department staff on call;
3. Emergency department staff who are out due to a positive COVID test but who are otherwise healthy and asymptomatic;
4. Medical staff outside the emergency department, such as:
1. PCPs with closed offices or canceled appointments; 
2. Physicians from closed outpatient surgical centers;
3. Surgeons with canceled elective surgeries;
4. Nurses from within the hospital; and
5. Nurses from outside the hospital;
5. Retired physicians;
6. Resident physicians;
7. Physicians and nurses from outside the organization;
8. Volunteer physicians;
9. Physicians from less-burdened areas of the country;
10. Locum physicians and nurses; and
11. Those trained to perform tele-triage; 
2. Debate who should perform tele-triage, including:
1. Emergency physicians, who are best able to recognize emergencies and nuances and start patients on the correct pathway, since once a patient starts on an incorrect pathway, it can be hard to discover and change;
2. NPs and PAs, who offer a lower-cost option and are often not as scarce, depending on the facility and location; and/or
3. Non–emergency physicians, who can provide extra help and free up emergency physicians; and
3. Determine emergency credentialing for physicians from outside health organizations.
6. Tele-triage training
1. Can be simple and similar to typical training;
2. Can simply use telemedicine as the vehicle; and
3. Should familiarize the trainee with the particular equipment in use.
7. Communication: Communication is always important, so:
1. Make communication between the care team easy;
2. Facilitate communication to other sites and the emergency medicine community;
1. Share successes, solutions, and innovations; and
2. Share challenges or warn of possible upcoming issues;
3. Communicate to the public by: 
1. Making them aware of services;
2. Familiarizing them with the experience; and thereby
3. Reducing fear and stress about the process and crisis; and
4. Communicate to the press to:
1. Educate them about services and facts, which
2. Gives them information to communicate to the public.
8. Billing and CMS rule changes (temporary waivers)
1. This is a very fluid situation as the government and private payers evaluate telehealth payment policies as we work through this crisis. As of March 23, for Medicare, emergency physicians can perform telehealth services from any location, including the emergency department. They can bill office/outpatient E/M services (CPT codes 99201-99215) or any other code on the list of approved Medicare telehealth services. Some of the other codes on the list that are commonly billed include psychiatric diagnostic evaluations (CPT codes 90791-90792), psychotherapy for crisis (CPT codes 90839-90840), and critical care consult G-codes (HCPCS codes G0508-G0509). 
2. Emergency department E/M codes (CPT codes 99281-99285) were not on the list of approved CMS (Medicare) telehealth services until now. The place of service code is 23 for the emergency department. CMS has allowed temporary flexibility to all E/M codes that include the 99281-99285 CPT codes, critical care CPT codes of 99291 and 99292, and observation CPT codes of 99217-99220, 99224-99226, and 99234-99236. The emergency physician can be located in the emergency department, can be located on the hospital “campus,” or can be providing the care remotely (from any location).
3. Other payers are considering allowing use of the emergency department E/M codes (99281-99285) via telehealth, but the situation is still developing. 
4. CMS has waived licensing requirements for Medicare and Medicaid patients. Any physician licensed in any state is allowed to provide care to any Medicare or Medicaid patient in any other state of the United States during this declared emergency.
5. CMS has also clarified and temporarily waived the in-person requirement for medical screening examinations (MSEs). During this declared emergency, physicians (and other qualified NPPs or designees) can perform MSEs via telemedicine (tele-triage) and meet the MSE requirement without any physician or non-physician being required to be in person or laying hands on the patient. Of course, the physician or NPP must believe that the telemedicine MSE is adequate to rule out a life-threatening or emergent condition. Otherwise, the patient would not be able to be screened out and would need further evaluation.
6. Telehealth can be provided in rural and urban areas with no location restriction during this declared emergency.
7. As stated in Section B above, the HIPAA requirement has been waived by CMS during this declared emergency.
8. CMS has waived the requirement to collect cost-sharing from Medicare beneficiaries for telehealth visits. As such, during this declared emergency, the Medicare patient’s copay can be reduced or waived, if we so choose, for telehealth encounters.
9. Miscellaneous 
1. This quick guide is only a guideline and should be adapted to the particulars of each site.
2. Telehealth can and should be used for nursing, registration, and other members of the health team when it is reasonable to do so to help protect everyone, not just physicians.
3. Know the laws, rules, and position of your organization, but do not ignore your intelligence, knowledge, understanding of medicine and patient care, judgment, and common sense. Don’t forget…Do no harm.
4. Communicate in real time, as needed, but also regularly and frequently with leaders (eg, medical directors, nursing directors, registration, security) so that everyone is on the same page at least at the start and end of every shift. Communications can be short-and-sweet meetings but must be consistent with the team and for the troops.
5. Always think about or make mental notes of ways to improve things to help the process and then make leaders aware of the ideas, so they can consider them to see if they work better.
6. Take care of yourself both physically and mentally. Everyone handles stress and challenges differently, and we are human. Make sure to take the time, even if it is just a minute here or there or after each shift, to decompress, keep things in perspective, and keep yourself in the best mental state you can. Yes, we are physicians and dedicated to our patients, but we also have family, friends, and coworkers. We must remember that we are all going through a stressful time and situation. We are all in this together, and together we will get through it.

For more information:

• COVID-19: Rapid Application of Technology for Emergency Department Tele-Triage
• CDC’s “Phone Advice Line Tool for Possible COVID-19 Patients.”