Forward Triage Surge Tents Help with COVID-19 Patient Increase

The Advocate Outpatient Collaborative (Advocate Aurora Health, HDR, Boldt, IMEG, and partners), an Integrated Lean Project Delivery team that has spent the past six years rapidly delivering clinics throughout the Chicagoland area, dramatically shifted its focus on March 18, 2020, to respond to the COVID-19 pandemic. Team members partnered to deliver 26 fully-outfitted and operational emergency department overflow Surge Tents across Illinois and Wisconsin.

Level 3 Pandemic Surge Relief

Surge Tents are designed to ensure patients with emergencies that are unrelated to COVID-19 are triaged to the emergency department while patients showing signs of the virus are separated from regular hospital traffic to assist in preventing infection.

Equipped with necessary infrastructure, such as power, water, mechanical and electrical systems, Surge Tents have been carefully designed so they are structurally secure, with portable partitions that can be easily adjusted or moved to accommodate changing surge needs. These tented clinics and their supporting trailers for data racks and supplies locate everything that caregivers need within the forward triage setting.

These projects are adopting an outpatient clinic approach to patient triage. A “Sorting Area” is identified at each site. The intent is to direct patients who truly need ED care into the ED, and redirect any patients with mild symptoms or COVID-19 concerns toward the Surge Tent or Upper Respiratory Infection Tent. The Surge Tent is typically set up in the closest parking area that can be blocked off, which is typically physician designated.

Level 3 Surge Tent features:

• Surge Tents generally include a small waiting area (six-foot clearance around each chair) and four exam spaces per provider (8’x8’).
• A mobile workstation is provided for each of the four exam pods and an additional workstation is provided near the tent exit for a physician workstation.
• Registration will occur in the exam bays or in the waiting space as needed.
• Tents are set up for one-way flow from entry/waiting through a hallway between exam bays to an exit.
• Personal Protection Equipment stations are located near the entrance, a central location, and near the exit.
• Centralized printing stations are provided near the waiting and near the exit.
• At the larger sites (40’x80’ or 40’x90’ tents), an additional printing station is located near the middle of the tent.
• A service area is provided at the back of the tent for EVS cart, waste receptacles, under-counter refrigerators, and a portable eyewash station.
• Tents are composed of aluminum tube frames with heavy, fire-retardant treated vinyl fabric.
• If the site has significant slope, a raised floor system helps level the floor, with ADA ramps to access the doors if they are more than threshold height.
• Exam bays are subdivided by solid, epoxy-paint-faced, plywood panels affixed to the floor at back to back exam bays, and pipes with fabric for the side walls.

Infrastructure for Pandemic Surge Tents

POWER: Power is supplied by generators and also run from the buildings where possible. In most cases, generator power is a short-term solution pending permanent power. In other cases, facilities can quickly provide permanent power. The biggest power draws are from portable AHUs. A single quad outlet is placed in close proximity to the mobile computer workstation serving each pod of four exam bays. More quad power outlets and data ports are provided at the printer stations and physician workstation. Duplex receptacles are also provided in the waiting space and for under-counter refrigerators. LED strip lights are attached to the aluminum framework of the tents.

AIR: Portable AHUs provide heating and cooling, with HEPA filters placed in the filter bank. In colder weather conditions, sealed combustion propane heaters are added in parallel with the supply duct to boost heating capacity. A duct sock down the centre of the tent structure provides even distribution of supply air. The tent is intended to be balanced to neutral pressure, 10 air changes per hour. All joints in the tent fabric are taped and bottom edges secured to the pavement with a flashing membrane. Whenever possible, tents are located on the highpoints in the parking areas to avoid storm water runoff under the tent.

TECHNOLOGY: Communication is provided via wireless computers and printers. Fiber lines are run to a data trailer/container just outside the entrance to the tent that contains the data rack and servers, and which also serves as locked supply storage for additional PPE and other supplies. Rechargeable wireless phones match whatever system each facility uses.

OXYGEN: Small, portable oxygen tanks are available mounted to carts in the service area at the rear of the tent, but the clinical leaders expect these will rarely be used. They expect 98-99% of the patients who are seen in the tent will be discharged to home care. They anticipate that some patients may be escorted by wheelchair back to the ED for admission as determined by providers.

FURNISHINGS: Each exam bay will have a recliner or exam table, stool, waste receptacle, hand sanitizer dispenser, and sanitary-wipes for EVS use. Each mobile workstation/four exam room pod will have one set of vitals equipment on a mobile cart (including pulse ox sensor, sphygmomanometer, temperature, otoscope/ophthalmoscope) and sanitary-wipes dispenser. Sharps tackle box and sharps disposal can be added to the mobile workstation if they begin taking blood specimens in the exam bays, but that is not planned initially.

Next Step: Level 4 Pandemic Surge Relief

The Level 4 strategy is to convert outpatient centres to house non-COVID-19, minimally complex and short-stay inpatients in order to provide surge space within all hospitals for confirmed COVID-19 cases.  

The benefit of this approach is that many of the new outpatient settings, including ASC and Procedure Centers, include essential facility requirements like hand washing stations, clearances for transporting and space for folding cots, appropriate team work areas and support spaces, recently upgraded Epic technology with digital controls for MEP systems, and minimal cost and time to rapidly deploy this solution.

Photo Credit: Images below courtesy of The Boldt Company and HDR