Dear Editor,

As we mark over a year of living with COVID-19, we want to again share themes from the last 6 months of our survey project of small animal emergency veterinary hospitals, previously summarized.^{1, 2} Seventy small animal 24-h emergency veterinary hospital representatives were recruited from the ACVECC and ACVIM listservs. Surveys were sent monthly with questions tailored based on current issues managing 24-h emergency veterinary hospitals during the COVID-19 pandemic. Raw data summaries of the surveys are shared back with listservs and recruited hospital representatives 1 week after surveys are initially sent.

A range of 23–34 hospitals across 25 states and one in Canada responded to monthly surveys between September 2020 and March 2021. Most hospitals responded consistently month to month, with 0-2 responses each month representing hospitals that had not previously responded. Four to six academic institutions and zero to two nonprofit hospitals are represented monthly with the remainder responding from corporate or privately owned hospitals.

All responding hospitals were still restricting access to clients in March, with only one reporting increased access, allowing clients in specific areas under specific circumstances. Six of 25 responding hospitals in March have started discussing plans to bring clients back inside the hospital, with four of six planning to re-open their lobbies to clients under limited circumstances and three of six planning to allow increased access for client visitation of hospitalized pets.

Almost all responding hospitals have had at least one COVID positive employee (and/or student where applicable) in the last 3 months. Only one had to close the entire hospital, and a few had to dramatically reduce caseload or close a specific service, but most were able to continue to function as normal. Three reported known spread of COVID-19 in their hospital. All responding hospitals said they were unable to maintain social distancing in the emergency department with about half saying “we try, but are not able” and about half responding, “not realistic, we don't even try.” All responders said employees are eating in common spaces with other people present, though many said it was not allowed, and 11 of 28 said it was done infrequently (less than daily) while 11 of 28 said it occurred on a daily basis.

In states where veterinarians are eligible, many hospitals are helping to coordinate vaccine appointments with state or local pharmacy and providing information about where and how to book appointments. Five of 13 responders said they knew someone in the veterinary field who was eligible but refusing a vaccine. More than half of responders reported drug shortages perceived to be related to COVID-19 over the last 6 months, and similar numbers reported shortages of personal protective equipment, with none reporting that it was affecting their ability to function.

Almost all responding hospitals reported an increase in caseload when compared to the same month last year, and many reported substantial increases of 25% or greater. In March, 10 hospitals reported that they were never diverting, six were diverting if owners called ahead, and seven diverting if they called ahead and also if they showed up with a pet that did not have a life-threatening emergency. Most hospitals reported that other area hospitals were also diverting cases at times. Many of those hospitals that never diverted said there was no other hospital in their area to divert emergency cases to, even when overwhelmed with cases. For hospitals that reported diverting cases, some were informally coordinating with other local hospitals, but no one had a formal communication system among area hospitals. To determine when to divert, hospitals reported point systems for technician: patient ratios or when client wait times in the emergency room reached a certain threshold.

In March, 13 of 26 responding hospitals were projecting continued growth and were actively looking to expand staff, another three hospitals reported that they were expecting continued growth but were unable to expand staff. Most hospitals reported staff fatigue around COVID-19, challenges with demanding and frustrated clients, not enough staff, low morale, and continued high caseload. Hospital responses to stress included frequent and open communication around COVID-19 policy changes and challenges, providing bonuses for staff, offering hiring or referral bonuses, and trying to relieve workload for emergency doctors by hiring medical scribes, increasing communication with clients about wait times, and encouraging noncritical cases to wait or go to primary veterinary to other practices.

When this project began in March 2020, we had no idea how wide-reaching and long-lasting the COVID-19 pandemic would be. As we hopefully emerge to a post-COVID-19 world, hospitals will need to continue to be flexible to meet changing demands on emergency veterinary medicine. We will continue to send monthly surveys to representatives and to share the summary data with listservs and other audiences as appropriate.

亲爱的编辑，

在我们与 COVID-19 共处一年多的日子里，我们想再次分享我们之前总结的小动物急诊兽医医院调查项目过去 6 个月的主题。^{1, 2}从 ACVECC 和 ACVIM 列表服务器中招募了 70 名小动物 24 小时急诊兽医医院代表。每月发送调查问卷，并根据 COVID-19 大流行期间管理 24 小时急诊兽医医院的当前问题量身定制问题。在最初发送调查后 1 周，调查的原始数据摘要将与列表服务人员和招募的医院代表共享。

25 个州的 23-34 家医院和加拿大的一家医院在 2020 年 9 月至 2021 年 3 月期间对月度调查做出了回应。大多数医院每月都做出一致回应，每月 0-2 次回应代表之前没有回应的医院。每月有四到六个学术机构和零到两个非营利医院代表，其余来自公司或私营医院。

3 月份，所有响应医院仍然限制访问客户，只有一家报告增加了访问权限，允许客户在特定情况下进入特定区域。3 月份做出回应的 25 家医院中有 6 家已开始讨论将客户带回医院的计划，六家中的四家计划在有限的情况下重新向客户开放大厅，六家中的三家计划允许更多的客户访问住院宠物.

在过去 3 个月内，几乎所有响应医院都至少有一名 COVID 阳性员工（和/或学生，如适用）。只有一个人不得不关闭整个医院，少数人不得不大幅减少病例量或关闭特定服务，但大多数人能够继续正常运作。三人报告了他们医院中已知的 COVID-19 传播。所有做出回应的医院都表示，他们无法在急诊科保持社交距离，大约一半的人说“我们尝试过，但不能”，大约一半的人回答说“不现实，我们甚至不尝试”。所有响应者都表示，员工在有其他人在场的公共空间用餐，但许多人表示这是不允许的，28 人中有 11 人表示很少这样做（少于每天），而 28 人中有 11 人表示每天都会发生。

在兽医有资格的州，许多医院正在帮助与州或当地药房协调疫苗预约，并提供有关预约地点和方式的信息。13 名响应者中有 5 名表示，他们认识兽医领域的某个人，他有资格但拒绝接种疫苗。超过一半的响应者报告了过去 6 个月内被认为与 COVID-19 相关的药物短缺，类似的数字报告了个人防护设备的短缺，但没有人报告说这影响了他们的运作能力。

与去年同月相比，几乎所有做出回应的医院报告的病例量都增加了，许多医院报告的数量大幅增加了 25% 或更高。3 月，有 10 家医院报告他们从未转移，如果主人提前打电话，则有 6 家医院会转移，如果他们提前打电话，并且如果他们带着没有危及生命的紧急情况的宠物出现，则有 7 家医院会转移。大多数医院报告说，其他地区的医院有时也在转移病例。许多从未转移过的医院表示，他们所在地区没有其他医院可以将急诊病例转移到，即使在病例不堪重负的情况下也是如此。对于报告分流病例的医院，有的与当地其他医院进行了非正式的协调，但地区医院之间没有正式的沟通系统。确定何时转移，

3 月份，26 家响应医院中的 13 家预计将继续增长并积极寻求增加人员，另外 3 家医院报告称他们预计将继续增长但无法增加人员。大多数医院报告称，员工在 COVID-19 前后出现疲劳、要求苛刻和沮丧的客户面临挑战、员工不足、士气低落以及案件量持续居高不下。医院对压力的反应包括围绕 COVID-19 政策变化和挑战进行频繁和公开的沟通，为员工提供奖金，提供招聘或推荐奖金，并试图通过聘请医疗文士来减轻急诊医生的工作量，增加与客户就等待时间的沟通，并鼓励非危重病例等待或转至初级兽医进行其他实践。

当该项目于 2020 年 3 月开始时，我们不知道 COVID-19 大流行的影响范围和持续时间会有多长。当我们希望进入 COVID-19 后的世界时，医院将需要继续保持灵活性，以满足对急诊兽医不断变化的需求。我们将继续向代表发送月度调查，并酌情与列表服务和其他受众共享汇总数据。