Article Text

other Versions

Download PDFPDF
Close air support: enhancing emergency care in the COVID-19 pandemic
  1. Tze Yi Low1,
  2. Ian Mathews2,
  3. Joel Wen-Liang Lau1,
  4. Kee Yuan Ngiam1
  1. 1Surgery, National University Hospital, Singapore
  2. 2Emergency Medicine, National University Hospital, Singapore
  1. Correspondence to Professor Kee Yuan Ngiam, National University Hospital, Singapore 119074, Singapore; kee_yuan_ngiam{at}


The COVID-19 pandemic has taken the world by storm and overwhelmed healthcare institutions even in developed countries. In response, clinical staff and resources have been redeployed to the areas of greatest need, that is, intensive care units and emergency rooms (ER), to reinforce front-line manpower. We introduce the concept of close air support (CAS) to augment ER operations in an efficient, safe and scalable manner. Teams of five comprising two on-site junior ER physicians would be paired with two CAS doctors, who would be off-site but be in constant communication via teleconferencing to render real-time administrative support. They would be supervised by an ER attending. This reduces direct viral exposure to doctors, conserves precious personal protective equipment and allows ER physicians to focus on patient care. Medical students can also be involved in a safe and supervised manner. After 1 month, the average time to patient disposition was halved. General feedback was also positive. CAS improves efficiency and is safe, scalable and sustainable. It has also empowered a previously untapped group of junior clinicians to support front-line medical operations, while simultaneously protecting them from viral exposure. Institutions can consider adopting our novel approach, with modifications made according to their local context.

  • clinical care
  • disaster planning and response
  • emergency care systems, efficiency
  • emergency department operations

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Handling editor Kirsty Challen

  • Contributors TYL was responsible for writing the manuscript, creation of the figure and literature search, and was involved in the trial as a CAS doctor. IM was responsible for vetting the manuscript and study design, and was involved in the trial as the attending/representative from the ED. JWLL was involved in the development of the workflow process as well as in the trial as a CAS doctor. KYN was responsible for conceptualising this approach, study design, as well as providing direction on writing and vetting the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.