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Analysis

Coronavirus: Drastic Actions Recommended to Avoid Critical Care Overload

By Christopher Cheney  
   March 19, 2020

Optimal mitigation efforts, which focus on slowing the spread of the novel coronavirus, will not avoid critical care resources being overwhelmed, new report says.

A new report on the novel coronavirus (COVID-19) pandemic predicts that even an optimal mitigation scenario would result in as many as 1.2 million deaths in the United States.

Since December, COVID-19 has spread from China to 166 countries and territories, with more than 207,000 confirmed cases and more than 8,600 deaths, according to the World Health Organization. As of March 19, 9,477 cases had been confirmed in the United States, with 155 deaths, worldometer reported.

The COVID-19 pandemic is one of the most serious public health emergencies in a century, according to the new report, which was published this week by the Imperial College COVID-19 Response Team in the United Kingdom. "The global impact of COVID-19 has been profound, and the public health threat it represents is the most serious seen in a respiratory virus since the 1918 H1N1 influenza pandemic," the report says.

As a baseline, the report estimates the human toll and healthcare-demand impact of taking no public health actions and making no individual behavior changes to control the COVID-19 pandemic:

  • 81% of the U.S. population would become infected during the pandemic
     
  • There would be 2.2 million deaths in the United States, "not accounting for the potential negative effects of health systems being overwhelmed on mortality"
     
  • The peak demand on ICU and other critical care capacity would be more than 30 times higher than available U.S. resources

Mitigation vs. suppression

There are two primary public health responses to the COVID-19 pandemic: mitigation and suppression, the report says. Mitigation seeks to slow down the spread of the novel coronavirus. Suppression seeks to reverse epidemic growth.

Based on modeling, the best mitigation scenario would involve a combination of case isolation, home quarantine, and social distancing for individuals at highest risk such as those over age 70. However, there would be dire consequences, the report says.

"In combination, this intervention strategy is predicted to reduce peak critical care demand by two-thirds and halve the number of deaths. However, this 'optimal' mitigation scenario would still result in an 8-fold higher peak demand on critical care beds over and above the available surge capacity in both [Great Britain] and the [United States]."

A combination of suppression measures would be the best strategy to control the pandemic in countries that could sustain the Herculean effort required, the report says.

"A combination of case isolation, social distancing of the entire population, and either household quarantine or school and university closure are required. Measures are assumed to be in place for a 5-month duration. Not accounting for the potential adverse effect on ICU capacity due to absenteeism, school and university closure is predicted to be more effective in achieving suppression than household quarantine. All four interventions combined are predicted to have the largest effect on transmission."

This suppression strategy would have the highest likelihood of keeping the number of severe COVID-19 cases within the surge capacity of critical care beds, but implementing the strategy would be daunting, the report says.

"The major challenge of suppression is that this type of intensive intervention package—or something equivalently effective at reducing transmission—will need to be maintained until a vaccine becomes available (potentially 18 months or more)—given that we predict that transmission will quickly rebound if interventions are relaxed."

Interpretation and reaction

The new report is a wakeup call for healthcare organizations, says Chris DeRienzo, MD, MPP, system chief medical officer and senior vice president of quality at Raleigh, North Carolina-based WakeMed Health & Hospitals.

"These projections are sobering at best. Acknowledging that any model comes with assumptions that may or may not bear out in real life, these results are appropriately driving massive efforts across America to dramatically increase hospital and critical care capacity," he says.

Regarding whether the COVID-19 pandemic will overwhelm critical care resources, U.S. hospitals should be prepared for the worst but hope for the best, DeRienzo says. "I am both a realist and an optimist by nature—doctors have to be. To borrow from Jim Collins, we have to confront the brutal fact that all evidence points to a tsunami of critical care needs. At the same time, we must also maintain an unwavering faith in our ability to join together and meet the challenge." 

There is uncertainty over how long mitigation and suppression efforts will have to be in place, he says. "No one has lived through a global pandemic of this magnitude since the 1918 Spanish flu.  In truly unprecedented times for 99% of people on Earth, I do not believe anyone can tell with certainty how long we will need to endure suppression and mitigation if we are to save as many lives as we can."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

If there were no public health actions and no changes in individual behavior, a new report estimates that 2.2 million Americans would die in the COVID-19 pandemic.

If public health actions to control the pandemic are limited to slowing the spread of COVID-19, peak demand for critical care beds will outstrip supply by 8-fold, the report says.

Actions to control the COVID-19 pandemic will need to be maintained for at least 18 months—the time required to develop and distribute a vaccine, the report says.


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