Experts anticipate hospital bed shortage and warn about dire consequences of personal protective equipment shortages.
As the U.S. coronavirus pandemic worsens, critical care capacity and protection of healthcare workers are top priorities, a pair of healthcare experts say.
The United States has the second-highest number of confirmed coronavirus disease 2019 (COVID-19) cases worldwide, behind China, according to worldometer. As of March 26, there were more than 74,000 confirmed U.S. cases, with 1,072 deaths, worldometer reported.
This week, The Commonwealth Fund and Alliance for Health Policy hosted a COVID-19 teleconference with two healthcare experts: Ashish Jha, MD, MPH, professor and dean for global strategy at the Harvard T.H. Chan School of Public Health, and director at the Harvard Global Health Institute in Boston; and Steve Parodi, MD, executive vice president at The Permanente Medical Group, Kaiser Permanente in Oakland, California.
Harvard has been conducting modeling of the COVID-19 pandemic and projects demand for hospitals beds will vastly exceed supply, Jha said. "Our primary model asked the question, if 40% of adult Americans get the virus over the next six months, what proportion of the beds that could become available would we need to take care of everybody? The answer is we would need about three times as many beds across the country as could be available."
Increasing hospital capacity
There are several ways to increase hospital bed capacity, Parodi said. These strategies include adding beds in non-clinical-care spaces at existing hospitals, reopening recently shuttered hospitals, setting up tents and mobile hospitals, and converting hotels into care settings. "Having tents and having mobile hospital units available to prepare for the surge is going to be critically important," he said.
Most hospitals should have contingency plans to expand the number of beds at their facilities, Parodi said. "You need to take out your surge plans and look at areas such as your cafeterias and conference rooms that have the power and the plumbing to put beds in those spaces, where you already have staff co-located."
Working with the National Guard and Department of Defense to activate resources such as hospital ships is another option to increase hospital bed capacity, he said. "In my estimation, all of these levers are going to need to be pulled because … that's the only way you get to the two-to-three times number of beds that we are going to need in response to this surge."
Increasing the supply of ventilators to treat the most severely ill COVID-19 patients is essential to expand critical care capacity at hospitals, Jha said. There are as few as 60,000 ventilators in the United States and modeling predicts that as many as 400,000 ventilators will be required at the peak of the country's COVID-19 pandemic, he said.
Another prime consideration in increasing hospital and critical care capacity is increasing the number of healthcare workers, Jha said. "The issue here is that at the baseline we are not going to have enough workers. If we just stick to a standard that only has intensivists in the ICU or only has ICU-trained nurses in the ICU, we are going to quickly run out of them."
He said there are several strategies to bolster the healthcare workforce. One strategy is recruitment of doctors and nurses who have retired in the past five years and can be relicensed for three to six months. These older healthcare professionals are at high risk if they become infected, so they should be deployed to care for non-COVID-19 patients, which will open up younger healthcare workers to care for COVID-19 patients, Jha said.
Another staffing strategy is "retooling" non-ICU nurses to work in the ICU setting, he said. With this strategy, a key challenge to resolve will be determining what level of training will be adequate to prepare non-ICU nurses to work in a critical care environment, Jha said. "A little bit of federal leadership could be effective here in trying to come up with some basic rules and standards, understanding that ultimately these are state decisions."
Telehealth capabilities can help to optimize staffing levels and protect the healthcare workforce, Parodi said. Telehealth enables intensivists and other specialists to support large numbers of healthcare workers who lack experience in critical care settings, he said.
Telehealth also contributes to healthcare worker safety, Parodi said. "Telehealth has contributed to the ability to have social distancing occur in our clinics, medical office buildings, and emergency departments. In fact, we are implementing some telehealth procedures in the hospital setting, so we can minimize the number of people going in and out of rooms and minimize exposures for healthcare workers."
Protecting healthcare workers
Making sure that healthcare workers have enough personal protective equipment (PPE) to avoid infection is essential to address the COVID-19 pandemic, Jha said.
"This is an issue I am deeply worried about because it creates a cascade. When one healthcare worker starts getting sick, everybody else has to work more hours, which increases their risk. That gets into a vicious cycle, and we've got to do everything we can to avoid that vicious cycle. Otherwise, it's going to get very hard to take care of patients," he said.
In China, Jha said there was a high infection rate among healthcare workers until head-to-toe PPE was adopted widely. "Our best understanding of the high rates of infection is because of a combination of inadequate PPEs and fatigue from long work hours and multiple shifts. People start to get tired and they are a little bit less vigilant and they make mistakes."
A recommendation from the Centers for Disease Control and Prevention that healthcare workers could use bandanas and scarfs for COVID-19 patient care if supplies of surgical masks and N95 respirators run out is problematic, he said.
"Using bandanas has mostly been met with derision for good reason. There is no evidence that bandanas protect doctors in the context of a potentially lethal droplet or airborne element. In general, we have to protect our doctors and nurses with real equipment as opposed to makeshift or hand-sewn masks, because there is no evidence base to suggest that those are reasonable alternatives. Until there is evidence, we have to assume that handmade products are no better than not having any protection at all."
Christopher Cheney is the senior clinical care editor at HealthLeaders.
The United States has the third highest number of confirmed COVID-19 cases worldwide.
Harvard University modeling of the COVID-19 pandemic predicts demand for hospital beds will exceed supply three-fold.
Coronavirus infection of healthcare workers has a cascade effect, putting an ever-increasing number of healthcare professionals at risk.