A healthcare consultancy anticipates a shortage of 7,900 critical care physicians nationwide when the coronavirus pandemic peaks.
The country is facing a "massive shortage" of critical care physicians, according to coronavirus pandemic modeling conducted by Array Advisors.
The United States leads the world in reported coronavirus disease 2019 (COVID-19) cases, with the total as of April 6 at more then 336,000, according to worldometer. A significant percentage of COVID-19 patients require mechanical ventilation in the ICU setting, which is expected to strain critical care resources including staff as coronavirus patients surge in the coming weeks.
ICU staffing shortages are an urgent concern, Neil Carpenter, strategic planning vice president at Conshohocken, Pennsylvania-based Array Advisors said in a prepared statement.
"While the public attention has been on beds and ventilators, we must not lose sight of the staff needed to serve the coming influx of patients. We need a national conversation about how to support and leverage our existing expertise, as well as how to contend with the coming surge of COVID-19 positive [healthcare] providers. In this fight, we need every provider to be well enough to work," he said.
Addressing intensivist shortages
Given the projected nationwide shortfall of critical care physicians, it likely will be impossible to shift intensivists from state to state to meet expected staffing demand, according to Array Advisors. The healthcare consultancy says there are six options for healthcare organizations and public health officials to cope with the shortage:
1. Retain intensivists who test positive for COVID-19 to treat ICU patients via telemedicine or, if personal protective equipment is available, treat ICU patients directly
2. Allow intensivists who have only completed one year of critical care fellowships to practice independently
3. Waive licensing regulations to increase existing international tele-ICU services and allow more international tele-ICU services
4. Enlist retired intensivists to provide direct patient care in ICUs
5. Combine artificial intelligence with advanced practice practitioners to expand the critical care workforce
6. Limit the allocation of critical care resources to patients with "extremely poor prognoses"
The Society of Critical Care Medicine has recommended that hospitals adopt a tiered staffing model in newly created ICUs to stretch the supply of critical care workers during the COVID-19 pandemic.
Critical care physician shortfall
Array Advisors' primary model for the anticipated critical care physician shortage pegs the shortfall at 7,900 doctors nationwide. The model is based on several assumptions, including a ratio of one intensivist for every 14 ICU patients during the day and the loss of 10% of critical care healthcare workers to coronavirus infection during the surge of COVID-19 patients.
The model projects there will be shortages of critical care physicians in every state except Maryland. New York leads the list of the Top 10 states that are expected to have intensivist shortages:
There are dire shortages of several kinds of coronavirus-related personal protective equipment across the country.
During the coronavirus pandemic, there are ways that healthcare organizations can reuse or extend the life of some personal protection equipment (PPE), an infection prevention expert says.
PPE is a crucial element of protecting healthcare workers from the virus that causes coronavirus disease 2019 (COVID-19). In China, Italy, and Spain, thousands of healthcare workers have been infected with the coronavirus. One-third of U.S. doctors are at high risk of serious illness from the coronavirus because they are over 60 years old, new research shows.
Last week, the Association of Professionals in Infection Control and Epidemiology (APIC) released national survey results that show severe PPE shortages at many U.S. healthcare facilities, including lack of respirators, surgical masks, face shields, and goggles. This week, HealthLeaders spoke with APIC President Connie Steed, MSN, RN, about how healthcare organizations can reuse or extend the life of PPE.
N95 respirator masks, face shields, goggles, and surgical masks
At this point in the U.S. COVID-19 pandemic, maintaining adequate supplies of N95 respirator masks is the primary PPE supply chain challenge, says Steed, who is director of infection prevention and control at Prisma Health-Upstate in South Carolina.
"Where most facilities are having trouble is with the N95; so, we are trying as much as possible to limit its use; and when it is used, we extend its life when it is acceptable," she says.
At Prisma Health, supplies of N95 respirators are being maximized through prioritization of use in the treatment of COVID-19 patients, Steed says. "It should be prioritized for aerosol generating procedures—that's when you have droplets during the intubation or extubation of a patient, for example. You can put people in surgical masks and face shields for other care."
Another option to conserve N95 respirators when treating COVID-19 patients is to use powered, air-purifying respirators (PAPRs), she says. "One of the things that some hospitals are doing is the use of the PAPR, which is a hood; and there has been discussion about the reuse of those hoods and using them instead of N95s. The PAPR's level of protection is the same or higher than the N95."
N95 respirators, face shields, and goggles are sturdy enough to reprocess after use with COVID-19 patients or patients suspected of coronavirus infection, Steed says.
Reprocessing requires a room designated for disinfection of PPE and other equipment. For N95 respirators, face shields, and goggles, she says two disinfection methods are currently being used across the country: hydrogen peroxide mist and/or ultraviolet light.
N95 respirators go through a four-step disinfection process, Steed says:
After use, the respirators are placed in a container
The respirators are carefully transported to the disinfection room
Inspectors make sure the respirators are intact and not visibly soiled
The respirators are suspended on "basically a clothesline," then they go through a disinfection process with either hydrogen peroxide mist or UV light, or both
Surgical masks can also be conserved, she says.
For example, Prisma Health started universal masking this week at its hospitals, which requires all employees to wear surgical masks except when they are eating, drinking, or working in a private room. When employees come to a hospital to start a shift, they are screened for fever and other COVID-19 symptoms; and if they screen negative, they are given a surgical mask and a bag, Steed says.
"When a healthcare provider gets ready to go into a room with a suspected or confirmed COVID-19 patient, they would take the regular mask off and put it in their bag. Then they put on an N95 mask, face shield, and other protective gear, go into the room, take care of the patient, come back out, doff safely, and clean their hands. Then they put their daily mask back on their face."
The Centers for Disease Control and Prevention has established guidance for maximizing the supply of N95 respirators.
Gloves and gowns
The options for conserving gloves and gowns in COVID-19 treatment are limited, with gloves only appropriate for single use, Steed says.
Plastic gowns also are single-use PPE in COVID-19 treatment, but some cloth gowns can be reused, she said. "There are some hospitals that use cloth gowns that have fluid repellency. If that's the case, they can be doffed and laundered through a routine process, then reused."
Retired clinicians, who are often at high risk because of age, can contribute to pandemic response in several ways that do not involve direct patient care.
The American Medical Association (AMA) is providing guidance to retired physicians who are willing to help during the coronavirus disease 2019 (COVID-19) pandemic.
There is widespread concern over the potential for healthcare worker shortages during surges of COVID-19 patients across the country in the weeks and months ahead. For example, New York Gov. Andrew Cuomo issued a plea this week to healthcare workers in other states to come to The Empire State to bolster hospital staffing.
"I am asking healthcare professionals across the country, if you do not have a healthcare crisis in your community, please come help us in New York now," Cuomo said.
In announcing the guidance to retired physicians, AMA President Patrice Harris, MD, MA, said in a prepared statement that there are several considerations for these doctors as they weigh returning to medical practice.
"As with all people in high-risk age groups, careful consideration must be given to the health and safety of retired physicians and their immediate family members, especially those with chronic medical conditions. The availability of personal protective equipment (PPE), and the opportunity to provide non-direct patient care are also special considerations," Harris said.
The AMA guidance to retired physicians features six factors they should consider.
1. Licensure: Retired physicians should check the licensing regulations in their state, the AMA guidance says.
"The licensure status of retired physicians varies by state. In some states retired physicians maintain their regular license while others create a separate category for retired or inactive physicians, and still others have no license category for retired physicians. In response to COVID-19, many states have taken action to allow retired physicians to temporarily return to practice through an executive order, department of health order, or board of medicine directive."
The path to re-entry is another licensure consideration, the AMA guidance says.
"For senior and retired physicians who maintain an active license, there are no licensure restrictions on re-entry to practice. For physicians who maintain an inactive, retired physician, or similar license, your state may have temporarily waived any barriers to re-entry. We encourage you to check the Federation of State Medical Boards' COVID-19 resource on state actions on license status for inactive/retired physicians for guidance."
Retired physicians should also consult with their state medical boards, the AMA guidance says.
2. Contributing effort: There are multiple ways for retired physicians to participate in COVID-19 pandemic response that do not include direct patient care, the AMA guidance says:
State health departments need volunteer clinicians and healthcare workers
Contact medical schools and offer to provide online teaching and mentoring for medical students
Donate blood
Social isolation is a challenge at nursing homes and senior residential communities—offer to provide online outreach
Help physician practices in your community to create patient education materials
3. Working at your former physician practice: "Explore opportunities to provide mentoring or training in your practice location. Many institutions have developed algorithms for telephone triage and/or assessment of symptomatic patients," the AMA guidance says.
4. Liability: There are several considerations for liability coverage, the AMA guidance says.
Check for coverage through your local health system
For licensed physicians who volunteer, the third federal economic COVID-19 stimulus package (H.R. 748), includes liability protections
Contact your state medical association to see whether you have liability protections under state law such as a recent gubernatorial executive order
5. Retirement income: "Some physicians are receiving retirement income that may be affected by a return to paid employment. Check the status of your retirement income according to the role you are being asked to perform," the AMA guidance says.
6. Clarify your role: If you will be working at a healthcare facility, ask questions about the role you will be playing such as the activities you will perform, provision of training or mentoring, and whether you will be given personal protective equipment.
As they confront the coronavirus pandemic, frontline healthcare workers are at risk for mental health conditions such as depression and anxiety.
During the coronavirus disease 2019 (COVID-19) pandemic, the mental health needs of healthcare workers should not be overlooked, a disaster response expert says.
Healthcare workers are in a precarious position on the frontlines of the struggle against COVID-19. In China, Italy, and Spain, thousands of healthcare workers have been infected with the coronavirus. Last week, more than 150 healthcare workers in four Boston hospitals were reported to have been infected.
HealthLeaders talked with disaster response expert Regardt "Reggie" Ferreira, PhD, to get his perspective on the mental health impact on healthcare workers during the pandemic. He is an associate professor at Tulane University School of Social Work, and program director of the Tulane University Disaster Resilience Leadership Academy in New Orleans.
Ferreira has been program director of the Disaster Resilience Leadership Academy for the past four years, and he has worked in the disaster response field since 2002.
The following is a lightly edited transcript of his discussion with HealthLeaders.
HealthLeaders: Do you have any overarching comments on supporting the mental health of healthcare workers during the COVID-19 pandemic?
Ferreira: The mental health aspect of a disaster oftentimes gets left behind. Especially for first responders and medical personnel, more attention should be given on this subject.
HL: For healthcare workers, what are the primary mental health concerns during the pandemic?
Ferreira: Medical professionals are likely to experience fear, anxiety, and a sense of powerlessness. There could even be aspects such as rage and anger toward the folks who have not followed the social distancing protocols.
There can also be compassion fatigue. Healthcare workers already had stressful jobs day-to-day. Adding the additional stresses from the COVID-19 pandemic—where there are so many unknowns—is going to be difficult on healthcare professionals. There is a lot of uncertainty about what is going to come at them and that can compound and filter into their home life. There is a range of emotions that is being felt at this stage of the pandemic.
HL: Are there emotional responses that could lead to a serious mental health crisis for healthcare workers?
Ferreira: For all of the things that I have mentioned, if they are not addressed, they can compound, and depression can set in and anxiety can set in. Over the long term, if healthcare workers are constantly operating under fear, they can make mistakes.
HL: What can healthcare workers do to avoid developing mental health problems during the pandemic?
Ferreira: Healthcare workers can focus on self-care, which can include reading, participating in self-help forums, keeping a diary, limiting social media exposure, talking to a friend or loved one about what they are experiencing, doing physical exercise, engaging in meditation and mindfulness, and switching off when they go home. These are all things that healthcare workers can do that are fairly easy to do if they are made a priority.
If healthcare workers are slipping into depression, they should be talking with a counselor or a therapist.
HL: What can health systems, hospitals, and physician practices do to support the mental health of healthcare workers during the pandemic?
Ferreira: At the top of the list is having clear communication with healthcare workers. They should be getting constant updates—this is a very fluid situation and there is new research coming out. There can be regular town halls with MDs, nurses, and other healthcare professionals.
Healthcare facilities should also be providing the necessary resources for providing care safely, which is difficult with shortages of materials and equipment.
Something tangible that can be of help is providing transportation to and from healthcare workers' places of residence; and if they are sequestered, healthcare facilities can provide housing. I spoke with a doctor in New York, and he said there are a lot of staff members who are afraid to go home because they have relatives who have diabetes, COPD, and other conditions, and they don't want to go home and infect family members.
Healthcare organizations can provide counseling and have support groups available—they can amplify the social support system at work. I'm sure there are many therapists at health systems who are willing to step up to the plate and help healthcare workers.
HL: From a mental health perspective, what aspects of this pandemic could be most challenging for healthcare workers?
Ferreira: The unknown. We fear the unknown, which creates stress. My advice is to take the situation day-by-day because it is so fluid. It's important not to look too far into the future. It's better to go day-by-day because if you try to look two or three months into the future, fear can lead to anxiety and depression.
If we have care rationing, there are going to be decisions that have to be made that are life-or-death decisions. Clinicians are going to be faced with those decisions—they are going to have to turn some patients away.
Doctors in Wuhan, China, share steps to establish temporary hospitals for coronavirus patients.
At the epicenter of the coronavirus disease 2019 (COVID-19) pandemic—Wuhan, China—health officials followed a five-step process to establish more than a dozen temporary hospitals in preexisting nonmedical buildings, a recent journal article says.
Over the past two weeks, China has had a relatively stable number of reported COVID-19 cases at more than 81,000, according to worldometer. in the United States as of March 31, there had been more than 164,000 confirmed cases, with more than 3,100 deaths, worldometer reported.
The recent journal article on temporary COVID-19 hospitals in Wuhan was published as part of a special article series in the journal Anesthesiology. The temporary hospitals played a key role in addressing the COVID-19 outbreak in Wuhan, the journal article says. "The establishment and operation of temporary COVID-19 specialty hospitals proved to be useful in the control of an infectious crisis within Wuhan, China, and will hopefully provide a blueprint for the management of future epidemiologic disasters."
The primary purpose of the temporary hospitals is to help control the COVID-19 outbreak in Wuhan by admitting all COVID-19 patients who are asymptomatic or exhibiting mild symptoms, the journal article says. "These temporary specialty hospitals can dramatically and immediately expand the admission capacities of the whole city, reduce the burdens/patient loads of designated comprehensive hospitals, manage COVID-19 patients centrally, eliminate virus transmission routes, and protect susceptible populations from COVID-19."
Patients who develop severe illness are transferred from the temporary hospitals to comprehensive care hospitals.
The temporary hospitals are 10 times less expensive than building a new comprehensive COVID-19 care hospital, and they reduce fear and anxiety in the community, the journal article says. "These facilities serve to quickly contain all potential sources of infection from the public, and because all patients have the same confirmed COVID-19 virus, patient-to-patient cross infection is not present."
Wuchang Ark Hospital in Wuhan, China, was established in a sports arena. Photo credit: Anesthesiology
5-step process
The Wuhan temporary COVID-19 hospitals utilized five strategies to build and operate the facilities.
1. Infrastructure renovation and infection control: In early February, the journal article's co-authors established a temporary hospital (Wuchang Ark Hospital) in a Wuhan sports arena. The first step was ensuring that the arena could be renovated to comply with international infection control and treatment standards.
"Through close communication with our architects and engineers, we provided constructive advice on patient care area distribution, hallway design, electricity arrangement, and information network connections," the journal article says.
2. Hospital configuration and staffing management: At Wuchang Ark Hospital, the clinical care area including an ICU is in the arena, and supply, screening, and testing facilities are located in tents and ambulances outside the arena. The clinical care staff is drawn from a national emergency team and local medical professionals.
Recent staffing at the temporary hospital featured 125 physicians, 500 nurses, and 90 administrative workers. There are several personnel departments at the hospital, including administration, clinical care, infection control, and supply chain.
3. Procedure and policy standardization: With the temporary hospital's staff drawn from several sources, standard procedures and policies were necessary, including patient identification verification policy, admission and discharge procedures, medical waste disposal procedures, and standards for nursing, infection control, and supply chain.
There also are priorities for patient care, the journal article says. "We especially focus on the elderly and patients with comorbidities secondary to the high mortality rate in this population. Fear, anxiety, and depression are common, and we provide mental health care and intervene on emotionally unstable patients."
4. Staff education and infection control measures: When the temporary hospital opened, infectious disease experts provided infection control and prevention training as well as guidance on how to use personal protective equipment. The infectious disease experts also provided training for three levels of infection control procedures.
Level 1 infection control features scrubbing, disposable hats, disposable gowns, and disposable surgical masks. Level 2 infection control features scrubbing, disposable hats, medical masks—N95 or above, anti-fog eye and face shields, disposable gloves, and disposable shoe covers. Level 3 infection control features all Level 2 requirements, except eye and face shields are replaced with positive pressure respirator hoods.
Training efforts were extensive, the journal article says. "Our Division of Infectious Disease provided 13 sessions to educate more than 500 physicians, nurses, policemen, security, and environmental services. For our team of more than 450 nurses, we provided training with lectures, simulations, and live demonstrations on proper throat swab procedures in COVID-19 patients for testing."
5. Supply preparation and logistics management: "Frontline leadership and the National Health Commission coordinated with local government public health departments to ensure adequate personal protective equipment for healthcare providers as well as daily necessities. Special attention is paid to fulfill the personal needs of patients if possible to help relieve their anxiety," the journal article says.
During the coronavirus pandemic, telemedicine is way for physician practices to offer expanded services and to interact with patients safely.
The American Medical Association (AMA) is providing guidance to physician practices to set up telemedicine services for their patients.
Telemedicine provides physician practices with a safe method to interact with patients remotely during the coronavirus disease 2019 (COVID-19) pandemic. Telemedicine also enables physician practices to expand services for patient care such as virtual patient check-in capabilities and remote patient monitoring that collects biometric data.
An overview document, "AMA quick guide helps doctors boot up the telemedicine practice," includes guidance on changes to federal telemedicine policy and privacy regulations during the COVID-19 pandemic.
"For example, the Centers for Medicare & Medicaid Services (CMS) is letting physicians provide beneficiaries a wider range of healthcare services without having to visit a healthcare facility. This CMS fact sheet explains more. Also, the Health and Human Services (HHS) Inspector General is waiving Medicare's cost-sharing requirements for COVID-19 treatment delivered via telehealth from a doctor's office or hospital emergency department," the overview document says.
In addition to the overview document, the AMA has a quick guide that features tabs for telemedicine practice implementation; policy, coding, and payment; and other helpful resources.
Telemedicine practice implementation
There are three steps to start setting up telemedicine services at a physician practice, the quick guide says:
1. Establish a team to lead the effort to implement telemedicine services and make decisions rapidly to expedite the launch.
2. Contact your malpractice insurance carrier to see whether your policy covers telemedicine services.
3. Learn about telemedicine payment and policy guidelines.
There are four steps for vendor vetting and contracting:
1. See whether your electronic health record vendor has a telemedicine capability that can be implemented.
2. Contact your state medical association to see whether it has guidance for telemedicine vendor vetting and contracting.
3. To implement telemedicine quickly, there are three primary considerations: making sure it is clear who has access to and ownership of data gathered in a patient visit, pricing structure such determining whether there is a monthly flat fee with your telemedicine vendor or a per visit fee, and Health Insurance Portability and Accountability Act compliance.
"Given the special circumstances of the COVID-19 pandemic, the federal government has announced that the Office for Civil Rights (OCR) will exercise its enforcement discretion and will not impose penalties on physicians using telehealth in the event of noncompliance with regulatory requirements under the Health Insurance Portability and Accountability Act (HIPAA) in connection with the good faith provision of telehealth during the COVID-19 national public health emergency," the AMA quick guide says.
4. Use American Telemedicine Association resources to identify possible vendors. Some vendors are offering quick implementation of telehealth services.
There are five primary considerations for workflow and patient care:
1. Set protocols for when a telemedicine visit is appropriate, and train clinicians, other healthcare workers, and office staff. Contact your most significant commercial payers to discuss telemedicine reimbursement.
2. Set when telemedicine visits will be conducted such as throughout the day or in a block of time.
3. Establish a space in your practice to conduct telemedicine visits such as an exam room.
4. Document telemedicine visits—ideally in your existing electronic health record. The documentation should include consent from patients to receive telemedicine services.
5. Conduct patient outreach such as alerting patients that telemedicine services are available when they call your office or visit your website.
The national survey shows widespread shortages of personal protective equipment, including respirators, surgical masks, face shields, and gowns.
Supplies of personal protective equipment (PPE) are running out across the country, according to a national survey conducted by the Association for Professionals in Infection Control and Epidemiology (APIC).
Coronavirus disease 2019 (COVID-19) is mainly spread person-to-person via respiratory droplets, the Centers for Disease Prevention and Control has reported. PPE is an essential element of protecting healthcare workers from novel coronavirus infection, according to the CDC.
APIC conducted a national survey last week of 1,140 infection preventionists in all 50 states and the District of Columbia. APIC executives presented the findings of the survey during a conference call on March 27.
"The results paint a disturbing and alarming picture. Nearly half—48%—of U.S. healthcare facilities surveyed are already out of or almost out of respirators, and these are used in caring for the patients with COVID-19 and other infectious diseases. Out of that 48%, 20% of the respondents are completely out of respirators," said APIC CEO Katrina Crist, MBA.
"This is simply unacceptable. Shortages of critical PPE and disinfection supplies are jeopardizing our ability to safely treat patients and protect the healthcare workers who put their lives on the line every day. The survey shows that we must act, and we must act now," she said.
In addition to the data about respirator shortages, the survey found scarcity of several other key infection control supplies:
Surgical masks: 1% have none, 31% are almost out, 48% are running low
Face shields: 13% have none, 37% are almost out, 38% are running low
Goggles: 11% have none, 28% are almost out, 38% are running low
Gloves: 5% are almost out, 32% are running low
Gowns: 1% have none, 23% are almost out, 44% are running low
Hand sanitizer: 3% have none, 26% are almost out, 43% are running low
"Our survey shows that the supply shortages are widespread throughout the country. Therefore, every hospital is concerned about putting patients and healthcare workers at unnecessary greater risk in these coming days and weeks due to lack of available PPE," said Ann Marie Pettis, RN, 2020 president-elect of APIC, and director of infection prevention for UR Medicine Highland Hospital in Rochester, New York.
Call for action
"We all know that time is critical. The federal government must act now to secure more PPE and coordinate distribution where it is needed most. Every minute matters. Every minute wasted puts more lives at risk," said Connie Steed, MSN, RN, 2020 president of APIC, and director of infection prevention and control at Prisma Health-Upstate in Greenville, South Carolina.
The federal government needs to compel manufactures to produce PPE and other essential supplies, she said. "APIC is calling on the federal government to activate the Defense Production Act and any other means at their disposal to ensure adequate supplies for healthcare personnel to safely treat COVID-19 patients."
Healthcare workers also need clarity from government officials and supply chain leaders, she said. "They need to know exactly when they can expect to get desperately needed supplies to arrive, so they don't have to turn to unproven methods. APIC is calling for transparency around delivery dates for these critically needed supplies. 'Soon' is simply not good enough. We need them immediately."
Delaying elective surgery during the COVID-19 pandemic increases hospital bed capacity as well as boosts supplies of personal protective gear and ventilators.
The American College of Surgeons (ACS) has released guidelines for triaging elective surgery during the coronavirus disease 2019 (COVID-19) pandemic.
On Feb. 29, the Centers for Disease Control and Prevention issued interim guidance for healthcare facilities that included a recommendation for hospitals to reschedule elective surgery during the pandemic. On March 18, the Centers for Medicare & Medicaid Services (CMS) announced that all elective surgeries should be delayed during the pandemic.
"As more healthcare providers are increasingly being asked to assist with the COVID-19 response, it is critical that they consider whether non-essential surgeries and procedures can be delayed so they can preserve personal protective equipment (PPE), beds, and ventilators," the CMS announcement says.
This week, ACS released guidelines for triaging elective surgery during the pandemic that include seven overarching principles:
1. Although some of the triaging guidelines include recommendations based on a low level of COVID-19 infections, coronavirus cases are expected to surge in the next few weeks and surgical teams are advised to prepare for much higher infection rates when triaging elective surgeries now.
2. Based on surgical judgment and resource availability, patients should get appropriate and timely surgical care.
3. Nonoperative management is advised when it is clinically appropriate for patients.
4. Surgical teams should consider waiting for COVID-19 test results for patients who may be infected.
5. With anticipated staffing shortages, emergency surgical procedures at night should be avoided.
6. Aerosol generating procedures such as intubation and electrocautery of blood increase healthcare worker risk for patients who test COVID-19 positive or are suspected of infection. If aerosol generating procedures are unavoidable, surgical staff should wear full personal protective equipment including an N95 mask or powered, air-purifying respirator designed for operating room use.
7. Although there is insufficient data to make a recommendation for open surgery vs. laparoscopy, surgical teams should pick an approach that reduces operating room time and increases safety for patients and healthcare workers.
The ACS guidelines include detailed recommendations for more than a dozen surgical specialties:
The ACS guidelines should be used in conjunction with a joint statement on creating a surgical review committee from ACS, the American Society of Anesthesiologists, and the Association of periOperative Registered Nurses, ACS Executive Director David Hoyt, MD, FACS, said this week in a prepared statement.
"These triage guidelines and joint recommendations are being issued as we appear to be entering a new phase of the COVID-19 pandemic with more hospitals facing a potential push beyond their resources to care for critically ill patients," he said.
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."
Virus outbreaks in the recent past have posed challenges, but the novel coronavirus has an uncommon potential to wreak havoc, an infectious disease expert says.
Although there are differences between the novel coronavirus (COVID-19) pandemic and the recent swine flu and Ebola outbreaks, there are valuable lessons from the earlier flareups, an infectious disease expert says.
The swine flu pandemic hit the United States in 2009 and 2010, with about 12,500 deaths and an estimated 60.8 million cases, according to the Centers for Disease Control and Prevention (CDC). During the 2014–2016 Ebola outbreak, 11 people were treated for the viral disease in the United States, with two deaths. Last week, the Imperial College COVID-19 Response Team declared the novel coronavirus is the most serious public health threat from a respiratory virus since the 1918 Spanish flu pandemic.
Last week, HealthLeaders held a discussion with infectious disease expert Charles Ericsson, MD, to compare the COVID-19 pandemic in the United States to the country's experience with the swine flu and Ebola outbreaks and to share lessons learned from each.
Ericsson is a professor of infectious diseases and professor of medicine at McGovern Medical School at UTHealth in Houston. He also is head of clinical infectious diseases in the medical school's department of internal medicine as well as director of the Travel Medicine Clinic and the Infectious Diseases Fellowship program. He earned his medical degree at Harvard Medical School in Boston.
The following is a lightly edited transcript of Ericsson's conversation with HealthLeaders.
HealthLeaders:How does the COVID-19 pandemic compare to the swine flu pandemic?
Ericsson: A major difference is we have had a poor response to COVID-19 testing. We arranged the testing for swine flu efficiently and rapidly, which helped a great deal in keeping it under control and flattening the epidemiologic curve.
For swine flu, we had testing to recognize the disease, we had treatments, and we had testing that was rapidly developed to recognize when the virus was becoming resistant to one reagent so we could switch to another reagent. We have nothing like this now to control the COVID-19 epidemic.
We have no treatment for COVID-19 that is recognized and actively in use. We have an experimental agent, but it is only for hospitalized patients who are in dire need of a rescue medication.
HL: What lessons were learned from the swine flu pandemic that are helpful in the COVID-19 pandemic?
Ericsson: A key lesson from swine flu is that we need to have a plan in place that we can rapidly adapt. A plan must be flexible enough to deal with the new realities of whatever develops. If you stack up all of the challenges of new viruses that we have had in the recent past, there have been many, but none have had the dangerous potential of COVID-19.
We also learned to try to anticipate supply chain issues and to have a national stockpile, which we are going to have to dip into for COVID-19 in short order. It's good that we have national stockpiles because our local institutions are running out of supplies quickly due to fear and hysteria.
One of the things that we should have anticipated for COVID-19 is that we would run out of the vials needed to test specimens, and that has become a supply chain problem. Now, we are rapidly trying to find ways to adapt that do not require the usual vials and solutions needed to collect samples.
HL: How does the COVID-19 pandemic compare to the U.S. Ebola outbreak in 2014?
Ericsson: What's similar is the fear. With Ebola, particularly for healthcare workers, the fear was quite justified because Ebola is a disease where infection protection had to be absolutely rigorous. We had to use expensive equipment to totally isolate healthcare workers from patients because Ebola is highly transmissible through bodily fluids. We had some healthcare workers become ill with Ebola, and it was deadly. We had no treatment for it.
Ebola was different from COVID-19 because of its rarity and unlikelihood to be imported into our country made containment important almost immediately. We were able to find infected patients and isolate them.
Another way Ebola is different than COVID-19 is that it kills quickly. So, it is unlikely that people are going to be traveling out of an area where there is an Ebola outbreak because they die.
With Ebola, it never reached the point of refusing to let anybody fly into the country. It was relatively easy to recognize people coming into the country from one area of the world instead of worrying about hotspots all over the world. It was a fundamentally different approach that lended itself to containment. With Ebola, we recognized that containment was the way to go, and we were quite successful with that approach.
HL: Why was containment successful with Ebola?
Ericsson: You could recognize people who were entering the country who were suspect. Anyone who was a traveler who had Ebola symptoms was jumped on immediately, isolated, and tested.
HL: Are there lessons from the Ebola outbreak that are helpful in the COVID-19 pandemic?
Ericsson: One thing we learned from the Ebola virus is the necessity to quickly develop vaccines, which is currently underway with the novel coronavirus. But it takes time to get a vaccine developed.
We also realized that we had to have plans for off-site assessment of people if we ever had a surge of disease such as Ebola. We certainly would not to be evaluating many people in the hospital, and we are seeing that now with tents being set up outside hospitals. With a disease such as COVID-19, which is not symptomatic in a large segment of the patients, we just send many people home and don't put them in the hospital.
The situation with Ebola was different, but it made us think through the possibility of needing off-site facilities in the event of a pandemic such as COVID-19. Ebola made us think a lot, and we modified our pandemic plans.
