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.
A crucial element of creating new ICUs during a pandemic is combining experienced critical care staff with reassigned non-ICU personnel.
The Society of Critical Care Medicine (SCCM) is recommending a tiered staffing model for hospitals opening new ICUs in response to the novel coronavirus (COVID-19) pandemic.
To avoid rationing of critical care services, which has been reported in China and Italy, U.S. hospitals are scrambling to find ventilators and critical care staff to expand ICU beds for treatment of high-acuity COVID-19 patients. Severe hypoxic respiratory failure requiring mechanic ventilation is the most common reason that COVID-19 patients are being admitted to ICUs globally, according to a recent SCCM report.
"As large numbers of critically ill patients are admitted to ICU, step-down, and other expansion beds, it must be determined who will care for them. Having an adequate supply of beds and equipment is not enough. Based on AHA 2015 data, there are 28,808 privileged and 19,996 full-time equivalent intensivists in the United States; however, 48% of acute care hospitals have no intensivists," the SCCM report says.
ICU tiered staffing model for COVID-19 pandemic
To address the anticipated shortage of ICU staff during the COVID-19 pandemic, SCCM is proposing that U.S. hospitals adopt a tiered staffing model that integrates experienced ICU personnel with reassigned hospital staff members. The integrated ICU personnel would be used to staff non-traditional ICUs created in repurposed hospital spaces such as post-anesthesia care units, Lewis Kaplan, MD, president of SCCM and professor of surgery at the University of Pennsylvania's Perelman School of Medicine in Philadelphia, told HealthLeaders last week.
An SCCM graphic of the proposed tiered staffing model is not absolute—each hospital will have to determine the best combination of staff members based on available resources, Kaplan says.
"The graphic is a helpful guide to see how you could do things, where you might begin to deploy your resources or education, and what the staffing model could look like. There will be some hospitals that have a different way of looking at their staffing model—there can be several successful approaches that reflect the unique elements of a hospital's capabilities and staffing," he says.
In the SCCM graphic, one trained or experienced critical care physician would supervise four ICU teams, with each team providing care to 24 mechanically ventilated COVID-19 patients. Each team would have four tiers:
At the top tier, each ICU team could be led by an experienced ICU advanced practice practitioner or a reassigned non-ICU physician.
The second tier would focus on mechanical ventilation and could be staffed by a combination of experienced and reassigned doctors, respiratory therapists, advanced practice practitioners, certified registered nurse anesthetists (CRNAs), and certified anesthesiologist assistants (CAAs).
The third tier could be staffed by experienced ICU nurses.
The fourth tier could be staffed by reassigned non-ICU nurses.
Tiered staffing model keys to success
Four actions are necessary for a tiered ICU staffing model to function effectively during the COVID-19 pandemic, Kaplan says.
1. Limiting elective surgeries frees up acute and ICU care beds, staff members, and ventilators. On the staffing front, reducing elective surgeries increases the availability of anesthesiologists, OR nurses, OR technicians, CRNAs, and CAAs. "Anesthesiologists and CRNAs are very good at managing mechanical ventilation and helping to care for people with acute illness," Kaplan says.
Reducing elective surgeries also increases the availability of ventilators, he says. "OR anesthesia machines are in fact ventilators that happen to have several other features such as delivering anesthetic gases."
2. Training of non-critical care staff who are reassigned to ICU duty is essential. The training should focus on education for new skills as well as refreshing staff members on any earlier critical care training. "People who are being trained or refreshed in conjunction with staff members who know how to care for patients with acute illness can work together in a repurposed space," Kaplan says.
3. Combining experienced and inexperienced ICU staff helps ensure an adequate level of care. "When you put people in a space where they don't typically work, it can be very trying. So, you need to have a partner system where the new ICU is not entirely composed of many people who have never worked in an ICU. … This will ultimately allow inexperienced staff members to have a buddy who can help them, guide them, or provide comfort," he says.
4. Public health measures limit viral transmission and viral spread, which slows down the rate at which COVID-19 patients present for hospital care. "This is the so-called flattening of the curve," Kaplan says.
COVID-19 tests have been in limited supply since the first U.S. novel coronavirus patient was identified in January. As of March 20, 14,372 cases had been confirmed in the United States, with 217 deaths, worldometer reported.
Public health officials and healthcare providers should prioritize who is tested for COVID-19 for as long as the test shortage persists, the IDSA recommendations say. "Given current limited availability of near-patient, or point-of-care, testing, IDSA has developed recommendations for diagnostic testing prioritization. These recommendations will likely change as testing becomes more widely available or as new information becomes available. IDSA continues to advocate for policies and investments to expand capacity to testing."
The IDSA is recommending a 4-tier approach to prioritize COVID-19 testing for patients, officials, and members of the general public.
Tier 1
There are five categories of people recommended for the highest priority testing:
Any hospitalized patients who are critically ill and receiving ICU-level care with unexplained viral pneumonia or respiratory failure
Anyone with fever and signs of a lower respiratory tract illness who has had close contact with a confirmed COVID-19 patient within 14 days of symptom onset
Anyone with fever and signs of a lower respiratory tract illness who has traveled within 14 days of symptom onset to countries or areas of the United States that have experienced sustained community transmission of novel coronavirus
Anyone with fever and signs of a lower respiratory tract illness who is immunosuppressed, elderly, or has underlying chronic health conditions
Individuals who are critical to pandemic response such as health workers and public health officials who have fever and signs of a lower respiratory tract illness
Tier 2
People at the second highest priority for testing are hospitalized patients and long-term care residents who have unexplained fever and signs of lower respiratory illness. "The number of confirmed COVID-19 cases in the community should be considered. As testing becomes more widely available, routine testing of hospitalized patients may be important for infection prevention and management at discharge," the recommendations say.
Tier 3
Patients in outpatient settings who meet influenza testing criteria, including people with co-morbid conditions such as diabetes and congestive heart failure as well as individuals over age 50. "Given limited available data, testing of pregnant women and symptomatic children with similar risk factors for complications is encouraged. The number of confirmed COVID-19 cases in the community should be considered," the recommendations say.
Tier 4
People targeted for community surveillance by public health or infectious disease officials.
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."
There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.
The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.
In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.
The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. "Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn't enough of these resources than what we anticipate needing," says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.
He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.
1. Treatment
In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. "The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can."
The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.
"But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility," Tabery says.
Medical utility is based on scientific assessments, he says. "You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient's condition quickly."
Rationing of critical care resources would be jarring for U.S. clinical staff.
Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.
However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.
"When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn't look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck," he says.
2. Testing
There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.
While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.
"The primary purpose of the test is pure public health epidemiology. It's about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn't so much about who is at greatest risk. It's about who is more likely to interact with lots of people, or who is more likely to have interacted with more people."
A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.
"For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street."
3. Healthcare workers
The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. "On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don't want to get sick, which can incline them not to work," he says.
"The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work," he says.
However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. "If hospitals don't have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem."
4. Vaccine
When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.
"When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups," he says.
Online medical ethics resources
The American Medical Association has the following online resources to help guide ethical decision making by clinicians and other healthcare workers during the COVID-19 pandemic:
