Eric Toner, MD, and Richard Waldhorn, MD | February 27, 2020
The World Health Organization (WHO) and the US Centers for Disease
Control and Prevention (CDC) have called on health systems around the
world to prepare for a possible COVID-19 pandemic. The purpose of this
article is to offer to American hospital administrators and clinicians
specific judgment on what hospitals should do to prepare for a COVID-19
pandemic. This is an update of a similar perspective related to pandemic
influenza, published in 2006.
1
These recommendations derive from the authors’ analysis of the
consequences of a flu pandemic, review of many existing hospital plans,
analysis of the federal government’s recommendations, and meetings with a
number of leaders in health care, public health, and emergency
management. Recognizing that any such recommendations must be based on
numerous untestable assumptions, any of which can be reasonably
challenged, we propose specific actions and priorities for the purpose
of making the discussion of hospital pandemic preparedness issues more
operationally useful. This commentary pertains to hospitals, but
long-term care facilities, outpatient clinics, medical offices, and
other healthcare facilities must also urgently prepare.
The Argument for Urgent Preparedness
The current COVID-19 epidemic looks very much like an early influenza
pandemic in many important respects. It is spreading from person to
person efficiently, much like influenza, including some degree of
pre-symptomatic spread. Although the true case fatality rate is as yet
uncertain, all evidence suggests that it is as severe as, if not more
severe than, influenza pandemics of the last century. The case fatality
rate (CFR) of confirmed COVID-19 patients in China is estimated to be
1-3%, although this may not account for all mildly symptomatic or
asymptomatic infections. In some regions of China outside Hubei, the CFR
has been less than 1%. For comparison, the CFR of the 2009 influenza
pandemic was around 0.1%, the 1968 and 1957 pandemics in the United
States were about 0.5%, and the CFR of the 1918 pandemic was estimated
to be 2.5 % in the United States.
Because it will take considerable time to fully understand the
epidemiology of COVID-19, it is reasonable to begin preparations using a
model we have studied extensively for decades and that seems similar to
COVID-19—pandemic influenza. The threat of a novel influenza pandemic
has stimulated international, national, and local planning and
preparedness efforts for years. In the event of a 1918-scale flu
pandemic, hospitals would be flooded with sick patients seeking care.
The impact of a COVID-19 pandemic on hospitals is expected to be
severe in the best of circumstances. Currently, US hospitals routinely
operate at or near full capacity and have limited ability to rapidly
increase services. There are currently shortages of healthcare workers
of all kinds. Emergency departments are overcrowded and often have to
divert patients to other hospitals.
In recent years, there has been a reduction in the overall number of
hospitals, hospital beds, and emergency rooms. During an epidemic, the
healthcare workforce would be greatly reduced. Healthcare workers would
face a high risk of infection because of contact with infected patients;
many would need to stay home to care for sick relatives, and, in the
absence of vaccine, others might fear coming to work lest they bring a
lethal infection home to their families. The provision of medical
services to both COVID-19 and non–COVID-19 patients may be adversely
affected in most communities.
Detailed modeling projections for COVID-19 have not yet been released
by the US government or WHO; however, the US Department of Health and
Human Services (HHS) released official planning assumptions for pandemic
influenza, ranging from a moderate pandemic like 1968 or 1957, to one
based on a very severe pandemic like 1918.
2
These may be the best tools we have at the moment. They differ by more
than 10-fold in the number expected to need hospitalization, intensive
care, and mechanical ventilation (see Table 1).
Table 1
HHS pandemic planning assumptions
| Moderate Scenario (1968-like) |
Very Severe Scenario (1918-like) |
| 38 M needing medical care |
38 M needing medical care |
| 1 M hospitalizations |
9.6 M hospitalizations |
| 200,000 needing ICU |
2.9 M needing ICU |
As a comparison, there are about 46,500 medical ICU beds in the
United States and perhaps an equal number of other ICU beds that could
be used in a crisis. Even spread out over several months, the mismatch
between demand and resources is clear.
Some patients in China have been treated with extracorporeal membrane
oxygenation (ECMO), and some US medical centers with this technology
are preparing to use it as well. For US hospitals with this capability,
it would be prudent to think through how this scarce resource would be
allocated if demand exceeds resources.
Preparedness Defined
Based on such calculations, it would seem that preparing for a
pandemic of even moderate severity is a difficult challenge. For the
purpose of this analysis, we use the following definition of
preparedness:
Every hospital, in collaboration with other hospitals and public
health agencies, will be able to provide appropriate care to COVID-19
patients requiring hospitalization while maintaining other essential
medical services in the community, both during and after a pandemic.
This definition recognizes that what constitutes “appropriate care”
and the criteria for hospital admission may well change during a
pandemic.
The Top Priorities
Individual hospitals and groups of hospitals involved in regional
coordination of pandemic preparedness should focus their initial
preparedness efforts in the following priority areas:
- Comprehensive and realistic planning based on actual CDC FluSurge
projections in each hospital, and collaborative planning among all
hospitals in a region (eg, healthcare coalitions).
- Limiting the nosocomial spread of the virus to (1) protect the
healthcare workers and, thus, maintain a hospital workforce; (2) prevent
the hospital from being a disease amplifier; and (3) protect the
non–COVID-19 patients from infection, so as to maintain the ability to
provide essential non–COVID-19 health care.
- Maintaining, augmenting, and stretching the hospital workforce.
- Allocating limited healthcare resources in a rational, ethical, and
organized way so as to do the greatest good for the greatest number.
Specific Priority Actions to Be Taken
To implement the priority goals above, hospitals should undertake the following specific actions:
- Employing a comprehensive and realistic planning process:
- Employ at least 1 full-time hospital emergency manager in each hospital.
- Dedicate a full-time infection prevention practitioner to work on
infection prevention aspects of the preparations, including education,
training, and exercises.
- Designate a medical director to work closely with the emergency manager and infection prevention practitioner.
- Create a pandemic preparedness committee (or use an existing
emergency management committee) that includes representatives of all
clinical and support departments as well as senior administrators.
- Participate in a local healthcare coalition, which includes
neighboring hospitals, local public health agencies, and emergency
management. Members of multi-hospital health systems should integrate
system-wide planning with local planning with other local hospitals.
- We do not yet have modeling tools or planning assumptions for
COVID-19. CDC has developed FluSurge 2.0, which can be used in
conjunction with HHS planning assumptions to guide planning for both a
moderate and severe pandemic.3
Note that the default assumptions in FluSurge are based on a 1968-like
pandemic. To model a severe pandemic, FluSurge allows the assumed number
of hospitalizations to be modified to correspond to the HHS planning
assumptions for a severe pandemic.
- Be able to make 30% of licensed bed capacity available for COVID-19
patients on 1 week’s notice. About 10-20% of a hospital’s bed capacity
can be mobilized within a few hours by expediting discharges, using
discharge holding areas, converting single rooms to double rooms, and
opening closed areas, if staffing is available. Another 10% can be
obtained within a few days by converting flat spaces, such as lobbies,
waiting areas, and classrooms.4
- Collaborate in regional plans to be able to make at least 200% of
licensed bed capacity in the region available for COVID-19 patients on 2
weeks’ notice.
- Use telephone and internet-based advice lines to reduce unnecessary visits to the hospital emergency department.
- Limiting the nosocomial spread of the virus:
- The CDC has provided good technical guidance on infection control for COVID-19 in healthcare facilities.5
- Limit the accidental contamination of the hospital environment by
implementing respiratory etiquette and by using simple surgical masks
for everyone entering the facility (staff, patients, and visitors)
during a pandemic. Assuming re-supply may be difficult during a
pandemic, stockpile enough masks for 3 weeks.
- Prevent staff from getting infected by training healthcare workers
on the use of personal protective equipment (PPE) and infection control
procedures and by stockpiling a supply of PPE. PPE availability is
currently limited, but hospitals should purchase what they can,
recognizing that a local outbreak could last at least several weeks to
several months. Given the preeminent need to protect healthcare workers,
we feel the highest level of protection available should be used. We
call for the use of N95 respirators for healthcare workers with direct
contact with COVID-19 patients. This is in concert with the CDC’s
COVID-19 guidelines. Powered air-purifying respirators (PAPRs) should be
available for use in high-risk aerosol-generating procedures.
- Limit the number of staff who are exposed to COVID-19 patients by
cohorting (dedicated staff in dedicated units) (see Figure 1). Utilize
overtime and long shifts for staff in the COVID-19 units to limit the
number of staff needed. When possible, use staff who are immune
(recovered) in the COVID-19 units.
- Prevent infected staff from working (except with COVID-19 patients)
by tracking staff who are sick and testing for COVID-19, if possible,
and keeping a log of staff who have had confirmed COVID-19.
Figure 1
Cohorting
- Maintaining, augmenting, and stretching the hospital workforce:
- Vaccinate all staff for influenza to reduce the burden of that disease.
- Organize in-home childcare for well children of healthcare workers if schools are closed, using screened volunteers.
- Provide medical daycare for sick family members.
- Allay fear through open, honest, and transparent planning and careful training.
- Shift clinical staff to highest-need areas from areas that may be
closed or quiet; employ “just in time” education and “buddy teaming.”
- Augment clinical staff with nontraditional personnel, employing
“just in time” education and “buddy teaming.” Use (1) medical
professionals with prior clinical experience (eg, administrators,
researchers, retirees, etc); (2) related health professionals (eg,
dentists, veterinarians, emergency medical technicians, etc); (3)
nonclinical hospital personnel; and (4) nonclinical outside personnel.
Specific training and operating procedures for each group must be
created in advance.
- Coordinate plans with other hospitals in the region to recruit and use volunteers.
- Allocating limited healthcare resources in a rational, ethical, and
organized way so as to do the greatest good for the greatest number
through deferral of nonemergency care and, if necessary, institution of
alternative patient care routines.
- Prioritize which services and types of procedures can be deferred,
for how long, and with what consequences and create an alternative plan
for patients who will be deferred. Create a process for refining and
updating this plan as circumstances change. Create a process to track
deferred patients.
- Plan for the graceful transition to contingency and crisis standards
of care. In a severe pandemic, not all patients in need of intensive
care will be able to be accommodated in the ICU. Normal staffing ratios
and standard operating procedures will not be able to be maintained.
- Plan for alternative sites to provide ICU-like care within the
hospital (eg, catheterization lab, catheterization recovery, OR, PACU,
endoscopy units, etc).
- Implement contingency and crisis standards, which will be justified
when conventional standards cannot be maintained despite the use of all
available resources, including mutual aid arrangements. The legal and
ethical framework for these decisions should be considered well in
advance of a crisis. Alterations in hospital policy and procedures
should be implemented by an active decision of the hospital leadership
in consultation with the medical staff and civil authorities.
- Create criteria/clinical guidelines for use (or denial) of
resource-intensive services (eg, admission, mechanical ventilation,
invasive monitoring) based on national guidelines, such as the Crisis
Standards of Care report6 in regional collaboration with other hospitals.
- Establish a process for triage of patients competing for limited
resources, including admission, early discharge, and life support. These
decisions should not be made solely by 1 person. The criteria used to
make these decisions should be created in advance and formally
sanctioned by the medical staff and hospital administration.
How to Proceed
Although a COVID-19 pandemic seems all but inevitable, there is still
uncertainty about its severity in the United States. Time will tell,
but, in the meantime, hospitals should not delay. In the event of a
pandemic, the predictable costs of not preparing, in human, societal,
and political terms, would be huge. Decision makers at all
levels—including hospital CEOs and their boards and state and federal
officials—should consider these issues and how to proceed. Several of
the first priority items (comprehensive and collaborative planning,
discussing allocation of scarce resources, and planning education and
training) take substantial time. Hospitals should begin these actions
now.
References
- Toner E, Waldhorn R. What hospitals should do to prepare for an influenza pandemic. Biosecur Bioterror 2006;4(4):397-402. http://www.centerforhealthsecurity.org/our-work/publications/2006/what-hospitals-should-do-to-prepare-for-an-influenza-pandemic. Accessed February 25, 2020
- US Department of Health and Human Services. Pandemic Influenza Plan. https://www.cdc.gov/flu/pandemic-resources/pdf/pan-flu-report-2017v2.pdf. Accessed February 25, 2020.
- Centers for Disease Control and Prevention. FluSurge 2.0. Reviewed August 22, 2016. https://www.cdc.gov/flu/pandemic-resources/tools/flusurge.htm. Accessed February 25, 2020.
- Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med 2004;44(3):253-261.
- Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19). Infection control. Reviewed February 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/index.html. Accessed February 26, 2020.
- Hanfling D, Hick J, Stroud C, eds. Committee on Crisis Standards of Care. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: National Academies Press; 2013. http://www.acphd.org/media/330265/crisis%20standards%20of%20care%20toolkit.pdf. Accessed February 25, 2020.
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