Early in the U.S. rise of COVID-19, Accumen and WCG cosponsored a discussion covering COVID-19 preparedness, during which renowned disaster medicine expert Dr. Paul Biddinger outlined several key drivers of COVID-19 preparedness for hospitals and health systems. Dr. Biddinger is a national, state, and local leader in emergency preparedness and disaster medicine, serving as special advisor to the Massachusetts Medical Society’s Committee on Preparedness and medical officer for the MA-1 Disaster Medical Assistance Team in the U.S. Department of Health and Human Services’ National Disaster Medical System.
As we’ve learned, epidemics follow a general bell curve which includes a period of rapid acceleration that eventually peaks before slowing. The goal of mitigation is to keep the curve’s peak as low as possible in order to blunt the continued strain on the healthcare system.
While it is easy to be overwhelmed by the magnitude and severity of this outbreak, forward-thinking hospitals and health systems have had a significant opportunity to impact the magnitude of the surge in the way they respond to the crisis, enabling them to care for the communities they serve more effectively. The prevalent strategy in doing so has quickly shifted from containment to mitigation, as COVID-19 continues to take root in communities across the country.
Hospitals and health systems nationwide have, or will, feel impacts in several key areas according to Dr. Biddinger. These are the critical few he highlights as needing focused preparation efforts.
Large surges in patients, both in the ambulatory and inpatient settings are inevitable. Organizations can expect a huge and rapid increase in the number of people coming into primary care sites, urgent care sites, and emergency departments with respiratory symptoms.
Compounding the problem for EDs is the fact many departments are crowded already, a reality that only makes infection control more difficult. As soon as the crowding worsens, then the opportunity for disease transmission increases.
Finding spaces to isolate patients under suspicion for COVID-19 also is becoming difficult for EDs. Such spaces are particularly important for patients undergoing aerosolizing procedures. For example, patients who are intubated, receiving nebulizers, or undergoing suctioning procedures should be in negative pressure rooms, and they are in incredibly short supply.
Any ED in any hospital is trying to provide rapid turnover to meet the demand of patients who are coming in, and that is starting to be a challenge for some hospitals.
Massive supply chain challenges, particularly in the areas of testing and personal protective equipment for healthcare workers will continue for the foreseeable future. N95 respirators, gowns, gloves, and eye protection are of particular focus, with non-healthcare suppliers coming forward to help meet demand. As this pandemic began to gain a foothold in the United States in March, the country had fewer than twenty-three COVID-19 tests per million people.
Healthcare systems are dealing with shortages of every type of PPE, including gowns, gloves, and eye protection. There is a lot of healthcare worker fear just like there is a lot of public anxiety. There is, frankly, a lot of fatigue. Even in my own hospital and healthcare system, we have had our incident command system activated since late January.
Of course, it is also tough to adhere to standards when frontline providers lack access to the appropriate personal protective equipment (PPE). The N95 respirators were running in short supply almost immediately around the country in January, long before there was any clinical need, and still we haven’t quite figured out how that happened. Manufacturers and distributors are trying to do a good job of allocating to hospitals and not letting anyone buy up the market, as happened in 2009 with the H1N1 [epidemic], but they are still running in short supply.
Providers across the country are racing to expand capacity and stretch their supplies of personal protective equipment (PPE) and life-saving ventilators. From this we have learned that an all-hands-on-deck mentality is essential for recovery today – and preparing for future outbreaks.
At the same time the number of COVID-19 cases has surged, the healthcare workforce available to evaluate and treat patients has decreased. Much of this decrease is due to healthcare workers needing to be quarantined because they have been exposed to the virus while others have fallen ill themselves. Frontline caregivers will continue to feel the brunt of COVID-19 as cases mount and epidemiologists forecast that the worst is to yet to come. Hospitals all over the country are now putting surge plans in place and intensifying infection control practices to minimize exposures.
We’re seeing decreases in available workforce; either physicians, RNs, or others who have exposure to patients with suspected COVID-19, are quarantined for 14 days. This cuts into the available health care workforce at a time when greater numbers of healthcare professionals are needed. There is a lot of healthcare fear, a lot of fatigue. In my own hospital, we’ve had a command center activated since late January, and I’m running six weeks-plus in emergency response mode, running 16-hour days. That takes a toll on frontline staff.
Focusing leadership and planning efforts on these critical areas today will help hospitals and health systems blunt the curve, potentially saving thousands of lives. At the same time, the health system has to balance such curbs with the obvious need to acquire knowledge related to the outbreak.
Paul Biddinger, MD, is the Endowed Chair in Emergency Preparedness, the Director of the Center for Disaster Medicine, and the Vice Chairman for Emergency Preparedness in the Department of Emergency Medicine at Massachusetts General Hospital. He is also the director for emergency preparedness at Partners Healthcare and the director of Director of the Emergency Preparedness Research, Evaluation and Practice (EPREP) program at the Harvard T. H. Chan School of Public Health.