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How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?

2020; American College of Physicians; Volume: 172; Issue: 9 Linguagem: Inglês

10.7326/m20-0907

1539-3704

Vineet Chopra, Eric Toner, Richard Waldhorn, Laraine Washer,

Disaster Response and Management

Ideas and Opinions11 March 2020How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?FREEVineet Chopra, MD, MSc, Eric Toner, MD, Richard Waldhorn, MD, and Laraine Washer, MDVineet Chopra, MD, MScUniversity of Michigan, Ann Arbor, Michigan (V.C., L.W.), Eric Toner, MDCenter for Health Security, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (E.T.), Richard Waldhorn, MDGeorgetown University, Washington, DC, and Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (R.W.), and Laraine Washer, MDUniversity of Michigan, Ann Arbor, Michigan (V.C., L.W.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-0907 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail "…make them believe, that offensive operations, often times, is the surest, if not the only (in some cases) means of defence."—George Washington (1799)Coronavirus disease 2019 (COVID-19) is on the verge of being declared a pandemic. As of 7 March 2020, a total of 423 cases and 19 deaths, including several non–travel-related cases, areas of sustained community transmission, and a nursing home outbreak, have been reported (1). Best-case estimates suggest that COVID-19 will stress bed capacity, equipment, and health care personnel in U.S. hospitals in ways not previously experienced (2). How can health systems prepare to care for a large influx of patients with this disease?Develop a Strategy for Patient Volume and ComplexityApproximately 95 000 critical care beds, including surgical and specialty unit beds, are available in U.S. hospitals today (3). Conservative estimates suggest that we may need almost twice this amount should the COVID-19 pandemic resemble the influenza pandemics of 1957 or 1968, especially if it is sustained (4). Because some patients will be critically ill and need scarce resources, such as extracorporeal membrane oxygenation and ventilators (5), hospitals must prepare now for how they will triage patients, allocate resources, and staff wards. The Table lists the essential elements of a hospital's planning process.Table. Essential Components of a Hospital Preparedness Plan for COVID-19Hospitals should attempt to geographically cohort patients with COVID-19 to limit the number of health care personnel exposed and conserve supplies. This type of geographic capacity generation is extremely difficult because many U.S. hospitals run at full capacity. Geographic cohorting options may also be challenged by locations of airborne isolation rooms, with negative pressure being scattered throughout the hospital. It may be necessary to use innovative approaches, such as converting single rooms to double occupancy; expediting discharges; slowing admission rates; and converting spaces like catheterization laboratories, lobbies, postoperative care units, or waiting rooms into patient care venues. For example, at Michigan Medicine, designated beds in critical care units and non–critical care settings for persons under investigation and patients who test positive for COVID-19 have been identified. A dedicated team of hospitalists and critical care providers has been established, with clinical schedules and roles for leadership, communication, and activation criteria. Contingency plans have been developed, including activation criteria for opening a respiratory intensive care floor where cohorting of both critically ill and noncritically ill patients can occur. Similarly, ensuring the ongoing care of vulnerable patients, such as those in the posttransplant and immunocompromised communities, remains imperative. Safe locations and staffing plans that separate vulnerable patients from COVID-19 activities have been carefully considered.Protect and Support Health Care Workers on the Front LinesThe best evidence currently available suggests that COVID-19 spreads primarily via droplet transmission and direct contact. With the appropriate precautions, nosocomial transmission can be mitigated. Health care personnel should receive training on proper donning and doffing of personal protective equipment, including fit testing of N95 masks and use of powered air-purifying respirators, as well as basic infection prevention tenets, such as hand hygiene. Hospitals should monitor rates of equipment use to ensure an adequate supply of personal protective equipment for those on the front lines and may need to engage hospital security to avoid theft or hoarding of such equipment. Extended use or limited reuse of N95 respirators may become necessary, and communication about preservation is important.To limit the total number of personnel engaged in patient care, hospitals should institute overtime and extended hours with appropriate compensation strategies. Clear exposure criteria with detailed plans outlining management of personnel in regard to work restrictions or other quarantine requirements must be developed. Hospitals must also safeguard their own by keeping logs of staff who care for patients and monitoring them for signs or symptoms of infection. Finally, even if care of patients with COVID-19 will be provided by a subset of providers, it is important not to lose sight of the needs of their family members and other staff. Support is important to the morale and well-being of the workforce.Define a Strategy to Allocate Health Care ResourcesDuring crises, health care resources should be allocated in an ethical, rational, and structured way to do the greatest good for the greatest number of patients. Hospitals and health systems must set aside a "business as usual" mentality and focus on how best to accommodate the patients likely to benefit the most from care. Specifically, a plan that outlines what services and types of procedures will be provided (for example, extracorporeal membrane oxygenation) and what will not (for example, elective cases) must be developed. Accordingly, clinical guidelines for use (or denial) of scarce services, such as mechanical ventilation and critical care, should be outlined, in consultation with ethics and medical staff. A protocol that defines how patients will be triaged for admission, observation, early discharge, and quarantine is important. Hospitals should anticipate that normal staffing ratios and some standards of care are unlikely to be maintained; plans for contingency and crisis standards that lay out a legal and ethical framework for care decisions, including who will make decisions, how, and under what circumstances, must be readied. At Michigan Medicine, scarce resource guidelines have not only been developed, but portions have been revised and circulated to staff to ensure agreement and buy-in for execution.Develop a Robust, Transparent, and Open Communication PolicyHospitals and health systems must develop agile ways to transmit timely and critical information in times of crises. A designated communication team that is integrated into the work so they have a strong understanding of the clinical care being provided and the communication needs of the workforce, patients, and public is recommended. Crisis communications should ideally occur via several media, such as a telephone hotline, the hospital Web page, social media platforms, or text-based messages. Important metrics, including the number of cases being triaged, investigated, or managed; bed capacity and availability; and new or emerging data on treatments or care strategies, should be provided. Similarly, timely communication of national updates on travel restrictions, policies for self-monitoring and quarantine, and trends in infection rates must occur. To this end, health care leaders must remember that patients and their families are as much in need of actionable information as hospital personnel. Comprehensive communication strategies for both internal and external stakeholders are key.The COVID-19 outbreak will test the resilience of our health care system. Planning for managing patients and our workforce must begin in full force.References1. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19) in the U.S. Accessed at www.cdc.gov/coronavirus/2019-nCoV/cases-in-us.html on 10 March 2020. Google Scholar2. Wu JT, Leung K, Leung GM. Nowcasting and forecasting the potential domestic and international spread of the 2019-nCoV outbreak originating in Wuhan, China: a modelling study. Lancet. 2020;395:689-697. [PMID: 32014114] doi:10.1016/S0140-6736(20)30260-9 CrossrefMedlineGoogle Scholar3. Society of Critical Care Medicine. Critical care statistics. Accessed at www.sccm.org/Communications/Critical-Care-Statistics on 5 March 2020. Google Scholar4. Swerdlow DL, Finelli L. Preparation for possible sustained transmission of 2019 novel coronavirus: lessons from previous epidemics. JAMA. 2020. [PMID: 32044915] doi:10.1001/jama.2020.1960 CrossrefMedlineGoogle Scholar5. MacLaren G, Fisher D, Brodie D. Preparing for the most critically ill patients with COVID-19: the potential role of extracorporeal membrane oxygenation. JAMA. 2020. [PMID: 32074258] doi:10.1001/jama.2020.2342 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Ana Lleo1,2, Paolo Omodei1, Claudio Angelini1, Michele Ciccarelli1, Alessio Aghemo1,21Humanitas Clinical and Research Center IRCCS, Rozzano, Milan, Italy; 2Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; 10 April 2020 Reshaping the hospital to face the COVID-19 pandemia: a real case from Italy We have read with interest the recent article by Chopra and colleagues (1). With a reported Covid-19 related mortality rate of 15% (2), this crisis is severely testing the Italian Health System and, given the lack of validated strategy, every single centre has spontaneously defined its own approach. We herein illustrate the strategic plan developed and implemented in a University Hospital in the area of Milan. An Emergency Management Team - including Hospital management, chief operating officer, chief medical officer, human resources, facility management, public relations officer, supply chain, and medical and nurse representatives - was constituted. The first defined action plan aimed to (i) identify and build independent flows for positive and negative patients, (ii) free up resources and personnel, (iii) avoid overcrowding, and (iv) adapt business continuity plans for healthcare facilities.Temporary treatment facilities were created in the Emergency Room (ER) and triage area, aiming to guarantee independent flows and appropriate cohorting. All patients that access the ER with respiratory symptoms were screened, and multidisciplinary discussion of compromised patients was activated to define therapeutic program and potential candidacy to invasive procedures (3). Operating rooms were turned into makeshift Intensive Care Unit (ICU) and wards were remodelled to include negative pressure rooms. The number of beds for Covid-19 patients was constantly re-evaluated based on both regional trends and ER access. 37 new ICU beds were created and seven Covid-19 wards (differentiated by complexity and intensity of care), have been gradually occupied by 250 patients. An independent team for non-infected patients was created. The Health Directorate defined protection protocols and activate training courses including patient management and appropriate use of personal protective equipment (PPE). Given the fact that there is no approved therapy and, beyond ventilatory support for acute respiratory distress syndrome, is empirical, the Health Directorate has coordinated multidisciplinary team for evaluation and approval of off-label drugs. In order to avoid overcrowding within the hospital, the team of human resources activated redeployment of staff and elective surgeries, non-urgent procedures, and outpatient visits were cancelled. Further, visitors were banned access and checkpoints were activated. The supply chain and facility management ensure PPE stocks, define the appropriate infrastructure with space to allow social distance, well-ventilated isolation rooms, and regular sanitation (4). Although we still cannot clearly evaluate efficacy and efficiency of our strategic plan, we think the framework we propose is a valid option that can be implemented in a medium size hospital. REFERENCES1. Chopra V, Toner E, Waldhorn R, Washer L. How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)? Ann Intern Med. 2020.2. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506.3. Murthy S, Gomersall CD, Fowler RA. Care for Critically Ill Patients With COVID-19. JAMA. 2020.4. https://www.ecdc.europa.eu/sites/default/files/documents/RRA-sixth-update-Outbreak-of-novel-coronavirus-disease-2019-COVID-19.pdf. Jingwen Li, Xi Fang, Qing Zhang, Zhicheng Lin*, Nian Xiong*Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (D.J.L.,N.X.); Wuhan Red Cross Hospital, Wuhan, Hubei, China (X.F., Q.Z., N.L., N.X.); Harvar20 March 2020 Emergent hospital reform in response to outbreak of COVID-19 TO THE EDITOR: Dr. Chopra and colleagues discussed preparation of U.S. Hospitals for Coronavirus Disease 2019 (COVID-19) (1), which broke out initially in December 2019 Wuhan of China (2). Immediately after the outbreak, the local Government designated seven hospitals to exclusively admit and intensively treat such flooding-in new patients (3). Our hospital, Wuhan Red Cross Hospital (WRCH), was one of them and turned into a COVID-19 treatment system on January 21, 2020. In agreement with Dr. Chopra et al's suggestion, we set up full time emergency management of operation task force as well as a well-resourced infection prevention team to coordinate and oversee COVID-19 operation. However, the number of COVID-19 patients was far beyond the bed capacity of respiratory departments in Wuhan so that every designated hospital had to reform into an infectious disease treatment center. Accordingly, we made seven hospital-wide changes. First, re-dividing WRCH into cleaning area for medical staff use and polluted area for treating in- and out-patients. Meanwhile, five passageways including patient channel, employee channel, administrative personnel channel, cleaning personnel channel and sewage channel were established to meet the requirements of hospital infection protection. Second, search for all kinds of personal protective equipment actively such as fit-tested N95 respirator and protective clothing from local and government resources(4). Moreover, to minimize transmission, a surgical mask was given to each patient. Third, urgently purchasing medical rescue equipment such as extracorporeal membrane oxygenation (5), mechanical ventilators, liquid oxygen tanks providing ample oxygen, and negative-pressure isolation system to support the treatment. Fourth, training all medical staff with infectious disease hospital instructions for self-protection and COVID-19 treatment with a standard protocol of Chinese Guideline. Fifth, to increase the bed capacity and reduce cross infection, patients without fever were all discharged within 24 hours, allowing hundreds of fever patients admitted the next day. Sixth, recruiting more doctors and nurses specialized in infectious disease. Fortunately, expert teams from Wuhan Union Hospital and Sichuan province came to strengthen the treatment forces. Seventh, a rear service team formed, including both our administrative staff and social volunteers, working together with greatest efforts to fully ensure the clothing, food, housing, travel and safety of key frontline personnel and steady operation of the hospital. Until March 15, 2020, reformed WRCH had received 15,000+ outpatients of fever, treated and discharged 1,200+ inpatients with COVID-19. Hopefully, our experience could be useful for other hospitals in similar epidemic situations.Author Contributions: JL, XF and QZ drafted the manuscript and share first authorship. NX and ZL revised the final manuscript. NX and ZL are responsible for summarizing all data.Funding: This work was supported by grants 2016YFC1306600 (to NX) and 2018YFC1314700 (to NX) from the National Key R&D Program of China, grants 81873782 (to NX) from the National Natural Science Foundation of China.References:1. Chopra V, Toner E, Waldhorn R, et al. How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)? Ann Intern Med. 2020.2. Zhu N, Zhang D, Wang W, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020.3. Swerdlow DL, Finelli L. Preparation for Possible Sustained Transmission of 2019 Novel Coronavirus: Lessons From Previous Epidemics. JAMA. 2020.4. Ng K, Poon BH, Kiat PT,et al. COVID-19 and the Risk to Health Care Workers: A Case Report. Ann Intern Med. 2020.5. MacLaren G, Fisher D, Brodie D. Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation. JAMA. 2020. Faisal SiddiquiVA Sierra Nevada Health Care System16 March 2020 Transfer of possible COVID-19 patients in a hospital setting Dear Editor:I am writing this letter in response to a recently published article by Dr Chopra. Recently in our intensive care unit we received a patient -a "PUI" (person under investigation for corona virus disease - COVID 19), on non invasive ventilation (NIV) from the emergency department. A question was raised of how to transfer the patient safely while on mechanical ventilation (MV) or NIV. I have taken this opportunity to address the issues related to patient admission and airborne precautions during their stay [1].Patient should not be transported out of the negative pressure isolation room unless it is absolutely necessary.If patient is on room air and needs to be transported he needs to wear a surgical mask. Healthcare professionals (HCP) need to maintain at least 3 feet distance from the patient during transfer unless medically necessary. HCPs should also wear standard personal protective equipment (PPE) and a surgical mask with a face shield during transfers [2]. If patient is on oxygen delivered via nasal cannula the transfer/transport guidance is the same as #2. During transfer it should be ensured that hallways and elevators are cleared and in the enclosed spaces there is only necessary staff along with the patient [3].If the patient is intubated we need to ensure that there are high efficiency particulate air (HEPA) filters for both the inspiratory and expiratory circuits on the transport ventilator. HCPs should also wear standard PPE and a surgical mask with a face shield during transfers [4]. If the patient is on NIV then the recommendation would be to consider discontinuing NIV if possible, or intubating the patient if clinically justified. This has to be judged against risks and benefits related to the transfer. If patient is transported with NIV then he would be considered "very-high" risk for airborne transmission of the virus. In that case the recommendation would be to consider N-95 masks for all the healthcare workers who are involved in the transportation in addition to standard PPEs. Consider additional precautions as mentioned in #4. References:1. https://www.cdc.gov/coronavirus/2019-ncov/index.html2. Lindsley WG, Noti JD, Blachere FM, Szalajda JV, Beezhold DH. Efficacy of face shields against cough aerosol droplets from a cough simulator. J Occup Environ Hyg. 2014;11(8):509-183. Gammon J, Hunt J. A review of isolation practices and procedures in healthcare settings. Br J Nurs. 2018 Feb 08;27(3):137-1404. Seto WH. Airborne transmission and precautions: facts and myths. J. Hosp. Infect. 2015 Apr;89(4):225-8 Author, Article, and Disclosure InformationAuthors: Vineet Chopra, MD, MSc; Eric Toner, MD; Richard Waldhorn, MD; Laraine Washer, MDAffiliations: University of Michigan, Ann Arbor, Michigan (V.C., L.W.)Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (E.T.)Georgetown University, Washington, DC, and Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (R.W.)Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0907.Corresponding Author: Vineet Chopra, MD, MSc, University of Michigan, 2800 Plymouth Road, Building 16 #432W, Ann Arbor, MI 48109; e-mail, vineetc@umich.edu.Current Author Addresses: Dr. Chopra: University of Michigan, 2800 Plymouth Road, Building 16 #432W, Ann Arbor, MI 48109.Dr. Toner: Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, 621 East Pratt Street, Baltimore, MD 21202.Dr. Waldhorn: Georgetown University, 3800 Reservoir Road, Washington, DC 20007.Dr. Washer: University of Michigan, F4151 University Hospital South, Ann Arbor, MI 48109.Author Contributions: Conception and design: V. Chopra, E. Toner, R. Waldhorn, L. Washer.Analysis and interpretation of the data: E. Toner.Drafting of the article: V. Chopra, E. Toner, R. Waldhorn, L. Washer.Critical revision of the article for important intellectual content: V. Chopra, E. Toner, R. Waldhorn, L. Washer.Final approval of the article: V. Chopra, E. Toner, R. Waldhorn, L. Washer.Administrative, technical, or logistic support: V. Chopra.Collection and assembly of data: V. Chopra, E. Toner.This article was published at Annals.org on 11 March 2020. 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