Nurses Becky Barton and Jess White help nurse Jeff Gates take off protective gear after interacting with a patient at a drive-through testing site for coronavirus, flu and RSV, currently by appointment for employees at UW Medical Center Northwest in Seattle, Washington, March 9, 2020, photo by Lindsey Wasson/Reuters

commentary

(Health Affairs Blog)

COVID-19: A Stress Test for a U.S. Health Care System Already Under Stress

Nurses Becky Barton and Jess White help nurse Jeff Gates take off protective gear after interacting with a patient at a drive-through testing site for coronavirus, flu and RSV at UW Medical Center Northwest in Seattle, Washington, March 9, 2020

Photo by Lindsey Wasson/Reuters

Experience from past health emergencies suggests that in the coming days and weeks hospitals, clinics, and health care systems around the United States may need to ensure they have well-functioning surge plans to deal with the advancing novel coronavirus (COVID-19) outbreak, including provisions for increased numbers of staff, hospital beds, and supplies.

The World Health Organization declared the coronavirus outbreak a global health emergency after human-to-human transmission outside of China. The Centers for Disease Control and Prevention predicts continued person-to-person spread in the United States.

A Potential Surge

The stresses of COVID-19 come as America's health care system already is under considerable daily stress. Many hospitals and health systems across the United States routinely operate near or at capacity, and a surge could create serious problems as patients pour in with acute health care needs that community clinics are unable to handle. Plans for reverse triage, early discharge of hospitalized patients to home or other facilities, could create additional bed capacity as needed. In addition, coronaviruses have shown a propensity to spread in hospital settings. The importance of prompt screening and isolation of suspected cases cannot be overstated. Implementing strict screening protocols upon patient arrival could help reduce spread of the disease in areas often crowded with patients in close proximity to one another.

Treating seriously ill patients could tax critical care capacity—including beds and resources such as ventilators to manage any patients with respiratory failure from COVID-19. Beyond hospitals, recent research suggests that the increased capacity for countermeasures and emergency preparedness that resulted from other outbreaks may be weakening.

Hospitals can leverage systems preparedness efforts developed for Ebola and other past emerging infectious diseases to enhance capacity to respond to a possible surge in acute health care needs with the spread of COVID-19. The SARS, MERS, and Ebola outbreaks demonstrated that infection control measures in health care settings are critical. SARS and MERS were “travel infections” that quickly became “hospital infections.” The“tale of two cities (PDF)” that faced a SARS outbreak—Vancouver and Toronto—illustrated the importance of protocols for patient isolation and organizational priority for infection control. The different approaches (PDF) taken in these cities during the outbreak showed drastically different results for suspected cases: Just four cases were reported in Vancouver compared to 247 cases in Toronto, with almost half of those infected in Toronto being health care workers compared to the one patient in Vancouver.

The Human Side

But outbreaks such as COVID-19 require more than good clinical practice—they also involve managing the human side of the equation. In outbreaks, the spread of disease is often accompanied by “infodemics” (PDF) or the rapid spread of unreliable information. The contrasting approaches to information dissemination in Japan and China was evident during the SARS outbreak. Conflicting reports (PDF) surrounding an outbreak can result in skepticism about the outbreak risk, reluctance to adopt recommended infection control measures, and promotion of mass hysteria. Guided by experts, the messaging from a wide range of health care systems, local public health agencies, and federal authorities may need to be coordinated to avoid confusion and undue public fear. Health systems should closely coordinate and partner with neighboring hospitals and health systems, public health agencies, first responders, and community organizations that tend to the needs of vulnerable populations. These entities could coordinate sharing of resources through health care coalitions, which are groups of hospitals, emergency medical services providers, public health organizations, and other key health care-related and community organizations that work in defined regions for organized response to emergencies.

Also, preparedness is a “long game.” There are many things hospitals and health systems could be doing in the coming weeks to best serve their communities. Evaluating their surge response plans will be critical. Planning gaps may need to be addressed. Assessment of capabilities and resources could best be addressed through collaboration among hospitals, public health agencies, and other health care stakeholders. Cross-sector collaboration will be essential to best prepare for the stress test that COVID-19 could pose to America's emergency preparedness response and health care systems.


Mahshid Abir is a senior physician policy researcher at the nonpartisan, nonprofit RAND Corporation and director of the Acute Care Research Unit at the University of Michigan. Christina Cutter is an emergency physician and a fellow in the University of Michigan Institute for Healthcare Policy and Innovation National Clinician Scholars Program. Christopher Nelson is a senior political scientist at the RAND Corporation and a professor of policy analysis at Pardee RAND Graduate School.

This commentary was first published on March 11, 2020 on Health Affairs Blog. Copyright ©2020 Health Affairs by Project HOPE—The People-to-People Health Foundation, Inc.

Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.