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Critical Care Surge Response Strategies for the 2020 COVID-19 Outbreak in the United States

by Mahshid Abir, Christopher Nelson, Edward W. Chan, Hamad Al-Ibrahim, Christina Cutter, Karishma Patel, Andy Bogart

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Research Questions

  1. How can hospitals meet the need for critical care capacity using available staff and resources?
  2. Where are the bottlenecks in critical care resources that might create a mismatch with the projected demand posed by the COVID-19 pandemic?

The coronavirus disease 2019 (COVID-19) virus is creating unprecedented stresses on hospital and critical care systems. Hospitals, health care systems, states, and regions urgently need to assess their resources, identify potential bottlenecks, and create strategies for increasing critical care surge capacity, which refers to the resources needed to care for the sickest patients with the novel coronavirus.

In this report, the authors present a list of strategies for creating critical care surge capacity and estimate the number of patients accommodated, given the number of available critical care doctors and nurses, respiratory therapists, ventilators, and hospital beds. They also document the development of a user-friendly, Microsoft Excel–based tool that allows decisionmakers at all levels — hospitals, health care systems, states, regions — to estimate current critical care capacity and rapidly explore strategies for increasing it.

The strategies are organized into two tiers. Tier 1 includes contingency capacity strategies: adaptations to medical care spaces, staffing constraints, and supply shortages in a way that can increase capacities without significant impact on medical care delivery. Tier 2 includes crisis capacity strategies: changes that likely will have significant impact on routine care delivery and operations.

Key Findings

The number of ventilators is the most common limiting factor for the United States

  • To function appropriately, intensive care units (ICUs) need space (ICU beds), staff (nurses, physicians, and respiratory therapists), and stuff (ventilators). For hospitals and communities to effectively respond to the anticipated surge in the critical care needs for COVID-19 patients, the balance between space, staff, and stuff (i.e., resources) needs to be maximized.
  • Strategies for creating space capacity include repurposing existing space and expanding telemedicine to allow ICU physicians to advise non-ICU physicians in community hospitals.
  • Strategies for creating staff capacity include using physician extenders to provide critical care under the supervision of ICU doctors and expanding staff through recruitment from outside organizations.
  • Strategies for creating stuff capacity include reusing personal protective equipment and regional sharing of available ventilators.
  • The overall number of patients who can be cared for is limited by whichever resource is most limited. In the majority of estimates for the United States, ventilators are the limiting factor. In a few instances, doctors are the limiting factor, but in no case is the number of nurses, respiratory therapists, or beds the limiting factor.

Recommendations

  • Hospitals should consider using the RAND Critical Care Surge Response Tool or similar resources to assess critical care bottlenecks in space, staff, and stuff and identify the most-effective surge strategies to address those bottlenecks.
  • Hospitals should consider having tiered critical care surge capacity plans in place ahead of time so that critical care surge capacity efforts can be escalated as indicated.
  • Hospitals should consider canceling elective procedures to free up critical care space, staff, and stuff.
  • Hospitals should consider developing an inventory of staff who might play unconventional roles in their COVID-19 response.
  • State, regional, and federal entities should consider facilitating communication and coordination among hospitals, health care systems, and public health entities.
  • State, regional, and federal entities should consider developing regional resource-sharing protocols to facilitate proportional distribution according to needs.
  • State, regional, and federal entities should consider instituting emergency credentialing policies for health care worker volunteers (e.g., waivers).
  • State, regional, and federal entities should consider instituting policies to combat price-gouging by suppliers of PPE, ventilators, and other critical care resources.

Table of Contents

  • Chapter One

    Background

  • Chapter Two

    Essential Components of Critical Care Capacity

  • Chapter Three

    Strategies to Create Critical Care Surge Capacity

  • Chapter Four

    Assessing Critical Care Capacity Created by Various Surge Strategies

  • Chapter Five

    Next Steps and Policy Recommendations

  • Appendix

    Research Methods

Research conducted by

Funding for this independent research was provided by gifts from RAND supporters and income from operations. This research was conducted by RAND Health Care.

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