How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?
Identifieur interne : 000336 ( Pmc/Corpus ); précédent : 000335; suivant : 000337How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?
Auteurs : Vineet Chopra ; Eric Toner ; Richard Waldhorn ; Laraine WasherSource :
- Annals of Internal Medicine [ 0003-4819 ] ; 2020.
Abstract
Estimates suggest that COVID-19 will stress bed capacity, equipment, and health care personnel in U.S. hospitals in ways not previously experienced. How can health systems prepare to care for a large influx of patients with this disease?
Url:
DOI: 10.7326/M20-0907
PubMed: 32160273
PubMed Central: 7081177
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<front><journal-meta><journal-id journal-id-type="nlm-ta">Ann Intern Med</journal-id><journal-id journal-id-type="iso-abbrev">Ann. Intern. Med</journal-id><journal-id journal-id-type="publisher-id">aim</journal-id><journal-title-group><journal-title>Annals of Internal Medicine</journal-title></journal-title-group><issn pub-type="ppub">0003-4819</issn><issn pub-type="epub">1539-3704</issn><publisher><publisher-name>American College of Physicians</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">32160273</article-id><article-id pub-id-type="pmc">7081177</article-id><article-id pub-id-type="doi">10.7326/M20-0907</article-id><article-id pub-id-type="publisher-id">aim-olf-M200907</article-id><article-categories><subj-group subj-group-type="heading"><subject>Ideas and Opinions</subject></subj-group></article-categories><title-group><article-title>How Should U.S. Hospitals Prepare for Coronavirus Disease 2019 (COVID-19)?</article-title><alt-title alt-title-type="short">How Should U.S. Hospitals Prepare for COVID-19?</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Chopra</surname><given-names>Vineet</given-names></name><degrees>MD, MSc</degrees><xref ref-type="aff" rid="aff1"></xref></contrib><contrib contrib-type="author"><name><surname>Toner</surname><given-names>Eric</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff2"></xref></contrib><contrib contrib-type="author"><name><surname>Waldhorn</surname><given-names>Richard</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff3"></xref></contrib><contrib contrib-type="author"><name><surname>Washer</surname><given-names>Laraine</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff1"></xref></contrib><aff id="aff1"><label>1</label>University of Michigan, Ann Arbor, Michigan (V.C., L.W.)</aff><aff id="aff2"><label>2</label>Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (E.T.)</aff><aff id="aff3"><label>3</label>Georgetown University, Washington, DC, and Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland (R.W.)</aff></contrib-group><pub-date pub-type="epub"><day>11</day><month>3</month><year>2020</year></pub-date><elocation-id>M20-0907</elocation-id><permissions><copyright-year>2020</copyright-year><copyright-holder>American College of Physicians</copyright-holder><license license-type="free"><license-p>This article is made available via the PMC Open Access Subset for unrestricted re-use for research, analyses, and text and data mining through PubMed Central. Acknowledgement of the original source shall include a notice similar to the following: “© 2020 American College of Physicians. Some rights reserved. This work permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.” These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.
</license-p></license></permissions><abstract abstract-type="precis"><p>Estimates suggest that COVID-19 will stress bed capacity, equipment, and health care personnel in U.S. hospitals in ways not previously experienced. How can health systems prepare to care for a large influx of patients with this disease?</p></abstract></article-meta></front><body><disp-quote><p>“…make them believe, that offensive operations, often times, is the surest, if not the only (in some cases) means of defence.”</p><attrib>—George Washington (1799)</attrib></disp-quote><p>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 (<xref rid="r1-0907" ref-type="bibr">1</xref>). 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 (<xref rid="r2-0907" ref-type="bibr">2</xref>). How can health systems prepare to care for a large influx of patients with this disease?</p><sec><title>Develop a Strategy for Patient Volume and Complexity</title><p>Approximately 95 000 critical care beds, including surgical and specialty unit beds, are available in U.S. hospitals today (<xref rid="r3-0907" ref-type="bibr">3</xref>). 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 (<xref rid="r4-0907" ref-type="bibr">4</xref>). Because some patients will be critically ill and need scarce resources, such as extracorporeal membrane oxygenation and ventilators (<xref rid="r5-0907" ref-type="bibr">5</xref>), hospitals must prepare now for how they will triage patients, allocate resources, and staff wards. The <xref rid="t1-0907" ref-type="table">Table</xref> lists the essential elements of a hospital's planning process.</p><table-wrap id="t1-0907" orientation="portrait" position="float"><label>Table. Essential Components of a Hospital Preparedness Plan for COVID-19</label><graphic xlink:href="aim-olf-M200907-M200907tt1"></graphic></table-wrap><p>Hospitals 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.</p></sec><sec><title>Protect and Support Health Care Workers on the Front Lines</title><p>The 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.</p><p>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.</p></sec><sec><title>Define a Strategy to Allocate Health Care Resources</title><p>During 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.</p></sec><sec><title>Develop a Robust, Transparent, and Open Communication Policy</title><p>Hospitals 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.</p><p>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.</p></sec><sec><title></title></sec></body><back><fn-group><fn id="n0-M200907"><p>This article was published at Annals.org on 11 March 2020.</p></fn></fn-group><bio id="d35e74"><p><bold>Disclosures:</bold> Authors have disclosed no conflicts of interest. Forms can be viewed at <uri xlink:type="simple" xlink:href="http://www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0907">www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-0907</uri>.</p><p><bold>Corresponding Author:</bold> Vineet Chopra MD, MSc, University of Michigan, 2800 Plymouth Road, Building 16 #432W, Ann Arbor, MI 48109; e-mail, <uri xlink:type="simple" xlink:href="vineetc@umich.edu">vineetc@umich.edu</uri>.</p><p><bold>Current Author Addresses:</bold> Dr. Chopra: University of Michigan, 2800 Plymouth Road, Building 16 #432W, Ann Arbor, MI 48109.</p><p>Dr. Toner: Center for Health Security, Bloomberg School of Public Health, Johns Hopkins University, 621 East Pratt Street, Baltimore, MD 21202.</p><p>Dr. Waldhorn: Georgetown University, 3800 Reservoir Road, Washington, DC 20007.</p><p>Dr. Washer: University of Michigan, F4151 University Hospital South, Ann Arbor, MI 48109.</p><p><bold>Author Contributions:</bold> Conception and design: V. Chopra, E. Toner, R. Waldhorn, L. Washer.</p><p>Analysis and interpretation of the data: E. Toner.</p><p>Drafting of the article: V. Chopra, E. Toner, R. Waldhorn, L. Washer.</p><p>Critical revision of the article for important intellectual content: V. Chopra, E. Toner, R. Waldhorn, L. Washer.</p><p>Final approval of the article: V. Chopra, E. Toner, R. Waldhorn, L. Washer.</p><p>Administrative, technical, or logistic support: V. Chopra.</p><p>Collection and assembly of data: V. Chopra, E. Toner.</p></bio><ref-list><title>References</title><ref id="r1-0907"><label>Centers for Disease Control and Prevention.</label><mixed-citation publication-type="unrecognized"><comment><bold>Centers for Disease Control and Prevention.</bold> Coronavirus disease 2019 (COVID-19) in the U.S. Accessed at <uri xlink:type="simple" xlink:href="http://www.cdc.gov/coronavirus/2019-nCoV/cases-in-us.html">www.cdc.gov/coronavirus/2019-nCoV/cases-in-us.html</uri> on 10 March 2020.</comment></mixed-citation></ref><ref id="r2-0907"><label>Wu JT, Leung K, Leung GM.</label><mixed-citation publication-type="unrecognized"><comment><bold>Wu JT, Leung K, Leung GM.</bold> 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</comment></mixed-citation></ref><ref id="r3-0907"><label>Society of Critical Care Medicine.</label><mixed-citation publication-type="unrecognized"><comment><bold>Society of Critical Care Medicine.</bold> Critical care statistics. Accessed at <uri xlink:type="simple" xlink:href="http://www.sccm.org/Communications/Critical-Care-Statistics">www.sccm.org/Communications/Critical-Care-Statistics</uri> on 5 March 2020.</comment></mixed-citation></ref><ref id="r4-0907"><label>Swerdlow DL, Finelli L.</label><mixed-citation publication-type="unrecognized"><comment><bold>Swerdlow DL, Finelli L.</bold> Preparation for possible sustained transmission of 2019 novel coronavirus: lessons from previous epidemics. JAMA. 2020. [PMID: 32044915] doi:10.1001/jama.2020.1960</comment></mixed-citation></ref><ref id="r5-0907"><label>MacLaren G, Fisher D, Brodie D.</label><mixed-citation publication-type="unrecognized"><comment><bold>MacLaren G, Fisher D, Brodie D.</bold> 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</comment></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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