COVID-19 has been a watershed event in medical history of epic proportions. With this fast-spreading pandemic stretching resources at health care institutions, practical considerations for management of a disease about which we are still learning has been a huge challenge.
Dr. Nitesh Kumar Jain
Although many guidelines have been made available by medical societies and experts worldwide, there appear to be very few which throw light on management in a resource-poor setup. The hospitalist, as a front-line provider, is likely expected to lead the planning and management of resources in order to deliver appropriate care.
As per American Hospital Association data, there are 2,704 community hospitals that can deliver ICU care in the United States. There are 534,964 acute care beds with 96,596 ICU beds. Additionally, there are 25,157 step-down beds and 1,183 burn unit beds. Of the 2,704 hospitals, 74% are in metropolitan areas (> 50,000 population), 17% (464) are in micropolitan areas (10,000-49,999 population), and the remaining 9% (244) are in rural areas. Only 7% (36,453) of hospital beds and 5% (4715) of ICU beds are in micropolitan areas. Two percent of acute care hospital beds and 1% of ICU beds are in rural areas. Although the US has the highest per capita number of ICU beds in the world, this may not be sufficient as these are concentrated in highly populated metropolitan areas.
Infrastructure and human power resource augmentation will be important. Infrastructure can be ramped up by:
- Canceling elective procedures
- Using the operating room and perioperative room ventilators and beds
- Servicing and using older functioning hospitals, medical wards, and ventilators.
As ventilators are expected to be in short supply, while far from ideal, other resources may include using ventilators from the Strategic National Stockpile, renting from vendors, and using state-owned stockpiles. Use of non-invasive ventilators, such as CPAP (continuous positive airway pressure), BiPAP (bi-level positive airway pressure), and HFNC (high-flow nasal cannula) may be considered in addition to full-featured ventilators. Rapidly manufacturing new ventilators with government direction is also being undertaken.
Dr. Raghavendra Tirupathi
Although estimates vary based on the model used, about 1 million people are expected to need ventilatory support. However, in addition to infrastructural shortcomings, trained persons to care for these patients are lacking. Approximately 48% of acute care hospitals have no intensivists, and there are only 28,808 intensivists as per 2015 AHA data. In order to increase the amount of skilled manpower needed to staff ICUs, a model from the Society of Critical Care Medicine’s Fundamental Disaster Management Program can be adopted. This involves an intensivist overseeing four different teams, with each team caring for 24 patients. Each team is led by a non-ICU physician or an ICU advanced practice provider (APP) who in turn cares for the patient with respiratory therapists, pharmacists, ICU nurses, and other non-ICU health professionals.
It is essential that infrastructure and human power be augmented and optimized, as well as contingency plans, including triage based on ethical and legal considerations, put in place if demand overwhelms capacity.