COVID 19: Healthcare system capacity

HPIO is collecting the latest research so that Ohio policymakers and other stakeholders can make informed decisions on the rapidly evolving COVID-19 pandemic. Regular research updates are mailed to HPIO’s email contact list (click here to join our mailing list and if you are already signed up for our mailing list and do not see the updates, please check your spam folder). 

April 30

Delayed care during the pandemic

A study of stroke cases in COVID-19 patients younger than 50 years old (NEJM, April 28) found that social distancing, isolation and reluctance to present to the hospital may contribute to poor health outcomes. The study of five cases of large-vessel stroke in patients in New York City found that two patients delayed calling an ambulance because they were concerned about going to a hospital during the pandemic.

A study investigating the rate of hospital admissions for acute coronary syndrome during the early days of the COVID-19 outbreak (NEJM, April 28) found a significant decrease in ACS-related hospitalization rates. Data suggest a significant increase in mortality during this period that was not fully explained by COVID-19 cases alone. This raises the question of whether some patients have died from ACS without seeking medical attention during the COVID-19 pandemic.

April 7

Articles examine hospital challenges, new approaches to protecting workers

A new report (U.S. Department of Health and Human Services, April 3) provides a national snapshot of hospital experiences and perspectives regarding difficulties and needs in responding to the COVID-19 pandemic. In response to brief telephone “pulse surveys,” hospital administrators reported that their most significant challenges are testing, caring for patients with known or suspected COVID-19 and keeping staff safe. Hospitals also reported substantial struggles maintaining or expanding their facilities’ capacity to treat patients with COVID-19.
An overview of emergent policy changes (JAMIA, April 2) during the COVID-19 pandemic identifies opportunities for technology-based clinical evaluation. One approach highlighted is electronic personal protective equipment (ePPE), which uses telemedicine tools to perform on-site electronic medical screening exams inside hospitals while satisfying the Emergency Medical Treatment and Labor Act. This approach has the potential to conserve PPE and protect providers while maintaining safe standards for medical screening exams in the emergency department for low-risk patients in whom COVID-19 is suspected.

Guidance for allocating ventilators when demand exceeds supply

A recent article (NEJM, March 23) discusses approaches to allocating ventilators during a pandemic such COVID-19. The article suggests that states should develop a comprehensive strategy to rationing resources during a pandemic. Anticipating the need to allocate ventilators to the patients who are most likely to benefit, clinicians should proactively engage in discussions with patients and families regarding do-not-intubate orders for high-risk subgroups of patients before their health deteriorates. In addition, the authors suggest creating a triage committee, composed of volunteers who are respected clinicians and leaders among their peers and the medical community.

April 3

Addressing nursing gaps in treatment of COVID-19

A new report (Johns Hopkins, March 30) outlines recommendations for addressing gaps in nursing staffing for the care of COVID-19 patients. The report also outlines the training and personal protective equipment necessary to keep nurses safe. The report recommends taking aggressive policy and practical actions to surge the nursing workforce while also protecting nurses and other healthcare workers from infection.

March 31

University of Washington model predicts state COVID-19 deaths, hospitalization

Modeling conducted by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington forecasts death and hospital utilization for each state. As displayed in the state data visualization (choose Ohio from the green drop-down menu), the analysis currently estimates that Ohio’s peak hospital resource use day will be in late April (projections may be frequently updated). Unlike many other states, this analysis predicts that Ohio may have enough hospital beds and ICU beds to meet demand. A companion methodology article describes how the model estimates the timing of deaths and demands for hospital beds, ICU occupancy and ventilator use.
It is important to note that the IHME model does not take into consideration the prevalence of chronic lung disease, heart disease, diabetes, obesity, smoking or other health conditions that may lead to variations in hospitalizations, ICU use and deaths across states. As described in the 2019 Health Value Dashboard and the 2019 State Health Assessment, Ohio has relatively high rates of chronic diseases that may increase the severity of COVID-19 complications. Ohio ranks in the bottom quartile, for example, for adult smoking, adult obesity and cardiovascular disease mortality. Predictive models such as these should be improved to incorporate data on the prevalence of these conditions in Ohio.

March 30

Guidelines aimed at helping providers care for COVID-19 patients

New guidance and analysis gives healthcare providers new insight on how to care for COVID-19 patients.
A panel of experts who had previously issued guidelines for sepsis and septic shock recently issued guidance for managing critically ill adults with COVID-19 (Journal of the American Medical Association, March 26). The guidelines include four best practice statements and 43 recommendations on infection control and testing, hemodynamic support, ventilatory support and therapy. The guidelines also specify areas in need of ongoing research.

March 26

New York City hospital chief provides insights on hospital preparedness

The Journal of the American Medical Association published an interview (JAMA, March 23, 2020) with Michelle N. Gong, MD, Chief of Critical Care at Montefiore Hospital in the Bronx to get perspective on the pandemic in New York City. Among the information that can be useful for Ohio are that:
  • Ohio hospital systems should prepare for longer intensive care stays for patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 relative to other causes of ARDS
  • More research is needed around treatment for COVID-19; Ohio hospitals can contribute to building this research base
  • Most patients who recover in New York are discharging to home, but some need recovery support. Facilitating arrangements between New York hospitals and recovery facilities has been problematic. This lesson learned should be considered in Ohio as people begin to recover.

March 25

Considerations for hospitals, other health providers

Several new studies provide guidance for hospitals and other healthcare providers treating patients with COVID-19.

A study (bioRxiv, March 22, 2020) of collected aerosol samples in various areas of hospitals in Wuhan, China found that there are several steps hospitals can take to prevent transmission and protect healthcare workers, including ventilation, frequent sanitization of all surfaces and careful removal of personal protective equipment apparel. In addition, the study supports the use of masks and social distancing for the public.

Another study (JAMA Insights, March 11, 2020) highlights how hospitals should prepare for caring for critically ill patients with COVID-19 in areas with access to mechanical ventilation. The study calls for more research that includes clear measurements of severity of critical illness and use of sufficiently common outcome measures to combine data and validly compare observations across regions.

A study (JAMA, March 23, 2020) of the high case fatality rate in Italy offers insight for how COVID-19 data should be reported by healthcare providers in the United States so that it can better be interpreted and analyzed. The study found that Italy’s high fatality rate can be attributed to the country’s older age distribution, the definition officials are using for defining COVID-19 related deaths and the country’s approach to testing.

The study found that transparency and consistency in reporting testing policies and definitions of terms is important for comparing results across geographies.