It's time for U.S. hospitals to dust off their playbooks for dealing with surges of patients, experts said.
In light of growing evidence the novel coronavirus is now spreading in the U.S., hospital emergency planners need to move beyond infection control planning to their strategies for handling large numbers of patients, said emergency department expert Gregg Miller, M.D.
"Hospitals are doing a great job of rolling out their infection and isolation protocols and training the staff of handling that next single patient," said Miller, the chief medical officer for Vituity, a physician staffing firm. The company works with about 150 emergency departments and 25 hospitalist programs around the country including Dignity Health and the Providence and Sutter Health systems.
"But what they're not doing a great job with is talking about how to manage the next 100 patients that come in," Miller said. "What's going to happen when you've got a waiting room that's full of respiratory patients or what's going to happen when you start running out of [personal protective equipment, or PPE], or what's going to happen when you no longer have the negative pressure rooms these patients are supposed to be in?"
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That was the experience when the swine flu began spreading more than a decade ago.
During that pandemic, plenty of patients who were asymptomatic or with mild symptoms showed up at hospitals to get checked out, said Blake McKinney, an emergency department doctor practicing in Northern California and the co-founder and CMO of telemedicine company CirrusMD.
His company, which provides telehealth services, is working to get the message out to convince patients to use telemedicine services before heading to the hospital. "It can be dangerous, but most people get over it," he said. "For mildly symptomatic for asymptotic, we still want you to see a doctor. We just want to you to do it from your couch," he said.
Hospital preparations and considerations
Hospital capacity is already stretched pretty thin on a regular basis, McKinney said.
"Most U.S. hospitals are not operating today with a great deal of margin or excess capacity. Most on any given day are quite full," McKinney said. "Prepare to hear about shortages of surgical masks, be prepared to watch hospitals capacity decrease as healthcare workers become sick. They are most vulnerable in an outbreak."
Hospital emergency planners should be considering how they plan to isolate large groups of respiratory patients should they run out of our negative pressure rooms, Miller said, referring to rooms that use negative air pressure to prevent cross-contamination from room to room.
Many emergency departments have one or two negative pressure rooms, and hospitals might have a few additional negative pressure rooms in the inpatient setting.
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Some hospitals will isolate flu patients in nonclinical care areas that have been converted for such a purpose. They may need to consider putting tents in the parking lot to expand capacity. They'll need to think about how they can better leverage their telemedicine platforms for urgent care needs.
They may also consider spaces, such as a nearby urgent care center, to dedicate as a respiratory care facility. They may need to consider dedicating certain staff to caring for suspected COVID-19 patients to get additional uses of PPEs, which could be in short supply.
"At some point, we're going to be overwhelmed," Miller said. "We're not going to have enough negative pressure rooms. We're not going to have enough PPE wear."
There may additional unexpected challenges, such as how to handle mildly ill patients who might typically be sent home to self-quarantine as they await test results but are homeless. Public health experts wouldn't want those individuals to go out on the street or into the close quarters of a shelter with other individuals, he said.
Another challenge might be an elderly patient coming from an adult family home, he said. Officials in Washington state said two residents of a senior nursing facility have tested positive for coronavirus, and another 27 residents of the nursing home and 25 staff are reporting similar symptoms.
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"You can't admit every patient who just has a mild cough and cold. The vast majority of patients with COVID-19 should be managed as outpatients and not hospitalized inpatients, but that management requires the ability to self isolate at home and there's a huge population out there where that's just not feasible," Miller said. "Are hospitals going to end up admitting all of those patients for quarantine for 14 days or until one or two of those tests come back negative? There's going to be some real capacity management issues."
Financial impacts
Hospitals could sustain some negative financial impacts as a result of the virus. There could also be other unexpected costs, such as increases in waste management, Miller pointed out.
Hospitals that are overwhelmed by respiratory patients may need to consider postponing elective surgical cases.
"Those are the revenue generators. These are some of the tough financial conversations for hospitals to have," Miller said. "They rely on their knee replacements and their hip replacements to generate the finances they need."
There could also be workforce concerns. The Centers for Disease Control and Prevention recommends a 14-day quarantine for a clinician who has an encounter with a patient suspected of having the virus.
"I think that's a great recommendation for the past couple of weeks where the cases are few and far between and our focus is really on quarantine and containment," Miller said. "What's going to happen when 10% of your workforce is on 14 days of leave? Hospitals don't have that kind of capacity or flexibility with our staffing. At some point, those recommendations are likely to change from a containment strategy to a mitigation strategy."