Crossing the Threshold from Outbreak to Surge

Hospitals worldwide face overwhelming pressure as the COVID-19 pandemic strikes their communities. Health care leaders train for disaster response, and they meticulously plan for patient surges from unforeseen events. However, this public health crisis is testing the bounds of those plans.

A Harvard Global Health Institute data analysis projects that under a moderate scenario in which 40% of adult Americans contract the disease over the course of a year, the U.S. would have to more than double available inpatient beds to treat those adults sick enough to be hospitalized – about a fifth of the infected adult population. Because of the anticipated surge in COVID-19 patients, many U.S. health care organizations are considering how to leverage both traditional and nontraditional care environments to manage projected shortages of general inpatient and intensive care beds. As the pandemic accelerates, we will quickly run out of space in existing hospitals, so we need to start pivoting community resources in creative ways.

An outbreak like that of the novel coronavirus has three primary phases:

  • Phase 1, or early transmission: Low numbers of patients show up at hospitals, and the system gets time to ramp up.
  • Phase 2, or widespread infection: High numbers of patients arrive, and the health care system becomes inundated with infectious patients.
  • Phase 3, or surveillance: The number of infected patients starts to taper off, and hospitals are monitoring for potential spikes.

In the U.S., we are currently in phase 2, and depending on where you are in the country, you may be facing the first, or second or third wave of critical decisions tied to dynamic spatial, operational and clinical constraints caused by the influx of critical care patients. For every decision, there are downstream consequences that must also be considered, which will ultimately impact the design response. To help guide those decisions, health care organizations work within a framework to screen, contain and treat patients and protect caregivers. The mobilization of resources typically happens in multiple waves.

The Three Waves of Decision-Making

Wave 1

During the first wave of decision-making, health care organizations must consider how to free up existing space within the hospital to increase acute and critical care capacity, while continuing to provide essential services to non-infected patients.

Crucial questions to address during this wave are: Are there low-acuity patients who can be rapidly transitioned to their homes or post-acute settings to immediately free up bed capacity? What surgeries or procedures can be placed on hold? How do we manage the financial fallout from loss of revenue? What happens to the staff who were conducting those procedures and supporting the care process?

Federal officials in the U.S. have already asked that elective surgeries and dental procedures be delayed nationwide. Officials are also expanding Medicare benefits to cover virtual screening, office, hospital and mental health visits that would generally occur in person. Meanwhile, health care organizations with robust telehealth capabilities are rapidly expanding virtual visits, and those with mobile health units are growing their community and home services.

Wave 2

With additional space now available, the second wave of decision-making focuses on how to extend critical care capacity within the walls of the health care organization’s own system by either quickly modifying or converting existing clinical and nonclinical infrastructure to meet increasing demand.

Essential questions to ask during this wave include: What is the best way to cohort patients of like acuity within the facility?  Are there any existing construction projects that should be fast-tracked? Do we have enough supplies and equipment to support the additional capacity? Do we have enough people to manage capacity? What precautions are needed to ensure staff safety while taking care of infectious patients?

Some health care organizations are addressing these concerns through these measures:

  • Implementing screening and pre-triage tents before emergency department entrances to sort patients, directing those with COVID-19 symptoms to properly resourced units and sending patients who don’t need emergency medical care to alternative care sites or home care.
  • Extending the capacity of hospital spaces by doubling up patients where headwalls allow, converting pre- and post-recovery areas and observation units into inpatient treatment rooms.
  • Using conference areas and lobbies outfitted to meet Facility Guidelines Institute (FGI) or other local parameters for multi-bed units to treat noncritical COVID-19 patients.
  • Converting existing shell space into entire COVID-19 critical care units to cohort COVID-19 patients into a single floor or unit and reduce the number of times caregivers need to put on or take off personal protective equipment (PPE).
  • Deploying mass casualty tents outfitted with movable privacy partitions and mobile workstations in hospital parking lots to serve as overflow ED units. These provide maximum flexibility to respond to the escalating situation and organize the flow of patients in and out of the hospital.
  • Placing all COVID-19 positive patients at a single facility within the hospital system and moving all noninfected patients to other facilities to reduce risk of contagion. This measure centralizes clinical workforce, as well as supplies, PPE and ventilators.

Wave 3

At this stage, health care organizations must look beyond their existing walls to meet demand. When assessing nontraditional care environments as part of surge plan, it is imperative to consider: Will these nontraditional venues provide health services or quarantine locations? If providing health services: Who will provide care? How will supplies and equipment get distributed?

Some emerging ideas for rapidly deployable nontraditional care environments are:

  • Identifying vacant hospitals and post-acute care facilities that could be reactivated to accommodate low-acuity patients.
  • Using college dorms or hotels for quarantining potentially infected patients or caregivers before integrating them back into their home environment
  • Exploring as potential places to care for lower-acuity COVID-19 patients
  • Deploying medical ships to contain and treat COVID-19 patients
  • Using existing hospitality suites such as Ronald McDonald houses that are near health care infrastructure to care for lower-acuity COVID-19 patients

In hopes of mobilizing a larger clinical workforce, some states are expediting licenses for former or retired health care workers. Additionally, the World Health Organization has stepped in to address the limited supply of PPE and help protect health care workers on the front lines. Efforts have also begun in the U.S. to develop guidelines for how to treat critically ill patients with COVID-19 and to offer advice on the allocation of limited resources, ethical considerations and delivery end-of-life treatment.

It is imperative that as the pandemic progresses, we think about operations and space in concert. As the crisis evolves, we will rely on the ingenuity of the design field to develop new solutions that allow us to flex rapidly to meet constantly increasing  needs.  Most importantly, as we lean on community resources, we must prioritize the safety and well-being of our front-line health care workers.