As the COVID-19 pandemic continues to evolve, hospitals and health systems need to think about ways to temporarily increase physical inpatient capacity so they can care for the projected influx of coronavirus patients while continuing to provide medically necessary care for other patients. According to an article on HealthLeaders Media, most states will run out of ICU beds by mid-April, with the earliest shortages beginning in the next two weeks.
Below are three steps organizations can take to create temporary inpatient capacity and safeguard valuable supplies and equipment.
Postpone elective surgeries and procedures
The American College of Surgeons (ACS) has stated that elective surgeries should be curtailed in all sites of service. While some cases can be postponed indefinitely, the vast majority of the cases performed are associated with progressive disease (such has cancer, vascular disease, and organ failure) that will continue to progress at variable, disease-specific rates. ACS provides the following guidance on the management of nonemergent operations:
- Hospitals and surgery centers should consider both their patients’ medical needs, and their logistical capability to meet those needs, in real time.
- The medical need for a given procedure should be established by a surgeon with direct expertise in the relevant surgical specialty to determine what medical risks will be incurred by case delay.
- Logistical feasibility for a given procedure should be determined by administrative personnel with an understanding of hospital and community limitations, taking into consideration facility resources (beds, staff, equipment, supplies, etc.) and provider and community safety and well-being.
- Case conduct should be determined based on a merger of these assessments using contemporary knowledge of the evolving national, local and regional conditions, recognizing that marked regional variation may lead to significant differences in regional decision-making.
- The risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be required to emerge from an environment in which COVID-19 is less prevalent.
ACS goes on to say that not only will these steps create physical capacity, they will also “immediately minimize the use of essential items needed to care for patients, including but not limited to ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators.”
Some hospitals and health systems that have reported canceling or postponing elective surgeries include but are not limited to:
- Brigham and Women’s Hospital.
- New York–Presbyterian.
- Northwell Health.
- Hackensack Meridian.
- Beaumont Health.
- Hospital for Special Surgery.
- Tufts Medical Center.
- Massachusetts General Hospital.
- Mount Sinai Health System.
- University of Utah Medical System.
- Intermountain Healthcare.
- Swedish Medical Center.
New York State Governor Andrew Cuomo earlier this week suspended regulations regarding the number of beds a hospital can have, giving hospitals the ability to temporarily increase capacity. With this suspension, New York hospitals can convert private inpatient rooms back to semiprivate patient rooms for noninfected patients. Consider your state’s regulations and lobby to suspend them.
Identify alternative care locations for noninfected patients
Health systems should encourage providers to treat patients in nonhospital settings and, as appropriate, via digital means.
- Digital Health/Telemedicine
Direct patients seeking nonemergency medical care (e.g., well patients with chronic medical conditions) and people concerned they may have coronavirus to digital health services, including nurse telephone lines, chat bots, and telemedicine platforms. Discourage face-to-face encounters unless medically necessary.
- Ambulatory Surgery Centers
ASCs are under the same CDC directive as hospitals to cancel elective and nonurgent surgeries. However, a recent statement issued by the Ambulatory Surgery Center Association noted that “ASCs must strictly adhere to federal and state guidance to immediately postpone all surgeries that can be delayed for six to eight weeks.” Therefore, ASCs can continue to provide safe surgical care for “urgent” patients whose condition cannot wait the six to eight weeks, and until hospitals return to normal operations. Multispecialty and single-specialty ASCs that specialize in orthopedics and general surgery, for example, may present opportunity for alignment with hospitals and support creating hospital capacity by servicing urgent cases that are qualified for the ASC. However, the ASC’s ability to provide all types of urgent surgical care will vary based on access to staffing and surgical equipment, as well as other factors. Finally, there may be opportunity for ASCs to provide services that are not on the approved ASC list; however, this would require the ASC to apply for the 1135 waiver.
- Outpatient Clinics, Medical Offices, and Sleep Centers
Temporarily close outpatient clinics, medical offices, and sleep centers located on the acute care hospital campus; utilize these patient care areas to care for noninfected, non–critically ill patients from the acute care hospital. Utilize existing staff, supplies, and equipment. Be sure to apply for the 1135 waiver.
- Urgent Care Centers
Convert urgent care locations within your hospital or health system to receive and care for noninfected, lower-acuity patients who cannot be safely discharged to home. Healthcare providers and support staff, along with supplies and equipment, already exist; however, supplies and equipment will need to be evaluated and enhanced. Be sure to apply for the 1135 waiver.
- Critical Access HospitalsCMS has waived the 25-bed and 96-hour rule for Critical Access Hospitals (CAHs). Coordinate with CAHs to receive noncritical patients from large acute care hospitals. Patients in large hospitals who require acute care but cannot be safely discharged to home can be safely cared for in the CAH, freeing up capacity and resources in the larger hospital for COVID-19–infected, critically ill patients.
Reduce the number of admissions from the ED
Emergency physicians often admit patients to the hospital for observation overnight for conditions that could be managed safely and effectively on an outpatient basis, but the resources, infrastructure, and processes are lacking. Patients with low-risk chest pain are a prime example. In many hospitals today, patients with low-risk chest pain are admitted from the ED to an acute care bed and placed on cardiac monitoring, awaiting a stress test and cardiologist visit the next day. Establish processes and infrastructure now so that these patients can be managed in the outpatient setting, freeing up acute care capacity to manage the expected influx of COVID-19 cases.
Of course, expanding physical capacity is only part of the challenge facing health system leaders. Hospitals will also need to increase the number of direct healthcare providers and support staff to address the needs of COVID-19–infected patients. Check back soon for a separate post concerning temporary staffing measures.