Actions Taken by US Hospitals to Prepare for Increased Demand for Intensive Care During the First Wave of COVID-19

Abstract

BackgroundThe COVID-19 pandemic placed considerable strain on critical care resources. How US hospitals responded to this crisis is unknown.Research QuestionWhat actions did US hospitals take to prepare for a potential surge in demand for critical care services in the context of the COVID-19 pandemic?Study Design and MethodsFrom September to November 2020, the chief nursing officers of a representative sample of US hospitals were surveyed regarding organizational actions taken to increase or maintain critical care capacity during the COVID-19 pandemic. Weighted proportions of hospitals for each potential action were calculated to create estimates across the entire population of US hospitals, accounting for both the sampling strategy and nonresponse. Also examined was whether the types of actions taken varied according to the cumulative regional incidence of COVID-19 cases.ResultsResponses were received from 169 of 540 surveyed US hospitals (response rate, 31.3%). Almost all hospitals canceled or postponed elective surgeries (96.7%) and nonsurgical procedures (94.8%). Few hospitals created new medical units in areas not typically dedicated to health care (12.9%), and almost none adopted triage protocols (5.6%) or protocols to connect multiple patients to a single ventilator (4.8%). Actions to increase or preserve ICU staff, including use of ICU telemedicine, were highly variable, without any single dominant strategy. Hospitals experiencing a higher incidence of COVID-19 did not consistently take different actions compared with hospitals facing lower incidence.InterpretationResponses of hospitals to the mass need for critical care services due to the COVID-19 pandemic were highly variable. Most hospitals canceled procedures to preserve ICU capacity and scaled up ICU capacity using existing clinical space and staffing. Future research linking hospital response to patient outcomes can inform planning for additional surges of this pandemic or other events in the future. The COVID-19 pandemic placed considerable strain on critical care resources. How US hospitals responded to this crisis is unknown. What actions did US hospitals take to prepare for a potential surge in demand for critical care services in the context of the COVID-19 pandemic? From September to November 2020, the chief nursing officers of a representative sample of US hospitals were surveyed regarding organizational actions taken to increase or maintain critical care capacity during the COVID-19 pandemic. Weighted proportions of hospitals for each potential action were calculated to create estimates across the entire population of US hospitals, accounting for both the sampling strategy and nonresponse. Also examined was whether the types of actions taken varied according to the cumulative regional incidence of COVID-19 cases. Responses were received from 169 of 540 surveyed US hospitals (response rate, 31.3%). Almost all hospitals canceled or postponed elective surgeries (96.7%) and nonsurgical procedures (94.8%). Few hospitals created new medical units in areas not typically dedicated to health care (12.9%), and almost none adopted triage protocols (5.6%) or protocols to connect multiple patients to a single ventilator (4.8%). Actions to increase or preserve ICU staff, including use of ICU telemedicine, were highly variable, without any single dominant strategy. Hospitals experiencing a higher incidence of COVID-19 did not consistently take different actions compared with hospitals facing lower incidence. Responses of hospitals to the mass need for critical care services due to the COVID-19 pandemic were highly variable. Most hospitals canceled procedures to preserve ICU capacity and scaled up ICU capacity using existing clinical space and staffing. Future research linking hospital response to patient outcomes can inform planning for additional surges of this pandemic or other events in the future. FOR EDITORIAL COMMENT, SEE PAGE 391COVID-19, the illness caused by the SARS-CoV-2 virus, has rapidly spread around the world in a global pandemic that has strained, and in some regions overwhelmed, the capacity of existing critical care resources. The virus first emerged in November 2019, and as of December 2020, there have been > 15 million cases worldwide, with ongoing spread at a rate of > 200,000 cases per day.1Johns Hopkins UniversityCoronavirus Resource Center.https://coronavirus.jhu.edu/Date accessed: December 16, 2020Google Scholar COVID-19 is associated with high rates of respiratory failure and critical illness. In the early phase of the pandemic, more than one-half of patients with COVID-19 required hospitalization,2Petrilli C.M. Jones S.A. Yang J. et al.Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study.BMJ. 2020; 369: m1966Crossref PubMed Scopus (1651) Google Scholar and 15% to 20% of hospitalized patients were admitted to ICUs predominantly for respiratory failure requiring mechanical ventilation and shock requiring vasopressor support.3Richardson S. Hirsch J.S. Narasimhan M. et al.Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area.JAMA. 2020; 323: 2052-2059Crossref PubMed Scopus (6061) Google Scholar, 4Bhatraju P.K. Ghassemieh B.J. Nichols M. et al.Covid-19 in critically ill patients in the Seattle region—case series.N Engl J Med. 2020; 382: 2012-2022Crossref PubMed Scopus (1738) Google Scholar, 5Yang X. Yu Y. Xu J. et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.Lancet Respir Med. 2020; 8: 475-481Abstract Full Text Full Text PDF PubMed Scopus (6599) Google Scholar Critically ill patients with COVID-19 have prolonged ICU courses, requiring an average of 2 weeks of mechanical ventilation.6Doidge J.C. Gould D.W. Ferrando-Vivas P. et al.Trends in intensive care for patients with COVID-19 in England, Wales and Northern Ireland.Am J Respir Crit Care Med. 2021; 203: 565-574Crossref PubMed Scopus (87) Google Scholar,7Karagiannidis C. Mostert C. Hentschker C. et al.Case characteristics, resource use, and outcomes of 10 021 patients with COVID-19 admitted to 920 German hospitals: an observational study.Lancet Respir Med. 2020; 8: 853-862Abstract Full Text Full Text PDF PubMed Scopus (510) Google Scholar Thus, the sheer volume of patients and their extended critical illness combined have created an unprecedented demand for intensive care. FOR EDITORIAL COMMENT, SEE PAGE 391 Prior to the current pandemic, several groups developed recommendations for hospitals and ICUs to respond to mass critical care needs in the case of an epidemic, bioterrorism, or other mass casualty event.8Christian M.D. Devereaux A.V. Dichter J.R. Geiling J.A. Rubinson L. Definitive care for the critically ill during a disaster: current capabilities and limitations: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL.Chest. 2008; 133: 8S-17SAbstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar,9Sprung C.L. Zimmerman J.L. Christian M.D. et al.Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster.Intensive Care Med. 2010; 36: 428-443Crossref PubMed Scopus (113) Google Scholar These recommendations were broad and far-reaching and were generally organized around the 3 S’s of preparedness: space, staff, and stuff.10Adams L.M. Exploring the concept of surge capacity.Online J Issues Nurs. 2009; 14Google Scholar,11Barbisch D.F. Koenig K.L. Understanding surge capacity: essential elements.Acad Emerg Med. 2006; 13: 1098-1102Crossref PubMed Google Scholar They outlined that hospitals should have the ability to expand ICU capacity by extending to other hospital areas, with appropriate beds and monitors for expansion areas; be able to rapidly increase clinical and nonclinical staffing and models of using noncritical care staff to care for ICU patients; and have plans to ensure availability of necessary medical equipment and medications. Recommendations also emphasized the importance of established networks of regional coordination across hospital systems and establishing objective, ethical, and transparent triage systems under the most extreme circumstances. Despite these recommendations, as the COVID-19 pandemic unfolded, it quickly became obvious that many hospitals and clinicians were ill-prepared to meet the demands of caring for the surges of patients with COVID-19. Clinicians had concerns about inadequate staffing; shortages of supplies, medications, and beds; and overcrowding.12Wahlster S. Sharma M. Lewis A.K. et al.The coronavirus disease 2019 pandemic’s effect on critical care resources and health-care providers: a global survey.Chest. 2021; 159: 619-633Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar,13Society of Critical Care MedicineICU readiness assessment: we are not prepared for COVID-19.https://www.sccm.org/getattachment/Blog/April-2020/ICU-Readiness-Assessment-We-Are-Not-Prepared-for/COVID-19-Readiness-Assessment-Survey-SCCM.pdf?lang=en-USDate accessed: December 16, 2020Google Scholar Anecdotal reports from hospitals experiencing surges suggested a patchwork of responses and solutions.14The Coronavirus is Forcing Hospitals to Cancel Surgeries. New York Times.https://www.nytimes.com/2020/03/14/us/coronavirus-covid-surgeries-canceled.htmlDate accessed: December 16, 2020Google Scholar, 15Barbash I.J. Sackrowitz R.E. Gajic O. et al.Rapidly deploying critical care telemedicine across states and health systems during the Covid-19 pandemic.NEJM Catalyst Innovations Care Delivery. 2020; 1Google Scholar, 16Yager P.H. Whalen K.A. Cummings B.M. Repurposing a pediatric ICU for adults.N Engl J Med. 2020; 382e80Crossref PubMed Scopus (36) Google Scholar, 17Anderson B.R. Ivascu N.S. Brodie D. et al.Breaking silos: the team-based approach to coronavirus disease 2019 pandemic staffing.Critical Care Explorations. 2020; 2Crossref Google Scholar, 18Carenzo L. Costantini E. Greco M. et al.Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy.Anaesthesia. 2020; 75: 928-934Crossref PubMed Scopus (215) Google Scholar, 19Griffin K.M. Karas M.G. Ivascu N.S. Lief L. Hospital preparedness for COVID-19: a practical guide from a critical care perspective.Am J Resp Crit Care Med. 2020; 201: 1337-1344Crossref PubMed Scopus (185) Google Scholar, 20Spina S. Marrazzo F. Migliari M. Stucchi R. Sforza A. Fumagalli R. The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy.Lancet. 2020; 395: e49-e50Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar, 21Xie J. Tong Z. Guan X. Du B. Qiu H. Slutsky A.S. Critical care crisis and some recommendations during the COVID-19 epidemic in China.Intensive Care Med. 2020; 46: 837-840Crossref PubMed Scopus (386) Google Scholar However, robust data on how hospitals actually responded to the surge in demand for critical care services during this period are lacking. To better understand this issue, we performed a structured survey of a representative sample of US hospitals asking what steps they planned for or during the first phase of the COVID-19 pandemic. performed a survey of US hospitals by using the Hospital also the for System to hospital not in the Hospital as as the to hospitals to regions that their care D. et regions for care in the Emerg Med. Full Text Full Text PDF PubMed Scopus Google Scholar To the population by from the were The New York COVID-19 case was to the incidence of COVID-19 according to and accessed: December 2020Google Scholar The survey was to care hospitals with an it was not to survey all hospitals, we created a sample using a of and all hospitals were on health and cumulative incidence of COVID-19 in the on the the was up to 10 hospitals in each we this sample by all hospitals in the regions with the cumulative COVID-19 incidence at the of sampling approach of a broad of hospital also of hospitals that with a of patients with COVID-19. of the sampling strategy is in the survey on ICU organizational M. et characteristics, and resource use in intensive care the Care Med. PubMed Scopus Google Scholar, The staffing and in the context of other ICU organizational a cohort Care Med. PubMed Scopus Google Scholar, The effect of care on intensive care unit Med. 2010; PubMed Scopus Google Scholar, R. et of intensive care unit organizational Google Scholar, staffing and among critically ill Engl J Med. PubMed Scopus Google Scholar existing for pandemic L.M. Exploring the concept of surge capacity.Online J Issues Nurs. 2009; 14Google Scholar,11Barbisch D.F. Koenig K.L. Understanding surge capacity: essential elements.Acad Emerg Med. 2006; 13: 1098-1102Crossref PubMed Google Y. L. and approach to hospital preparedness for surge events due to Care Explorations. 2020; 2Crossref PubMed Scopus Google Scholar and case about hospital responses during the early of the L. Costantini E. Greco M. et al.Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy.Anaesthesia. 2020; 75: 928-934Crossref PubMed Scopus (215) Google Scholar, 19Griffin K.M. Karas M.G. Ivascu N.S. Lief L. Hospital preparedness for COVID-19: a practical guide from a critical care perspective.Am J Resp Crit Care Med. 2020; 201: 1337-1344Crossref PubMed Scopus (185) Google Scholar, 20Spina S. Marrazzo F. Migliari M. Stucchi R. Sforza A. Fumagalli R. The response of Milan's Emergency Medical System to the COVID-19 outbreak in Italy.Lancet. 2020; 395: e49-e50Abstract Full Text Full Text PDF PubMed Scopus (252) Google Scholar, 21Xie J. Tong Z. Guan X. Du B. Qiu H. Slutsky A.S. 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