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• W3149969729 abstract "Although coronavirus disease 2019 (COVID-19) is the worst pandemic the medical community has seen in our lifetimes, it is, for many of us, unfortunately not the first. There were three major pandemics in the 20th century and one in the 21st century. As such, there was never a question of if the next pandemic would come—only a question of when and how devastating it would be. In this context, disaster preparedness was already a topic of considerable ongoing importance in recent years. In response to the strain on hospital operations caused by the H1N1 influenza pandemic, the National Academies of Science released the Crisis Standards of Care in 2012 in the hopes of providing hospitals with a unified framework for designing disaster response plans (1). Following this, the U.S. Department of Health and Human Services Officer of the Assistant Secretary for Preparedness and Response (ASPR) created the Interim Healthcare Coalition Checklist for Pandemic Planning, outlining eight specific domains that hospitals should be prepared to address when planning for disasters (2). More recently, the ASPR produced (2) tools to evaluate hospital capacity and response intended to identify gaps in hospital preparedness (3,4). In addition to these federal efforts, several professional medical societies created their own recommendations for ICU response planning (5–8). Yet, as the worldwide severe acute respiratory syndrome coronavirus 2 pandemic has laid bare, many hospitals had not fully adapted these recommendations (9). Further, even if they had, these frameworks could not have fully prepared the global health community for the scale of the COVID-19 pandemic. This has led to devastating and prolonged strain on every aspect of hospital capacity resource including the “four Ss” of preparedness—space, staffing, stuff, and system coordination. COVID-19 has raised concerns that even though signs of vulnerabilities were present in prior years, our approach to hospital preparedness for mass-casualty events may be outdated (10). Within this context, Mathews et al (11), in their article published in this issue of Critical Care Medicine, sought to characterize the response within the United States to the COVID-19 pandemic from January to June 2020 by surveying all hospitals participating in the National Heart, Lung, and Blood Institute Prevention and Early Treatment of Acute Lung Injury (PETAL) Clinical Trials Network. A 41-question survey was completed by 45 hospitals (94% response rate) representing all main census regions of the continental United States. The survey had three main domains: 1) hospital and ICU characteristics prior and during the pandemic, 2) changes (if any) in ICU staffing structures as a result of the pandemic, and 3) surge responses for both ICU and ward patients. This self-reported data were subsequently linked to matched county-level data obtained from a publicly accessible repository (12). From this survey, the authors obtained insights into system coordination and structure, space allocation and repurposing, and staffing alterations. They found that upper-echelon system-level coordination changes including incident command activation and the canceling of elective procedures occurred at greater than 95% of hospitals surveyed. In addition, the survey demonstrated that 63% of hospitals increased ICU capacity through repurposing of existing clinical space. The study also found that 66% of hospitals adapted new staffing structures as a result of the surge of patients, almost half created tiered staffing models, 49% added additional staff, and nearly 1/3 altered physician:patient or nurse:patient ratios. Prior to this broad overview, significantly less was known about COVID-19 preparedness on a nationwide scale although several hospital systems published their specific planning approaches (13–15). In interpreting the results, it is imperative to note that they represent a snapshot of hospital responses in the early portion of the pandemic. When COVID-19 came to the United States, it did not impact all regions of the country equally, and relatively little was known about optimal treatment for a virus that had first been identified only a few months earlier. Further, there was marked uncertainty about how widely and rapidly the pandemic would spread. In the setting of this uncertainty, it is perhaps not surprising that although preemptive planning occurred in all sites, specifics varied widely. Considering that the individual hospitals surveyed were acting independently, it is instructive to examine commonalities in hospital response, as actions taken by nearly every respondent are likely to have been deemed essential to the overall response. An example would be incident command center activation which occurred in all but one hospital. Given the complexity of COVID-19 response—ranging from staffing to supply chain to bed availability to communications—this common response seems both vital and prudent and is almost certain to have continued in the months that followed the period covered by the survey. In contrast, an action that was equally common that might look somewhat different with the benefit of hindsight was the cancellation of elective procedures, which occurred in all but two hospitals. Although the survey cannot identify the reasons for surgery cancellation, the authors list multiple potential reasons including preservation of hospital bed capacity for patients with COVID-19, preservation of personal protective equipment, and preservation of national society recommendations. This decision likely had tangible downstream effects on nearly every domain the survey asked about—from staffing to potential ventilator strategies to ICU bed availability. The decision to cancel elective procedures likely led to availability of a large group of healthcare professionals to be redeployed to the overall effort against COVID-19 by a workforce who would otherwise be working in the operating room or the perioperative space (intensivists, nurses, surgeons, anesthesiologists, respiratory therapists, etc.). However, although cancelling procedures was a near ubiquitous response, less than half of ICUs surveyed used either temporary workforce or employed a tiered staffing model over the 6-month period examined, which suggests that many highly skilled perioperative clinicians were providing less (or no) patient care for a period of time. This response inevitably led to a delay in care to many patients suffering from non-COVID ailments. Further, considering the large role that procedures play in the economic wellbeing of hospitals, this decision led to a massive loss of income to hospitals, whose effects will be felt for years to come. It is notable that the approach to this issue has evolved over the course of the year, and anecdotally, most hospitals that cancelled elective surgeries during the first wave of COVID-19 successfully returned to a busy operative schedule later in the year. This highlights the fact that pandemic response is dynamic, and the identical survey sent out 6 months later might yield different responses as a result of the lessons learned over the course of the pandemic. It is also worth noting that activation of incident command centers and cancellation of elective procedures occurred nearly simultaneously throughout the country. However, the timing of these decisions did not always closely correlate to increases in case rates, and there were significant geographic variations between when these interventions were initiated and when COVID-19 cases surged. Specifically, although these interventions occurred only a few weeks before cases surged in the Northeast, there was a 4-month lag between these interventions and when cases surged in the South, Mountain and Pacific regions. This common nationwide response that occurred in the absence of a homogenous rise of cases suggests that responses could potentially be fine-tuned on a more regional or local level as appears to have occurred regarding staffing decisions. Despite the robust data obtained, there are generalizability concerns about the survey results. The use of the highly respected PETAL Network guaranteed representation from a wide geographic range of hospitals with acknowledged academic expertise, and the authors are to be congratulated for getting nearly 100% of sites to respond to a survey request in the middle of a pandemic. At the same time, the average hospital in the study had almost 100 ICU beds which means that the survey respondents likely had significant technological resources at baseline not available in smaller hospitals. Further, the fact that 95% of hospitals had residents means that an additional workforce was available that would not be available to many hospitals, and whether the results can be extrapolated to hospitals without MD trainees is unclear. Additionally, the fact that only 57% of hospitals reported an increase in peak capacity from prior to the pandemic is consistent with observations that not only every region was similarly affected during the first wave but also raises concerns of whether the large academic hospitals surveyed are generally reflective of all hospitals in the United States. Ultimately, the survey by Mathews et al (11) provides a much needed, high-level overview of the range of responses that occurred in the early stages of the pandemic. As the world begins the second year of an unprecedented disaster, it is vital to examine the effectiveness of individual responses at a granular level to understand what should be done in the future. The variability in hospital response highlights the message that there may be no golden “one size fits all” approach. At the same time, the “one size fits one” model equally does not work as it does not make sense for each hospital to reinvent the wheel when it comes to pandemic planning and response. Understanding the commonalities in approach to the pandemic—as well as the host of options available—in the early days of COVID-19 is an important step toward improved disaster planning for the ongoing pandemic and for the ones that inevitably await us in the future." @default.
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• W3149969729 title "Capacity Strain and Response During Coronavirus Disease 2019: One Size Does Not Fit All, and One Size Does Not Fit One*" @default.
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