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

Abstract

Background The coronavirus disease 2019 (COVID-19) pandemic placed considerable strain on critical care resources. How United States (U.S.) hospitals responded to this crisis is unknown. Research question What actions did U.S. 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 methods From September to November 2020 we surveyed the chief nursing officers of a representative sample of U.S. hospitals regarding organizational actions taken to increase or maintain critical care capacity during the pandemic. We calculated weighted proportions of hospitals for each potential action in order to create estimates across the entire population of U.S. hospitals, accounting for both the sampling strategy and non-response. We also examined whether the types of actions taken varied by the cumulative regional incidence of COVID-19 cases. Results We received responses from 169 of 540 surveyed U.S. hospitals (response rate: 31.3%). Almost all hospitals canceled or postponed elective surgeries (96.7%) and non-surgical 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 intensive care unit (ICU) staff, including use of ICU telemedicine, were highly variable, without any single dominant strategy. Hospitals experiencing higher incidence of COVID-19 did not consistently take different actions compared to hospitals facing lower incidence. Interpretation 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 work linking hospital response to patient outcomes can inform planning for additional surges of this pandemic or other events in the future.

Family Presence for Critically Ill Patients During a Pandemic

“…Initially, the decision to prohibit family presence reflected the primacy of dedicating space, equipment, and personnel resources to provide life-saving care to the surge of patients with COVID-19. 10,30 However, advancement in our knowledge and stabilization of resources since those early months have led to an enhanced understanding of the anticipated effect of family visitation on health-care system resources.…”

“…of family members. 8,9 Although such restrictions were reasonable in the early periods of limited scientific knowledge about viral transmission, supply shortages, and rapid efforts to restructure hospitals to expand capacity, 10 reevaluation of these policies is now critical given our increased information and resources. [11][12][13] ICU visitation restrictions such as those enacted because of COVID-19 lead to incomplete grief (eg, inability to fully experience the grieving process) 11, [14][15][16][17][18] ; emotional distress experienced by patients, families, and physicians 11, [14][15][16][17][18][19][20][21][22][23] ; barriers to high-quality communication and decision-making 11, [14][15][16][17][18][19][20][21][22]24 ; perpetuation of existing inequities 11,20 ; and poor clinical outcomes.…”

The Contribution of COVID-19-Forced Transformations in Critical Care Delivery to Patient Mortality: Still an Underexplored Association

“…The rapidly evolving shortages of intensive care unit (ICU) beds brought by the surge of COVID-19 patients have led to increasing use of alternative spaces for care of the critically ill, including repurposing for ICU care step-down units, medical/surgical wards, clinical spaces not typically dedicated to inpatient care, and creating ICUs in areas not typically dedicated to health care [ 11 ]. The prognostic implications of increased use of critical care spaces beyond those of existing ICUs have been examined in a recent multicenter study by Toth and colleagues on the impact of increased surge in New York City.…”

“…In addition, the corresponding shortage in critical care-trained clinicians was addressed by hospitals through multiple strategies, including among others increased patient/clinician ratios, asking clinicians to work longer hours or extra shifts, and using non-ICU clinicians to “extend” ICU teams [ 11 ]. Some of these approaches were previously shown to increase patient mortality [ 15 ] and it may be postulated that the other ones may have adversely affected patient outcomes.…”

Pharmacogenomic and drug interaction risk associations with hospital length of stay among Medicare Advantage members with COVID-19

“…The COVID-19 pandemic placed unprecedented demands for hospitals across the globe, and patient demand for hospitalization exceeded hospital resources in several regions. [13][14][15][16][17] In the US, roughly half of those hospitalized with COVID-19 have been Medicare and Medicare Advantage beneficiaries and the majority of these beneficiaries have been hospitalized for more than 5 days. 18,19 Medication management interventions may especially help the Medicare population as 54% of patients 65 and older report taking four or more prescription drugs daily.…”