By Bob Arnot, M.D., sponsored by DeVry University
March 31, 2020
6 min read
March 31, 2020
6 min read
Healthcare leaders are facing extraordinary challenges in preparing for and responding to COVID-19. Do they and will they continue to have enough beds, ventilators, supplies and personnel? Look at the types of data and models available to help inform these important questions.
How, as an administrator, do you undertake the very complex task of estimating patient load? You would use the knowledge you've gained so far in this course. First looking at the epidemiology, for instance, looking at how much transmission there is in your community. If it occurs in nursing homes or schools, and if as in the case of Corona, it will impact critical services. Then you want to look at the characteristics of your community, for everything from population density like New York to transportation and vulnerable population sizes.
Let's look at how to estimate requirements for each age group. You can see the percentages of patients requiring critical care increasing from 5% in the 20 to 29 group, to 70.9% in the 80 plus and requiring a much higher level of care in the older ages.
In Italy, these older age groups were by and large not treated in hospital and simply told to go home because there was no capacity for them.
What is the overall US capacity? You'll see many different numbers. Johns Hopkins reports that there are 924,100 hospital beds. In a moderate pandemic, one million would be hospitalized and 9,600,000 in a severe epidemic. Far more than the capacity. More importantly, there are roughly 64,000 ICU beds in the US, a moderate pandemic easily exceeds that number with 200,000 ICU beds needed and if severe, would have that number at 2,900,000 again requiring ICU beds.
How prepared is the US? While Japan has 13.3 beds per population, the US has steadily weaned itself of beds with more and more outpatient procedures and has only 2.9 per thousand, behind France, Germany and South Korea. The saturation of patient beds varies by state with most found in the Dakotas, Wyoming, and several other States.
The most important job of planning is determining when you'll see the influx of patients and how many. This graph shows the estimated peak hospitalizations, at 20, 40 and 60% intervention rates in various levels of curve flattening. Only a 20% infection promises a chance of meeting most needs.
How many precious ICU beds will you need? This range is for two million for a 20% infection to seven million for 60%. This is why damping the number of new infections and spreading them over a longer period of time is critical to treating as many patients as possible.
As we've seen, every model shows the epidemic producing more cases than the healthcare system can possibly manage. New York city has planning for the use of a major convention center and even hotels to treat patients. With a brand new virus, hospitals struggle to estimate demand. In preparation for corona, one New York hospital emptied all its specialty beds. Hospitals put off virtually all of their key elective procedures. The national guard may build field hospitals. There are 17,500 army medics trained in the use of field ventilators.
This New York times map shows where each state would run out of hospital beds if the epidemic is spread over 18, 12 or six months. 60% infection over six months saturates virtually the entire country.
The disease varies greatly from one country to the next. Have a look at 20 to 49 years of age. These were 52% of the diagnoses in Korea, 44% in China, and just 24% in Italy, which had the greatest number of infections. So as you see, the number of infections varies tremendously by age, country, and state.
Finally, the biggest priority is ventilators. Most ventilator companies have a very small output and strained supply. It is now fractured by flight cancellations and lockdowns in many of the countries where these parts are located. There's a vast effort to scale up ventilator production, but this will take months. Still, ventilators are the single biggest priority. There are over 14,000 in the national stockpile.
Finally, ventilators used for outpatient procedures may be converted for use in the epidemic, according to the White House briefing on March 25th.
For planning purposes, you want to estimate the number of ventilators required. This was 6% of patients in Wuhan, yet 75% of patients died without ventilators. So the estimate is that more than 20% of very sick patients may require ventilators. Already ICU rooms are near capacity and will easily be overwhelmed in the first weeks of a major outbreak, pressing the need for unusual speed in increased production and availability of armed forces and national reserve ventilators.
How many ventilators does your hospital require? Up to 30% of hospitalized patients may require them. 50% in critical care will die. Critical patients will stay in your hospital for 15 days and eight days if not critical. These hospitals stay figures are most vital for your day to day planning.
There will be an acute shortage of protective gear and personnel. You may look to cross training your own staff in infectious disease using telemedicine, doctors from other States or re-engaging healthcare providers who are retired and the military.
All in all, this is the biggest challenge ever in America for administrators whose talents will need to manage a pandemic that could kill anywhere from 200,000 to over two million Americans.
HOW SUCCESSFUL WILL YOUR HOSPITAL BE?
The death rate varies widely by country. It may be a function of underlying health, quality of healthcare and social exposure of various groups.
Here's what research shows so far. China, 4% case fatality rate, with Korea, 0.9%, Italy, 6.8%, the United States 2.4% in the earliest stages, Norway, well under 1%. The true overall fatality rate won't be known until much wider testing is undertaken, but mortality in each age group will be the ultimate yardstick of how you as an administrator are managing a pandemic at your hospital.
Thank you so much for watching. Good luck in our worldwide battle against corona.
Disclaimer: The opinions expressed are those of the author. The content is intended to provide general information on the nature of the pandemic, potential exposures, and is not intended to provide medical advice or address medical concerns or specific risk circumstances. Always seek the advice of your doctor or other qualified health provider regarding a medical condition. Neither DeVry University nor its employees or business partners, nor any contributor to this content, makes any representations, express or implied, with respect to the information provided herein or to its use.
View the prior episodes, Understanding COVID-19: Episodes 6 & 7 – Treatment & Vaccine
View the next episode, Understanding COVID-19: Episode 9 – Disease Reproduction
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