Minimizing Population Health Loss in Times of Scarce Surgical Capacity During the Coronavirus Disease 2019 Crisis and Beyond: A Modeling Study.

OBJECTIVES: Coronavirus disease 2019 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model to estimate the impact of postponing semielective surgical procedures on health, to support prioritization of care from a utilitarian perspective. METHODS: A cohort state-transition model was developed and applied to 43 semielective nonpediatric surgical procedures commonly performed in academic hospitals. Scenarios of delaying surgery from 2 weeks were compared with delaying up to 1 year and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization Global Burden of Disease study. For each surgical procedure, the model estimated the average expected disability-adjusted life-years (DALYs) per month of delay. RESULTS: Given the best available evidence, the 2 surgical procedures associated with most DALYs owing to delay were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 DALY/month, 95% confidence interval [CI]: 0.13-0.36) and transaortic valve implantation (0.15 DALY/month, 95% CI: 0.09-0.24). The 2 surgical procedures with the least DALYs were placing a shunt for dialysis (0.01, 95% CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95% CI: 0.01-0.02). CONCLUSION: Expected health loss owing to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgical procedures to minimize population health loss in times of scarcity. The model results should be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.

National Estimates of the Reserve Capacity of Registered Nurses Not Currently Employed in Nursing and Emergency Nursing Job Mobility in the United States.

STUDY OBJECTIVE: In a large-scale disaster, recruiting from all retired and nonworking registered nurses is one strategy to address surge demands in the emergency nursing workforce. The purpose of this research was to estimate the workforce capacity of all registered nurses who are not currently working in the nursing field in the United States by state of residence and to describe the job mobility of emergency nurses. METHODS: Weighted population estimates were calculated using the 2018 National Sample Survey of Registered Nurses. Estimates of all registered nurses, including nurse practitioners who were not actively working in nursing as well as only those who were retired, based on demographics, place of residence, and per 1,000 state population, were visualized on choropleth maps. Workforce mobility into and out of the emergency nursing specialty between 2016 and 2017 was quantified. RESULTS: Of the survey participants, 61% (weighted n=2,413,382) worked full time as registered nurses at the end of both 2016 and 2017. At the end of 2017, 17.3% (weighted n=684,675) were not working in nursing. The Great Lakes states and Maine demonstrated the highest per capita rate of those not working in nursing, including those who had retired. The largest proportion of those entering the emergency nursing specialty were newly licensed nurses (15%; weighted n=33,979). CONCLUSION: There is an additional and reserve capacity available for recruitment that may help to meet the workforce needs for nursing, specifically emergency nurses and nurse practitioners, across the United States under conditions of a large-scale disaster. The results from this study may be used by the emergency care sector leaders to inform policies, workforce recruitment, workforce geographic mobility, new graduate nurse training, and job accommodation strategies to fully leverage the potential productive human capacity in emergency department care for registered nurses who are not currently working.

Rapid Implementation of an Adult Coronavirus Disease 2019 Unit in a Children's Hospital.

OBJECTIVE: To describe the rapid implementation of an adult coronavirus disease 2019 (COVID-19) unit using pediatric physician and nurse providers in a children's hospital and to examine the characteristics and outcomes of the first 100 adult patients admitted. STUDY DESIGN: We describe our approach to surge-in-place at a children's hospital to meet the local demands of the COVID-19 pandemic. Instead of redeploying pediatric providers to work with internist-led teams throughout a medical center, pediatric physicians and nurses organized and staffed a 40-bed adult COVID-19 treatment unit within a children's hospital. We adapted internal medicine protocols, developed screening criteria to select appropriate patients for admission, and reorganized staffing and equipment to accommodate adult patients with COVID-19. We used patient counts and descriptive statistics to report sociodemographic, system, and clinical outcomes. RESULTS: The median patient age was 46 years; 69% were male. On admission, 78 (78%) required oxygen supplementation. During hospitalization, 13 (13%) eventually were intubated. Of the first 100 patients, 14 are still admitted to a medical unit, 6 are in the intensive care unit, 74 have been discharged, 4 died after transfer to the intensive care unit, and 2 died on the unit. The median length of stay for discharged or deceased patients was 4 days (IQR 2, 7). CONCLUSIONS: Our pediatric team screened, admitted, and cared for hospitalized adults by leveraging the familiarity of our system, adaptability of our staff, and high-quality infrastructure. This experience may be informative for other healthcare systems that will be redeploying pediatric providers and nurses to address a regional COVID-19 surge elsewhere.

Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy.

The first person-to-person transmission of the 2019 novel coronavirus in Italy on 21 February 2020 led to an infection chain that represents one of the largest known COVID-19 outbreaks outside Asia. In northern Italy in particular, we rapidly experienced a critical care crisis due to a shortage of intensive care beds, as we expected according to data reported in China. Based on our experience of managing this surge, we produced this review to support other healthcare services in preparedness and training of hospitals during the current coronavirus outbreak. We had a dedicated task force that identified a response plan, which included: (1) establishment of dedicated, cohorted intensive care units for COVID-19-positive patients; (2) design of appropriate procedures for pre-triage, diagnosis and isolation of suspected and confirmed cases; and (3) training of all staff to work in the dedicated intensive care unit, in personal protective equipment usage and patient management. Hospital multidisciplinary and departmental collaboration was needed to work on all principles of surge capacity, including: space definition; supplies provision; staff recruitment; and ad hoc training. Dedicated protocols were applied where full isolation of spaces, staff and patients was implemented. Opening the unit and the whole hospital emergency process required the multidisciplinary, multi-level involvement of healthcare providers and hospital managers all working towards a common goal: patient care and hospital safety. Hospitals should be prepared to face severe disruptions to their routine and it is very likely that protocols and procedures might require re-discussion and updating on a daily basis.

COVID-19 in obstetrics 2020: the experience at a New York City medical center.

The global spread of the SARS-CoV-2 virus during the early months of 2020 was rapid and exposed vulnerabilities in health systems throughout the world. Obstetric SARS-CoV-2 disease was discovered to be largely asymptomatic carriage but included a small rate of severe disease with rapid decompensation in otherwise healthy women. Higher rates of hospitalization, Intensive Care Unit (ICU) admission and intubation, along with higher infection rates in minority and disadvantaged populations have been documented across regions. The operational gymnastics that occurred daily during the Covid-19 emergency needed to be translated to the obstetrics realm, both inpatient and ambulatory. Resources for adaptation to the public health crisis included workforce flexibility, frequent communication of operational and protocol changes for evaluation and management, and application of innovative ideas to meet the demand.

Surge and Surge Capacity in Labor and Delivery Triage Volumes.

Objective To understand the variation in Labor and Delivery triage and delivery volumes in an urban tertiary care center and the types of visits associated with this variability. Study Design Retrospective descriptive study from the electronic medical record of 7,678 women presenting to Labor and Delivery Triage. Results Overall, there was a sixfold variation in Labor and Delivery triage visits (mean: 21, SD: 5.7, range: 6-36), with the least and most busy days having 28.6% and 171.4% of mean volume. Volumes varied 3.8- to 17-fold on weekdays and 4- to 11-fold on weekends. Significant variation in volume and triage evaluation type also occurred through the day, with admission for delivery as the predominate reason between 2 to 10 am, and outpatient assessments predominating thereafter (p < 0.001). Conclusion There is substantial variation in daily and hourly Labor and Delivery triage activity. If not planned for, this variability could strain available resources and negatively impact care. Further study of the effect of surges in Labor and Delivery triage and delivery volumes on pregnancy outcomes and of optimal methods to improve surge capacity in the Labor and Delivery setting are needed.

Declining trends in local health department preparedness capacities.

OBJECTIVES: We examined local health department (LHD) preparedness capacities in the context of participation in accreditation and other performance improvement efforts. MetHODS: We analyzed preparedness in 8 domains among LHDs responding to a preparedness capacity instrument from 2010 through 2012. Study groups included LHDs that (1) were exposed to a North Carolina state-based accreditation program, (2) participated in 1 or more performance improvement programs, and (3) had not participated in any performance improvement programs. We analyzed mean domain preparedness scores and applied a series of nonparametric Mann-Whitney Wilcoxon tests to determine whether preparedness domain scores differed significantly between study groups from 2010 to 2012. RESULTS: Preparedness capacity scores fluctuated and decreased significantly for all study groups for 2 domains: surveillance and investigation and legal preparedness. Significant decreases also occurred among participants for plans and protocols, communication, and incident command. Declines in capacity scores were not as great and less likely to be significant among North Carolina LHDs. CONCLUSIONS: Decreases in preparedness capacities over the 3 survey years may reflect multiple years of funding cuts and job losses, specifically for preparedness. An accreditation program may have a protective effect against such contextual factors.

Fueling the public health workforce pipeline through student surge capacity response teams.

In January 2003, the University of North Carolina Center for Public Health Preparedness established Team Epi-Aid to match graduate student volunteers with state and local health departments to assist with outbreaks and other applied public health projects. This study assessed whether Team Epi-Aid participation by full-time graduate students impacted post-graduation employment, particularly by influencing students to work in governmental public health upon graduation. In September 2010, 223 program alumni were contacted for an online survey and 10 selected for follow-up interviews. Eighty-three Team Epi-Aid alumni answered the survey (response rate = 37 %). Forty-one (49 %) reported participating in at least one activity, with 12/41 (29 %) indicating participation in Team Epi-Aid influenced their job choice following graduation. In 6 months prior to enrolling at UNC, 30 (36 %) reported employment in public health, with 16/30 (53 %) employed in governmental public health. In 6 months following graduation, 34 (41 %) reported employment in public health, with 27 (80 %) employed in governmental public health. Eight alumni completed telephone interviews (response rate = 80 %). Five credited Team Epi-Aid with influencing their post-graduation career. Experience in applied public health through a group such as Team Epi-Aid may influence job choice for public health graduates.

The 2022-2023 Pediatric Respiratory Illness Surge: Survey of Acute and Critical Care Resource Use.

OBJECTIVE: A surge of pediatric respiratory illnesses beset the United States in late 2022 and early 2023. This study evaluated within-surge hospital acute and critical care resource availability and utilization. The study aimed to determine pediatric hospital acute and critical care resource use during a respiratory illness surge. METHODS: Between January and February 2023, an online survey was sent to the sections of hospital medicine and critical care of the American Academy of Pediatrics, community discussion forums of the Children's Hospital Association, and PedSCCM-a pediatric critical care website. Data were summarized with median values and interquartile range. RESULTS: Across 35 hospitals with pediatric intensive care units (PICU), increase in critical care resource use was significant. In the month preceding the survey, 26 (74%) hospitals diverted patients away from their emergency department (ED) to other hospitals, with 46% diverting 1-5 patients, 23% diverting 6-10 patients, and 31% diverting more than 10 patients. One in 5 hospitals reported moving patients on mechanical ventilation from the PICU to other settings, including the ED (n = 2), intermediate care unit (n = 2), cardiac ICU (n = 1), ward converted to an ICU (n = 1), and a ward (n = 1). Utilization of human critical care resources was high, with PICU faculty, nurses, and respiratory therapists working at 100% capacity. CONCLUSIONS: The respiratory illness surge triggered significant hospital resource use and diversion of patients away from hospitals. Pediatric public health emergency-preparedness should innovate around resource capacity.

What If Nice Terrorist Attack Would Have Happened in Milan? Drawing a Disaster Plan for Mass Casualty Incidents Involving the Pediatric Population.

Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.

Health systems' "surge capacity": state of the art and priorities for future research.

CONTEXT: Over the past decade, a number of high-impact natural hazard events, together with the increased recognition of pandemic risks, have intensified interest in health systems' ability to prepare for, and cope with, "surges" (sudden large-scale escalations) in treatment needs. In this article, we identify key concepts and components associated with this emerging research theme. We consider the requirements for a standardized conceptual framework for future research capable of informing policy to reduce the morbidity and mortality impacts of such incidents. Here our objective is to appraise the consistency and utility of existing conceptualizations of health systems' surge capacity and their components, with a view to standardizing concepts and measurements to enable future research to generate a cumulative knowledge base for policy and practice. METHODS: A systematic review of the literature on concepts of health systems' surge capacity, with a narrative summary of key concepts relevant to public health. FINDINGS: The academic literature on surge capacity demonstrates considerable variation in its conceptualization, terms, definitions, and applications. This, together with an absence of detailed and comparable data, has hampered efforts to develop standardized conceptual models, measurements, and metrics. Some degree of consensus is evident for the components of surge capacity, but more work is needed to integrate them. The overwhelming concentration in the United States complicates the generalizability of existing approaches and findings. CONCLUSIONS: The concept of surge capacity is a useful addition to the study of health systems' disaster and/or pandemic planning, mitigation, and response, and it has far-reaching policy implications. Even though research in this area has grown quickly, it has yet to fulfill its potential to generate knowledge to inform policy. Work is needed to generate robust conceptual and analytical frameworks, along with innovations in data collection and methodological approaches that enhance health systems' readiness for, and response to, unpredictable high-consequence surges in demand.

Disaster metrics: quantitative estimation of the number of ambulances required in trauma-related multiple casualty events.

INTRODUCTION: Estimating the number of ambulances needed in trauma-related Multiple Casualty Events (MCEs) is a challenging task. HYPOTHESIS/PROBLEM: Emergency medical services (EMS) regions in the United States have varying "best practices" for the required number of ambulances in MCE, none of which is based on metric criteria. The objective of this study was to estimate the number of ambulances required to respond to the scene of trauma-related MCE in order to initiate treatment and complete the transport of critical (T1) and moderate (T2) patients. The proposed model takes into consideration the different transport times and capacities of receiving hospitals, the time interval from injury occurrence, the number of patients per ambulance, and the pre-designated time frame allowed from injury until the transfer care of T1 and T2 patients. METHODS: The main theoretical framework for this model was based on prehospital time intervals described in the literature and used by EMS systems to evaluate operational and patient care issues. The North Atlantic Treaty Organization (NATO) triage categories (T1-T4) were used for simplicity. RESULTS: The minimum number of ambulances required to respond to the scene of an MCE was modeled as being primarily dependent on the number of critical patients (T1) present at the scene any particular time. A robust quantitative model was also proposed to dynamically estimate the number of ambulances needed at any time during an MCE to treat, transport and transfer the care of T1 and T2 patients. CONCLUSION: A new quantitative model for estimation of the number of ambulances needed during the prehospital response in trauma-related multiple casualty events has been proposed. Prospective studies of this model are needed to examine its validity and applicability.

Potential pediatric intensive care unit demand/capacity mismatch due to novel pH1N1 in Canada.

OBJECTIVE: To investigate the possibility of pediatric intensive care unit shortfalls, using pandemic models for a range of attack rates and durations. The emergence of the swine origin pH1N1 virus has led to concerns about shortfalls in our ability to provide pediatric ventilation and critical care support. DESIGN: Modeling of pediatric intensive care demand based on pH1N1 predictions using simulation techniques. SETTING: Simulation laboratory. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data collected during the first wave of the pH1N1 in children in Canada were applied to several second wave pandemic models to explore potential pediatric intensive care unit ventilatory demands for Canada and to investigate the impact of vaccination upon these demands. In almost all cases studied, even for relatively low attack rates of 15%, significant pediatric intensive care unit shortages would be expected to occur. Vaccination strategies targeting 50% of the population significantly reduced demand, but shortages may still be expected. Although shortfalls can occur in all provinces, Ontario and British Columbia may experience the greatest supply-demand difference, even at low attack rates. CONCLUSION: Reducing the attack rate among children, whether through vaccination or additional measures, such as social distancing, will be critical to ensure sufficient pediatric intensive care unit capacity for continued pediatric care.

Investigating a pediatric hospital's response to an inpatient census surge during the 2009 H1N1 influenza pandemic.

BACKGROUND: On November 4, 2009, the 250-bed Seattle Children's Hospital (SCH) identified a surge in its census--245 inpatients, well above the average midnight census of 207. In response, SCH activated its pandemic influenza surge plan in an effort to decrease the inpatient census. Within 16 hours, 51 patients (20.4% of total bed capacity) had been discharged, and inpatient census at SCH decreased to 222 patients. METHODS: As part of a quality improvement project, SCH's response to the surge was investigated, with data drawn from interviews, a review of records created in the course of the surge plan implementation, an e-mail survey of attending physicians responsible for patient discharges, and models examining predictors of hospital discharges. FINDINGS: Analysis of three years of hospital data (2007-2009) indicated that the high census on November 4 was an uncommon but not unprecedented occurrence. In addition, there was a clear positive association between an evening's census and the number of discharges during the following 24 hours. SCH discharged essentially the same number of patients on November 4 as on previous high-census days when the surge plan was not activated, suggesting that the surge plan did not succeed in creating excess discharges. CONCLUSIONS: Increasingly, evidence indicates that care quality depends on the degree to which hospital resources are sufficient to meet demand. Reverse triage, at least as implemented by SCH on November 4, 2009, is unlikely to represent an effective solution to surge outside of a disaster setting because of its requirement for centralized decision making. SCH has incorporated the results of this review into the way that it collects and analyzes data, manages flow, and responds to inpatient surges.

Ramping Up a Pediatric Hospital Medicine Advanced Practice Provider Team Rapidly.

Pediatric Hospital Medicine (PHM) is a growing subspecialty with a broad scope. The Covid-19 pandemic demands flexible staffing models. Advanced practice providers (APPs) can be a valuable addition to hospital medicine teams, although there is no established training program for APPs within PHM. The authors' purpose is to describe how one institution rapidly established a PHM APP team by collaborating with experienced APPs working in other areas of the hospital. This APP team cared for 16% of the average daily census during the pilot period with no significant difference in length of stay compared to traditional teams.

The potential effectiveness of the WHO International Health Regulations capacity requirements on control of the COVID-19 pandemic: a cross-sectional study of 114 countries.

OBJECTIVES: We examined if the WHO International Health Regulations (IHR) capacities were associated with better COVID-19 pandemic control. DESIGN: Observational study. SETTING: Population-based study of 114 countries. PARTICIPANTS: General population. MAIN OUTCOME MEASURES: For each country, we extracted: (1) the maximum rate of COVID-19 incidence increase per 100,000 population over any 5-day moving average period since the first 100 confirmed cases; (2) the maximum 14-day cumulative incidence rate since the first case; (3) the incidence and mortality within 30 days since the first case and first COVID-19-related death, respectively. We retrieved the 13 country-specific International Health Regulations capacities and constructed linear regression models to examine whether these capacities were associated with COVID-19 incidence and mortality, controlling for the Human Development Index, Gross Domestic Product, the population density, the Global Health Security index, prior exposure to SARS/MERS and Stringency Index. RESULTS: Countries with higher International Health Regulations score were significantly more likely to have lower incidence (ß coefficient -24, 95% CI -35 to -13) and mortality (ß coefficient -1.7, 95% CI -2.5 to -1.0) per 100,000 population within 30 days since the first COVID-19 diagnosis. A similar association was found for the other incidence outcomes. Analysis using different regression models controlling for various confounders showed a similarly significant association. CONCLUSIONS: The International Health Regulations score was significantly associated with reduction in rate of incidence and mortality of COVID-19. These findings inform design of pandemic control strategies, and validated the International Health Regulations capacities as important metrics for countries that warrant evaluation and improvement of their health security capabilities.

Laboratory surge capacity and pandemic influenza.

In this issue, Crawford et al. describe their experiences running a clinical diagnostic laboratory during the first 3 weeks of the influenza A pandemic (H1N1) 2009 outbreak (1). During the early weeks of the outbreak, their laboratory, which serves 15 hospitals and affiliated physician practices in the greater New York City metropolitan area, experienced an approximately 8x increase in respiratory virus testing, reaching a maximum of about 900 samples processed in 1 day.

Laboratory surge response to pandemic (H1N1) 2009 outbreak, New York City metropolitan area, USA.

The North Shore-Long Island Jewish Health System Laboratories serve 15 hospitals and affiliated regional physician practices in the New York City metropolitan area, with virus testing performed at a central reference laboratory. The influenza A pandemic (H1N1) 2009 outbreak began in this area on April 24, 2009, and within weeks respiratory virus testing increased 7.5 times. In response, laboratory and client service workforces were increased, physical plant build-out was completed, testing paradigms were converted from routine screening tests and viral culture to a high-capacity molecular assay for respiratory viruses, laboratory information system interfaces were built, and same-day epidemiologic reports were produced. Daily review by leadership of data from emergency rooms, hospital facilities, and the Health System Laboratories enabled real-time management of unfolding events. The ability of System laboratories to rapidly increase to high-volume comprehensive diagnostics, including influenza A subtyping, provided key epidemiologic information for local and state public health departments.