Measures and Impact of Caseload Surge During the COVID-19 Pandemic: A Systematic Review.

OBJECTIVES: COVID-19 pandemic surges strained hospitals globally. We performed a systematic review to examine measures of pandemic caseload surge and its impact on mortality of hospitalized patients. DATA SOURCES: PubMed, Embase, and Web of Science. STUDY SELECTION: English-language studies published between December 1, 2019, and November 22, 2023, which reported the association between pandemic "surge"-related measures and mortality in hospitalized patients. DATA EXTRACTION: Three authors independently screened studies, extracted data, and assessed individual study risk of bias. We assessed measures of surge qualitatively across included studies. Given multidomain heterogeneity, we semiquantitatively aggregated surge-mortality associations. DATA SYNTHESIS: Of 17,831 citations, we included 39 studies, 17 of which specifically described surge effects in ICU settings. The majority of studies were from high-income countries ( n = 35 studies) and included patients with COVID-19 ( n = 31). There were 37 different surge metrics which were mapped into four broad themes, incorporating caseloads either directly as unadjusted counts ( n = 11), nested in occupancy ( n = 14), including additional factors (e.g., resource needs, speed of occupancy; n = 10), or using indirect proxies (e.g., altered staffing ratios, alternative care settings; n = 4). Notwithstanding metric heterogeneity, 32 of 39 studies (82%) reported detrimental adjusted odds/hazard ratio for caseload surge-mortality outcomes, reporting point estimates of up to four-fold increased risk of mortality. This signal persisted among study subgroups categorized by publication year, patient types, clinical settings, and country income status. CONCLUSIONS: Pandemic caseload surge was associated with lower survival across most studies regardless of jurisdiction, timing, and population. Markedly variable surge strain measures precluded meta-analysis and findings have uncertain generalizability to lower-middle-income countries (LMICs). These findings underscore the need for establishing a consensus surge metric that is sensitive to capturing harms in everyday fluctuations and future pandemics and is scalable to LMICs.

Assessing health care leadership and management for resilience and performance during crisis: The HERO-36.

BACKGROUND: Whereas organizational literature has provided much insight into the conceptual and theoretical underpinnings of organizational leadership and management during emergencies, measures to operationalize related effective practices during crises remain sparse. PURPOSE: To address this need, we developed the Healthcare Emergency Response Optimization survey, which set out to examine the leadership and management practices in health care organizations that support resilience and performance during crisis. METHODOLOGY: We administered an online survey in April to May 2022 to health care administrators and frontline staff intimately involved in their hospital's emergency response during the COVID-19 pandemic, which included a sample of 379 respondents across nine rural and urban hospitals (response rate: 44.4%). We used confirmatory factor analysis and quantile regressions to examine the results. RESULTS: Applying confirmatory factor analysis, we retained 36 items in our survey that comprised eight measures for formal and informal practices to assess crisis leadership and management. To test effectiveness of the specified practices, we regressed self-reported resilience and performance measures on the formality and informality scores. Findings show that informal practices mattered most for resilience, whereas formal practices mattered most for performance. We also identified specific practices (anticipation, transactional and relational interactions, and ad hoc collaborations) for resilience and performance. PRACTICE IMPLICATIONS: These validated measures of organizational practices assess emergency response during crisis, with an emphasis on the actions and decisions of leadership as well as the management of organizational structures and processes. Organizations using these measures may subsequently modify preparedness and planning approaches to better manage future crises.

Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series.

Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient's clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.

Right care, right place, right time. Regional systems of care are the best way to ensure patients with emergent conditions have the best outcomes.

A bystander calls 911 after witnessing an auto accident in rural Minnesota in which a passenger has been seriously injured. The dispatcher provides the caller with instructions on how to care for the person until the ambulance arrives. When emergency medical services personnel get to the scene, they find that the patient meets the criteria for trauma and activate a "trauma code" at the local hospital. Upon receiving that radio notification, the hospital calls in additional staff and also calls for a helicopter to transfer the patient to a tertiary care trauma center. Staff at the receiving hospital do an initial assessment and stabilize the patient. Helicopter personnel provide additional medications and interventions en route to the trauma center, where a specialty team is ready to deliver definitive care.

Splenic artery aneurysm: an important cause of hemoperitoneum and shock.

BACKGROUND: Splenic artery aneurysm ruptures are rare and highly morbid events that are frequently associated with pregnancy. However, approximately 15% may occur in men, and it is important to have this possibility in the differential diagnosis in cases of hemoperitoneum and hemorrhagic shock. Rapid diagnosis and treatment is essential to survival. OBJECTIVES: The aim of this report is to educate emergency physicians on the early recognition and treatment of this life-threatening event and to increase the awareness of this condition in male patients. CASE REPORT: We describe the evaluation and management of two cases of splenic artery rupture in male patients with unique presentations. CONCLUSION: Splenic artery aneurysm ruptures should be considered in the differential diagnosis in any patient with undifferentiated shock. Early diagnosis and treatment can save lives.

3 Echo: concept of operations for early care and evacuation of victims of mass violence.

This report describes the successful use of a simple 3-phase approach that guides the initial 30 minutes of a response to blast and active shooter events with casualties: Enter, Evaluate, and Evacuate (3 Echo) in a mass-shooting event occurring in Minneapolis, Minnesota USA, on September 27, 2012. Early coordination between law enforcement (LE) and rescue was emphasized, including establishment of unified command, a common operating picture, determination of evacuation corridors, swift victim evaluation, basic treatment, and rapid evacuation utilizing an approach developed collaboratively over the four years prior to the event. Field implementation of 3 Echo requires multi-disciplinary (Emergency Medical Services (EMS), fire and LE) training to optimize performance. This report details the mass-shooting event, the framework created to support the response, and also describes important aspects of the concepts of operation and curriculum evolved through years of collaboration between multiple disciplines to arrive at unprecedented EMS transport times in response to the event.

Trends in Patient Transfers From Overall and Caseload-Strained US Hospitals During the COVID-19 Pandemic.

Importance: Transferring patients to other hospitals because of inpatient saturation or need for higher levels of care was often challenging during the early waves of the COVID-19 pandemic. Understanding how transfer patterns evolved over time and amid hospital overcrowding could inform future care delivery and load balancing efforts. Objective: To evaluate trends in outgoing transfers at overall and caseload-strained hospitals during the COVID-19 pandemic vs prepandemic times. Design, Setting, and Participants: This retrospective cohort study used data for adult patients at continuously reporting US hospitals in the PINC-AI Healthcare Database. Data analysis was performed from February to July 2023. Exposures: Pandemic wave, defined as wave 1 (March 1, 2020, to May 31, 2020), wave 2 (June 1, 2020, to September 30, 2020), wave 3 (October 1, 2020, to June 19, 2021), Delta (June 20, 2021, to December 18, 2021), and Omicron (December 19, 2021, to February 28, 2022). Main Outcomes and Measures: Weekly trends in cumulative mean daily acute care transfers from all hospitals were assessed by COVID-19 status, hospital urbanicity, and census index (calculated as daily inpatient census divided by nominal bed capacity). At each hospital, the mean difference in transfer counts was calculated using pairwise comparisons of pandemic (vs prepandemic) weeks in the same census index decile and averaged across decile hospitals in each wave. For top decile (ie, high-surge) hospitals, fold changes (and 95% CI) in transfers were adjusted for hospital-level factors and seasonality. Results: At 681 hospitals (205 rural [30.1%] and 476 urban [69.9%]; 360 [52.9%] small with <200 beds and 321 [47.1%] large with ≥200 beds), the mean (SD) weekly outgoing transfers per hospital remained lower than the prepandemic mean of 12.1 (10.4) transfers per week for most of the pandemic, ranging from 8.5 (8.3) transfers per week during wave 1 to 11.9 (10.7) transfers per week during the Delta wave. Despite more COVID-19 transfers, overall transfers at study hospitals cumulatively decreased during each high national surge period. At 99 high-surge hospitals, compared with a prepandemic baseline, outgoing acute care transfers decreased in wave 1 (fold change -15.0%; 95% CI, -22.3% to -7.0%; P < .001), returned to baseline during wave 2 (2.2%; 95% CI, -4.3% to 9.2%; P = .52), and displayed a sustained increase in subsequent waves: 19.8% (95% CI, 14.3% to 25.4%; P < .001) in wave 3, 19.2% (95% CI, 13.4% to 25.4%; P < .001) in the Delta wave, and 15.4% (95% CI, 7.8% to 23.5%; P < .001) in the Omicron wave. Observed increases were predominantly limited to small urban hospitals, where transfers peaked (48.0%; 95% CI, 36.3% to 60.8%; P < .001) in wave 3, whereas large urban and small rural hospitals displayed little to no increases in transfers from baseline throughout the pandemic. Conclusions and Relevance: Throughout the COVID-19 pandemic, study hospitals reported paradoxical decreases in overall patient transfers during each high-surge period. Caseload-strained rural (vs urban) hospitals with fewer than 200 beds were unable to proportionally increase transfers. Prevailing vulnerabilities in flexing transfer capabilities for care or capacity reasons warrant urgent attention.

The Minnesota Medical Operations Coordination Center: A COVID-19 Statewide Response to Ensure Access to Critical Care and Medical-Surgical Beds.

BACKGROUND: COVID-19 led to unprecedented inpatient capacity challenges, particularly in ICUs, which spurred development of statewide or regional placement centers for coordinating transfer (load-balancing) of adult patients needing intensive care to hospitals with remaining capacity. RESEARCH QUESTION: Do Medical Operations Coordination Centers (MOCC) augment patient placement during times of severe capacity challenges? STUDY DESIGN AND METHODS: The Minnesota MOCC was established with a focus on transfer of adult ICU and medical-surgical patients; trauma, cardiac, stroke, burn, and extracorporeal membrane oxygenation cases were excluded. The center operated within one health care system's bed management center, using a dedicated 24/7 telephone number. Major health care systems statewide and two tertiary centers in a neighboring state participated, sharing information on system status, challenges, and strategies. Patient volumes and transfer data were tracked; client satisfaction was evaluated through an anonymous survey. RESULTS: From August 1, 2020, through March 31, 2022, a total of 5,307 requests were made, 2,008 beds identified, 1,316 requests canceled, and 1,981 requests were unable to be fulfilled. A total of 1,715 patients had COVID-19 (32.3%), and 2,473 were negative or low risk for COVID-19 (46.6%). COVID-19 status was unknown in 1,119 (21.1%). Overall, 760 were patients on ventilators (49.1% COVID-19 positive). The Minnesota Critical Care Coordination Center placed most patients during the fall 2020 surge with the Minnesota Governor's stay-at-home order during the peak. However, during the fall 2021 surge, only 30% of ICU patients and 39% of medical-surgical patients were placed. Indicators characterizing severe surge include the number of Critical Care Coordination Center requests, decreasing placements, longer placement times, and time series analysis showing significant request-acceptance differences. INTERPRETATION: Implementation of a large-scale Minnesota MOCC program was effective at placing patients during the first COVID-19 pandemic fall 2020 surge and was well regarded by hospitals and health systems. However, under worsening duress of limited resources during the fall 2021 surge, placement of ICU and medical-surgical patients was greatly decreased.

Minneapolis bridges falling down: emergency transfusion preparedness.

The 7/1/2007 bridge collapse into the Mississippi River was instructional from both a disaster response and a mass casualty transfusion response perspective. It is a well cited example of how community disaster response coordination can work well, especially following systematic preparation of an integrated response network. The blood center is and should be an integral part of this disaster response and should be included in drills where appropriate. We give personal perspectives on both the hospital and transfusion service response to this particularly dramatic event.

Experiences of US Clinicians Contending With Health Care Resource Scarcity During the COVID-19 Pandemic, December 2020 to December 2021.

Importance: The second year of the COVID-19 pandemic saw periods of dire health care resource limitations in the US, sometimes prompting official declarations of crisis, but little is known about how these conditions were experienced by frontline clinicians. Objective: To describe the experiences of US clinicians practicing under conditions of extreme resource limitation during the second year of the pandemic. Design, Setting, and Participants: This qualitative inductive thematic analysis was based on interviews with physicians and nurses providing direct patient care at US health care institutions during the COVID-19 pandemic. Interviews were conducted between December 28, 2020, and December 9, 2021. Exposure: Crisis conditions as reflected by official state declarations and/or media reports. Main Outcomes and Measures: Clinicians' experiences as obtained through interviews. Results: Interviews with 23 clinicians (21 physicians and 2 nurses) who were practicing in California, Idaho, Minnesota, or Texas were included. Of the 23 total participants, 21 responded to a background survey to assess participant demographics; among these individuals, the mean (SD) age was 49 (7.3) years, 12 (57.1%) were men, and 18 (85.7%) self-identified as White. Three themes emerged in qualitative analysis. The first theme describes isolation. Clinicians had a limited view on what was happening outside their immediate practice setting and perceived a disconnect between official messaging about crisis conditions and their own experience. In the absence of overarching system-level support, responsibility for making challenging decisions about how to adapt practices and allocate resources often fell to frontline clinicians. The second theme describes in-the-moment decision-making. Formal crisis declarations did little to guide how resources were allocated in clinical practice. Clinicians adapted practice by drawing on their clinical judgment but described feeling ill equipped to handle some of the operationally and ethically complex situations that fell to them. The third theme describes waning motivation. As the pandemic persisted, the strong sense of mission, duty, and purpose that had fueled extraordinary efforts earlier in the pandemic was eroded by unsatisfying clinical roles, misalignment between clinicians' own values and institutional goals, more distant relationships with patients, and moral distress. Conclusions and Relevance: The findings of this qualitative study suggest that institutional plans to protect frontline clinicians from the responsibility for allocating scarce resources may be unworkable, especially in a state of chronic crisis. Efforts are needed to directly integrate frontline clinicians into institutional emergency responses and support them in ways that reflect the complex and dynamic realities of health care resource limitation.

Using a web platform for equitable distribution of COVID-19 monoclonal antibodies: a case study in resource allocation.

While medical countermeasures in COVID-19 have largely focused on vaccinations, monoclonal antibodies (mAbs) were early outpatient treatment options for COVID-positive patients. In Minnesota, a centralized access platform was developed to offer access to mAbs that linked over 31,000 patients to care during its operation. The website allowed patients, their representative, or providers to screen the patient for mAbs against Emergency Use Authorization (EUA) criteria and connect them with a treatment site if provisionally eligible. A validated clinical risk scoring system was used to prioritize patients during times of scarcity. Both an ethics and a clinical subject matter expert group advised the Minnesota Department of Health on equitable approaches to distribution across a range of situations as the pandemic evolved. This case study outlines the implementation of this online platform and clinical outcomes of its users. We assess the impact of referral for mAbs on hospitalizations and death during a period of scarcity, finding in particular that vaccination conferred a substantially larger protection against hospitalization than a referral for mAbs, but among unvaccinated users that did not get a referral, chances of hospitalization increased by 4.1 percentage points.

Allocating scarce resources in disasters: emergency department principles.

Decisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the "greatest good for the greatest number" to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.

Allocating resources during a crisis: you can't always get what you want.

During a disaster or disease outbreak, health care providers may have to make difficult decisions about how to allocate scarce resources. A committee convened by the Minnesota Department of Health has recently focused on this issue as part of statewide disaster preparedness planning. This article presents the group's recommendation that health care facilities need to plan for shortages and introduces resources and strategies that can be used in planning. It also discusses ethical considerations that must be taken into account when shortages occur and decisions must be made about how to distribute equipment, supplies, or medications in short supply.

Opportunity Among Disaster: Reflecting on 2 Disaster Scenarios During the COVID-19 Pandemic.

Maintaining a public health emergency response for a sustained period of time requires availability of resources, physical and information technology infrastructure, and human capital. What perhaps is unprecedented is a medical center experiencing multiple disasters simultaneously. In this case study, the authors describe 2 separate disaster events experienced during the ongoing COVID-19 pandemic: (1) a cyberattack at Nebraska Medicine in Omaha, Nebraska, and (2) civil unrest following the murder of George Floyd in Minneapolis, Minnesota. Although these settings were very different, the following common themes can inform future disaster planning: the benefit of an already active incident command system, the prescient need for continuity of operations, and the anticipation of workforce fatigue. These dual-disaster experiences provide an opportunity to identify lessons learned that will drive improvements in emergency management through preparedness and mitigation measures and response innovations for future simultaneous disasters.