The NEW ENGLA ND JOURNAL of MEDICINE

Perspective May 14, 2020

Novel Coronavirus and Old Lessons —

Preparing the Health System for the Pandemic
John L. Hick, M.D., and Paul D. Biddinger, M.D.​​

H
ow sad that the people who remember the health care coalitions and other
Novel Coronavirus and Old Lessons

last major pandemic — influenza in 1968 constructs to share information

and policies and to create a region-
— are the primary victims of today’s. How al framework that supports a con-
sad that despite the many medical advances that sistent level of care. The following
actions are ones that we believe
have been made since then — cupied as possible. During the sec- health care organizations must
critical care, extracorporeal mem- ond week of March, only 21 of prioritize immediately so that we
brane oxygenation (ECMO), emer- more than 400 ICU beds were can do the most with what we
gency medicine, and emergency available in a typical U.S. metro- have available.
medical services, to name a few politan area. How will we cope To begin with, organizations
— the treatments offered to many with the thousands of Americans need to establish incident com-
patients in areas where Covid-19 who will need care? mand. Using well-developed prin-
has exploded are the same ones First, we need to work with ciples of incident action planning
they might have received in that our public health colleagues to and the concepts of crisis stan-
era. Perhaps the lessons they re- ensure that population-based in- dards of care,1 hospitals can plan
member, those of quarantine, iso- terventions — including social for volume-based adjustments to
lation, and social distancing, are distancing, quarantine, and iso- care delivery in all services lines,
the ones that will save us again. lation actions — are taken prompt- balancing demand and focusing
Modern medicine has so much, ly and prudently in order to flatten resources on acute care.2 The pan-
yet so little, to offer. Just-in-time the epidemic curve. demic is a long-term dynamic
staffing and supplies, “right- Second, we can use the foun- event that will require nearly con-
sizing,” and other competitive dations of preparedness built over stant proactive strategy develop-
strategies for health care and the recent decades to respond to the ment and problem solving.
supply chain conspire against pre- challenges of a novel threat. None In conjunction with public
paredness by reducing the num- of us is an island; we must work health efforts, hospitals can dra-
ber of hospital beds and ensuring with our health systems and local matically expand access to testing
that existing beds are kept as oc- and regional partners though through commercial, hospital, and

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PERS PE C T IV E Novel Coronavirus and Old Lessons

public health laboratories. We can- tute); in particular, it’s important family members, and convalescent
not afford large numbers of per- to agree on principles of initiation community volunteers may help to
sons seeking care at health care and withdrawal of ECMO and to support patient care. Working long
facilities and exposing each other use the processes dictated by crisis shifts in social and physical iso-
as well as uninfected patients. standards of care to make difficult lation while wearing PPE, risking
Rapid testing to ensure appropri- decisions about other critical care illness and even death, and work-
ate sorting of inpatients into co- resources, in keeping with pub- ing under great duress in new and
horts is required, as is testing of lished guidelines and evolving in- demanding roles will harm our
staff members who are ill, in or- formation about Covid-19 progno- providers. Hospitals should be
der to define safe work practices. sis.4,5 A regional plan for critical prepared to support them at work
Public health officials must take care referrals may optimize con- and at home to mitigate this
a lead role in clearly communicat- sistency as well as efficiency of stress, promoting resilience, pro-
ing which patients truly need test- transfers. viding appropriate rest, and re-
ing and who can safely stay home Expansion of inpatient critical warding their service. Educating
to prevent the medical care system care also relies on long-term care, staff now on their potential roles,
from being overwhelmed. alternative systems of care (in- challenges, use of PPE, and the
In addition, understanding peo- cluding alternative care sites), and expected adaptations to their prac-
ple’s end-of-life wishes is of critical home-based care to bear a greater tice can help empower them and
importance in a situation of poten- burden of discharges; careful plan- anticipate their needs.
tial resource scarcity in the face of ning with long-term care providers There are some opportunities
an illness that can require pro- is critical, since patients convalesc- for augmenting resources. Covid-19
longed aggressive interventions. ing from Covid-19 should be dis- seems to affect children at much
Difficult questions need to be ad- charged only to designated facili- lower rates than older adults, so
dressed, such as how to approach ties or to those already caring for many pediatric resources may be
each person’s desire for longer- such patients. available for both outpatient and
term mechanical ventilation, dialy- Protecting health care workers inpatient adult support. Specialty
sis, and continuation of aggres- is essential, and despite increases clinic and elective procedure vol-
sive measures if others are dying in production, we cannot avoid the umes may decrease rapidly, owing
without them. If we don’t ask reality that demand for N95 res- to both patient preference and
these questions, we may not have pirator masks and other personal decisions to cancel procedures,
the chance to honor wishes that protective equipment (PPE) will which will free up providers, clin-
could have saved another patient. continue to exceed supply for the ics, and operating rooms that can
At the same time, we need to near future. We must conserve be leveraged for acute care. Am-
expand inpatient critical care. A masks and other protective equip- bulatory surgical centers, proce-
staged plan to meet or exceed ment now, so that clinicians can dure centers, and other facilities
the 200% increase in critical care be protected later. We must also may offer substantial capacity, as
beds advised by the American Col- be strategic in our plans for PPE well as staff well versed in moni-
lege of Chest Physicians should be use and consider extraordinary toring patients with complex con-
developed using expanded areas strategies to extend our supply, in- ditions.
of cohort care for patients with cluding extended wear and reuse, Tremendous expansion of care
Covid-19.3 Non–Covid-related ser- as well as convalescent providers is possible with creative use of
vices will need to be preserved as forgoing PPE while working with space, staff, and supplies. How-
well, so hospitals should deter- infected patients. ever, the health care response will
mine how staffing will be man- Even if we do our best at pro- still be dependent for the most
aged to accommodate surges in tection, maintaining an adequate part on what we have right now
demand across a wide range of health care workforce in the face and the public health actions that
needs. They will have to plan for of school closures and illness will will help to blunt (though proba-
facility and regional processes for be exceptionally difficult. Under- bly prolong) the impact.
triage of resources, since there taking new assignments, practic- We applaud the $8.5 billion in
may be a shortage of “apex ther- ing at “top of license,” reducing federal funding for Covid-19 and
apies” (therapies that prevent death documentation and other burdens, the state legislatures that are
and have no appropriate substi- and using ancillary personnel, passing emergency funding bills,

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PE R S PE C T IV E Novel Coronavirus and Old Lessons

but these steps are akin to order- not understood by the public. Be- This article was published on March 25,
2020, at NEJM.org.
ing the best fire engine possible cause you can’t rely on private-
while your home burns. Why, in sector infrastructure to take on a 1. Institute of Medicine. Crisis standards
the years since the 2009 H1N1 massive public responsibility in of care:​a systems framework for catastrophic
influenza threat have we not de- disasters without proper planning disaster response:​Vol. 1:​Introduction and
CSC framework. Washington, DC:​National
veloped artificial intelligence so- and resources. Academies Press, 2012..
lutions integrated with our elec- No matter how severe the im- 2. Hick JL, Hanfling D, Wynia MK, Pavia AT.
tronic health records that could pact of Covid-19 is, the onus is 2020. Duty to plan:​health care, crisis stan-
dards of care, and novel coronavirus SARS-
be giving us real-time informa- on us all to do better next time, CoV-2 — discussion paper. NAM Perspectives.
tion on prognosis and treatment whether that outbreak is 1 year March 5, 2020. Washington, DC:​National
effectiveness? Why do we assume or 20 years hence. Let us clearly Academy of Medicine (https://nam​.edu/​duty​
-­to​-­plan​-­health​-­care​-­crisis​-­standards​-­of​
that a health care system that communicate our limitations and -­care​-­and​-­novel​-­coronavirus​-­sars​-­cov​-­2/​).
must run at maximal efficiency abilities and agree on where we 3. Einav S, Hick JL, Hanfling D, et al. Surge
and full occupancy to survive will, want to be — with agreed-on capacity logistics: care of the critically ill
and injured during pandemics and disasters:
without additional support, sud- thresholds, standards, and enter- CHEST consensus statement. Chest 2014;​
denly be able to meet the needs prise-wide capabilities that allow 146:​(4 Suppl):​e17S-e43S.
of all in a crisis? Why do we not us to say we learned our lessons 4. Christian MD, Sprung CL, King MA, et al.
Triage: care of the critically ill and injured dur-
have caches of inexpensive vol- this time. ing pandemics and disasters: CHEST con-
ume-cycled ventilators with basic Disclosure forms provided by the au- sensus statement. Chest 2014;​146(4 Suppl):​
alarm systems? thors are available at NEJM.org. e61S-74S.
5. Patient care:​strategies for scarce re-
Because we fail to learn the source situations. St. Paul:​Minnesota De-
From the Department of Emergency Medi-
lessons and dedicate the funding cine, University of Minnesota, and Henne- partment of Health, April 2019 (https://www​
and planning efforts required. Be- pin Healthcare — both in Minneapolis .health​.state​.mn​.us/​communities/​ep/​surge/​
(J.L.H.); and the Department of Emergency crisis/​standards​.pdf).
cause doing so is not prioritized by
Medicine, Harvard Medical School, and
regulators, payers, or most hos- Massachusetts General Hospital — both in DOI: 10.1056/NEJMp2005118
pital leaders. Because the need is Boston (P.D.B.). Copyright © 2020 Massachusetts Medical Society.
Novel Coronavirus and Old Lessons

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The New England Journal of Medicine
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Copyright © 2020 Massachusetts Medical Society. All rights reserved.