Planning for the Next COVID-19 Surge and Preventing a Crisis Care Scenario

Infectious diseases have been killing people throughout history, from the earliest known instances of smallpox—found on Egyptian mummies dating back to the third century BCE—to the ongoing coronavirus disease 2019 (COVID-19) pandemic. Addressing pandemics requires preventing infections, controlling the spread of the disease, and minimizing deaths through the use of comprehensive plans, policies, and procedures, explained Catherine Wittman, MD, BS, assistant professor of medicine at National Jewish Health, during her presentation.

Travel, she said, has always exacerbated these pandemics. When smallpox was spread among the ancient Egyptians, it was because of travelers had brought the disease to the area.

“As traveling has become quicker and cheaper, epidemics have turned into pandemics,” Wittman said. “There have been a number over the last century-plus, but only COVID has changed our daily life and severely affected our economy.”

When preparing for the next surge in COVID-19, or even the next pandemic, plans and procedures must address hospital capacity, emergency services, shortages of equipment and medicines, personal protective equipment, and the use of trained staff.

For instance, she said that HHS has estimated in the event of a moderate to severe flu pandemic, between 32 million and 48 million people will need outpatient care and up to 1.7 million will need intensive care unit (ICU) beds. However, there are only about 85,000 ICU beds in the United States.

If there is a surge in cases similar to the way New York City saw a surge in COVID-19 cases this past spring, health care facilities will need additional bed capacity, potentially by turning lobbies and patient waiting areas into hospital rooms.

According to Michal Sobieszczyk, MD, of Brook Army Medical Center, who presented during the same session as Wittman, another crisis will require care space to extend beyond traditional medical spaces to parking garages, hotels, schools, or sports arenas. However, he warned there are logistical challenges and this sort of solution “looks better on paper” than it actually does during implementation.

However, the main goal during times of disaster or a pandemic should be to avoid getting into a crisis care situation. During a crisis scenario, as patient care moves into nontraditional settings, there is insufficient staffing as well as supply usage outside the usual scope of care.

Crisis care is the last stage in a continuum of care, he explained; it starts with conventional care, which is largely business as usual with some extra demand that might require longer shifts but stays within the usual resources. Next is contingency care, which is a little out of the norm and requires repurposing space for patient care; this has a minimal but noticeable impact on usual care. In the last stage, crisis care, a health system cannot provide patient care that is consistent with its usual standards.

“The progression through continuum makes providing care increasingly difficult,” Sobieszczyk said. “It is important to keep underscoring that the transition to crisis care should be avoided or delayed as much as possible, since as the continuum passes through contingency into crisis, the standard of care drops and mortality and morbidity increase.”

Most patients during a pandemic are admitted to the hospital through the emergency department (ED), which can get quickly overwhelmed, Wittman said. These waiting rooms then turn into a source of infection, so it is important to find ways to minimize wait times. Some hospitals have been doing this through the use of telehealth for ED visits, zero contact registration to minimize wait times, and even geolocation to help prepare for patient arrivals, she said.

Testing and case finding is key to stopping a pandemic, but while it is estimated that 200 million monthly tests are needed for schools to open and stay open and to protect vulnerable populations in nursing homes, the United States Is currently conducting fewer than 30 million monthly COVID-19 tests, according to Wittman.

In addition to testing and case finding, the federal government needs to provide clear evidence-based guidance about public health laws, such as physical distancing, face coverings, and the use of federal contact tracers to monitor cases across state lines, she said. State and local governments should provide their own evidence-based public education on prevention strategies, such as mask wearing and social distancing, and public health laws should be implemented such as capacities at restaurants and bars and stay-at-home laws, she added.

During a pandemic, it is important to remember that “life goes on and disease goes on,” Wittman said. The majority of Americans have at least 1 chronic disease, and without continued monitoring, hospitalizations and deaths will increase. She noted that research has shown cancer screenings were down 86% to 94% in March and new cancer diagnoses fell 46.4% from January to April.

Circling back to smallpox, Wittman pointed out that smallpox was only eradicated after the World Health Organization set up a surveillance system to detect and investigate new cases and set up a campaign for mass vaccinations. Finally, in 1980, the world was declared smallpox free, but before that happened, 300 million to 500 million people were killed from the disease in just the 20th century, she said.

The eradication of smallpox is considered the biggest achievement in international public health, Wittman said, adding, “If smallpox can be eradicated from the world in the 1970s, surely with all the technology we have in 2020, COVID can be controlled and eliminated too.”