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Critical Care Surge Response Strategies for the 2020 COVID-19 Outbreak in the United States

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Critical Care Surge Response Strategies for the 2020 COVID-19 Outbreak in the United States Research Report Critical Care Surge Response Strategies for the 2020 COVID-19 Outbreak in the United States Mahshid Abir, Christopher Nelson, Edward W. Chan, Hamad Al-Ibrahim, Christina Cutter, Karishma Patel, Andy Bogart C O R P O R A T I O N For more information on this publication, visit www.rand.org/t/RRA164-1 Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2020 RAND Corporation R® is a registered trademark. Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org About This Report The coronavirus disease 2019 (COVID-19) pandemic is placing extraordinary strains on the U.S. medical system, most especially hospitals. Hospitals are searching for ways to ramp up their surge capacity to provide critical care for the sickest COVID-19 patients. This report presents a range of strategies for creating critical care surge capacity in the nation’s hospitals. The report is accompanied by a user-friendly, Microsoft Excel–based tool that allows decisionmakers at all levels—hospitals, health care systems, states, regions—to estimate current critical care capacity and rapidly explore strategies for increasing it. The Excel tool and related user guide can be accessed at www.rand.org/t/TLA164-1. This research was conducted within RAND Health Care, a division of the RAND Corporation. The division promotes healthier societies by improving health care systems in the United States and other countries. We do this by providing health care decisionmakers, practitioners, and consumers with actionable, rigorous, objective evidence to support their most complex decisions. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s research findings and recommendations are based on data and evidence and therefore do not necessarily reflect the policy preferences or interests of its clients, donors, or supporters. For more information about RAND Health Care, see www.rand.org/health-care, or contact Peter Hussey, Vice President and Director, RAND Health Care 1776 Main Street P.O. Box 2138 Santa Monica, CA 90407-2138 (310) 393-0411, ext. 7775 [email protected] Funding for this research was provided by gifts from RAND supporters and income from operations. iii Contents About This Report .......................................................................................................................... iii Figures, Tables, and Boxes ............................................................................................................. v Summary ........................................................................................................................................ vi Acknowledgments ........................................................................................................................ viii 1. Background ................................................................................................................................. 1 2. Essential Components of Critical Care Capacity ........................................................................ 4 Baseline Capacity ..................................................................................................................................... 4 Surge Capacity .......................................................................................................................................... 5 3. Strategies to Create Critical Care Surge Capacity ...................................................................... 7 Space Strategies ........................................................................................................................................ 8 Staff Strategies ........................................................................................................................................ 12 Stuff Strategies ....................................................................................................................................... 15 Bringing It All Together in Systems: The Fourth “S” of Surge ............................................................. 16 4. Assessing Critical Care Capacity Created by Various Surge Strategies ................................... 19 5. Next Steps and Policy Recommendations ................................................................................ 27 Appendix. Research Methods ....................................................................................................... 31 Abbreviations ................................................................................................................................ 35 References ..................................................................................................................................... 36 iv Figures, Tables, and Boxes Figures Figure 1.1. Timeline of Key Events in the COVID-19 Outbreak ................................................... 1 Figure 1.2. Critical Care Bed Demand and Suppression Strategies Modeled for the United States ....................................................................................................................................... 2 Figure 2.1. Depiction of the Balance Needed Between Space, Staff, and Stuff for an Effective Critical Care Surge Response ................................................................................................. 4 Figure 3.1. Tiered Critical Care Staffing to Expand Capacity ...................................................... 14 Figure 4.1. U.S. FEMA Regions ................................................................................................... 19 Figure 4.2. Visual Display of FEMA Region–Level Estimates of Number of Patients Cared for Concurrently Under Baseline, Tier 1, and Tier 2 Scenarios ................................................. 25 Figure A.1. ACEP COVID-19 Survey .......................................................................................... 32 Figure A.2. Semistructured Roundtable Discussion Guide .......................................................... 34 Tables Table 2.1. Survey Responses to the Question: “What Areas Are You Currently Challenged with in the Setting of the COVID-19 Outbreak? Check All That Apply.” ..................................... 6 Table 3.1. Tiered Critical Care Surge Strategies for Space, Staff, and Stuff .................................. 8 Table 3.2. Intensive Care Unit Bed and Other Special Care Bed Capacity in the United States . 10 Table 3.3. Strategies from Roundtable Participants for Creating Space Capacity ....................... 11 Table 3.4. Strategies from Roundtable Participants for Creating Staff Capacity ......................... 14 Table 3.5. Strategies from Roundtable Participants for Creating Stuff Capacity ......................... 16 Table 3.6. Specific Strategies from Experts on Creating Critical Care System and Whole-of-Community Surge Capacity ................................................................................. 18 Table 4.1. Summary of Numeric Assumptions ............................................................................. 22 Table 4.2. Estimates of Surge Creation Using Data from FEMA Regions (Limiting Factor Shaded) ................................................................................................................................. 23 Boxes Box 1.1. COVID-19 Disease Characteristics and Critical Care Needs .......................................... 3 Box 2.1. Key Facts About Critical Care Capacity in the United States .......................................... 5 Box 5.1. Selected Resources on COVID-19 Critical Care Capacity ............................................ 29 v Summary The coronavirus disease 2019 (COVID-19) outbreak is creating unprecedented stresses on hospital and health care systems around the globe. Hospitals, health care systems, states, and regions need to urgently assess their resources, identify potential bottlenecks, and create strategies for increasing critical care surge capacity, the resources needed to care for the sickest patients with the novel coronavirus. In late March 2020, the United States surpassed China as the country with the greatest numbers of confirmed COVID-19 cases (Lin, 2020), and it is estimated that up to 60 percent of the population in the United States could be infected over the course of the pandemic if social
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