Tool Helps Hospitals Plan for Critical Care Surges During COVID-19

To help hospitals and health systems plan for a surge in critically ill patients during the COVID-19 pandemic, researchers from Rand Corporation have developed an interactive tool that allows decisionmakers to estimate current care capacity and explore strategies for increasing it.

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COVID-19 has created unprecedented strains on hospitals and healthcare systems, leaving many organizations with limited resources to care for severely ill patients. States, regions, hospitals, and health systems will need to assess their resources, identify potential bottlenecks, and develop strategies for increasing critical care capacity.

"Because the crisis falls upon a system that already is stretched thin, creating the critical care capacity needed for the surge in COVID-19 patients will require creative thinking about the allocation and use of space, staff and the stuff needed to provide critical care," said Dr. Mahshid Abir, co-author of the report and senior physician researcher at RAND.

The team designed a user-friendly tool that allows healthcare decisionmakers at all levels to estimate current care capacity and explore strategies for increasing it. Inputs into this spreadsheet tool include baseline number of beds, critical care doctors and nurses, respiratory therapists, and ventilators.

The model also allows users to set baseline numbers of ICU doctors, ICU nurses, and respiratory therapists per shift, as well as ratios of these providers to patients.

Additionally, users can input information related to how critical care physicians, critical care nurses, and respiratory therapists can act as supervisors for extender care providers – including ICU doctors supervising hospitalists, ICU nurses supervising floor nurses, and respiratory therapists supervising nurse anesthetists.

The tool allows users to specify additional spaces that can be created and used as ICU space, and additional ventilators that can be added to create critical care surge capacity.

The model then uses this information to estimate the number of patients who can be cared for, as well as which among the three of staff (critical care providers, respiratory therapists), space (beds), and stuff (ventilators) resources is the limiting factor in increasing capacity.

“These critical care capacity estimates can inform cross-regional critical care resource sharing—from regions with less demand to those with more demand,” the research team stated.

“We encourage hospital leaders and regional and state officials to use this tool to examine critical care capacity creation strategies using assumptions based on data from their communities.”

In addition to developing the tool, the group reviewed literature on experiences during past outbreaks and during COVID-19, conducted surveys of frontline clinicians, and held roundtables with leading emergency and critical care physicians to examine a range of strategies for increasing critical care capacity.

The team identified two tiers of activities that hospitals can undertake to expand critical care capacity. Tier one includes contingency capacity strategies: Adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on medical care delivery.

This might include converting post-anesthesia care unit (PACU) beds or operating rooms to ICU beds, drawing on emergency department and/or PACU nurses not on shift for ICU care, and borrowing, purchasing, or acquiring additional ventilators from stockpiles.

Tier two includes crisis capacity strategies. This involves changes that will likely have a significant impact on routine care delivery and operations. Strategies could include turning regular hospital beds into ICU beds, using open ICU beds in the Veterans Health Administration (VHA) and other federal or non-civilian facilities, using ICU beds in mobile hospitals, and reopening shuttered hospitals.

To examine the possible impact of these strategies on hospital capacity, the team used data on the ten Federal Emergency Management Agency (FEMA) regions to estimate the number of patients accommodated, given the number of available critical care doctors and nurses, respiratory therapists, ventilators, and hospital beds.

Researchers found that the number of ventilators is the most common limiting factor, followed by the number of critical care doctors. The number of nurses, respiratory therapists, or beds were not the limiting factor in any FEMA region. In most situations, tier two strategies produce more capacity than tier one options, but in some cases, there is little additional gain, the team noted.

In the roundtable discussions with providers, participants discussed the importance of whole-of-community partnerships, as well as an urgent need to identify community alternate care site partners.

“Alternate care sites could include community primary care clinics, urgent care centers, ambulatory surgical centers, and long-term care facilities,” researchers said. “Key partners include home health agencies, local governance, medical examiners’ offices, nonprofit organizations, pharmacies, public health departments, and needs agencies.”

Additionally, participants emphasized the need for real-time data sharing to increase situational awareness of critical care capacity among hospitals and across regions.

“When Italy began to appreciate the community spread of COVID-19, it began using an ICU network to increase capacity to care for and to distribute infected patients and non-COVID-19 patients with critical care needs," said Christopher Nelson, co-author of the study and a senior political scientist at RAND.

"Regionalization of critical care should be considered as the United States prepares for a surge in critical care needs with COVID-19."