V. Logistics / Resource Allocation (Current / Future)

March 29, 2021

• Hospital load and increased COVID-19 related mortality in Israel. 3/26/21. Rossman H. Nature.
  An analysis of all 22,636 Israeli COVID-19 inpatients from mid-July 2020 – mid-January 2021 determined that in-hospital mortality increased significantly when >62.5% of the national capacity for severely ill patients (800 beds) was occupied. A validated model using Monte-Carlo methods and a set of Cox regressions was used to predict mortality. Two high-occupancy periods had 22% (SE 3.1%) and 27% (SE 3.3%) greater mortality. Authors postulate that excess mortality during periods of high caseload was most likely due to “an insufficiency of health-care resources.”

February 1, 2021

• Association of Intensive Care Unit Patient Load and Demand With Mortality Rates in US Department of Veterans Affairs Hospitals During the COVID-19 Pandemic. 1/19/2021. Bravata DM. JAMA Netw Open.
  VA Study – 88 facilities/8516 RT-PCR + COVID-19 patients admitted March-August 2020. Defined 2 variables: ICU Load (ratio mean number COVID-19 ICU patients during patients’ hospitalization and facility total number ICU beds;) ICU Demand (ratio mean number COVID-19 ICU patients and the peak number of COVID-19 ICU patients at facility during study period). Trended data suggested mortality increased when ICU resources overextended. While not surprising, authors suggest mechanisms to reduce ICU overload including regional referrals/transfers and enhanced public health awareness to reduce ICU and hospital burden. Results may not reflect current therapeutic interventions and mortality statistics.
• Intensive Care Unit Strain and Mortality Risk Among Critically Ill Patients With COVID-19-There Is No “Me” in COVID. 1/19/2021. Rubinson L. JAMA Netw Open.
  Commentary adds context and stimulates consideration/discussion beyond primary hypothesis. Raises questions regarding regional patient transfer and newer management strategies developed during study that may have impacted results. Discusses positive effects of public policy interventions and organized central/community/government response to implement pandemic control strategies designed to decrease requirements for hospital admissions.

January 8, 2021

• Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools. 12/14/20. Li Y. Anesth Analg.
  In this pragmatic report from Boston, authors share their revised workflows and checklists for all aspects of obstetric anesthesia care in the COVID-19 era. A cyclical improvement methodology was used to design each new workflow. Challenges include simultaneous care of infected patients alongside noninfected patients, inherent uncertainties regarding the course of labor and delivery, and need for coordination with other departments such as neonatology. Authors developed independent workflows and procedure-specific material kits that may be used alone or in sequence without extensive staff training to facilitate care and conserve resources.

October 26, 2020

• Sensible Medicine—Balancing Intervention and Inaction during the COVID-19 Pandemic. 10/15/20. Seymour CW. JAMA.
  This article, which contains a discussion relevant for all practitioners engaged in clinical care cautions against abandoning clinical experience and consultation for early adoption of unproven and potentially harmful therapies. The authors urge that practitioners use sensible medicine, a blend between doing nothing and going all in. Their argument is well illustrated and supports the current therapeutic state in which good clinical care in well-managed ICUs following established protocols appears to be effective management strategy. No therapeutic agent has demonstrated significant mortality benefit with the exception of dexamethasone administered appropriately. The discussion supports the decision to steer a middle course with elegance and logic and is refreshing, timely and relevant.

September 9, 2020

• Cardiac Surgery-Enhanced Recovery Programs Modified for COVID-19: Key Steps to Preserve Resources, Manage Caseload Backlog, and Improve Patient Outcomes. 9/1/20. Gregory AJ. J Cardiothorac Vasc Anesth.
  The authors discuss modifications to cardiac ERPs given case backlogs and overlapping resource utilization requirements between cardiac surgery patients and COVID-19 patients. The discussion includes specific metrics as well as an overview of organizational approaches relevant to the COVID-19 environment. Adaptations are likely to influence care models beyond the pandemic and concepts are applicable to a wide range of specialty care.

May 29, 2020

• Emergence from the COVID-19 Pandemic and the Care of Chronic Pain: Guidance for the Interventionalist. May 21. Deer T. Anesth Analg.
  Chronic pain management took a back seat during the peak of the COVID-19 crisis which resulted in considerable hardship for many chronic pain sufferers. This publication by the American Society of Pain and Neuroscience COVID-19 Task Force provides guidance for chronic pain interventionalists and outlines methods and resources necessary to safely re-introduce essential pain management procedures into daily practice.

May 16, 2020

• Organ procurement and transplantation during the COVID-19 pandemic. May 11. Loupy. Lancet.
  The authors conclude that the COVID-19 pandemic has caused a dramatic loss of organs all across the world. Deceased organs denied means more preventable death likely in coming months. The overall reduction in deceased donor transplantations since the COVID-19 outbreak was 90.6% in France and 51.1% in the USA, respectively. In both France and the USA, this reduction was mostly driven by kidney transplantation, but a substantial effect was also seen for heart, lung, and liver transplants, all of which provide meaningful improvement in survival probability. Leaders of medical institutions will make difficult decisions about how best to deploy limited medical resources. The authors state that the data from public record suggests the only option is living related organ transplant.

May 15, 2020

• COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU
  May 7. Verdiner. Anesthesia & Analgesia.
  Opinion from SAB Member: Dr. Jagdip Shah
  Practitioners from the American Society of Anesthesiologists (ASA), the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF), representing more than a dozen universities in the USA, created the COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU working group. The specific goal is to address the shortage of critical care medicine (CCM) MDs in this current COVID-19 pandemic when supply is mismatched with demand, by fast-tracking anesthesiologists with short notice. This long article is formatted as a knowledge-based guideline. It addresses all possible potential areas of weaknesses in anesthesiology knowledge as it pertains to practicing in the ICU on day #1. The authors have provided state of the art information about the pathophysiology of COVID-19, pertaining to all the disciplines (respiratory, cardiovascular, renal, inflammation cascades, central nervous system, infection control, endocrinology, coagulation dichotomy, etc.) in a dynamic fashion. The article is a well referenced and complete effort to inform non-ICU physicians in simple formats of an inner working of the ICU regarding: multi-specialty involvement, scoring systems for patients, the ABCDEF Bundle (Assess, prevent, and manage pain, Both spontaneous awakening trials and spontaneous breathing trials, Choice of analgesia and sedation, Delirium: assess, prevent, and manage, Early mobility and exercise, and Family engagement and empowerment), drug therapy / interactions, supply shortages and their implications, managing codes, interpretation of monitors, ventilator synchronizations, proning, CPR, ARDS, glucose control, ECHO, ECMO, CRRT/dialysis/ultrafiltration, ethical philosophy, the role of the triage committee, and role of palliative care and hospice. The authors explain clearly that COVID-19 is a very different disease regarding its transmissibility to the caregivers, and stresses the need for adaptability of the healthcare system for a huge surge of ICU demand while optimizing the patients for greater benefit and greater good without wasting time, effort and resources.

May 2, 2020

• Return to normal—prioritizing elective surgeries with low resource utilization. Apr 29. Wilson. Anesthesia & Analgesia.
  In an effort to commence elective surgery without overburdening their ICU, a large hospital in NYC did a statistical analysis of pre-COVID-19 elective surgeries, looking at ICU admission and ventilator use. Cardiac, abdominal and spine surgeries in patients with a high co-morbidity burden were at greatest risk. Such an organized approach to determining how to open to elective surgery is commendable, and is likely to vary in different institutions. Ventilation and ICU care may not be the limiting resource to make such decisions.

April 29, 2020

• Regional Planning for Extracorporeal Membrane Oxygenation Allocation During COVID-19
  Apr 20. Prekker. CHEST.
  Opinion from SAB Member: Dr. Lydia Cassorla
  This pre-proof review from the University of Minnesota and the Mayo Clinic provides a well thought out and succinctly described framework for regional ECMO resource planning and operational deployment. Their approach involves regional situation awareness, a high degree of coordination between centers with ECMO capability, clinical decision support tools, involvement of expert clinicians in decision making and triage of resources to those most likely to benefit. It also addresses the ethical and practical aspects of not continuing to offer ECMO during a disaster, a decision best based upon a pre-existing framework. Priority for ECMO, which is described as a “trial of support rather than an indefinite resource assignment”, is based upon probability of survival, expected duration of ECMO, illness severity and patient age. A table outlines their framework for prioritization. Acute respiratory failure due to infection including flu and corona viruses is expected to require a “long” duration of >5 days with anticipated survival >60% if all other organ systems are intact. The authors anticipate that when more data of sufficient quality is available for COVID-19 patients treated with ECMO, it may become clearer how to optimally leverage this limited resource.

April 25, 2020

• COVID-19 in Children in the United States. Intensive Care Admissions, Estimated Total Infected, and Projected Numbers of Severe Pediatric Cases in 2020. Apr 16. Pathak. J Public Health Management and Practice.
  This study projects the number of children with COVID-19 that will need hospitalization in the US by the end of 2020, based on US PICU admission data from Virtual PICU Systems (VPS) March 18 through April 6, 2020 and studies from China. For every COVID-19 PICU admission, there are an estimated 2400 infected children in the community — 176,000 nationwide as of April 6. Modeling scenarios projected 11% of children hospitalized for COVID-19 will require PICU care. The authors caution that real-time surveillance of US COVID-19 cases need to be improved.

April 20, 2020

• A conceptual and adaptable approach to hospital preparedness for acute surge events due to emerging infectious diseases. Apr 20. Anesi. Crit Care Explor.
  This narrative review provides a framework for factors that must be incorporated into an effective response to an epidemic or pandemic. The focus is on bringing order to what might otherwise be a chaotic situation. Graphics and definitions are useful in conceptualizing the many stressors and optimal responses to a surcharged system. Causes of healthcare capacity strain are defined as increased volume, increased acuity, special care requirements and resource reduction (relative to demand), and the “4 Ss” of surge preparation discussed: Space, Staff, Stuff, Systems. Perhaps most useful for clinical leaders, policy experts and healthcare administrators.
• Hospital Preparedness for COVID-19: A Practical Guide from a Critical Care Perspective. Apr 17. Griffin KM. Am J Respir Crit Care Med.
  This detailed report from Cornell outlines the adaptations implemented at a large university medical center in one of the epicenters of the SARS CoV2 pandemic. Topics include evolving indications for O2 therapy, intubation and ECMO, PPE, team models, physician staffing and expansion of duties, multidisciplinary care including infectious disease, critical care medicine (CCM), cardiology, anesthesiology, respiratory care, physical therapy, palliative care, and nursing. ICU care was standardized under supervision of CCM specialists regardless of patient location or provider background. Many adaptations in care were designed to limit opportunities for infection of workers, such as dedicated smart phones within ICU care rooms, monitors and care information outside rooms when feasible (compliant due to restricted visitors), bundled care, and dedicated or defined teams for many aspects of care such as invasive procedures and proning. Education, triage, and ethical considerations and wellness are also discussed.
• The Utah Model: mental bandwidth and strategic risk generation in COVID-19 airway management. Apr 17. Runnels S. Anaesthesia.
  Correspondence regarding the Consensus guidelines for managing the airway in patients with COVID-19 by Cook et al.
  Two points are raised: “First, failure to minimise aggregate airway management risk poses a strategic threat to our medical systems, and two, it is critical to include the risk of mental bandwidth saturation as a risk for contamination.” They feel that protecting providers is the first principle of the current resource-constrained system. The authors provide a graph which shows that increasing aerosolization risk due to increasing airway management complexity correlates with increasing provider stress.

April 16, 2020

• Balancing Supply and Demand for Blood during the COVID-19 Pandemic. Apr 13. Gehrie E. Anesthesiology.
  Thoughtful discussion on COVID-19 impact on disruption of normal sources to maintain national blood supply highlights decreased donations due to elimination of mobile blood drives at schools, universities and other public locations contrasting with continuing demand and overall decrease in donation which parallels other efforts to decrease demand over past decade. Further mitigation discussion recognizes cancellation of elective surgeries (living donor transplantation, etc.), “keeping the blood in the patient”, single unit transfusions in order to keep blood available for other needs. Recommendations: encourage healthy donors to go to donation centers and optimize currently available and practice recommended blood management techniques.

April 15, 2020

• Application and effects of fever screening system in the prevention of nosocomial infection in the only designated hospital of coronavirus disease 2019 (COVID-19) in Shenzhen, China. Apr 14. Huang T. Infect Control Hosp Epidemiol.
  Nothing new or unique.

April 14, 2020

• Collaborative Delirium Prevention in the Age of COVID-19. Apr 12. LaHue. J Am Geriatr Soc.
  This is an opinion piece without data. The authors highlight the burden of delirium when it occurs and propose strategies to reduce the likelihood of delirium in both Covid-19 patients and other hospitalized patients in the Covid-19 era.
• COVID-19 and Crisis Management Resource Management on L&D. Apr 13. Minehart. OpenAnesthesia and SOAP.
  This 55 min video of a talk by an OB Anesthesiologist and Crisis Management specialist from Massachusetts General Hospital is about general principals of team building and crisis management.
• COVID-19 Guidance for Triage of Operations for Thoracic Malignancies: A Consensus Statement from Thoracic Surgery Outcomes Research Network Mar 24. Thoracic Surgery Outcomes Research Network, Inc. The Annals of Thoracic Surgery
  Opinion from SAB Member: Dr. Jagdip Shah, Dr. Jay Przybylo
  Dr. Jagdip Shah: A working model proposed by a group of surgeons for cancer patients for delayed surgery. Dr. Jay Przybylo: For all specialties, classifying elective versus urgent procedures places the onus of decision making on the person charged with running the procedural schedule. This position would be aided with a uniformed determination of those procedures presently classified differently between institutions. Little disagreement exists with procedures such as cardiac valve failure. Postponing tumor biopsy and therapy has resulted in patients waiting before treatment can begin. A national declaration could be beneficial to afflicted patients.
• Disinfection of N95 respirators by ionized hydrogen peroxide in pandemic coronavirus disease 2019 (COVID-19) due to SARS-CoV-2. Apr 12. Cheng. J Hosp Infect.
  Validation of the effectiveness of hydrogen peroxide in decontaminating N95 masks. This Hong Kong based team used a SteraMist™ Surface Unit which sends ionized H2O2 through mask material like a gas and demonstrated negative viral cultures following treatment. Influenza A virus was used as a test virus as it has similar characteristics to a coronavirus. The process was considered faster than competing systems with only a few hours drying time until reuse. There was no mention of testing for integrity of the treated material.
• Medically-Necessary, Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic Apr 9. Prachand. Journal of the American College of Surgeons.
  Opinion from SAB Member: Dr. W. Heinrich Wurm
  A resource and safety conscious scoring system, created by surgeons at the University of Chicago to identify medically-necessary, time-sensitive procedures and facilitate surgical treatment of non-COVID-19 related disease during the height of the pandemic in an efficient and ethical manner. Taking into consideration perioperative outcome, likelihood of virus transmission to health care personnel and utilization of hospital resources, the authors identified 21 factors related to procedural complexity, aspects of disease and patient co-morbidities. As proof of concept, the scoring system was applied retrospectively to cases done in the week of March 20th and performed well. A few limitations were identified, particularly in factor weight assignment, and may require adjustments as the pandemic runs its course.
• Sterilization of disposable face masks by means of standardized dry and steam sterilization processes; an alternative in the fight against mask shortages due to COVID-19. Apr 12. Van Straten. J Hosp Infect.
  This study was performed in the Netherlands in preparation for the Covid-19 pandemic to assess potential re-sterilization of normally disposable face masks in case of shortage. 3M FFP2 masks, individually packed in laminate bags were steam sterilized at 121°C for 15 min. (effective to inactivate bacteria and viruses) up to 5 times. They were functionally indistinguishable from new masks regarding particle filtration, breathability (pressure/flow), and fit. Only a few masks were tested and the authors encouraged others to test and validate their results. The authors relayed experiences of others that higher heat (134°C) had resulted in mask deformation. Gamma radiation was also evaluated however the particle filtration of the masks decreased.

April 8, 2020

• Ark of Life and Hope-Role of Cabin Hospital in Facing COVID-19. Apr 4. Shu. J Hosp Infect.
  Chinese government transformed public places into Cabin hospitals for the treatment of patients with mild and moderate COVID-19. Over one month, a total of 14 Cabin hospitals were opened in Wuhan, and more than 12,000 patients confirmed with COVID-19 were treated, most of whom were cured and discharged and only a few patients were transferred to designated hospitals for further treatment due to exacerbations. These played a crucial role in the prevention and treatment of COVID-19 patients, and quickly solved the problem of insufficient beds in a short period of time, which greatly accelerated the admission of patient, reducing the conversion rate from mild and moderate cases of COVID-19 to severe and critical cases.
• Covid-19: Increased demand for steroid inhalers causes “distressing” shortages. Apr 5. Mahase. BMJ.
  Brief note regarding shortages of steroid inhalers with recommendation not the “stock pile.”
• Essential care of critical illness must not be forgotten in the COVID-19 pandemic. Apr 5. Baker. Lancet.
  Lancet correspondence highlighting difficulties associated with CCM in low resourced environments and emphasizing excellent basic care as a fundamental requirement that may ameliorate disease progression and prevent complications from early disease. While important, states the obvious and is a future looking approach rather than an immediate aid, even in low income environments. Longer range awareness and planning should incorporate these principles which already are in effect in many such areas.
• Fangcang shelter hospitals: a novel concept for responding to public health emergencies. Apr 6. Chen. Lancet.
  Defines criteria for creating temporary isolation hospitals designed to care for mild to moderate disease with provisions for triage to higher level care in traditional facilities if condition deteriorates. Hospital designed for basic care with important feature of isolating mild symptoms from community and home environment while providing appropriate medical and social care. A form of isolation that provides relief from traditional hospitals and supports home environment from contamination with infected family member. Different concept than current additional bed capacity construction in US. Cultural environment may make universal adoption problematic. The discussion is interesting and may prove useful in future epidemic/pandemic strategic planning.
• Harnessing Our Humanity – How Washington’s Health Care Workers Have Risen to the Pandemic Challenge Apr 1. Rosenbaum. NEJM.
  COVID-19 SAB Opinion from: Dr. Philip Lumb
  Articulate discussion of challenges faced when balancing traditional medical treatment priorities with realities of equipment shortages (protective and therapeutic), patient isolation, loss of family support and healthcare worker tensions arising from the unknown challenges ahead. The discussion presents challenges across all areas including Trainees, Nursing staff, front line CCM and ED providers, Environmental Service Workers, Patients and their Families. Fundamental message is that clear direction and agile protocols are supportive and reassuring, but must be focused, adaptable and transparent.
• Hospital surge capacity in a tertiary-emergency referral-centre during the COVID-19 outbreak in Italy. Apr 5. Carenzo. Anaesthesia.
  An Italian experience: the author reviews the steps of disaster preparedness: setting up a dedicated cohort COVID ICU with its own Command / Control & Coordination Center overseeing these several wings of an existing hospital. It was managing the dedicated: SPACE – each wing of building / supply constant monitoring demand / staff in shifts. Emphasizes the training of new recruits of qualified personnel from other specialties. Early importance of pre-Triage is mandatory and explains how this becomes more dynamic process with time. The hospital was broadly divided in Red/ yellow / green zone for patient & staff movement.
• Monitoring behavioural insights related to COVID-19. Apr 6. Betsch. Lancet.
  Interesting insight into population management in times of crisis based on Weekly COVID Snapshot Monitoring (COSMO) initiated on March 3 in Germany. Contains links to COSMO and WHO Europe websites detailing data collection methodology and resources for information integration. Interesting insight and information.
• Setup of a Dedicated Coronavirus Intensive Care Unit: Logistical Aspects Mar 30. Anesthesiology. Mojoli.
  COVID-19 SAB Opinion from: Dr. Jagdip Shah
  Short, informative article. There is a diagram about isolation ICU set up as a hospital is trying to increase “surge capacity” by 50%. The article explains exactly what/how to set up an isolation ICU.
• Where Have All the Heart Attacks Gone? Apr 6. Krumholz. NY Times.
  Except for treating Covid-19, many hospitals seem to be eerily quiet.

April 7, 2020

• A nightmare approaches: Hospitals painfully prepare for life and death decisions. Apr 7. AAMC News.
  A report on how some university-based hospitals are making decisions about allocation of medical resources to patients.

April 2, 2020

• The COVID-19: Role of Ambulatory Surgery Facilities in This Global Pandemic. Mar 31. Rajan. Anesthesia & Analgesia.
  Explores the potential contribution of ambulatory surgery facilities in the current healthcare crisis.

April 1, 2020

• COVID-19: Elective Case Triage Guidelines for Surgical Care. Mar 24. AMS.
  The American College of Surgeons issues guidelines for scheduling elective surgeries.
• Statement from the Ambulatory Surgery Center Association regarding Elective Surgery and COVID-19. ASCA.
  ASCA issues statement for how to decide if elective surgery should be scheduled during the COVID-19 pandemic.

March 30, 2020

• Leading Health Care Groups Issue Urgent Call for Federal Action to Address Medical Equipment Shortages. AHA.

March 28, 2020

• Options to Prolong Existing and Surge Capacity Supplies of Respirators during Infection with Novel Influenza A Viruses Associated with Severe Disease.

March 27, 2020

• Coronavirus (COVID-19) Update: FDA takes action to help increase U.S. supply of ventilators and respirators for protection of health care workers, patients. FDA. March 27, 2020.
• Experts say COVID-19 will likely lead to US drug shortages.

March 25, 2020

• ECDC warns of overwhelmed hospitals, Italy-type COVID-19 pattern. CIDRAP. March 25, 2020.
• Perspective: Critical Supply Shortages — The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic. NEJM. March 25, 2020.

March 24, 2020

• Coronavirus (COVID-19) Update: FDA takes action to increase U.S. supplies through instructions for PPE and device manufacturers. March 24, 2020.

March 23, 2020

• Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. March 23, 2020.
• FDA Continues to Facilitate Access to Crucial Medical Products, Including Ventilators. March 22, 2020.

March 20, 2020

• SCCM: Scaled Pandemic Preparedness: From Large Medical Center to Community Hospital – What Do You Need To Do?
• Strategies to Inform Allocation of Stockpiled Ventilators to Healthcare Facilities During a Pandemic. Health Security. March 20, 2020.

March 19, 2020

• United States Resource Availability for COVID-19 (beds, ventilators, staff). March 19, 2020.