“An influenza pandemic has been expected by health officials for years, and one of the top concerns has been healthcare staffing,” according to a March 9 blog post by Terrey L. Hatcher with Relias.
Hatcher quoted an article in Emergency Medicine Reports offering validation, “ ‘In an infectious disease pandemic, the hospital resource most at risk for inadequate supply is staff.’ In fact, all healthcare staffing is at risk when a pandemic occurs.”
News reports from coronavirus “hot spots” across the US over the last several months indicate this has proven true. In summarizing a webinar offered July 29, 2020, by the National Academy of Medicine and the American Public Health Association, writer Stephanie Miceli noted, “Six months into the COVID-19 pandemic, many hospitals are still faced with staffing shortages due to the sheer volume of patients, staff illnesses, and non-COVID care that cannot be delayed.”
Of course, this is where locum tenens staffing often comes into play. In a CompHealth blog post on April 15, long-time locum tenens neurologist Andrew Wilner, who currently works in a permanent position at a teaching hospital in Tennessee, observed about the COVID-19 crisis, “We could not have been less well-prepared. We don’t have the equipment, we don’t have strategies, we don’t have medications, we don’t have vaccines, we’re not set up to work from home. Everything is completely ad hoc. I hope the curve continues to improve soon, because we’re really not set up for this.”
Fears of the Flu
As with the novel coronavirus now circulating around the globe, influenza produces a higher mortality rate among elderly individuals, infants, and people with comorbid chronic conditions. Influenza infects five to 20% of the population annually.
According to The Next Pandemic: Hospital Management, a monograph by Robert E. Falcone, MD, FACS, and Andrew Detty (both in clinical policy and population health with the Ohio Hospital Association), “The potential scope and scale of pandemic influenza, in particular, could be immense. Using previous 20th-century pandemics as a guide, the Department of Health and Human Services (HHS) estimates that 90 million Americans could fall ill and 209,000 (moderate HHS planning scenario) to 1.9 million (severe HHS planning scenario) could die.”
In the most recent flu season (October 1, 2019, to April 4, 2020), the US Centers for Disease Control (CDC) estimates there were 39 to 56 million flu illnesses; 410,000 to 740,000 hospitalizations; and 24,000 to 62,000 deaths in the United States (mortality rate estimated in range of 0.006% to 10%).
Meanwhile, with today’s COVID-19 pandemic, we so far (as of August 12, 2020) have hit roughly 5.2 million US cases with 166,073 deaths, for a three-percent mortality rate. Of course, there is a flu vaccine, but no COVID-19 vaccine (unless one counts the Russians’), less than a year since the coronavirus hit the United States.
The Power of Pandemics
The ‘Next Pandemic’ paper referred to by Relias’ Hatcher examined pandemics’ historical impact–both in the United States and worldwide, their likely impact in the near future, how prepared United States hospitals were in late 2015 (five years after the H1N1 pandemic, but five years before we knew COVID-19 existed), and special considerations for hospital operations during a pandemic. It begins as follows:
“Pandemics have had devastating consequences for civilizations worldwide since antiquity. Two ongoing world pandemics include tuberculosis (TB) and HIV/AIDS. Mortality from tuberculosis has fallen 47% worldwide since 2000. However, it is now the infectious disease responsible for the most deaths worldwide annually.” (Who knew?)
TB killed 1.5 million people in 2018, compared to 1.2 million people killed by HIV/AIDS (including 251,000 HIV-positive people in the TB death toll). In 2018 an estimated 10 million people fell ill with tuberculosis (TB) worldwide; the disease has killed more than 47 million people worldwide over the past 30 years. There were an estimated 38 million people living with HIV around the world at the end of 2019; the disease has killed more than 39 million people worldwide over the past 60 years.
While those are staggering statistics, consider that between the years 541 and 542 the Plague of Justinian (bubonic plague) killed 100 million people–and between 1346 and 1350 the Black Death (bubonic plague) killed another 50 million, according to authors Falcone and Detty.
 Statistics updated to latest available from the World Health Organization (WHO). Original monograph quoted 2014 data.
Health Organization Guidance
The World Health Organization (WHO) released new interim guidance for pandemic influenza risk management in 2013, delineating four phases. The HHS Pandemic Influenza Plan (published in November 2005) serves as a blueprint for US preparedness and response, and includes guidance for states and localities. In 2014, the CDC released a revised, six-interval framework aligned with the four WHO phases. The CDC updated its Hospital Preparedness for COVID-19 as of March 25, 2020. It includes guidance for healthcare facility workers, as well as healthcare facility tools.
Last reviewed July 2018, the Agency for Healthcare Research and Quality’s (AHRQ) Surge Toolkit and Facility Checklist offers a guide for reopening a closed (“shuttered”) hospital to expand surge capacity in an emergency. Key elements of the checklist include:
- Reviewing the emergency facility plan every six months.
- Establishing advance contracts with key vendors in categories including commercial cleaning, moving, temporary mechanical services staffing, refrigerated truck rental, and medical gas systems.
- Setting up ICU/quarantine areas (spaces with negative pressure).
- Setting up a surge staffing team to define type and numbers of staff needed, identify sources for each type of staff, develop credentialing verification procedures, prepare training and orientation materials, and provide for staff support.
- Activating the plan immediately after a catastrophic event occurs so the hospital can open within a week.
Possibly this (or similar military guidance) was the protocol followed in preparing the two US Navy hospital ships for deployment to New York and Los Angeles as overflow bed/ICU capacity during the devastating initial phase of COVID-19 in the United States.
There’s no reason why locum tenens staffing agencies couldn’t be added to the list of advance contractors for surge staffing consideration.
Healthcare Industry Response
Regarding coronavirus, executives participating in the July 29 webinar, How Can Hospitals Overcome Staffing and Supply Shortages Amid COVID-19 Surges?, included the chairman and CEO of Kaiser Foundation Health Plan Inc. and Kaiser Foundation Hospitals, the chief of Massachusetts General Hospital’s infectious diseases division, the president and CEO of Emory Healthcare, and New York State’s health commissioner.
Webinar reviewer Miceli noted that, “COVID-19 surges—and resurgences in some states—have meant that some hospitals are forced to implement their crisis standards of care (CSC) plans. CSC plans help determine who gets what care when resources are scarce, whether that’s related to staff with specialized skills, ventilators, or treatments like remdesivir.
“ ‘Just looking at the crisis standard of care documents was a sobering experience,’ said Rochelle Wallensky, chief of the division of infectious diseases at Massachusetts General Hospital and professor at Harvard Medical School. At Mass General, which has 12 hospitals, the number of patients on ventilators surged in mid-April—more than fourfold its standard ventilator use.”
Panelists discussed their strategies for “handling an influx of patients, including adjusting staff roles and responsibilities; pausing nonessential surgeries; and preserving staff morale and well-being.
“ ‘We’re looking, in essence, at running two systems—a COVID system and a non-COVID system of care,” Emory Healthcare President and CEO Jonathan Lewin said. ‘We’ve had to redeploy perioperative services staff to provide front-line testing, and redeploy people at the front desk to be temperature screeners. And there are patients who depend on us for care for heart attacks, transplants and brain surgery—and we need to be able to take care of them while flexing up our COVID care.’ ”
New York State Health Commissioner Howard Zucker suggested that what happens outside the hospital is just as important for managing COVID-19 surges. He noted New York ‘flattened the curve’ by sharing data to establish public trust, scaling-up testing and contact tracing, and ensuring consistent reopening efforts with neighboring states.
“Panelists anticipate that we’ll have to coexist with COVID-19 for at least a few years,” webinar reviewer Micheli said. “The pandemic has revealed that public health has been chronically underfunded and under-resourced—but it has also forced the healthcare system to reimagine new ways of doing things.
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