key: cord-0846360-lrijqav0
authors: Patel, Ravi; DeWaters, Ami; Khalid, Muhammad; Wojnar, Margaret; Haouzi, Philippe
title: Share Patients, Not Ventilators: Lessons From an Academic Center With a Low Admission Rate of COVID-19 Patients
date: 2020-11-04
journal: Chest
DOI: 10.1016/j.chest.2020.06.036
sha: 96ad7f63f7f08e193c97e32432219ffd5629c0a3
doc_id: 846360
cord_uid: lrijqav0

nan

To the Editor:

We still have a very poor understanding of the mechanisms driving the outcome of patients in acute respiratory failure, when dealing with limited critical care resources in face of sheer patient surges as has occurred during the current coronavirus disease 2019 (COVID-19) pandemic. In their paper recently published in CHEST (September 2020), Ramachandran et al 1 called attention to the need for a coordinated nationwide strategy aiming at sharing ventilators between hospitals. There is, however, a paucity of evidence to support that the mortality rate has been influenced by limited access to ventilators or equipment in the United States. In addition, the benefit of increasing the number of accessible ventilators without the proper experienced "human power" or while treating mechanically ventilated patients outside the setting of well-organized ICU units, can certainly be challenged on several grounds. For instance, our institution-Milton S. Hershey Medical Center-underwent strategic expansion to increase the number of beds available by the early March. To our surprise, from March through May, 107 COVID-19 patients were admitted to our institution, with two fatalities (case fatality rate ¼ 1.8%), considerably lower than the figures reported in the literature. Our community-based affiliate, St. Joseph's Medical Center, simultaneously experienced a similar number of admissions (95 patients; Table 1 ) during the same 2-month period, but with a case fatality rate that reached 9.5% (c 2 ¼ 5.65; P < .05). Fundamentally, the two hospitals differ in bed and thus personnel capacity, resulting in a much higher "burden ratio," the ratio between the number of COVID-19 patients admitted and the overall number of beds (46.5% for St Joseph's Medical Center vs 19.5% for Milton S. Hershey Medical Center). The experience described in the Northwell Health Hospitals in New York 2 is highlighted by an extremely high burden ratio (124%), with a global mortality rate computed over 1 month only (March) at 9.7%. We, therefore, propose that our fortunate outcome is primarily attributable to a disproportionate excess of relative capacity and resources allocated to a low rate of admission of COVID-19 patients. This contention implies that limiting the number of COVID-19 patients below an individualized threshold should be associated with a reduction in the overall mortality rate.

The development of regional and national policies 3 allowing for rapid, safe, and effective dispersal of patients between medical institutions that have experience and expertise in treating patients in acute respiratory failure, rather than increasing capacity to accommodate more patients in a given institution, could well represent the primary remedy to this burden/ mortality relationship. We appreciate Dr Patel and colleagues' response to our article. 1 Their experience mirrors findings of others that suggest the case fatality from coronavirus disease 2019 (COVID-19) rises with increasing burden ratio placed on medical centers. 2 We agree that hospitals should attempt to mitigate this effect by following surge capacity principles such as those laid out in the CHEST Consensus Statement. 3 These may include sharing of resources among hospitals in a health care system, as well as timely and safe transportation of patients between centers based on utilization. We also agree that transfer of patients to regional centers that have developed experience and expertise in treating these challenging patients would be useful and may indeed lead to improved outcomes.

The focus of our message remains, however, that preparation by individual medical centers will likely be insufficient when there is a catastrophe that affects an entire region. Referring back to the analogy used in their letter, let us imagine that all of the hospitals in their entire health system reached full ICU capacity, but excess ICU capacity remained in neighboring regions.

This type of catastrophe would require a coordinated response across county, state, and corporate lines. Surge capacity preparations by individual health systems and interfacility transfers, while crucial, may be insufficient to deal with such a surge of COVID-19 patients, for several reasons. Interfacility transfers of patients, which are neither timely nor efficient during the best of times, would be impractical during a mass disaster. The available mechanisms to transport patients would likely become saturated in such situations. In addition, if all of the facilities in a given region have reached their surge capacity, the distance to transport patients to an available facility may be too great.

In such situations, it would be most efficient to bring critical care resources to the patients, a concept endorsed by CHEST Consensus Statement. 3 Unfortunately, health care systems cannot do this on their own. Regional control of the critical care supply chain requires the coordination of a patchwork of health systems, private companies, and government agencies. As cases of COVID-19 increase in multiple states, 4 it is imperative that government agencies work quickly to create the framework allowing for the rapid reallocation of critical care supplies within and across their borders. 

Risk factors for dysphagia in ICU patients following invasive mechanical ventilation

Dysphagia in Mechanically Ventilated ICU Patients (DYnAMICS): a prospective observational trial

Nomogram for survival analysis in the presence of competing risks

Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management

Dysphagia in the intensive care unit: a (multidisciplinary) call to action

A national strategy for ventilator and ICU resource allocation during the coronavirus disease 2019 pandemic

Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area

Surge capacity principles