Health care providers — including physicians, nurses, respiratory therapists and more — are projected to be the bottleneck resource in providing care for COVID-19 patients in the coming weeks. Even if we have enough beds and ventilators (which itself is not a given), the surge plan recommended by the Society of Critical Care calls for nonintensive care unit physicians and other providers without specialized critical care training to be pulled in to help care for the overwhelming number of patients.
But if the government officials don’t act now to help and protect our health care providers from becoming sick themselves, thousands of lives that otherwise might be saved will be lost.
A team at Imperial College in the United Kingdom predicted that, by mid-June — even with social distancing and household quarantines — the demand for intensive care beds in the United States would exceed capacity. This is the current situation facing patients in Italy, where nearly 13,000 patients were hospitalized last week and more than 2,000 were in the ICU.
The Imperial College analysis, however, did not account for provider absenteeism — which may be increasing, because our health care providers are constantly being exposed and are at risk of infection. In Italy, an estimated 20-30 percent of providers may have been infected.
In America, hospitals and health care providers are appealing for donations of personal protective equipment, like masks, gloves and gowns, to protect themselves from COVID-19 during what may turn out to be the early stages of the pandemic, knowing that sick health care providers will most likely worsen the crisis.
With protective equipment in such short supply, providers caring for COVID-19 patients are at greater risk of infection. But, the Centers for Disease Control and Prevention recently recommended that providers reuse masks, contrary to manufacturer guidelines, or even resort to bandanas in what seems to be an inevitable scenario in which there are no masks available. Certainly, such an approach will fall well short of the level of protection provided by standard equipment and procedures, and make American health care workers even more vulnerable to infection.
Mathematical simulations we performed of various scenarios show that, compared to using nothing, makeshift protective equipment can reduce the rate of infection among health care providers by only 10 percent, and partial protective equipment by only 25 percent — versus our conservative estimate of 50 percent with full equipment, based on the probability of community spread outside the hospital and research that shows protective equipment is subject to both failure and human error, especially in high-stress situations.
These findings suggest that providing only partial equipment has the potential to also reduce ICU treatment capacity by up to 3,000 patients at the time of peak infection. If full personal protective gear were really able to completely eliminate the risk of infection — as many clinicians believe it could under perfect conditions — the impact of only having enough to reduce infections by 25 percent would reduce ICU capacity by over 9,000 patients at the time of peak infection.
But even with full equipment, the inevitability of health care providers being infected will be a problem exacerbated by the United States’ severely limited testing capacity. Hospitals around the country simply do not have the ability at this time to test all symptomatic people, let alone all providers — and they may never get there. In the absence of test results, providers who exhibit any symptoms are (or should be) sent home for self-quarantine. This could be unnecessarily sidelining numerous providers. (If they are not being sent home to self-quarantine, then the results of those decisions are potentially more catastrophic.)
We created a model of the infection rate among providers, which accounts for the fact that the U.S. is still in the midst of influenza and cold season, so some providers may have symptoms common to all three viruses and thus be removed from their duties due to the inability to be tested for COVID-19. Our analysis suggests that, by April 15, the U.S. would have the capacity to treat up to 1,900 fewer critical patients if we are only able to test 30 percent of symptomatic providers instead of 100 percent.
If the U.S. were able to do widespread testing of providers and ensure broad protective equipment availability, more patients will be able to receive treatment because more providers will remain healthy and at work. Our analysis suggests that with a combination of full protective equipment and the testing of 100 percent of symptomatic providers, we will be able to increase ICU capacity by an average of 1,824 patients per day over the first 200 days, relative to a baseline of enough protective equipment availability to reduce infection by 25 percent and only a 30 percent testing rate. Assuming an eight-day ICU length-of-stay, this translates into over 45,600 more critically ill patients that could potentially be treated over the next 200 days.
While we may never get to the testing capacity of South Korea, it is unfathomable that our front-line health care providers are unable to get tests while young, healthy asymptomatic celebrities and athletes are getting tested. If testing is going to be limited to those who are symptomatic and require treatment, it should truly be limited, and if exceptions are made, they should only be made for people like health care providers and other essential workers whose status can make a real difference in the lives of others.
It is also time for the federal government to take drastic action and use the Defense Production Act to its fullest extent to increase our production capacity for both testing and protective equipment. Our health care providers need to be protected as they work the front line.
The mortality rate in China outside of Wuhan was 0.7 percent — but it was much higher in Wuhan itself, as there was diminished access to care there. We have to ensure that our front-line providers have the equipment they need and access to testing to minimize their risks and to maintain a healthy workforce. With many hospitals already nearing their capacity limits, we cannot afford to lose any more of our most vital health care resources: our providers. If the federal government doesn’t act now, lives will be unnecessarily lost.