The Case for Designated COVID-19 Hospitals
COVID-19 is a zoonotic virus originating from the Hubei province of China. COVID-19’s typical presentation of fever and cough can rapidly escalate to acute respiratory distress syndrome (ARDS) and sepsis (1). The initial outbreak rapidly spread into what is now a global pandemic, infecting over 750,000 people and leading to over 37,000 deaths (2, 3). The massive influx of COVID-19 patients quickly overwhelmed healthcare systems throughout the world including Italy, South Korea, and Iran (4, 5). The global impact of COVID-19 has been profound, and the public threat COVID-19 represents to the United States (U.S.) is the most serious since the H1N1 influenza outbreak in 1918 (6).
COVID-19 has an estimated R0 of 2.24 - 3.58, leading to a doubling rate every 6.4 days and has thus far demonstrated global exponential growth. With the optimal antiviral therapy still unknown and vaccines still in the early stages of development, the most effective action to combat this pandemic is to limit the human-to-human transmission (3, 7). Without large-scale measures to decrease transmission, projections estimate that 81% of the U.S. would become infected (8). The impact of public health interventions, such as social distancing, will reduce this number to 20-50% of the U.S. becoming infected. What is especially important is it will lead to a more gradual increase in case volume with a less dramatic but prolonged peak of the pandemic (Figure 1). As described below, this becomes incredibly important for the ability of the U.S. healthcare system to cope (9, 10).
Figure 1. The projected critical care beds needed (per 100,000) in the upcoming months based on the levels of community measures put in place (8).
The U.S. has 925,000 staffed hospital beds with 75,000 - 90,000 of those being critical care beds (11). The number of full-featured ventilators in the United States is approximately 62,000, with an additional 98,000 ventilators that are not full-featured but can provide basic ventilatory support in emergent cases (12). Approximately 4-5% of the U.S. population will require hospitalization, with 30% of these patients requiring critical care admission (13). This equates to 13.1 - 16.4 million patients being admitted and 3.93 – 4.92 million ICU admissions. Even with these infections spreading across 3-6 months, the need for hospital beds may be at least eight times the actual hospital capacity. An additional consideration is that patients admitted to the hospital with COVID-19 infection have an average hospital stay of 10.4 days (8). This issue is compounded by the exposure physicians and other healthcare staff are experiencing, which may lead to up to 20% of healthcare staff being unable to work for periods of time from being ill or self-isolated from high-risk exposure (13).
An example that provides a more tangible set of numbers: Philadelphia is a relatively hospital-rich metropolitan area compared to most cities in the United States. The greater Philadelphia area is home to about 4.1 million residents with 10,228 staffed hospital beds, 941 ICU beds, and 150 ventilators (14-17). This would equate to a projected 164,000 – 205,000 patients requiring hospital admission and 49,200 - 61,500 requiring ICU admission. Most models suggest a majority of these infections will occur within a 3-month surge. If the lower end of the COVID-19 case projection (164,000) in the greater Philadelphia area were spread evenly across 12 weeks, then that would lead to roughly 13,700 cases weekly. With an average hospital stay of 10.4 days, this would overwhelm the hospitals within a week with patients that require admission continuing to come in at the same pace for 11 more weeks.
Manpower and supply shortages also remain a major limitation in the U.S. healthcare system’s ability to handle the pandemic. These include the previously mentioned undersupply of ventilators, personnel shortages secondary to exposure and/or contracting COVID-19, lack of personal protective equipment (PPE), and supply chain roadblocks. To make matters worse, hoarding of PPE by the general public and unequal distribution of supplies have created a serious nationwide shortage. This has forced some medical professionals to use PPE that is below clinical standards, putting themselves and patients at risk (18).
The presence of COVID-19 positive patients in every hospital has also led to a massive strain on the healthcare infrastructure. Healthcare personnel that have the skills and training needed to treat COVID-19 patients are not optimally utilized. They are decentralized working under various healthcare systems where standardization of protocols for prevention, containment, and treatment of the disease will most likely change in each institution, making it difficult to establish best practices and advance our understanding of COVID-19 management.