Healthcare Hygiene magazine April 2020 | Page 34

As we have seen, ramped-up production of ventilators is also occurring to help address the shortage caused by COVID-19. As well, in late March, the Pentagon announced it will spend $84.4 million to purchase 8,000 ventilators from four vendors, with the first deliveries slated to happen in May. As Koonin, et al. (2020) observe, “During a severe pandemic, especially one causing respiratory illness, many people may require mechanical ventilation. Depending on the extent of the outbreak, there may be insufficient capacity to provide ventilator support to all of those in need.” The researchers suggest that, as part of the overall strategy to assist state and local planners to allocate stockpiled venti- lators to healthcare facilities during a pandemic, accounting for critical factors in facilities’ ability to make use of additional ventilators is key. They explain, “As a part of pandemic preparedness, public health officials should identify healthcare facilities in their jurisdiction that currently care for critically ill patients on mechanical ventilation to determine existing inventory of these devices and facilities’ ability to absorb additional ventilators. Facilities must have sufficient staff, space, equipment and supplies to utilize allocated ventilators adequately. At the time of an event, jurisdictions will need to verify and update information on facilities’ capacity prior to making allocation decisions. Allocation of scarce life-saving resources during a pandemic should consider ethical principles to inform state and local plans for allocation of ventilators. In addition to ethical principles, decisions should be informed by assessment of need, determination of facilities’ ability to use additional ventilators, and facilities’ capacity to ensure access to ventilators for vulnerable populations (e.g., rural, inner city, and uninsured and underinsured individuals) or high-risk populations that may be more susceptible to illness.” Experts have debated the adequacy of the current number of ventilators available in a pandemic scenario. “Although the current supply of approximately 62,000 ventilators in U.S. acute-care hospitals would likely be adequate to support patient care needs during a pandemic with mild to moderate severity (similar to the 2009 H1N1 pandemic), a pandemic with greater severity would probably result in many more patients requiring ventilatory support,” says Koonin, et al. (2020). “In this severe scenario, there will likely be insufficient capacity to ventilate all those who need this treatment.” They continue, “Assuming that ventilators would be effective in reducing morbidity and mortality during a future severe pandemic, researchers estimate that approximately 35,000 to 60,500 additional ventilators will be needed. To support this need, scientists estimate that with robust planning, if US hospitals could increase space and the number of trained and qualified staff to care for ventilated patients during a pandemic, approximately 26,200 to 52,400 additional patients could be ventilated at the peak of a pandemic. Another study of more than 4,400 hospitals found a significant increase in the number of adult intensive care beds between 2009 and 2011, but this growth was seen mostly in large urban teaching facilities, rather than in rural areas or smaller, less-resourced hospitals, which often serve residents with little or no other access to care. In addition, there has been an increase in the number of rural hospitals closing each year.” 34 In addition to having ventilator equipment and ancillary supplies, the researchers emphasize it is critical for healthcare facilities to have sufficient staff and space to care for as many patients as possible who require ventilation: “Legal experts have advised that hospitals, public health entities, and clinicians have an obligation to develop comprehensive, vetted plans for mass casualty incidents involving large numbers of critically ill patients,” Koonin, et al. (2020) say. “Considering these critical factors (i.e., sufficient staff, supplies and space), jurisdictions should plan for how they would allocate stockpiled ventilators to their relevant healthcare facilities. Researchers have proposed that allocation decisions for a limited supply of stockpiled ventilators to healthcare facilities should not use a pro-rata or ‘first come–first serve’” model, but rather they should base allocation on a detailed assessment of facilities’ capacity to absorb and use additional ventilators and to ‘ensure the efficient, effective, and ethical distribution of stockpiled ventilators’ to facilities that can best use them during an emergency.” In 2015, as part of a Pandemic Influenza Readiness Assessment exercise, the CDC assessed all Public Health Emergency Preparedness jurisdictions (n = 62) to ask about their readiness to respond to a pandemic. Within the Med- ical Countermeasures Module, jurisdictions were asked to identify the key considerations they would use to determine ventilator allocation to hospitals during a pandemic. Of the 62 jurisdictions queried, 57 responded. Several key findings from the response included that almost two-thirds of the jurisdictions had conducted a hospital-based assessment between 2010 and 2014 to determine their mechanical ventilation capabilities, and 48 percent of jurisdictions (in aggregate covering 46.4 percent of the U.S. population at the time) had not determined when or how they would train healthcare systems to operate ventilators from stockpiles. In addition, jurisdictions were asked about the key parameters that they would consider when evaluating to which facility they would allocate stockpiled ventilators. The most frequent parameter cited was the availability of trained and qualified staff, although this item as well as the number of ICU beds and availability of equipment and space were all cited by more than 70 percent of jurisdictions. As Koonin, et al. (2020) explain, “Patients who need mechanical ventilation will be critically ill and will require trained clinicians to provide comprehensive intensive care. The ability to absorb additional ventilators will depend on having sufficient trained and qualified staff to operate ventilators and care for patients, as well as adequate bed space, and availability of essential equipment and supplies needed to care for critically ill patients (e.g., oxygen, suctioning, airway management, monitoring equipment).” The researchers recommend, “As a part of pandemic preparedness, public health officials should identify and query healthcare facilities in their jurisdiction that care for critically ill patients on mechanical ventilation to learn about their current inventory of these devices and their ability to absorb additional ventilators. Information about the types of patient populations served (including facilities’ ability to care for critically ill neonatal and pediatric patients and adults including pregnant patients) should be collected. Healthcare coalitions that work with these facilities may be able to assist public health partners in april 2020 • www.healthcarehygienemagazine.com