Preserving access to care is a high priority, even in a pandemic. We need to strengthen the existing coordinated regional treatment network for better preparedness.
One consequence of the COVID-19 pandemic has been that people are scared to seek health care because they fear getting infected in clinics and hospitals. Although in many cases it is possible to delay elective care, that is less likely to be the case for urgent or emergency care. Restructuring care delivery to optimize resource diversion during a crisis such as COVID-19 could reduce the extent of delayed care.
Extent of delayed care
An analysis of national data from the Department of Veterans Affairs (VA) found that between March 11 and April 21, 2020, 42% fewer patients were admitted to VA inpatient facilities compared with the preceding 6 weeks. Data from New York City showed four times higher call volume for cardiac arrest during the week of March 30, 2020, compared with the same period last year. A higher rate of cardiac arrests could indicate delayed cardiac care-seeking practices during the pandemic. A complete analysis of the “collateral damage” resulting from deferred care during the pandemic will have to wait. However, it is evident that diverting healthcare resources is already having a significant impact on healthcare utilization.
Learning from the Ebola outbreak: Establishing a tiered coordinated response
While pandemics require large investments of resources, a key test of our preparedness is how well we can optimize resources during such critical times so that other healthcare services can continue uninterrupted. Management of the first Ebola case during the 2014-15 outbreak in the United States showed how limited preparedness can trigger significant resource diversion towards a major crisis. That first Ebola case was treated in a 24-bed intensive care unit (ICU) that was converted into an isolation unit, making the other 23 ICU beds unavailable.
An independent panel reviewed [PDF] the response of the US Department of Health and Human Services (DHHS) to the Ebola outbreak. The report cites a lack of preparedness in activating a coordinated response. The US invested billions of dollars [PDF] to improve the preparedness of its healthcare system to manage future outbreaks. Strategies [PDF] pursued included regionalized care in specific centers and establishing a protocol for a tiered coordinated approach to health care during outbreaks.
Regionalization of care is not a novel concept. It is already in place for the care of trauma, stroke, burn and cardiac patients. According to the Institute of Medicine, the phrase “regionalization of health care” refers to a structured system of care “to improve patient outcomes by directing patients to facilities with optimal capabilities for a given type of illness or injury.”
Gaps in the current system
A 2018 DHHS survey reported several challenges and barriers [PDF] faced by hospital administrators in sustaining their preparedness for emerging infectious diseases — in particular, financial constraints and competing priorities. The current pandemic has laid bare these deficiencies and shown that we are far from being able to activate the desired tiered coordinated response that can preserve access to care for non-COVID-19 needs. It is also important to note that in 2017, the DHHS acknowledged [PDF] that “…the current capacity of this system is not likely to be sufficient for many types of infectious disease outbreaks (e.g., pandemic influenza and other respiratory pathogens).”
Strengthening the Coordinated Regional Treatment Network
This isn’t likely to be the last novel virus we face. We need to build upon our efforts to have a systematic way to identify, assess, and treat people during an outbreak of a respiratory virus such as SARS CoV-2:
- Strengthening the existing Coordinated Regional Treatment Network could help to better triage care and more efficiently deal with both an outbreak-induced surge and routine care.
- A triage system can facilitate the staggered deployment of limited healthcare resources and reduce the fear of infection in all facilities.
- Designated centers can also enable improved coordination for the distribution of key supplies from federal, state, and local governments.
This care delivery structure will be critical as we loosen current restrictions on movement and social distancing while facing additional waves of cases. For example, we could start to triage COVID-19 patients to specialized facilities so that the overloaded facilities can recover and return to taking care of non-COVID patients sooner.
Let’s coordinate
The current pandemic has again taught us that maximizing outbreak response with minimal disruption to routine care is a critical part of our preparedness for future outbreaks. Using COVID-19 as an opportunity, we need to rethink what measures can be taken to strengthen the existing system of coordinating a tiered response to an outbreak to enable its quick and effective activation, with the goal of managing the outbreak without affecting access to other healthcare services.
Avni Gupta