Hospital Capacity and Operations in the Coronavirus Disease 2019 (COVID-19) Pandemic—Planning for the Nth Patient

The coronavirus disease 2019 (COVID-19) news coming from Italy should be sobering to health system leaders throughout the world. We are witnessing an advanced health system stretched beyond its capacity. When the capacity of the system is exceeded, rationing decisions may need to be made that extend well beyond patients with COVID-19. On March 11, the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care was forced to publish guidelines for rationing care. Infectious disease and epidemiology experts1 have been outlining the worst-case scenarios possible with the unchecked spread of a novel virus, both in terms of immunity and preparedness. Unfortunately, hospital systems are designed for average patient loads, not epidemics. Observations from Italy demonstrate what is at stake. When containment fails, the exponential growth of cases can transform a public health emergency into an operational crisis.


Introduction
The coronavirus disease 2019 (COVID-19) news coming from Italy should be sobering to health system leaders throughout the world. We are witnessing an advanced health system stretched beyond its capacity. When the capacity of the system is exceeded, rationing decisions may need to be made that extend well beyond patients with COVID-19. On March 11, the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care was forced to publish guidelines for rationing care.
Infectious disease and epidemiology experts 1 have been outlining the worst-case scenarios possible with the unchecked spread of a novel virus, both in terms of immunity and preparedness.
Unfortunately, hospital systems are designed for average patient loads, not epidemics. Observations from Italy demonstrate what is at stake. When containment fails, the exponential growth of cases can transform a public health emergency into an operational crisis.

What Can We Learn?
Operationally, what can be gleaned from the dire situation in Italy to avoid a similar fate in other countries? The geographic and temporal clustering of outbreaks can overwhelm a health care system. Most Italian cases and deaths have been concentrated in the northern region of Lombardy, which should concern US states working to manage their own clusters, including Washington and New York. President Trump has imposed sweeping travel restrictions on visitors from China and Europe, but these restrictions will have little effect in US regions with widespread community transmission. Public containment measures implemented in recent days will take a week or longer to have an effect; with an incubation period of 2 to 7 days 2 and a wait for test results of 2 to 3 days, new cases reflect infections from more than a week ago.
Patients with severe disease from COVID-19 require a mean of approximately 13 days of respiratory support. 2 Such lengthy treatment time will further stress resources. This time in the system multiplied by the arrival rate (known as Little's law) is a simple but elegant formula for modeling system capacity before a queue develops. In manufacturing or customer service, queues may result in decreased profitability and/or the loss of customers; in critical care medicine, queues can be deadly. For example, take a large hospital with 100 beds in the intensive care unit. Assume that at any given time, 70% of these beds are occupied. 3  have prided themselves on the efficiency that comes with just-in-time supply management and minimizing empty beds, but as a result, they may be ill equipped for an epidemic surge.
Hospital administrators need to start preparing for worst case scenarios now, and thankfully, most are doing so. Toner and Waldhorn 6 have assembled a comprehensive list of preventive actions.
This planning and response will require a multidisciplinary effort; physicians, nurses, respiratory therapists, pharmacists, environmental services staff, supply chain managers, and many others possess needed expertise. Messaging from hospital leadership must be communicated often and clearly. The protection of staff from infection must remain a high priority.

What Lies Ahead?
Some countries, such as Taiwan, 7 have been successful at combating the virus through aggressive testing and containment measures. South Korea, while initially inundated with patients from a rapidly spreading cluster, has successfully mitigated spread (at least temporarily) with minimal associated mortality. These examples provide encouragement that a well-executed public health response can minimize the potential for operational crises. The common themes in success have been massive testing, adaptive policy recommendations for different regions, and communication by public officials that is constant, transparent, and honest. The public needs to trust public officials and see the good and bad news every day.
In our interconnected world, the life-and-death consequences of health care needs exceeding the system's capacity could hit any region at any time. It is imperative to learn the lessons of Italy and Hubei, China: waiting until an exponentially increasing epidemic becomes self-evident will ensure that draconian efforts will be required for control, and even with these measures, there will be a significant loss of life. Actions taken now by society and health care systems will determine whether history regards 2020 as a great public health achievement or an epic failure of our public health and health care infrastructure.