By Melinda Young

EXECUTIVE SUMMARY

The COVID-19 pandemic has disrupted American life and threatens to inundate hospitals with critically ill patients through the spring. Hospitals and case managers can use phone and video conferencing when feasible. Also, they can follow all infectious disease prevention measures.

  • A surge of critically ill patients is expected by May in hospitals across the United States.
  • The 2019-2020 flu season was the worst in 30 years in terms of its effect on children, but it was ending before COVID-19 hit the United States.
  • Even with widespread social distancing and closed businesses and venues, communities and hospitals are not prepared for peak outbreaks.

It started in the United States with an infection outbreak on the West Coast. Soon after, America’s way of life shut down, and infections and deaths escalated because of the COVID-19 pandemic.

By mid-March, only a few hospitals began receiving a surge of patients critically ill from the coronavirus. Infectious disease physicians and epidemiologists predicted that by May, many cities would experience surges of severely ill patients from COVID-19.

“What happened in China and what is happening before our eyes in Italy is a tsunami of critical cases coming to medical systems. They cannot handle them, and the mortality rate is skyrocketing,” says Greg Poland, MD, professor of medicine and infectious diseases at the Mayo Clinic. Poland also is the director of the Mayo Vaccine Research Group. “In countries that do not have that overwhelming demand, the mortality rate is very low.”

“America has not gotten the memo,” he adds. “I’m going out now, and people are crowded into a restaurant with the assumption they won’t have a serious illness, based on their age. They may or may not be correct.”

But it is a false assumption, Poland says. “We’re a selfish culture and do not understand the effect on other people and those who have very high risk,” he adds.

If there is a silver lining in the pandemic, it is that it hit the United States at the tail end of the flu season instead of during its peak, says Kathleen Fraser, MSN, MHA, RN-BC, fellow of the American Academy of Nursing and executive director of the Case Management Society of America (CMSA). Fraser also is chief executive officer of Fraser Imagineers in Houston.

The 2019-2020 flu season was the worst in 30 years in terms of its effect on children. Usually, influenza A dominates. But, this season, influenza B spread, which hits children harder than does influenza A, Fraser notes.

“Flu season hit earlier than it has in the past three decades, and it hit more kids this year than it has in 30 years,” she adds. “It was a very different and difficult flu season.”

Then, starting in January or February, COVID-19 began to spread in the United States. This novel viral infection typically presents with a cough, fever, and shortness of breath.

This particular virus infectious for a long time while the patient is asymptomatic, said Dawn Bowdish, PhD, assistant professor at McMaster University in Hamilton, Ontario. Bowdish spoke at a March 16 video conference on COVID-19. (The recording is available at: https://www.newswise.com/articles/covid-19-exploring-the-unanswered-questions-with-newswise-live-expert-panel?sc=sphn.)

Unprecedented Situation

When people begin to feel symptoms, it means their immune response is dealing with that virus. As a result, most people will limit their public activity. But when a virus has a long incubation period, it can spread easily and infect more people.

“Most people display symptoms five to seven days after they’re infected,” Bowdish said.

Public health officials have called for 14-day (or longer) quarantine periods because of evidence the virus stays infectious longer, she added.

“We are facing a situation in this country that the vast majority of us have never experienced before, and it’s at a level we have no experience with,” said R. Sean Morrison, MD, co-director of the Patty and Jay Baker National Palliative Care Center and an Ellen and Howard C. Katz professor and chair, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai in New York City. Morrison spoke about COVID-19 at a March 18 webinar from the Center to Advance Palliative Care (CAPC). CAPC has made several COVID-19 response toolkits and resources available at no charge to the public at: https://www.capc.org/toolkits/covid-19-response-resources/.

“Everyone in this country with serious illness will need to be cared for. We need a workforce with knowledge about palliative care, and we need it right now,” Morrison said.

Case managers and palliative care professionals can support patients through phone calls and, when possible, video conferencing. “Complex patients with the highest symptoms may need bedside consultation,” Morrison explained. “But most of our work will be through telemedicine and telephone support. That’s critical for a number of reasons, including because it allows us to keep our workforce, which is very scarce, healthy.”

If closings and social distancing measures work as planned — slowing and stretching out infection clusters — then healthcare facilities have time to prepare for expected surges in viral outbreaks. This is where case managers can help. Hospital case managers can continue to perform their discharge and transition planning duties as well as they can, Fraser suggests.

“Case managers are making sure they can get patients out of the hospital when they don’t need to be there,” she says. “They make certain patients are ready to be discharged safely.”

Case managers and other healthcare professionals can learn more about the pandemic and ethical issues through a recent framework report for healthcare institutions, available at: https://www.thehastingscenter.org/ethicalframeworkcovid19/.

Ebola Experience Helped Preparation

The Ebola outbreak of 2014-2015 helped prepare U.S. hospitals for an epidemic, said Paul Biddinger, MD, MGH endowed chair in emergency preparedness, director of the Center for Disaster Medicine, and vice chairman for emergency preparedness in the department of emergency medicine at Massachusetts General Hospital. Biddinger spoke to journalists and others at a web conference on March 13.

“Many hospitals and healthcare systems felt unprepared in 2015 for Ebola,” Biddinger explained. “As serious a disease as it is in a nation with a significantly developed healthcare system, it’s much less of a threat [than COVID-19] because it only spreads with symptoms and by contact, so we’re grateful that disease outbreak didn’t spread further.”

A national Ebola education center was developed to help health systems deal with outbreaks and epidemics involving unusual infectious diseases, he said. “We’ve been preparing for something like this coronavirus,” he added.

The University of Nebraska Medical Center, Emory University, and New York Health and Hospitals established the National Ebola Training and Education Center (NETEC). NETEC’s goal is to increase the U.S. public health system’s capability to effectively manage cases with suspected and confirmed infection by special pathogens. (More information is available at: https://netec.org/about/.)

Proper PPE Usage Is Critical

Biddinger is involved with NETEC through Massachusetts General Hospital. Through the Ebola experience, public health and emergency preparedness experts learned the importance of wearing personal protective equipment (PPE) and doffing properly, he said.

“The importance of donning and doffing PPE is one of our most important lessons learned,” Biddinger explained. “How you take off PPE is one of the most important things a healthcare organization can focus on.”

Healthcare workers who doff PPE incorrectly, or in the wrong sequence, can release droplets in the air and breathe them in, he noted.

Hospital patients with lung disease, diabetes, and compromised immune conditions are at greatest risk of critical illness from COVID-19. Healthcare providers should keep in mind that geriatric patients might not have as high of a fever with the disease as do younger adults and children, said XinQi Dong, MD, a researcher in epidemiology at Rutgers University in New Brunswick, NJ. Dong spoke at a March 12 video conference.

The most vulnerable patients also might include those with ongoing pulmonary disease, emphysema, asthma, hepatitis, lupus, and those taking medication that suppresses the immune system, Dong added. “Elderly patients are in most need of care,” he said.

Despite the United States’ efforts to slow COVID-19 and hospitals’ more recent efforts to acquire additional PPE, ventilators, and other necessary supplies, the public health sector is not prepared for multiple outbreaks and surges in hospitalized, critically ill patients, noted Ali Khan, MD, PhD, professor in the department of epidemiology at the University of Nebraska Medical Center. Khan also spoke at the March 12 video conference about COVID-19.

“During a really bad flu year, we see emergency room and hospital diversions [of resources] because we can’t handle a bad flu year in the United States, let alone this pandemic,” Khan says. “How do we take care of patients coming in the door, making sure we do it safely?”

Also, how do hospitals ensure their staff and non-COVID-19 patients remain safe from infection? How do they handle dozens of patients being admitted on one day with the viral infection?

“Now, ERs are screening people outside and quickly triaging them based on where they need to go, so they’re less likely to infect other people,” Khan says. “There is drive-through testing of healthcare workers.”

As cities, states, businesses, and others stopped most in-person commerce and gatherings across the United States through March, hospitals in some areas were experiencing an influx of patients in need of a bed because of viral infection.

Elective surgeries ground to a halt, and hospitals geared up for a change that was expected to require more equipment and PPE. If a hospital experiences an outbreak, RN case managers are ready to take on frontline tasks, Fraser says.

“Most of us are registered nurses, and we were trained so heavily on isolation techniques and wearing masks, gloves, and isolation gowns,” she says. “We’re first and foremost RNs.”

What case managers and RNs might need from management are self-care reminders, Fraser says.

“Case managers need to remember to take care of themselves,” Fraser adds. “Watch out, use all the precautionary tactics with isolation techniques, and make sure you are eating healthy and taking lots of vitamin C. Don’t forget about yourself, especially if you are working long hours.”