During the initial wave of the Covid-19 pandemic, hospitals worldwide diverted resources from routine inpatient critical care and outpatient clinics to meet the surge in demand. Because of the resulting resource constraints and fear of infection, clinicians and non-Covid patients deferred “non-urgent” visits, evaluations, diagnostics, surgeries and therapeutics. Indeed, early in the pandemic physicians and leading public health officials noted a dramatic decline in non-Covid-related health emergencies, including upwards of a 60% decrease in patients with acute myocardial infarctions and strokes.
While these postponements may have reduced the amount of unnecessary services used, they likely also caused a perilous deferral of needed services, which many believe will lead to later hospitalizations requiring higher levels of care, longer lengths of stay, and increased hospital readmissions, thereby further straining hospitals’ inpatient capacity. It is critical that we not only focus on the acute care of Covid-19 patients, but that we also proactively manage patients without Covid-19, particularly those with time-sensitive and medically complex conditions who are postponing their care. This is important not only to sustain health and life, but to preserve future hospital capacity.
Drawing on key principles from operations management and applying a health-systems perspective, we propose four strategies to facilitate care of non-Covid patients even as hospitals are stretched to absorb waves of patients with Covid-19.
1. Innovate outpatient management to reduce demand at downstream bottlenecks.
To reduce future bottlenecks in emergency departments (EDs) and hospitals, outpatient clinicians should expand their proactive management of patients at high risk of needing acute or inpatient services, such as those with poorly managed hypertension or diabetes, and triage patients with acute needs to EDs now in order to reduce more serious complications later. This will help reduce potential future spikes in demand on EDs and inpatient beds from non-Covid patients.
While most clinicians have rapidly adopted some form of telemedicine, they will need to increase their digital engagement with high-risk patients in a more targeted fashion. Clinicians should evaluate their patient panels to identify high-risk individuals and initiate telemedicine visits, rather than relying on patients to initiate contact, similar to the process for proactive disease management used by several community health care organizations.
Although high-risk patients will vary by specialty, targeted populations may include patients recently discharged from the hospital and those at high risk for hospitalization, including those with uncontrolled heart failure or active malignancy. To facilitate remote patient monitoring of high-risk patients, clinicians may opt to send telehealth kits tailored to patients’ medical and technological needs. These kits may include connected health devices such as blood pressure monitors, pulse oximeters, and heart rate monitors, and even mobile technology devices such as tablets or smart phones. To most effectively leverage telemedicine during the pandemic, clinicians must also promote multidisciplinary virtual collaboration across primary care clinicians, specialists, social workers, home health clinicians, administrative support, and patients and their caregivers.
2. Combine essential non-Covid inpatient services across hospitals.
To balance demand across hospitals, public health officials should apply a version of the logistics strategy known as “location pooling,” combining demands from multiple locations. Rather than each hospital in a region redundantly providing the full suite of essential inpatient non-Covid clinical services, each of these services should be concentrated at one location. For example, each region should have a single designated cancer center, transplant center, stroke center, and trauma center. Implementing this strategy is fraught with challenges as hospitals are currently organized independently and compete with one another for patients and revenue. Nevertheless, during the initial Covid-19 wave, several hospitals in Boston collaborated to share data on the availability of hospital beds to efficiently route patients based on their clinical need and the available capacity. And centralization of acute stroke care, in which patients are taken to central specialty hospitals rather than the nearest hospital, demonstrates both the feasibility and potential improved outcomes of utilizing this approach in several countries including the United States, Canada, the Netherlands, Denmark, and Australia.
Crises require all possible realizations of economies of scale. Location pooling mitigates variability in service-specific demand faced by each hospital. As demand falls for specific non-Covid services at an individual hospital (e.g., for acute stroke care), hospital administrators can close those services and repurpose the specialty capacity to care of Covid-19 patients with underlying conditions, as discussed below. If all hospitals implement this strategy, not all non-Covid services will be available at every hospital. However, location pooling draws demand from across hospitals, ensuring that as a given hospital loses some patients it gains others, allowing it to maintain sufficient census to remain fiscally viable.
Centrally coordinated regional organization, similar to mass casualty planning, is critical to ensure that each essential service remains fully operational for routine emergencies, while adapting to dynamic changes in the region’s hospital capacity. The number of hospitals to include in location pooling should be determined by weighing the tradeoff of efficiency gains from pooling across more locations versus inefficiencies from increased travel time incurred by patients and emergency medical services.
3. Group hospitalized Covid-19 patients by their underlying clinical conditions.
At the same time that hospitals should be location-pooling specialty services for non-Covid patients, to the extent possible they should place their Covid-19 patients who have serious underlying health issues (e.g., cardiac conditions) with other Covid-19 patients with the same condition. In each of these “cohorted wards,” redeployed clinical staff from the relevant specialty service, such as cardiology, can provide essential specialty care alongside clinicians addressing patients’ Covid-specific care needs.
While such cohorting limits efficiency gains from pooling all Covid-19 patients in one ward, it maintains specialty care for patients who still need it while reducing the additional inpatient capacity strain resulting from patients being dispersed across the hospital. Indeed, prior research demonstrates that displacing patients from cohorted specialty units is associated with prolonged hospital length of stay and more frequent readmissions.
4. Discharge patients into post-acute care based on Covid-19 status.
Nursing home, rehabilitation hospital, and long-term acute care facility leadership should collaborate to establish separate regional, specialized, post-acute care facilities for Covid-19 and non-Covid patients. Sending patients to specialized post-acute care facilities based on their Covid-19 status will facilitate discharge planning, improving patient flow out of the hospital for Covid-19 and non-Covid patients alike. This will relieve strain at ED and hospital bottlenecks while maintaining care quality. Furthermore, having dedicated post-acute care facilities for Covid-19 patients will preserve post-acute care capacity for those recovering from non-Covid illnesses, while lowering their risk of becoming infected.
Challenges to this model include ensuring timely access to Covid-19 testing and rapid test results to guide appropriate patient routing. To prevent discharge delays due to testing constraints, hospitals need to implement rapid tests more widely, and post-acute care facilities should designate quarantine areas for patients to receive care while awaiting results.
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These strategies will undoubtedly be challenging to implement. But now is the time to rethink health care delivery and adopt operations management strategies with demonstrated success that are most promising. This will allow us to be better prepared for future waves of the Covid-19 pandemic.