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Plastic Surgery Focus: Special Topics

Surviving the COVID-19 Pandemic: Surge Capacity Planning for Nonemergent Surgery

Squitieri, Lee M.D., Ph.D., M.S.; Chung, Kevin C. M.D., M.S.

Author Information
Plastic and Reconstructive Surgery: August 2020 - Volume 146 - Issue 2 - p 437-446
doi: 10.1097/PRS.0000000000007075
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Abstract

The rapid progression of the coronavirus disease 2019 (COVID-19) pandemic has confronted nations around the world with unprecedented clinical and economic challenges. With each passing day, news in the United States and many other countries becomes more dire, vividly exposing the strengths and weaknesses of governments and health systems as they scramble to manage this novel public health crisis. In the United States, the rising number of confirmed COVID-19 patients, limited testing capabilities, and a shortage of personal protective equipment have left many patients and health care workers vulnerable and unprepared to accommodate sudden increases in demand and also maintain necessary nonemergent care.1–3 Furthermore, the fragmented health care system in the United States impedes a centralized, coordinated approach to confront this pandemic.

Epidemiologic models of the COVID-19 pandemic estimate that it may last as long as 18 months, with multiple waves of illness.2,3 Given the potentially prolonged impact on health care use and personnel, it is imperative to develop surge capacity protocols that not only address acute care needs, but also guide organizational expansion for routine nonemergent care. To protect high-risk patients from unnecessary exposure, government, payers, industry, and health system stakeholders have worked in concert to rapidly expand access to telehealth.3–6 Although virtual interfaces have the ability to offload many aspects of patient evaluation and management, they are not able to replace critical health care processes that require direct patient-provider encounters and interventions.

Currently, hospitals across the country have been urged to cancel thousands of nonemergent diagnostic tests, procedures, and operations, with limited guidance regarding when or how to accommodate these interventions moving forward.4,7,8 To advocate for patients and participate in emerging discussions regarding surge capacity for nonemergent procedures, plastic surgeons must have in-depth knowledge regarding infectious disease epidemiology and public health strategies. The purpose of this article is to provide necessary and timely public health information relevant to plastic surgery and also share a conceptual framework to guide surge capacity protocols for nonemergent surgery. This information will enable plastic surgeons to critically evaluate their own patient practice capacity in the context of the current COVID-19 pandemic and stimulate productive discussion between plastic surgeons and health systems within their communities to meet their responsibility for other conditions and diseases that require similar attention.

INFECTIOUS DISEASE EPIDEMIOLOGY AND PUBLIC HEALTH IN THE UNITED STATES

The importance of infectious disease surveillance and epidemiology in national public health agendas began in the United States during World War II as part of an effort to limit malaria and other vector-borne diseases (e.g., typhus) around military training bases.9 In 1949, Alexander Langmuir was chosen to direct the new Epidemiology branch of the Communicable Disease Center, now known as the Centers for Disease Control and Prevention.9,10 Through his work tracking malaria, poliomyelitis, and influenza, he defined the essential components of all surveillance programs.9,10 Then, in 1955, Donald Henderson built on Langmuir’s surveillance foundation by applying public health principles and methodologies to inform global programs and policies responsible for the eradication of smallpox (1967 to 1980).10 Over the past several decades, surveillance programs have grown substantially, both in number and in sophistication, as systems for data collection, evaluation, and communication have evolved. As a result, public health and infectious disease epidemiology now assume central roles in government planning and evaluation in most countries around the world.

The U.S. government public health system is composed of federal agencies, state agencies, and territorial or local health departments (Fig. 1).11 At the federal level, the Department of Health and Human Services includes 11 operating divisions: eight agencies within the U.S. Public Health Service led by the Surgeon General and three independent human service agencies. The Department of Health and Human Services also includes 10 regional offices under the Office of Intergovernmental and External Affairs that directly serve state and local organizations.12 During a viral pandemic or public health emergency, the responsibilities of the federal public health system include the following: (1) setting policies, standards, and regulations related to public health; (2) assisting states when they lack expertise or resources to effectively respond in a public health emergency; and (3) taking action when health threats span more than one state.11,13 Through powers to regulate interstate commerce (e.g., labeling hazardous substances), tax/spend for the general welfare (e.g., financing Medicare and Medicaid), and enlist additional support from other federal agencies (e.g., Department of Homeland Security, Federal Emergency Management Agency), the federal government is able to facilitate coordination among states and drive large-scale interventions to confront national public health emergencies.13,14

Fig. 1.
Fig. 1.:
U.S. public health infrastructure.

To accomplish public health goals, the federal government may either act directly or through contracts with state and local government agencies.11 At present, there are 51 state health agencies (50 states and the District of Columbia) and over 2500 local/territorial health departments with varying levels of state governance (Fig. 1).11 Under the original articles of confederation, states (not the federal government) are primarily responsible for public health and safety.11,13,15 Therefore, despite differences in public health priorities, funding structure, and organization, all states have a general responsibility to work with local entities and provide the following services: (1) screening and treatment of diseases/conditions, (2) state laboratory services, (3) technical assistance and teaching, and (4) epidemiology and surveillance programs.11,13

In a stable environment, the federalist approach to public health in the United States affords a more customized and efficient delivery of services for diverse populations. However, during a public health emergency, the fragmentation of our public health infrastructure makes it challenging to rapidly coordinate efforts in response.16 From a surveillance standpoint, data, equipment, and service decentralization make it difficult to adequately monitor and evaluate communicable diseases across large geographic areas.16 On the intervention side, fragmented reimbursement and lack of guaranteed compensation make it difficult for hospitals and health systems to coordinate care delivery in an efficient manner without risking financial vulnerability.17 As we learn from the painful lessons of this pandemic and the disorganized governmental response, it is essential for all policies and protocols involving nonemergent procedures to understand these limitations and improve on our existing public health infrastructure.

PUBLIC HEALTH STRATEGIES TO CONTROL INFECTIOUS DISEASES

During a public health emergency, the government has a special responsibility to thoughtfully balance public health protections and civil liberties.18 As epidemiologic data for COVID-19 evolve, it is important to understand how these data inform public health strategy.19–21Table 1 provides a brief overview of epidemiologic terms and definitions.22–24 Each of these factors plays an important role in determining the relative responsibility of the federal government, estimating projection models, and informing public health strategies in the absence of pharmacologic interventions (e.g., vaccination, treatment).18–24

Table 1. - Epidemiology Terms and Definitions*
Definition
Population term†
 Sporadic A disease that occurs infrequently and irregularly
 Endemic Constant presence and/or usual prevalence of disease or infectious agent in a population within a geographic area
 Cluster Aggregation of cases grouped in a specific geographic place and time that are suspected to be greater than the number expected, even though the expected number may not be known
 Outbreak Increase, often sudden, in the number of cases of a disease above what is normally expected in a specific population in a specific geographic place
 Epidemic Increase, often sudden, in the number of cases of a disease above what is normally expected in a specific population
 Pandemic Epidemic that has spread over several countries or continents, usually affecting large numbers of people
Disease term
 Incubation Time between initial contact with an infectious agent and appearance of the first sign or symptoms of disease
 Communicability Time during which an infectious agent may be transferred directly or indirectly from an infected person to another person, from an infected animal to humans, or from an infected person to animals
 Latent period Period between exposure and the onset of the period of communicability; may be shorter or longer than the incubation period
 Herd immunity Occurs when a significant proportion of a population is not susceptible (e.g., vaccinated, recovered immune); decreases likelihood that an infected person will come in contact with a susceptible person
Mathematical term
 Basic reproduction number (R0) Average number of secondary infections produced by a typical case of an infection in a population where everyone is susceptible; epidemic requires R0 > 1
 Effective reproduction number (R) Average number of secondary cases per infectious case in a population made up of both susceptible and nonsusceptible hosts (equivalent to R0 multiplied by the fraction of the host population that is susceptible)
 Herd immunity threshold Proportion of a population that is needed to be immune for an infectious disease to become stable in a community [equivalent to (R0 − 1) ÷ R0]
*From the Centers for Disease Control and Prevention. Principles of Epidemiology in Public Health Practice. 3rd ed. Atlanta, Ga: Centers for Disease Control and Prevention; 2012. Available at: https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html. Accessed April 1, 2020; Rothman KJ, Lash T, Greenland S. Modern Epidemiology. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2013; and Last JM. A Dictionary of Epidemiology. New York: Oxford University Press; 1998.
†Population terms indicate an increasing public health threat.

Table 2 describes public health strategies that may be implemented to control the spread of infectious diseases.18 When faced with a novel pandemic, the choice between interventions is extremely difficult and time sensitive, requiring constant incorporation of new data to balance public health and economic factors.18,19 The anticipated effectiveness of public health interventions is challenging to estimate at the beginning of an outbreak because key viral transmission data (e.g., viral shedding, transmission efficiency, incubation period, reproduction number) is often unknown.18,19 Furthermore, the usefulness of any given intervention depends on the pandemic phase. At the beginning of a pandemic, surveillance, medical prophylaxis, and isolation are important tools for “containment” of disease.18,25 However, during the pandemic, the focus of public health interventions must shift toward delaying spread through population-based measures and disease “mitigation.”18,25

Table 2. - Public Health Strategies*
Strategy Interventions Public Benefits Private Rights Recommendations
Surveillance Screening, reporting, contact tracing, and monitoring Provides essential data: early warning, transmission, incidence, response Privacy; fair information practices Improve public health infrastructure: laboratories, workforce, data systems
Animal-human interchange Occupational health, quarantines, and culls Protect animal health; prevent “species jump” to humans Farmer livelihood; national economy/international trade Improve hygiene/infection control in animal farming; improve international law and cooperation
Community hygiene Handwashing, disinfection, respiratory hygiene, and PPE Reduce transmission in families and the community Minimal but requires behavioral change Public education grounded in risk communication science
Hospital infection control Handwashing, disinfection, PPE, health care worker vaccination Reduce transmission among patients, health care workers, and their families/communities Collective bargaining agreements; health care worker autonomy; freedom of religion and conscience Training/monitoring in infection control; encourage greater acceptance of vaccination
Decreased social mixing Close public places, cancel public events, restrict mass transit Slow spread of infection in public settings Free association; free commerce Target closures to high-risk settings based on evidence
Border controls Screening (entry/exit), reporting, health alerts, passenger data, travel advisories, hygiene (infection, disinfection, pest extermination) Prevent cross-border spread of infectious disease Free travel; international trade Adequate resources for surveillance, treatment, and response in affected areas and U.S. borders
Isolation and quarantine Home, hospital, school, workplace, institutional settings, “shelter in place” Separate the infected or exposed from the healthy Free movement; personal health and livelihood; nondiscrimination Safe/humane settings; ensure necessities of life; logistics; modern laws with due process
Medical countermeasures Vaccines, antiviral agents Prophylaxis; reduced infectiousness; treatment Bodily integrity; fairness to disadvantaged; intellectual property; business and trade Stable, economically viable supplies: incentives, public/private partnerships, tort reform, compensation
PPE, personal protective equipment.
*From Gostin L. Public health strategies for pandemic influenza: Ethics and the law. JAMA 2006;295:1700–1704. 10.1001/jama.295.14.1700

Although 80 percent of COVID-19 patients are estimated to recover after mild to moderate symptoms that are similar to seasonal influenza, it is important to understand the key differences of COVID-19 that have impacted current public health strategy and decision-making.26 Compared to seasonal influenza, COVID-19 is a completely novel disease without any established herd immunity from previous cycles of disease or vaccination.26–28 Thus, everyone is initially susceptible, and the basic reproductive number of COVID-19 is much higher than that for seasonal influenza (basic reproduction number = 2 to 2.5 versus 1.3).26,29 COVID-19 also has a higher degree of presymptomatic transmission and the potential to be transmitted by means of surface contact, making it very difficult to trace infectious contacts and perform symptom-based disease surveillance.30–32 Considered together, these factors support the use of more aggressive strategies to slow the spread of disease.21 However, the social and economic consequences of these interventions are profound and must be considered in the context of immediate public health benefit and long-term impact on our health system and economy.

During the current COVID-19 pandemic, social isolation and quarantining are necessary to save millions of lives and also prevent overwhelming collapse of our current health system and other economies that rely on a healthy population.1–4 Without aggressive social distancing measures, projection models estimate that COVID-19 will affect 40 to 81 percent of the U.S. population, and that 20 percent of those infected will require hospitalization for approximately 11 days’ duration.1,22,28,33 This is an overwhelming contrast to seasonal influenza that has an annual infection rate of 8.3 percent, a hospitalization rate of 1 to 2 percent among those infected, and an average of 5 to 6 days’ hospital duration.27,34,35 In a health system that is already near capacity with seasonal influenza and routine medical care, failure to flatten the curve will result in an acute crippling gap of intensive care unit beds, ventilators, equipment, and health care personnel.1–4 Secondary effects will also include large populations of sick individuals (from COVID-19 or other delayed medical care) that suffer unnecessary morbidity/mortality and are unable to contribute to the economy.

When estimating the impact of social distancing measures on viral transmission, health care use, patient outcomes, and the economy, there are key epidemiologic factors that must be considered and input into model projections. These factors include (but are not limited to) population size/density, hospital intensive care unit capacity, viral disease characteristics (asymptomatic spread, reproductive number, time to recovery), proportion of population that is infected at the onset of intervention, duration of intervention, and estimated intervention adherence.36–38 The lack of early testing and wide variation of these epidemiologic factors at the state level make it very difficult to accurately estimate the national impact of social distancing. However, there are many interactive sites that are frequently updated with local and national information to derive local/state models and inform state and national level policy.37,38 It is important to note that for a novel pandemic without an effective vaccine or treatment, early withdrawal of social distancing measures results in a second wave of illness that potentially necessitates subsequent rounds of social distancing and further economic burden (Fig. 2).36

Fig. 2.
Fig. 2.:
Impact of social distancing on number of cases reported. [Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020;395:931–934. 10.1016/S0140-6736(20)30567-5]

SURGE CAPACITY CONSIDERATIONS

To meet acute anticipated COVID-19 demands, hospitals and health systems around the country are working tirelessly to develop contingency plans that rapidly expand emergency room triage, primary care, and intensive care unit capacity. Historically, surge capacity in health care took a reactive approach, carrying out local interventions based on instinctual behavior in the absence of thoughtful data collection.39 However, in the aftermath of the attacks of September 11, 2001, the federal government and medical community recognized the need to develop a coherent framework to understand and proactively plan for surges of patients during a public health emergency or medical disaster.39,40

Surge capacity generally refers to the ability of a health system to maintain a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the present capacity of the system.39,40 Effective surge responses require sufficient system infrastructure, space, equipment, and personnel, and may be categorized into three different levels: conventional, contingency, or crisis surge.39,40 Conventional surge capacity protocols use space, staff, and supplies that are consistent with daily practices and maintain a traditional standard of care.39,40 Examples include extending work hours of existing staff or redistributing existing equipment to accommodate busy days or seasonal trends. Contingency surge capacity refers to strategies that use space, equipment, or personnel that is not typically used but have minimal impact on usual patient care practices.39,40 These interventions usually involve transformation of existing space, purchase of additional equipment, and just-in-time training for new personnel. Crisis surge capacity occurs when adaptive space, equipment, and supplies are not consistent with usual standards of care but provide sufficiency of care in the setting of a catastrophic disaster.39,40 Given the potential to deliver substandard patient care, every effort should be made to minimize the time spent in a crisis surge capacity category.

Table 3 outlines key management considerations when developing surge capacity protocols.41,42 It is important to note that even during a uniform public health crisis, surge capacity protocols for different health systems may vary substantially because of differences in baseline medical system infrastructure, capacity, and resiliency. For public health emergencies with the potential to last for extended periods, it is critical to develop various levels of surge capacity that address all of the factors outlined in Table 3. Furthermore, surge capacity protocols to overcome acute needs in times of crisis must also consider how to effectively downgrade to lower acuity protocols. For example, as we rapidly expand access to telehealth, cancel nonemergent procedures, and transform operating rooms into intensive care units, we must also simultaneously develop thoughtful protocols to deescalate these crisis surge capacity protocols in the best interest of our patients by organizing alternative pathways of care for those patients requiring surgical procedures who were displaced by the pandemic.

Table 3. - Surge Capacity Management Considerations*
Consideration Description Purpose
Medical system resiliency The ability of health care organizations to survive a hazard and rapidly recover any compromised medical services Ensures reliable platform to address medical surge needs; provides public with access to regular medical services, minimizing risk of “secondary surge” that can result when people with chronic health conditions decompensate because they lack access to their normal care
Responder safety Protection of health care personnel and other responders as they perform activities to minimize the hazard impact on an affected population Ensures adequate PPE, vaccination, prophylactic medication, and other interventions that may be necessary in the midst of a rapidly evolving emergency
Information management A large amount of complex information must be collected, analyzed, and managed to determine incident parameters and response needs Ensures that information is rapidly and accurately collected and used in a timely fashion to inform evaluation, treatment, and public health strategies
Coordinating diverse operating systems Coordinating effort among multiple disciplines and health systems that do not routinely work together Attempts to optimize efficiency of care and take advantage of specific skills within each discipline and capacity within each health system
Resolving intergovernmental issues Major public health or medical incidents often involve initiatives across multiple levels of government Usually federal and state governments operate in support of the local response, though the reverse may occur; management activities at each level will vary from incident to incident and must be well coordinated
Medical asset support For public health and medical response agencies to perform optimally, extensive logistic, financial, and administrative support is necessary Ensures prompt and reasonable financial compensation for extraordinary medical efforts, and temporarily waiving certain regulatory and compensatory requirements so medical assets may keep up with increased patient volume
Addressing time constraints Medical emergencies are time-sensitive and require rapid intervention by clinicians to address the urgent medical and surgical needs of patients Proposed protocols should be developed rapidly and estimate impact of time delays
Incorporating public health and medical assets into public safety response Public health officials, medical staff, and other front-line professionals are not recognized as traditional first-responders Ensures that these workers receive adequate and equal treatment/prioritization for training, funding, and compensation, compared to other traditional public safety/first response assets
PPE, personal protective equipment.
*From U.S. Department of Health and Human Services. Medical Surge Capacity Handbook: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies. 2nd ed. Washington, DC: U.S. Department of Health and Human Services; 2007. Available at: https://www.phe.gov/Preparedness/planning/mscc/handbook/Pages/default.aspx. Accessed March 23, 2020; and U.S. Department of Health and Human Services. MSCC: The Healthcare Coalition in Emergency Response and Recovery. Washington, DC: U.S. Department of Health and Human Services; 2009. Available at: https://www.phe.gov/Preparedness/planning/mscc/healthcarecoalition/Pages/default.aspx. Accessed March 23, 2020.

CONCEPTUAL FRAMEWORK FOR SURGE CAPACITY EXPANSION OF NONEMERGENT PROCEDURES

As inpatient hospitals across the country prepare for an overwhelming influx of highly contagious COVID-19 cases, many states and health systems have begun to implement crisis surge capacity protocols that divert existing resources to acute care and embrace nontraditional expansion of space, equipment, and personnel. Nonemergent procedures at most health systems around the country have been cancelled or indefinitely postponed without guidance regarding eventual safe accommodation of these procedures in the future. In anticipation of a potentially long pandemic with multiple waves of illness and varying patient demand, it is critical for plastic surgeons to develop tiered levels of surge capacity protocols accompanied by escalation/deescalation criteria to guide nonemergent surgery within their health system infrastructure.

Figure 3 provides a conceptual framework to guide development of surge capacity protocols for nonemergent surgery. Although specific protocol details for each practice will vary depending on the local patient burden and acute health system infrastructure built in response to the COVID-19 crisis, the key considerations for developing nonemergent surgery protocols are generally the same. First, plastic surgeons must assess their own practices in the context of all delayed nonemergent procedures (e.g., diagnostic/laboratory tests, interventions, surgery) and work with other specialties to define levels of urgency that are appropriately suited for the resources that are available. For example, if an inpatient hospital is overwhelmed with COVID-19 patients and the only available resources are small ambulatory surgery centers, physicians will need to decide what types of procedures may be performed there and develop a system to prioritize various levels of urgency. By understanding the big picture, plastic surgeons will be more prepared to advocate for their patients and work collaboratively with other specialties to balance medical need and resource allocation.

Fig. 3.
Fig. 3.:
Conceptual framework to guide surge capacity protocols regarding nonemergent surgery.

Next, plastic surgeons will need to develop clear process maps for their procedures and address any anticipated infrastructure gaps or bottlenecks (e.g., space, personnel, equipment, medication, preoperative testing). This may include novel partnerships between academic and private practice in addition to multidisciplinary collaboration among specialties. Given the ability of COVID-19 to survive in the air and on contact surfaces, it will be very difficult for inpatient hospitals to maintain noncontaminated spaces and control the spread of infection to non–COVID-19 patients who require nonemergent procedures. One interesting idea that has been suggested to mitigate spread and allow continuation of routine medical procedures is expansion of ambulatory surgery centers and clinics that can perform local anesthesia procedures to accommodate uninfected vulnerable patients in a smaller space that is separate from acute care facilities.43,44

Once patient triage and processes have been organized, plastic surgeons will need to work with their local governments and communities to develop coordinated implementation plans that maximize safety both for patients and for providers. Guidelines for equipment handling, personal protective equipment, and monitoring/viral testing among patients and providers must be developed in concert with other surgical specialties and agreed on. It is also important to establish new preoperative and postoperative protocols that minimize exposure and take advantage of new telehealth guidelines. Finally, to avoid infrastructural collapse during waves of viral illness and patient demand, it is critical to foster a method of collecting data and tracking surgical demand and use. Criteria to escalate/deescalate protocols in response to local burden of viral illness are essential, as is understanding patient disparities in accessing care.

The U.S. health care system is currently experiencing unprecedented challenges amidst a tenuous economic environment. The COVID-19 pandemic has exposed the weaknesses of our decentralized public health system and inspired collaboration among all sectors of our government and economy. Without an effective vaccine and population herd immunity, similar to our experience with annual influenza, we can expect multiple waves of illness that occur in response to lifting of social distancing measures to preserve our economy. Given the unique epidemiologic characteristics of each state’s pandemic curve and current lack of a unified federal response, it is suitable to assume that social distancing measures will be strengthened and lifted at the state level in response to their own individual pandemic curve and health system capacity. As states decide to lift their social distancing measures, they will likely develop mandates for personal protective equipment (e.g., masks, gloves) and risk-reduction protocols (e.g., avoidance of large group gatherings, telework, telehealth) to minimize the impact of subsequent waves of illness while allowing a substantial segment of the workforce to return to work, and to leverage additional time for effective vaccine testing.

Although we hope the COVID-19 pandemic does not have a lasting impact on our health system infrastructure, it is incumbent on surgeons of all specialties to prepare and develop surge capacity protocols that allow continuation of safe, high-quality nonemergent procedures during current and subsequent waves of illness. As plastic surgeons, we are well positioned to lead the transformation and expansion of ambulatory surgical centers to accommodate clean nonemergent surgical procedures from a variety of disciplines and ensure that uninfected patients are still able to maintain high-quality nonurgent surgical care. However, there is currently no comprehensive centralized data set with information to estimate national surge capacity of physician-owned ambulatory surgery centers. Existing databases, such as the State Ambulatory Surgery Databases, primarily include data from hospital-owned ambulatory surgery centers and do not provide specific operational data (e.g., staff, size, equipment, specialization) to inform capacity building.45

The lack of comprehensive data and tremendous variation in state pandemic curves, local government responses, and existing health system capacity gaps preclude development of specific surge capacity guidelines at this time. The purpose of this article is to give plastic surgeons a framework to engage their local health systems and governments and inform future data collection/surge capacity protocol development. As we eventually deescalate from the current pandemic curve and prepare for potential future waves of illness, plastic surgeons will need to collect critical data regarding physician-owned ambulatory surgery centers, develop novel perioperative protocols that integrate expanded testing capabilities, and establish consensus among surgical specialties regarding procedure priority and resource allocation. If there was ever a time for plastic surgery to work together and invest in public health infrastructure to improve care for our patients, it is now.

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