As the novel coronavirus incubated in Wuhan from mid-December to mid-January, the Chinese state made evidently intentional misrepresentations to its people concerning the outbreak, providing false assurances to the population preceding the approach of the Lunar New Year celebrations on Jan. 25. In mid-December, an outbreak of a novel influenza-like illness was traced to workers and customers of the city’s Huanan Seafood Wholesale Market, which contained exotic and wild animal species. On Dec. 26, multiple Chinese news outlets released reports of an anonymous laboratory technician who made a startling discovery: The sickness was caused by a new coronavirus that was 87 percent similar to SARS, or Severe Acute Respiratory Syndrome. Li Wenliang, an ophthalmologist at Wuhan Central Hospital, sounded the alarm in an online chatroom on Dec. 30. That night, Wuhan public health authorities solicited information on the emergence of a “pneumonia of unclear cause,” but omitted Li’s discussion about SARS or a novel coronavirus. Li and other medical professionals who tried to disclose the emergence of the virus were suppressed or jailed by the regime. On Jan. 1, the state-run Xinhua News Agency warned, “The police call on all netizens to not fabricate rumors, not spread rumors, not believe rumors.” Four days after Li’s chatroom discussion, officers of the Public Security Bureau forced him to sign a letter acknowledging he had made “false comments,” and that his revelations had “severely disturbed the social order.” Li, who has become something of an underground folk hero in China against chicanery by state officials, ultimately died of the disease. China silenced other doctors raising the alarm, minimizing the danger to the public even as they were bewildered and overwhelmed. State media suppressed information about the virus. Although authorities closed the Wuhan “wet market” at the epicenter of the contagion, they did not take further steps to stop the wildlife trade. By Jan. 22, when the virus had killed just 17 yet had infected more than 570 people, China tightened its suppression of information about the coronavirus that it deemed “alarming,” and further censored criticism of its malfeasance. “Even as cases climbed, officials declared repeatedly that there had likely been no more infections.” On Dec. 31, the Wuhan Municipal Health Commission falsely stated that there was no human-to-human transmission of the disease, which it described as a seasonal flu that was “preventable and controllable.” On Feb. 1, the New York Times reported that “the government’s initial handling of the epidemic allowed the virus to gain a tenacious hold. At critical moments, officials chose to put secrecy and order ahead of openly confronting the growing crisis to avoid public alarm and political embarrassment.”
Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus , that was first
recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that it is a betacoronavirus closely
linked to the SARS virus (1).
While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that
requires hospitalization and oxygen support, and 5% require admission to an intensive care unit (1). In severe cases, COVID-19
can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, multiorgan failure, including
acute kidney injury and cardiac injury (2). Older age and co-morbid disease have been reported as risk factors for death, and
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Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
recent multivariable analysis confirmed older age, higher Sequential Organ Failure Assessment (SOFA) score and d-dimer > 1
µg/L on admission were associated with higher mortality. This study also observed a median duration of viral RNA detection of
20.0 days (IQR 17.0–24.0) in survivors, but COVID-19 virus was detectable until death in non-survivors. The longest observed
duration of viral shedding in survivors was 37 days (3, 4).
Building on evidence-informed guidelines developed by a multidisciplinary panel of health care providers with experience in the
clinical management of patients with COVID-19 and other viral infections, including SARS and MERS, as well as sepsis and
ARDS, this guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival
and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials (5, 6).
There are few data on the clinical presentation of COVID-19 in specific populations, such as children and pregnant women. In
children with COVID-19 the symptoms are usually less severe than adults and present mainly with cough and fever, and coinfection has been observed (7, 8). Relatively few cases have been reported of infants confirmed with COVID-19; those
experienced mild illness (9). There is currently no known difference between the clinical manifestations of COVID-19 pregnant
and non-pregnant women or adults of reproductive age. Pregnant and recently pregnant women with suspected or confirmed
COVID-19 should be treated with supportive and management therapies, as described below, taking into account the
immunologic and physiologic adaptations during and after pregnancy.
1. Screening and triage: early recognition of patients with SARI associated with COVID-19
Screening and triage: Screen and isolate all patients with suspected COVID-19 at the first point of contact with the
health care system (such as the emergency department or outpatient department/clinic). Consider COVID-19 as a
possible etiology of patients with acute respiratory illness under certain conditions (see Table 1). Triage patients using
standardized triage tools and start first-line treatments.
Remark 1: Although the majority of people with COVID-19 have uncomplicated or mild illness (81%), some will develop
severe illness requiring oxygen therapy (14%) and approximately 5% will require intensive care unit treatment. Of those
critically ill, most will require mechanical ventilation (2, 10). The most common diagnosis in severe COVID-19 patients is
severe pneumonia.
Remark 2: Early recognition of suspected patients allows for timely initiation of appropriate IPC measures (see Table 3). Early
identification of those with severe illness, such as severe pneumonia (see Table 2), allows for optimized supportive care
treatments and safe, rapid referral and admission to a designated hospital ward or intensive care unit according to institutional or
national protocols.
Remark 3: Older patients and those with comorbidities, such as cardiovascular disease and diabetes mellitus, have increased risk
of severe disease and mortality. They may present with mild symptoms but have high risk of deterioration and should be
admitted to a designated unit for close monitoring.
Remark 4: For those with mild illness, hospitalization may not be required unless there is concern about rapid deterioration or an
inability to promptly return to hospital, but isolation to contain/mitigate virus transmission should be prioritized. All patients
cared for outside hospital (i.e. at home or non-traditional settings) should be instructed to manage themselves appropriately
according to local/regional public health protocols for home isolation and return to a designated COVID-19 hospital if they get
worse (https://www.who.int/publications-detail/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infectionpresenting-with-mild-symptoms-and-management-of-contacts).
Table 1. Definitions of SARI and surveillance case definitions for COVID-19*
Surveillance
case
definitions
for COVID19*
Suspect case
See latest WHO case definitions for suspect case of COVID-19*
Confirmed case
A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms.
* See Global Surveillance for human infection with coronavirus disease (COVID-19) for latest case definitions.
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Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
Table 2. Clinical syndromes associated with COVID-19
Mild illness
Patients uncomplicated upper respiratory tract viral infection may have non-specific symptoms such as fever,
fatigue, cough (with or without sputum production), anorexia, malaise, muscle pain, sore throat, dyspnea,
nasal congestion, or headache. Rarely, patients may also present with diarrhoea, nausea, and vomiting
(3, 11-13).
The elderly and immunosuppressed may present with atypical symptoms. Symptoms due to physiologic adaptations of
pregnancy or adverse pregnancy events, such as dyspnea, fever, GI-symptoms or fatigue, may overlap with COVID19 symptoms.
Pneumonia
Adult with pneumonia but no signs of severe pneumonia and no need for supplemental oxygen.
Child with non-severe pneumonia who has cough or difficulty breathing + fast breathing: fast breathing (in
breaths/min):
< 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40, and no signs of severe pneumonia.
Severe
pneumonia
Adolescent or adult: fever or suspected respiratory infection, plus one of the following: respiratory rate > 30
breaths/min; severe respiratory distress; or SpO2 ≤ 93% on room air (adapted from 14).
Child with cough or difficulty in breathing, plus at least one of the following: central cyanosis or SpO2 < 90%; severe
respiratory distress (e.g. grunting, very severe chest indrawing); signs of pneumonia with a general danger sign:
inability to breastfeed or drink, lethargy or unconsciousness, or convulsions (15). Other signs of pneumonia may be
present: chest indrawing, fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40 (16).
While the diagnosis is made on clinical grounds; chest imaging may identify or exclude some pulmonary
complications.
Acute
respiratory
distress
syndrome
(ARDS) (17-
19)
Onset: within 1 week of a known clinical insult or new or worsening respiratory symptoms.
Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully explained by volume
overload, lobar or lung collapse, or nodules.
Origin of pulmonary infiltrates: respiratory failure not fully explained by cardiac failure or fluid overload. Need
objective assessment (e.g. echocardiography) to exclude hydrostatic cause of infiltrates/oedema if no risk
factor present.
Oxygenation impairment in adults (17, 19):
• Mild ARDS: 200 mmHg < PaO2/FiO2
a ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O, ornon-ventilated)
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated)
• When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS (including in non-ventilatedpatients).
Oxygenation impairment in children: note OI = Oxygenation Index and OSI = Oxygenation Index using SpO2.
Use PaO2-based metric when available. If PaO2 not available, wean FiO2 to maintain SpO2 ≤ 97% to
calculate OSI or SpO2/FiO2 ratio:
• Bilevel ( NIV or CPAP) ≥ 5 cmH2O via full face mask: PaO2/FiO2 ≤ 300 mmHg or SpO2/FiO2 ≤ 264
• Mild ARDS (invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
• Moderate ARDS (invasively ventilated): 8 ≤ OI < 16 or 7.5 ≤ OSI < 12.3
Severe ARDS (invasively ventilated): OI ≥ 16 or OSI ≥ 12.3.
Sepsis (5, 6) Adults: life-threatening organ dysfunction caused by a dysregulated host response to suspected or proven infection.b
Signs of organ dysfunction include: altered mental status, difficult or fast breathing, low oxygen saturation,
reduced urine output (5, 20), fast heart rate, weak pulse, cold extremities or low blood pressure, skin
mottling, or laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate, or
hyperbilirubinemia.
Children: suspected or proven infection and ≥ 2 age- based systemic inflammatory response syndrome criteria, of
which one must be abnormal temperature or white blood cell count.
Septic shock
(5, 6)
Adults: persisting hypotension despite volume resuscitation, requiring vasopressors to maintain MAP MAP ≥ 65
mmHg and serum lactate level > 2 mmol/L.
Children: any hypotension (SBP < 5th centile or > 2 SD below normal for age) or two or three of the following: altered
mental state; tachycardia or bradycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in
children); prolonged capillary refill (> 2 sec) or feeble pulse; tachypnoea; mottled or cool skin or petechial or purpuric
rash; increased lactate; oliguria; hyperthermia or hypothermia (21).
a If altitude is higher than 1000 m, then correction factor should be calculated as follows: PaO2/FiO2 x barometric pressure/760.
b The SOFA score ranges from 0 to 24 and includes points related to six organ systems: respiratory (hypoxemia defined by low PaO2/FiO2); coagulation (low platelets); liver (high
bilirubin); cardiovascular (hypotension); central nervous system (low level of consciousness defined by Glasgow Coma Scale); and renal (low urine output or high creatinine).
Sepsis is defined by an increase in the sepsis-related SOFA score of ≥ 2 points. Assume the baseline score is 0 if data are not available (22).
Abbreviations: ARI acute respiratory infection; BP blood pressure; bpm beats/minute; CPAP continuous positive airway pressure; FiO2 fraction of inspired oxygen; MAP mean
arterial pressure; NIV non-invasive ventilation; OI Oxygenation Index; OSI Oxygenation Index using SpO2; PaO2 partial pressure of oxygen; PEEP positive end-expiratory
pressure; SBP systolic blood pressure; SD standard deviation; SIRS systemic inflammatory response syndrome; SOFA sequential organ failure assessment; SpO2 oxygen
saturation.
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Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
2. Immediate implementation of appropriate IPC measures
IPC is a critical and integral part of clinical management of patients and WHO guidance is available
(https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/infection-prevention-and-control).
Initiate IPC at the point of entry of the patient to hospital. Screening should be done at first point of contact at the
emergency department or outpatient department/clinics. Suspected COVID-19 patients should be given a mask and
directed to separate area. Keep at least 1 m distance between suspected patients.
Standard precautions should always be applied in all areas of health care facilities. Standard precautions include
hand hygiene and the use of personal protective equipment (PPE) when in indirect and direct contact with patients’
blood, body fluids, secretions (including respiratory secretions) and non-intact skin. Standard precautions also include
prevention of needle-stick or sharps injury; safe waste management; cleaning and disinfection of equipment; and
cleaning of the environment.
In addition to standard precautions, health care workers should do a point-of-care risk assessment at every patient
contact to determine whether additional precautions (e.g. droplet, contact, or airborne) are required.
Table 3. How to implement IPC measures for patients with suspected or confirmed COVID-19
Instructions for patients
Give suspect patient a medical mask and direct patient to separate area; --aan isolation room if available. Keep at least 1 m distance between suspected
patients and other patients. Instruct all patients to cover nose and mouth during coughing or sneezing with tissue or flexed elbow and perform hand
hygiene after contact with respiratory secretions.
Apply droplet precautions
Droplet precautions prevent large droplet transmission of respiratory viruses. Use a medical mask if working within 1 m of the patient. Place patients in
single rooms, or group together those with the same etiological diagnosis. If an etiological diagnosis is not possible, group patients with similar clinical
diagnosis and based on epidemiological risk factors, with a spatial separation. When providing care in close contact with a patient with respiratory
symptoms (e.g. coughing or sneezing), use eye protection (face mask or goggles), because sprays of secretions may occur. Limit patient movement within
the institution and ensure that patients wear medical masks when outside their rooms.
Apply contact precautions Contact precautions prevent direct or indirect transmission from contact with contaminated surfaces or equipment (i.e.
contact with contaminated oxygen tubing/interfaces). Use PPE (medical mask, eye protection, gloves and gown) when entering room and remove PPE
when leaving and practise hand hygiene after PPE removal. If possible, use either disposable or dedicated equipment (e.g. stethoscopes, blood pressure
cuffs, pulse oximeters, and thermometers). If equipment needs to be shared among patients, clean and disinfect between each patient use. Ensure that
health care workers refrain from touching their eyes, nose, and mouth with potentially contaminated gloved or ungloved hands. Avoid contaminating
environmental surfaces that are not directly related to patient care (e.g. door handles and light switches). Avoid medically unnecessary movement of
patients or transport. Perform hand hygiene.
Apply airborne precautions when performing an aerosol-generating procedure
Ensure that health care workers performing aerosol-generating procedures (e.g. open suctioning of respiratory tract, intubation, bronchoscopy,
cardiopulmonary resuscitation) use the appropriate PPE, including gloves, long-sleeved gowns, eye protection, and fit-tested particulate respirators (N95 or
equivalent, or higher level of protection). A scheduled fit test should not be confused with a user’s’ seal check before each use. Whenever possible, use
adequately ventilated single rooms when performing aerosol-generating procedures, meaning negative pressure rooms with a minimum of 12 air changes
per hour or at least 160 L/second/patient in facilities with natural ventilation. Avoid the presence of unnecessary persons individuals in the room. Care for
the patient in the same type of room after mechanical ventilation begins. commences.
Abbreviations: ARI acute respiratory infection; PPE personal protective equipment.
3. Collection of specimens for laboratory diagnosis
WHO guidance on specimen collection, processing and laboratory testing is available (https://www.who.int/publicationsdetail/laboratory-testing-for-2019-novel-coronavirus-in-suspected-human-cases-20200117). Additionally, guidance on related
biosafety procedures is available (https://apps.who.int/iris/bitstream/handle/10665/331138/WHO-WPE-GIH-2020.1-eng.pdf).
Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial therapy. DO NOT
delay antimicrobial therapy to collect blood cultures.
Collect specimens from the upper respiratory tract (URT; nasopharyngeal and oropharyngeal) AND, where clinical
suspicion remains and URT specimens are negative, collect specimens from the lower respiratory tract when readily
available (LRT; expectorated sputum, endotracheal aspirate, or bronchoalveolar lavage in ventilated patient) for COVID19 virus testing by RT-PCR and bacterial stains/cultures.
In hospitalized patients with confirmed COVID-19, repeated URT and LRT samples can be collected to demonstrate
viral clearance. The frequency of specimen collection will depend on local epidemic characteristics and resources. For
hospital discharge, in a clinically recovered patient, two negative tests, at least 24 hours apart, is recommended.
Remark 1: Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens; airborne
precautions for LRT specimens). When collecting URT samples, use viral swabs (sterile Dacron or rayon, not cotton) and viral
5
Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
transport media. Do not sample the nostrils or tonsils. In a patient with suspected COVID-19, especially with pneumonia or
severe illness, a single URT sample does not exclude the diagnosis, and additional URT and LRT samples are recommended.
LRT (vs URT) samples are more likely to be positive and for a longer period (23). Clinicians may elect to collect only LRT
samples when these are readily available (for example, in mechanically ventilated patients). Sputum induction should be avoided
owing to increased risk of aerosol transmission.
Remark 2 for pregnant patients: COVID-19 testing of symptomatic pregnant women may need to be prioritized to enable
access to specialized care.
Remark 3: Dual infections with other respiratory viral and bacterial infections have been found in SARS, MERS and COVID-19
patients (8). As a result, a positive test for a non-COVID-19 pathogen does not rule out COVID-19. At this stage, detailed
microbiologic studies are needed in all suspected cases. Both URT and LRT specimens can be tested for other respiratory
viruses, such as influenza A and B (including zoonotic influenza A), respiratory syncytial virus, parainfluenza viruses,
rhinoviruses, adenoviruses, enteroviruses (e.g. EVD68), human metapneumovirus and endemic human coronaviruses (i.e.
HKU1, OC43, NL63, and 229E). LRT specimens can also be tested for bacterial pathogens, including Legionella pneumophila.
In malaria-endemic areas, patients with fever should be tested for the presence of malaria or other co-infections with validated
rapid diagnostic tests (RDTs) or thick and thin blood films and treated as appropriate. In endemic settings arbovirus infection
(dengue/chikungunya) should also be considered in the differential diagnosis of undifferentiated febrile illness, particularly when
thrombocytopenia is present. Co-infection with COVID-19 virus may also occur and a positive diagnostic test for dengue (e.g.
dengue RDTs) does not exclude the testing for COVID-19 (24).
4. Management of mild COVID-19: symptomatic treatment and monitoring
Patients with mild disease do not require hospital interventions, but isolation is necessary to contain virus
transmission and will depend on national strategy and resources.
Remark: Although most patients with mild disease may not have indications for hospitalization, it is necessary to implement
appropriate IPC to contain and mitigate transmission. This can be done either in hospital, if there are only sporadic cases or small
clusters, or in repurposed, non-traditional settings; or at home.
Provide patients with mild COVID-19 with symptomatic treatment such as antipyretics for fever.
Counsel patients with mild COVID-19 about signs and symptoms of complicated disease. If they develop any of these
symptoms, they should seek urgent care through national referral systems.
5. Management of severe COVID-19: oxygen therapy and monitoring
Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress, hypoxaemia or shock
and target SpO2 > 94%.
Remarks for adults: Adults with emergency signs (obstructed or absent breathing, severe respiratory distress, central cyanosis,
shock, coma, or convulsions) should receive airway management and oxygen therapy during resuscitation to target SpO2 ≥ 94%.
Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥ 93% during resuscitation; or use face mask with
reservoir bag (at 10–15 L/min) if patient in critical condition. Once patient is stable, the target is > 90% SpO2 in non-pregnant
adults and ≥ 92–95% in pregnant patients (16, 25).
Remarks for children: Children with emergency signs (obstructed or absent breathing, severe respiratory distress, central
cyanosis, shock, coma or convulsions) should receive airway management and oxygen therapy during resuscitation to target
SpO2 ≥ 94%; otherwise, the target SpO2 is ≥ 90% (25). Use of nasal prongs or nasal cannula is preferred in young children, as
they may be better tolerated.
Remark 3: All areas where patients with SARI are cared for should be equipped with pulse oximeters, functioning oxygen
systems and disposable, single-use, oxygen-delivering interfaces (nasal cannula, nasal prongs, simple face mask, and mask with
reservoir bag). See Appendix for details of resources.
Closely monitor patients with COVID-19 for signs of clinical deterioration, such as rapidly progressive respiratory
failure and sepsis and respond immediately with supportive care interventions.
Remark 1: Patients hospitalized with COVID-19 require regular monitoring of vital signs and, where possible, utilization of
medical early warning scores (e.g. NEWS2) that facilitate early recognition and escalation of treatment of the deteriorating
patient (26).
Remark 2: Haematology and biochemistry laboratory testing and ECG should be performed at admission and as clinically
indicated to monitor for complications, such as acute liver injury, acute kidney injury, acute cardiac injury, or shock. Application
6
Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
of timely, effective, and safe supportive therapies is the cornerstone of therapy for patients who develop severe manifestations of
COVID-19.
Remarks 3: After resuscitation and stabilization of the pregnant patient, then fetal well-being should be monitored.
Understand the patient’s co-morbid condition(s) to tailor the management of critical illness.
Remark 1: Determine which chronic therapies should be continued and which therapies should be stopped temporarily. Monitor
for drug-drug interactions.
Use conservative fluid management in patients with SARI when there is no evidence of shock.
Remarks: Patients with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation may
worsen oxygenation, especially in settings where there is limited availability of mechanical ventilation (27). This applies for care
of children and adults.
6. Management of severe COVID-19: treatment of co-infections
Give empiric antimicrobials to treat all likely pathogens causing SARI and sepsis as soon as possible, within 1 hour
of initial assessment for patients with sepsis.
Remark 1: Although the patient may be suspected to have COVID-19, administer appropriate empiric antimicrobials within 1
hour of identification of sepsis (5). Empiric antibiotic treatment should be based on the clinical diagnosis (community-acquired
pneumonia, health care-associated pneumonia [if infection was acquired in health care setting] or sepsis), local epidemiology and
susceptibility data, and national treatment guidelines.
Remark 2: When there is ongoing local circulation of seasonal influenza, empiric therapy with a neuraminidase inhibitor should
be considered for the treatment for patients with influenza or at risk for severe disease (5).
Empiric therapy should be de-escalated on the basis of microbiology results and clinical judgment.
7. Management of critical COVID-19: acute respiratory distress syndrome (ARDS)
Recognize severe hypoxemic respiratory failure when a patient with respiratory distress is failing to respond to
standard oxygen therapy and prepare to provide advanced oxygen/ventilatory support.
Remarks: Patients may continue to have increased work of breathing or hypoxemia even when oxygen is delivered via a face
mask with reservoir bag (flow rates of 10–15 L/min, which is typically the minimum flow required to maintain bag inflation;
FiO2 0.60–0.95). Hypoxemic respiratory failure in ARDS commonly results from intrapulmonary ventilation-perfusion mismatch
or shunt and usually requires mechanical ventilation (5).
Endotracheal intubation should be performed by a trained and experienced provider using airborne precautions.
Remarks: Patients with ARDS, especially young children or those who are obese or pregnant, may desaturate quickly during
intubation. Pre-oxygenate with 100% FiO2 for 5 minutes, via a face mask with reservoir bag, bag-valve mask, HFNO or NIV.
Rapid-sequence intubation is appropriate after an airway assessment that identifies no signs of difficult intubation (28, 29,.30).
The following recommendations pertain to mechanically ventilated adults and paediatric patients with ARDS (5, 31).
Implement mechanical ventilation using lower tidal volumes (4–8 mL/kg predicted body weight, PBW) and lower
inspiratory pressures (plateau pressure < 30 cmH2O).
Remarks for adults: This is a strong recommendation from a clinical guideline for patients with ARDS (5), and is suggested for
patients with sepsis-induced respiratory failure who do not meet ARDS criteria (5). The initial tidal volume is 6 mL/kg PBW;
tidal volume up to 8 mL/kg PBW is allowed if undesirable side effects occur (e.g. dyssynchrony, pH < 7.15). Permissive
hypercapnia is permitted. Ventilator protocols are available (32). The use of deep sedation may be required to control respiratory
drive and achieve tidal volume targets.
Remarks for children: In children, a lower level of plateau pressure (< 28 cmH2O) is targeted, and lower target of pH is
permitted (7.15–7.30). Tidal volumes should be adapted to disease severity: 3–6 mL/kg PBW in the case of poor respiratory
system compliance, and 5–8 mL/kg PBW with better preserved compliance (31).
In adult patients with severe ARDS, prone ventilation for 12–16 hours per day is recommended.
Remarks for adults and children: Application of prone ventilation is strongly recommended for adult patients, and may be
7
Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
considered for paediatric patients with severe ARDS but requires sufficient human resources and expertise to be performed
safely; protocols (including videos) are available (33, 34) (https://www.nejm.org/doi/full/10.1056/NEJMoa1214103).
Remark for pregnant women: There is little evidence on prone positioning in pregnant women. Pregnant women may benefit
from being placed in the lateral decubitus position.
Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.
Remarks for adults and children: This is a strong guideline recommendation (5); the main effect is to shorten the duration of
ventilation. See reference (35) for details of a sample protocol.
In patients with moderate or severe ARDS, higher PEEP instead of lower PEEP issuggested.
Remark 1: PEEP titration requires consideration of benefits (reducing atelectrauma and improving alveolar recruitment) vs risks
(end-inspiratory overdistension leading to lung injury and higher pulmonary vascular resistance). Tables are available to guide
PEEP titration based on the FiO2 required to maintain SpO2 (32). In younger children, maximal PEEP rates are 15 cmH2O.
Although high driving pressure (plateau pressure − PEEP) may more accurately predict increased mortality in ARDS compared
with high tidal volume or plateau pressure (36), data from RCTs of ventilation strategies that target driving pressure are not
currently available.
Remark 2: A related intervention of recruitment manoeuvres (RMs) is delivered as episodic periods of high continuous positive
airway pressure (CPAP) (30–40 cmH2O), progressive incremental increases in PEEP with constant driving pressure, or high
driving pressure; considerations of benefits vs risks are similar. Higher PEEP and RMs were both conditionally recommended in
a clinical practice guideline. For PEEP, the guideline considered an individual patient data meta-analysis(37) of three RCTs.
However, a subsequent RCT of high PEEP and prolonged high-pressure RMs showed harm, suggesting that the protocol in this
RCT should be avoided (38). Monitoring of patients to identify those who respond to the initial application of higher PEEP or a
different RM protocol and stopping these interventions in non-responders are suggested (39).
In patients with moderate-severe ARDS (PaO2/FiO2 < 150), neuromuscular blockade by continuous infusion should
not be routinely used.
Remark: A trial found that this strategy improved survival in adult patients with severe ARDS (PaO2/FiO2 < 150) without
causing significant weakness (40), but results of a recent larger trial found that use of neuromuscular blockade with high PEEP
strategy was not associated with a survival benefit when compared with a light sedation strategy without neuromuscular blockade
(41). Continuous neuromuscular blockade may still be considered in patients with ARDS, both adults and children, in certain
situations: ventilator dyssnchrony despite sedation, such that tidal volume limitation cannot be reliably achieved; or refractory
hypoxemia or hypercapnia.
Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis.
Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection is required (for
example, transfer to a transport ventilator).
The following recommendations pertain to adult and paediatric patients with ARDS who are treated with non-invasive or
high-flow oxygen systems.
High-flow nasal oxygen (HFNO) should be used only in selected patients with hypoxemic respiratory failure.
Non-invasive ventilation (NIV) should be used only in selected patients with hypoxemic respiratory failure.
Patients treated with either HFNO or NIV should be closely monitored for clinical deterioration.
Remark 1: Adult HFNO systems can deliver 60 L/min of gas flow and FiO2 up to 1.0. Paediatric circuits generally only handle
up to 25 L/min, and many children will require an adult circuit to deliver adequate flow.
Remark 2: Because of uncertainty around the potential for aerosolization, HFO, NIV, including bubble CPAP, should be used
with airborne precautions until further evaluation of safety can be completed.
Remark 3: Compared with standard oxygen therapy, HFNO reduces the need for intubation (42). Patients with hypercapnia
(exacerbation of obstructive lung disease, cardiogenic pulmonary oedema), hemodynamic instability, multiorgan failure, or
abnormal mental status should generally not receive HFNO, although emerging data suggest that HFNO may be safe in patients
with mild-moderate and non-worsening hypercapnia (42, 43, 44). Patients receiving HFNO should be in a monitored setting and
cared for by experienced personnel capable of performing endotracheal intubation in case the patient acutely deteriorates or does
not improve after a short trial (about 1 hour). Evidence-based guidelines on HFNO do not exist, and reports on HFNO in patients
infected with other coronaviruses are limited (44).
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Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
Remark 4: NIV guidelines make no recommendation on use in hypoxemic respiratory failure (apart from cardiogenic
pulmonary oedema and postoperative respiratory failure) or pandemic viral illness (referring to studies of SARS and pandemic
influenza) (5). Risks include delayed intubation, large tidal volumes, and injurious transpulmonary pressures. Limited data
suggest a high failure rate in patients with other viral infections such as MERS-CoV who receive NIV (45).
Remark 5: Patients receiving a trial of NIV should be in a monitored setting and cared for by experienced personnel capable of
performing endotracheal intubation in case the patient acutely deteriorates or does not improve after a short trial (about 1 hour).
Patients with haemodynamic instability, multiorgan failure, or abnormal mental status should likely not receive NIV in place of
other options such as invasive ventilation.
Remark 6: In situations where mechanical ventilation might not be available, bubble nasal CPAP may be used for newborns and
children with severe hypoxemia, and may be a more readily available alternative in resource-limited settings (46).
The following recommendations pertain to adult and paediatric patients with ARDS in whom lung protective ventilation
strategy fails.
In settings with access to expertise in extracorporeal membrane oxygenation (ECMO), consider referral of patients who have
refractory hypoxemia despite lung protective ventilation.
Remarks for adult and children: An RCT of ECMO for adult patients with ARDS was stopped early and found no statistically
significant difference in the primary outcome of 60-day mortality between ECMO and standard medical management (including
prone positioning and neuromuscular blockade) (47). However, ECMO was associated with a reduced risk of the composite
outcome of mortality and crossover to ECMO (47), and a post hoc Bayesian analysis of this RCT showed that ECMO is very
likely to reduce mortality across a range of prior assumptions (48). In patients with MERS, ECMO vs conventional treatment was
associated with reduced mortality in a cohort study (49). ECMO should be offered only in expert centres with a sufficient case
volume to maintain expertise and that can apply the IPC measures required for adult and paediatric COVID-19 patients (50, 51).
8. Management of critical illness and COVID-19: prevention of complications
Implement the following interventions (Table 4) to prevent complications associated with critical illness. These interventions are
based on Surviving Sepsis (5) or other guidelines (52-55), and are generally limited to feasible recommendations based on highquality evidence.
Table 4. Prevention of complications
Anticipated
outcome
Interventions
Reduce days of
invasive
mechanical
ventilation
• Use weaning protocols that include daily assessment for readiness to breathespontaneously
• Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless
contraindicated) or with daily interruption of continuous sedative infusions
Reduce incidence
of ventilatorassociated
pneumonia
• Oral intubation is preferable to nasal intubation in adolescents and adults
• Keep patient in semi-recumbent position (head of bed elevation 30–45º)
• Use a closed suctioning system; periodically drain and discard condensate intubing
• Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or
damaged, but not routinely
• Change heat moisture exchanger when it malfunctions, when soiled, or every 5–7 days
Reduce incidence
of venous
thromboembolism
• Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000
units subcutaneously twice daily) in adolescents and adults without contraindications. For those with
contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices)
Reduce incidence
of catheter-related
bloodstream
infection
• Use a checklist with completion verified by a real-time observer as reminder of each step needed for
sterile insertion and as a daily reminder to remove catheter if no longer needed
Reduce incidence
of pressure ulcers • Turn patient every 2 hours
Reduce incidence
of stress ulcers
and
gastrointestinal
(GI) bleeding
• Give early enteral nutrition (within 24–48 hours of admission)
• Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI
bleeding. Risk factors for GI bleeding include mechanical ventilation for ≥ 48 hours, coagulopathy, renal
replacement therapy, liver disease, multiple comorbidities, and higher organ failure score
Reduce incidence
of ICU-related
weakness
• Actively mobilize the patient early in the course of illness when safe to do so
9
Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
9. Management of critical illness and COVID-19: septic shock
Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain
mean arterial pressure (MAP) ≥ 65 mmHg AND lactate is ≥ 2 mmol/L, in absence of hypovolemia.
Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] < 5th centile or > 2 SD below
normal for age) or two or more of the following: altered mental state; bradycardia or tachycardia (HR < 90 bpm or >
160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulses;
tachypnea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia.
Remark 1: In the absence of a lactate measurement, use blood pressure (i.e. MAP) and clinical signs of perfusion to define
shock.
Remark 2: Standard care includes early recognition and the following treatments within 1 hour of recognition: antimicrobial
therapy, and initiation of fluid bolus and vasopressors for hypotension (5). The use of central venous and arterial catheters should
be based on resource availability and individual patient needs. Detailed guidelines from the Surviving Sepsis Campaign and
WHO are available for the management of septic shock in adults(5) and children (6, 16). Alternate fluid regimens are suggested
when caring for adults and children in resource-limited settings (56, 57).
The following recommendations pertain to resuscitation strategies for adult and paediatric patients with septic shock.
In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid as rapid bolus in first 15–30 minutes
and reassess for signs of fluid overload after each bolus.
In resuscitation from septic shock in children, give 10–20 mL/kg crystalloid fluid as a bolus in the first 30–60
minutes and reassess for signs of fluid after each bolus.
Fluid resuscitation may lead to volume overload, including respiratory failure, particularly with ARDS. If there is no
response to fluid loading or signs of volume overload appear (e.g. jugular venous distension, crackles on lung
auscultation, pulmonary oedema on imaging, or hepatomegaly in children), then reduce or discontinue fluid
administration. This step is particularly important in patients with hypoxemic respiratory failure.
Remark 1: Crystalloids include normal saline and Ringer’s lactate.
Remark 2: Determine need for additional fluid boluses (250–500 mL in adults or 10–20 mL/kg in children) based on clinical
response and improvement of perfusion targets. Perfusion targets include MAP (> 65 mmHg or age-appropriate targets in
children), urine output (> 0.5 mL/kg/hr in adults, 1 mL/kg/hr in children), and improvement of skin mottling and extremity
perfusion, capillary refill, heart rate, level of consciousness, and lactate.
Remark 3: Consider dynamic indices of volume responsiveness to guide volume administration beyond initial resuscitation
based on local resources and experience (5). These indices include passive leg raises, fluid challenges with serial stroke volume
measurements, or variations in systolic pressure, pulse pressure, inferior vena cava size, or stroke volume in response to changes
in intrathoracic pressure during mechanical ventilation.
Remark 4: In pregnant women, compression of the inferior vena cava can cause a decrease in venous return and cardiac preload
and may result in hypotension. For this reason, pregnant women with sepsis and or septic shock may need to be placed in the
lateral decubitus position to off-load the inferior vena cava (58).
Remark 5: Clinical trials conducted in resource-limited studies comparing aggressive versus conservative fluid regimens
suggest higher mortality in patients treated with aggressive fluid regimens (56, 57).
Do not use hypotonic crystalloids, starches, or gelatins for resuscitation.
Remark 1: Starches are associated with an increased risk of death and acute kidney injury compared with crystalloids. The
effects of gelatins are less clear, but they are more expensive than crystalloids (5, 59). Hypotonic (vs isotonic) solutions are less
effective at increasing intravascular volume. Surviving Sepsis also suggests albumin for resuscitation when patients require
substantial amounts of crystalloids, but this conditional recommendation is based on low-quality evidence (5).
In adults, administer vasopressors when shock persists during or after fluid resuscitation. The initial blood
pressure target is MAP ≥ 65 mmHg in adults and improvement of markers of perfusion.
In children administer vasopressors if:
1. Signs of shock such as altered mental state; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and
H R < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 seconds) or feeble pulses; tachypnea; mottled
or cool skin or petechial or purpuric rash; increased lactate; oliguria persists after two repeat boluses; or
2. age-appropriate blood pressure targets are not achieved; or
3. signs of fluid overload are apparent (6).
10
Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance
If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein
and closely monitor for signs of extravasation and local tissue necrosis. If extravasation occurs, stop infusion.
Vasopressors can also be administered through intraosseous needles.
If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors,
consider an inotrope such as dobutamine.
Remark 1: Vasopressors (i.e. norepinephrine, epinephrine, vasopressin, and dopamine) are most safely given through a central
venous catheter at a strictly controlled rate, but it is also possible to safely administer them via peripheral vein (60) and
intraosseous needle. Monitor blood pressure frequently and titrate the vasopressor to the minimum dose necessary to maintain
perfusion and prevent side effects. A recent study suggests that in adults 65 years or older a MAP 60–65 mmHg target is
equivalent to ≥ 65 mmHg (61).
Remark 2: Norepinephrine is considered first-line treatment in adult patients; epinephrine or vasopressin can be added to
achieve the MAP target. Because of the risk of tachyarrhythmia, reserve dopamine for selected patients with low risk of
tachyarrhythmia or those with bradycardia.
Remark 3: In children, epinephrine is considered first-line treatment, while norepinephrine can be added if shock persists
despite optimal dose of epinephrine.
Remark 4: No RCTs have compared dobutamine with placebo for clinical outcomes.
Remark 5: See section 11 on adjunctive therapies for remarks on corticosteroids and sepsis.
10. Adjunctive therapies for COVID-19: corticosteroids
Do not routinely give systemic corticosteroids for treatment of viral pneumonia outside clinical trials.
Remark 1: A systematic review of observational studies of corticosteroids administered to patients with SARS reported no
survival benefit and possible harms (avascular necrosis, psychosis, diabetes, and delayed viral clearance) (62). A systematic
review of observational studies in influenza found a higher risk of mortality and secondary infections with corticosteroids; the
evidence was judged as very low to low quality owing to confounding by indication (63). A subsequent study that addressed this
limitation by adjusting for time-varying confounders found no effect on mortality (64). Finally, a recent study of patients
receiving corticosteroids for MERS used a similar statistical approach and found no effect of corticosteroids on mortality but
delayed LRT clearance of MERS-CoV (65). Given the lack of effectiveness and possible harm, routine corticosteroids should be
avoided unless they are indicated for another reason. Other reasons may include exacerbation of asthma or COPD, septic shock,
and risk/benefit analysis needs to be conducted for individual patients.
Remark 2: A recent guideline issued by an international panel and based on the findings of two recent large RCTs makes a
conditional recommendation for corticosteroids for all patients with sepsis (including septic shock) (66). Surviving Sepsis
guidelines, written before these RCTs were reported, recommend corticosteroids only for patients in whom adequate fluids and
vasopressor therapy do not restore hemodynamic stability (5). Clinicians considering corticosteroids for a patient with COVID19 and sepsis must balance the potential small reduction in mortality with the potential downside of prolonged shedding of
coronavirus in the respiratory tract, as has been observed in patients with MERS (65). If corticosteroids are prescribed, monitor
and treat hyperglycaemia, hypernatraemia, and hypokalaemia. Monitor for recurrence of inflammation and signs of adrenal
insufficiency after stopping corticosteroids, which may have to be tapered. Because of the risk of strongyloides stercoralis
hyper-infection with steroid therapy, diagnosis or empiric treatment should be considered in endemic areas if steroids are used
(67).
Remark 2 for pregnant women: WHO recommends antenatal corticosteroid therapy for women at risk of preterm birth from 24
to 34 weeks of gestation when there is no clinical evidence of maternal infection, and adequate childbirth and newborn care is
available. However, in cases where the woman presents with mild COVID-19, the clinical benefits of aantenatal corticosteroid
might outweigh the risks of potential harm to the mother. In this situation, the balance of benefits and harms for the woman and
the preterm newborn should be discussed with the woman to ensure an informed decision, as this assessment may vary
depending on the woman’s clinical condition, her wishes and that of her family, and available health care resources
Chinese hospitals overflowing with COVID-19 patients a few weeks ago now have empty beds. Trials of experimental drugs are having difficulty enrolling enough eligible patients. And the number of new cases reported each day has plummeted the past few weeks.
These are some of the startling observations in a report released on 28 February from a mission organized by the World Health Organization (WHO) and the Chinese government that allowed 13 foreigners to join 12 Chinese scientists on a tour of five cities in China to study the state of the COVID-19 epidemic and the effectiveness of the country's response. The findings surprised several of the visiting scientists. "I thought there was no way those numbers could be real," says epidemiologist Tim Eckmanns of the Robert Koch Institute, who was part of the mission.
But the report is unequivocal. "China's bold approach to contain the rapid spread of this new respiratory pathogen has changed the course of a rapidly escalating and deadly epidemic," it says. "This decline in COVID-19 cases across China is real."
The question now is whether the world can take lessons from China's apparent success—and whether the massive lockdowns and electronic surveillance measures imposed by an authoritarian government would work in other countries. "When you spend 20, 30 years in this business it's like, ‘Seriously, you're going to try and change that with those tactics?'" says Bruce Aylward, a Canadian WHO epidemiologist who led the international team and briefed journalists about its findings in Beijing and Geneva last week. "Hundreds of thousands of people in China did not get COVID-19 because of this aggressive response."
"This report poses difficult questions for all countries currently considering their response to COVID-19," says Steven Riley, an epidemiologist at Imperial College London. "The joint mission was highly productive and gave a unique insight into China's efforts to stem the virus from spread within mainland China and globally," adds Lawrence Gostin, a global health law scholar at Georgetown University. But Gostin warns against applying the model elsewhere. "I think there are very good reasons for countries to hesitate using these kinds of extreme measures."
There's also uncertainty about what the virus, dubbed SARS-CoV-2, will do in China after the country inevitably lifts some of its strictest control measures and restarts its economy. COVID-19 cases may well increase again.
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The report comes at a critical time in what many epidemiologists now consider a pandemic. Just this past week, the number of affected countries shot up from 29 to 61. Several countries have discovered that they already have community spread of the virus—as opposed to cases only in travelers from affected areas or people who were in direct contact with them—and the numbers of reported cases are growing exponentially.
The opposite has happened in China. On 10 February, when the advance team of the WHO-China Joint Mission began its work, China reported 2478 new cases. Two weeks later, when the foreign experts packed their bags, that number had dropped to 409 cases. (Yesterday, China reported only 206 new cases, and the rest of the world combined had almost nine times that number.) The epidemic in China appears to have peaked in late January, according to the report.
Ambitious, agile, and aggressive
The team began in Beijing and then split into two groups that, all told, traveled to Shenzhen, Guangzhou, Chengdu, and the hardest hit city, Wuhan. They visited hospitals, laboratories, companies, wet markets selling live animals, train stations, and local government offices. "Everywhere you went, anyone you spoke to, there was a sense of responsibility and collective action, and there's war footing to get things done," Aylward says.
The group also reviewed the massive data set that Chinese scientists have compiled. (The country still accounts for more than 90% of the global total of the 90,000 confirmed cases.) They learned that about 80% of infected people had mild to moderate disease, 13.8% had severe symptoms, and 6.1% had life-threatening episodes of respiratory failure, septic shock, or organ failure. The case fatality rate was highest for people over age 80 (21.9%), and people who had heart disease, diabetes, or hypertension. Fever and dry cough were the most common symptoms. Surprisingly, only 4.8% of infected people had runny noses. Children made up a mere 2.4% of the cases, and almost none was severely ill. For the mild and moderate cases, it took 2 weeks on average to recover.
A critical unknown is how many mild or asymptomatic cases occur. If large numbers of infections are below the radar, that complicates attempts to isolate infectious people and slow spread of the virus. But on the positive side, if the virus causes few, if any, symptoms in many infected people, the current estimated case fatality rate is too high. (The report says that rate varies greatly, from 5.8% in Wuhan, whose health system was overwhelmed, to 0.7% in other regions.)
To get at this question, the report notes that so-called fever clinics in Guangdong province screened approximately 320,000 people for COVID-19 and only found 0.14% of them to be positive. "That was really interesting, because we were hoping and maybe expecting to see a large burden of mild and asymptomatic cases," says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security. "That piece of data suggests that's not happening, which would imply that the case fatality risk might be more or less as we currently have." But Guangdong province was not a heavily affected area, so it is not clear whether the same holds in Hubei province, which was the hardest hit, Rivers cautions.
Much of the report focuses on understanding how China achieved what many public health experts thought was impossible: containing the spread of a widely circulating respiratory virus. "China has rolled out perhaps the most ambitious, agile, and aggressive disease containment effort in history," the report notes.
The most dramatic—and controversial—measure was the lockdown of Wuhan and nearby cities in Hubei province, which has put at least 50 million people under a mandatory quarantine since 23 January. That has "effectively prevented further exportation of infected individuals to the rest of the country," the report concludes. In other regions of mainland China, people voluntarily quarantined and were monitored by appointed leaders in neighborhoods.
Chinese authorities also built two dedicated hospitals in Wuhan in just over 1 week. Health care workers from all over China were sent to the outbreak's center. The government launched an unprecedented effort to trace contacts of confirmed cases. In Wuhan alone, more than 1800 teams of five or more people traced tens of thousands of contacts.
Aggressive "social distancing" measures implemented in the entire country included canceling sporting events and shuttering theaters. Schools extended breaks that began in mid-January for the Lunar New Year. Many businesses closed shop. Anyone who went outdoors had to wear a mask.
Two widely used mobile phone apps, AliPay and WeChat—which in recent years have replaced cash in China—helped enforce the restrictions, because they allow the government to keep track of people's movements and even stop people with confirmed infections from traveling. "Every person has sort of a traffic light system," says mission member Gabriel Leung, dean of the Li Ka Shing Faculty of Medicine at the University of Hong Kong. Color codes on mobile phones—in which green, yellow, or red designate a person's health status—let guards at train stations and other checkpoints know who to let through.
"As a consequence of all of these measures, public life is very reduced," the report notes. But the measures worked. In the end, infected people rarely spread the virus to anyone but members of their own household, Leung says. Once all the people in an apartment or home were exposed, the virus had nowhere else to go and chains of transmission ended. "That's how the epidemic truly came under control," Leung says. In sum, he says, there was a combination of "good old social distancing and quarantining very effectively done because of that on-the-ground machinery at the neighborhood level, facilitated by AI [artificial intelligence] big data."
Deep commitment to collective action
How feasible these kinds of stringent measures are in other countries is debatable. "China is unique in that it has a political system that can gain public compliance with extreme measures," Gostin says. "But its use of social control and intrusive surveillance are not a good model for other countries." The country also has an extraordinary ability to do labor-intensive, large-scale projects quickly, says Jeremy Konyndyk, a senior policy fellow at the Center for Global Development: "No one else in the world really can do what China just did."
Nor should they, says lawyer Alexandra Phelan, a China specialist at Georgetown's Center for Global Health Science and Security. "Whether it works is not the only measure of whether something is a good public health control measure," Phelan says. "There are plenty of things that would work to stop an outbreak that we would consider abhorrent in a just and free society."
The report does mention some areas where China needs to improve, including the need "to more clearly communicate key data and developments internationally." But it is mum on the coercive nature of its control measures and the toll they have exacted. "The one thing that's completely glossed over is the whole human rights dimension," says Devi Sridhar, an expert on global public health at the University of Edinburgh. Instead, the report praises the "deep commitment of the Chinese people to collective action in the face of this common threat."
"To me, as somebody who has spent a lot of time in China, it comes across as incredibly naïve—and if not naïve, then willfully blind to some of the approaches being taken," Phelan says. Singapore and Hong Kong may be better examples to follow, Konyndyk says: "There has been a similar degree of rigor and discipline but applied in a much less draconian manner."
The report doesn't mention other downsides of China's strategy, says Jennifer Nuzzo, an epidemiologist at the Johns Hopkins University Bloomberg School of Public Health, who wonders what impact it had on, say, the treatment of cancer or HIV patients. "I think it's important when evaluating the impact of these approaches to consider secondary, tertiary consequences," Nuzzo says.
And even China's massive efforts may still turn out to have only temporarily slowed the epidemic. "There's no question they suppressed the outbreak," says Mike Osterholm, head of the Center for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities. "That's like suppressing a forest fire, but not putting it out. It'll come roaring right back." But that, too, may teach the world new lessons, Riley says. "We now have the opportunity to see how China manages a possible resurgence of COVID-19," he says.
Aylward stresses that China's successes so far should give other countries confidence that they can get a jump on COVID-19. "We're getting new reports daily of new outbreaks in new areas, and people have a sense of, ‘Oh, we can't do anything,' and people are arguing is it a pandemic or not," Aylward says. "Well, sorry. There are really practical things you can do to be ready to be able to respond to this, and that's where the focus will need to be."
Importantly, China failed to expeditiously share information with the World Health Organization (WHO) on the novel coronavirus. For example, China waited until Feb. 14, nearly two months into the crisis, before it disclosed that 1,700 healthcare workers were infected. Such information on the vulnerability of medical workers is essential to understanding transmission patterns and to devise strategies to contain the virus. The experts at WHO were stymied by Chinese officials for data on hospital transmissions. China’s failure to provide open and transparent information to WHO is more than a moral breakdown. It is also the breach of a legal duty that China owed to other states under international law, and for which injured states — now numbering some 150 nations — may seek a legal remedy.
Unfortunately, China’s evasions are part of the autocratic playbook, repeating its obstruction of information that worsened the SARS crisis 18 years earlier. In that case, China tried to cover up the SARS epidemic, which led WHO member states to adopt the new International Health Regulations in 2005. In both cases, China and the world would have been spared thousands of unnecessary deaths had China acted forthrightly and in accordance with its legal obligations. Although China’s public health system has been modernized, observed Jude Blanchette, head of China Studies at the Center for Strategic and International Studies, its political system has regressed.As one of the 194 states party to the legally binding 2005 International Health Regulations, China has a duty to rapidly gather information about and contribute to a common understanding of what may constitute a public health emergency with potential international implications. The legally binding International Health Regulations were adopted by the World Health Assembly in 1969, to control six infectious diseases: cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. The 2005 revision added smallpox, poliomyelitis due to wild-type poliovirus, SARS, and cases of human influenza caused by a new subtype, set forth in the second annex.Article 6 of the International Health Regulations requires states to provide expedited, timely, accurate, and sufficiently detailed information to WHO about the potential public health emergencies identified in the second annex in order to galvanize efforts to prevent pandemics. WHO also has a mandate in Article 10 to seek verification from states with respect to unofficial reports of pathogenic microorganisms. States are required to provide timely and transparent information as requested within 24 hours, and to participate in collaborative assessments of the risks presented. Yet China rejected repeated offers of epidemic investigation assistance from WHO in late January (and the U.S. Centers for Disease Control and Prevention in early February), without explanation. The Washington Post concluded in a story on Feb. 26 that China “was not sending details that WHO officials and other experts expect and need.” While WHO later commended China for its efforts, Mara Pillinger of Georgetown’s O’Neill Institute for National and Global Health Law concluded that Beijing’s partial collaboration “makes it politically tricky for WHO to publicly contradict” China while still getting at least some useful data from China.
While China’s intentional conduct is wrongful, is it unlawful? If so, do other states have a legal remedy? Under Article 1 of the International Law Commission’s 2001 Responsibility of States for Internationally Wrongful Acts, states are responsible for their internationally wrongful acts. This commission’s restatement of the law of state responsibility was developed with the input of states to reflect a fundamental principle of international customary law, which binds all nations. “Wrongful acts” are those that are “attributable to the state” and that “constitute a breach of an international obligation” (Article 2). Conduct is attributable to the state when it is an act of state through the executive, legislative, or judicial functions of the central government (Article 4). While China’s failures began at the local level, they quickly spread throughout China’s government, all the way up to Xi Jinping, the general secretary of the Chinese Communist Party. He is now being pilloried by Chinese netizens for his failures of action and inaction. The most prominent critic, Chinese tycoon Ren Zhiqiang, lambasted Xi for his mishandling of the coronavirus, calling him a “power hungry clown.” Ren soon disappeared. Responsibility flows from local Wuhan authorities to Xi himself, which are all organs of the state of China, and whose conduct is therefore attributable to China. An “organ of the state” includes any person or entities that are acting in accordance with national law. Even if China were to disavow conduct by local authorities or state media as not necessarily directly attributable to the national government, such actions nevertheless are accorded that status if and to the extent the state acknowledged and adopted the conduct as its own, as was done by the officials in Beijing (Article 11).
Wrongful acts are those that constitute a breach of an international obligation (Article 11). A breach is an act that is “not in conformity with what is required of it by that obligation … .” China’s failure to expeditiously and transparently share information with WHO in accordance with the International Health Regulations constitutes an early and subsequently extended breach of its legal obligations (Article 14). Consequently, China bears legal responsibility for its internationally wrongful acts (Article 28). The consequences include full reparations for the injury caused by the wrongful acts. China did not intentionally create a global pandemic, but its malfeasance is certainly the cause of it. An epidemiological model at the University of Southampton found that had China acted responsibly just one, two, or three weeks more quickly, the number affected by the virus would have been cut by 66 percent, 86 percent, and 95 percent, respectively. By its failure to adhere to its legal commitments to the International Health Regulations, the Chinese Communist Party has let loose a global contagion, with mounting material consequences.
The cost of the coronavirus grows daily, with increasing incidents of sickness and death. The mitigation and suppression measures enforced by states to limit the damage are wrecking the global economy. Under Article 31 of the Articles of State Responsibility, states are required to make full reparations for the injury caused by their internationally wrongful acts. Injuries include damages, whether material or moral. Injured states are entitled to full reparation “in the form of restitution in kind, compensation, satisfaction and assurances and guarantees of non-repetition” (Article 34). Restitution in kind means that the injured state is entitled to be placed in the same position as existed before the wrongful acts were committed (Article 35). To the extent that restitution is not made, injured states are entitled to compensation (Article 36), and satisfaction, in terms of an apology and internal discipline and even criminal prosecution of officials in China who committed malfeasance (Article 37). Finally, injured states are entitled to guarantees of non-repetition, although the 2005 International Health Regulations were designed for this purpose after SARS (Article 48). As the world continues to suffer the costs of China’s breach of its legal duties, it remains to be seen whether the injured states can be made whole. No one expects that China will fulfill its obligations, or take steps required by the law of state responsibility. So, how might the United States and other nations vindicate their rights? The legal consequences of an internationally wrongful act are subject to the procedures of the Charter of the United Nations. Chapter XIV of the charter recognizes that states may bring disputes before the International Court of Justice or other international tribunals. But the principle of state sovereignty means that a state may not be compelled to appear before an international court without its consent. This reflects a general proposition in international law, and its fundamental weakness.
Still, injured states are not without remedy. Barring any prospect for effective litigation, states could resort to self-help. The law of state responsibility permits injured states to take lawful countermeasures against China by suspending their own compliance with obligations owed to China as a means of inducing Beijing to fulfill its responsibilities and debt (Article 49). Countermeasures shall not be disproportionate to the degree of gravity of the wrongful acts and the effects inflicted on injured states (Article 51). The choice of countermeasures that injured states may select is wide open, with only minimal limitations. For example, countermeasures may not involve the threat or use of force or undermine the human rights of China (Article 50). Except for these limitations, however, the United States and other injured states may suspend existing legal obligations or deliberately violate other legal duties owed to China as a means to induce Beijing to fulfill its responsibilities and address the calamitous damages it has inflicted on the world.
The menu for such countermeasures is as limitless as the extent that international law infuses the foreign affairs between China and the world, and such action by injured states may be individual and collective and does not have to be connected explicitly to the kind or type of violations committed by China. Thus, action could include removal of China from leadership positions and memberships, as China now chairs four of 15 organizations of the United Nations system. States could reverse China’s entry into the World Trade Organization, suspend air travel to China for a period of years, broadcast Western media in China, and undermine China’s famous internet firewall that keeps the country’s information ecosystem sealed off from the rest of the world. Remember that countermeasures permit not only acts that are merely unfriendly, but also licenses acts that would normally be a violation of international law. But the limitations still leave considerable room to roam, even if they violate China’s sovereignty and internal affairs, including ensuring that Taiwanese media voices and officials are heard through the Chinese internet firewall, broadcasting the ineptness and corruption of the Chinese Communist Party throughout China, and reporting on Chinese coercion against its neighbors in the South China Sea and East China Sea, and ensuring the people of China understand the responsibility of the Chinese Communist Party in unleashing a global contagion.
James Kraska is chair and Charles H. Stockton professor of international maritime law in the Stockton Center for International Law at the U.S. Naval War College. The views expressed here are his own and do not represent those of the Stockton Center, the U.S. Naval War College, the Department of the Navy, the Department of Defense, or any part of the U.S. government.
CORRECTION: A previous version of this article stated, “On Jan. 31, the Wuhan Municipal Health Commission falsely stated that there was no human-to-human transmission of the disease.” That was incorrect. The Wuhan Municipal Heath Commission’s released the statement on Dec. 31, not Jan. 31.
1
Hospital Experiences Responding
to the COVID-19 Pandemic:
Results of a National Pulse
Survey March 23–27, 2020
U.S. Department of Health and Human Services
Office of Inspector General
Christi A. Grimm
Principal Deputy Inspector General
April 2020, OEI-06-20-00300
Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp
Hospital Experiences Responding to the COVID-19
Pandemic: Results of a National Pulse Survey
March 23–27, 2020
Purpose of the Review
This review provides the Department of Health and Human Services (HHS) and other decision-makers (e.g., State
and local officials and other Federal agencies) with a national snapshot of hospitals’ challenges and needs in
responding to the coronavirus 2019 (COVID-19) pandemic. This is not a review of HHS response to the
COVID-19 pandemic. We have collected this information as an aid for HHS as it continues to lead efforts to
address the public health emergency and support hospitals and other first responders. In addition, hospitals
may find the information about each other’s strategies useful in their efforts to mitigate the challenges they are
facing.
The hospital input that we describe reflects their experiences and perspectives at a point in time—March 23–27,
2020. The pandemic is fast-moving, as are the efforts to address it. We recognize that HHS, Congress, and other
government entities across the Federal, State, local, and Tribal levels are taking substantial actions on a continual
basis to support hospitals in responding to COVID-19. HHS has already taken and continues to take actions
related to each of the challenges that hospitals identified in our survey, and the Coronavirus Aid, Relief, and
Economic Security (CARES) Act provides the basis for additional actions. We present this information for HHS’s
and other decision-makers’ consideration as they continue to respond to the COVID-19 pandemic.
Key Takeaway
Hospitals reported that their most significant challenges centered on testing and caring for patients with known
or suspected COVID-19 and keeping staff safe. Hospitals also reported substantial challenges maintaining or
expanding their facilities’ capacity to treat patients with COVID-19. Hospitals described specific challenges,
mitigation strategies, and needs for assistance related to personal protective equipment (PPE), testing, staffing,
supplies and durable equipment; maintaining or expanding facility capacity; and financial concerns.
How OIG Did This Review
This information is based on brief telephone interviews (“pulse surveys”) conducted March 23–27, 2020, with
hospital administrators from 323 hospitals across 46 States, the District of Columbia, and Puerto Rico, that were
part of our random sample. Our rate of contact was 85 percent. Interviews focused on three key questions:
1. What are your most difficult challenges in responding to COVID-19?
2. What strategies is your hospital using to address or mitigate these challenges?
3. How could government best support hospitals responding to COVID-19?
Respondent hospitals included Special Pathogen Centers, critical access hospitals, and a range of hospitals
nation-wide of various sizes and characteristics. At the time of our surveys, most hospitals reported they were
treating patients with confirmed or suspected COVID-19, but some were not currently treating any patients with
confirmed or suspected COVID-19. (See Methodology on pages 18–20 for additional information.)
Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp
Findings at a Glance: Hospital Challenges
Severe Shortages of Testing Supplies and Extended Waits for Results
Hospitals reported that severe shortages of testing supplies and extended waits for test results limited
hospitals’ ability to monitor the health of patients and staff. Hospitals reported that they were unable
to keep up with COVID-19 testing demands because they lacked complete kits and/or the individual
components and supplies needed to complete tests. Additionally, hospitals reported frequently
waiting 7 days or longer for test results. When patient stays were extended while awaiting test results,
this strained bed availability, personal protective equipment (PPE) supplies, and staffing.
Widespread Shortages of PPE
Hospitals reported that widespread shortages of PPE put staff and patients at risk. Hospitals reported
that heavier use of PPE than normal was contributing to the shortage and that the lack of a robust
supply chain was delaying or preventing them from restocking PPE needed to protect staff. Hospitals
also expressed uncertainty about availability of PPE from Federal and State sources and noted sharp
increases in prices for PPE from some vendors.
Difficulty Maintaining Adequate Staffing and Supporting Staff
Hospitals reported that they were not always able to maintain adequate staffing levels or offer staff
adequate support. Hospitals reported a shortage of specialized providers needed to meet the
anticipated patient surge and raised concerns that staff exposure to the virus may exacerbate staffing
shortages and overwork. Hospital administrators also expressed concern that fear and uncertainty
were taking an emotional toll on staff, both professionally and personally.
Difficulty Maintaining and Expanding Hospital Capacity to Treat Patients
Capacity concerns emerged as hospitals anticipated being overwhelmed if they experienced a surge of
patients, who may require special beds and rooms to treat and contain infection. Many hospitals
reported that post-acute-care facilities were requiring negative COVID-19 tests before accepting
patients discharged from hospitals, meaning that some patients who no longer required acute care
were taking up valuable bed space while waiting to be discharged.
Shortages of Critical Supplies, Materials, and Logistic Support
Hospitals reported that shortages of critical supplies, materials, and logistic support that accompany
more beds affected hospitals’ ability to care for patients. Hospitals reported needing items that
support a patient room, such as intravenous therapy (IV) poles, medical gas, linens, toilet paper, and
food. Others reported shortages of no-touch infrared thermometers, disinfectants, and cleaning
supplies. Isolated and smaller hospitals faced special challenges maintaining the supplies they needed
and restocking quickly when they ran out of supplies.
Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp
Findings at a Glance: Hospital Challenges (continued)
Anticipated Shortages of Ventilators
Anticipated shortages of ventilators were identified as a big challenge for hospitals. Hospitals
reported an uncertain supply of standard, full-feature ventilators and in some cases used alternatives
to support patients, including adapting anesthesia machines and using single-use emergency
transport ventilators. Hospitals anticipated that ventilator shortages would pose difficult decisions
about ethical allocation and liability, although at the time of our survey no hospital reported limiting
ventilator use.
Increased Costs and Decreased Revenue
Hospitals described increasing costs and decreasing revenues as a threat to their financial viability.
Hospitals reported that ceasing elective procedures and other services decreased revenues at the
same time that their costs have increased as they prepare for a potential surge of patients. Many
hospitals reported that their cash reserves were quickly depleting, which could disrupt ongoing
hospital operations.
Changing and Sometimes Inconsistent Guidance
Hospitals reported that changing and sometimes inconsistent guidance from Federal, State, and local
authorities posed challenges and confused hospitals and the public. Hospitals reported that it was
sometimes difficult to remain current with Centers for Disease Control and Prevention (CDC) guidance
and that they received conflicting guidance from different government and medical authorities,
including criteria for testing, determining which elective procedures to delay, use of PPE, and getting
supplies from the national stockpile. Hospitals also reported concerns that public misinformation has
increased hospital workloads (e.g., patients showing up unnecessarily, hospitals needing to do public
education) at a critical time.
Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp
Findings at a Glance: Hospital Strategies
Secure Necessary PPE, Equipment, and Supplies
To secure the necessary PPE, equipment, and supplies, hospitals reported turning to new, sometimes
un-vetted, and non-traditional sources of supplies and medical equipment. To try to make existing
supplies of PPE last, hospitals reported conserving and reusing single-use/disposable PPE, including
using or exploring ultra-violet (UV) sterilization of masks or bypassing some sanitation processes by
having staff place surgical masks over N95 masks. Hospitals also reported turning to
non-medical-grade PPE, such as construction masks or handmade masks and gowns, which they
worried may put staff at risk.
Ensure Adequate Staffing
To ensure adequate staffing to treat patients with COVID-19, hospitals were training medical staff such
as anesthesiologists, hospitalists, and nursing staff to help care for patients on ventilators.
Support Staff
To support staff, some hospitals reported assisting staff to access services such as childcare, laundry,
grocery services, and hotel accommodations to promote separation from elderly family members.
Manage Patient Flow and Hospital Capacity
To manage patient flow and hospital capacity, some hospitals were providing ambulatory care for
patients with less severe symptoms, offering telehealth services when possible, and setting up
alternate facilities such as fairgrounds, vacant college dorms, and closed correctional facilities as
additional spaces for patient care.
Secure Ventilators and Alternative Equipment to Support Patients
In anticipation of increased needs for ventilators, hospitals tried to obtain additional machines by
renting ventilators, buying single-use emergency transport ventilators, or getting ventilators through
an affiliated facility. Some hospitals reported converting other equipment, such as anesthesia
machines, to use as ventilators.
Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp
Findings at a Glance: Hospital Requests for Assistance
The hospital input and suggestions in this report reflect a specific point in time—March 23–27, 2020. We
recognize that HHS is also getting input from hospitals and other frontline responders and has already
taken and continues to take actions toward each of these suggestions. For example, on March 28, 2020,
the Centers for Medicare & Medicaid Services (CMS) announced the availability of advanced payments to
hospitals and other providers, and on March 30, 2020, CMS announced an array of regulatory changes to
increase hospitals’ and other health care providers’ flexibility in responding to this pandemic, including
changes to support facility capacity and workforce, among many others.
We present hospitals’ suggestions for ways that the government could assist them for HHS’s and other
decision-makers’ consideration as they continue to respond to COVID-19. We note that authorities for
some of the assistance sought by hospitals may reside with entities outside of HHS (e.g., other Federal
agencies or States).
Testing, Supplies, and Equipment
Many hospitals noted that they were competing with other providers for limited supplies, and that
government intervention and coordination could help reconcile this problem nationally. For example,
hospitals wanted the government to ensure that they have access to test kits and swabs, make tests
faster by allowing more entities to conduct and produce tests, and help hospitals obtain PPE supplies
and other equipment such as ventilators.
Workforce Allocation
Hospitals requested that government allow reassignment of licensed professionals and realignment of
duties as needed, provide flexibility with respect to licensed professionals practicing across State lines,
and provide relief from regulations that may restrict using contracted staff or physicians based on
business relationships.
Capacity of Facilities
Hospitals asked for relaxed rules around bed designations, the ability to establish surge facilities in
non-traditional settings, and expanded flexibilities in telehealth, such as the types of services,
caregivers, and modalities eligible to receive reimbursement.
Financial Assistance
All types of hospitals, and especially small rural hospitals, requested financial assistance, including
faster and increased Medicare payments, and loans and grants.
Communication and Information
Hospitals sought centralized communication and public information, including evidence-based
guidance, reliable data and predictive models, and a central repository for all COVID-19-related
guidance, data, and information.
TABLE OF CONTENTS
FINDINGS 1
Hospitals reported that their most significant challenges centered on testing and caring for
patients with COVID-19 and keeping staff safe
1
Hospitals also reported substantial challenges maintaining and expanding capacity to
care for patients
5
Hospitals reported using a range of strategies to maintain or expand their capacity to care for
patients and to keep staff safe
9
Hospitals reported pressing needs for government assistance to meet COVID-19 challenges 11
CONCLUSION 14
BACKGROUND 15
METHODOLOGY 18
APPENDICES 21
A. Strategies Reported By Hospitals 21
B. Glossary of Key Terms 26
ACKNOWLEDGMENTS AND CONTACT 30
ABOUT THE OFFICE OF INSPECTOR GENERAL 31
ENDNOTES 32
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 1
FINDINGS
Hospitals reported that their most significant challenges
centered on testing and caring for patients with COVID-19
and keeping staff safe
Hospitals across the country reported facing similar challenges, regardless of which stage of the process
they were in—treating patients with coronavirus 2019 (COVID-19), testing patients who were potentially
infected, or preparing to treat COVID-19 patients in the near future. The most commonly reported
challenges centered on hospitals’ efforts to confirm cases of COVID-19, to keep health care staff safe,
and to provide needed services to patients requiring hospital care for a wide array of medical reasons,
including COVID-19. Challenges included difficulties related to testing, lack of personal protective
equipment (PPE), and staffing, including specialized staffing.
Hospitals reported that severe shortages of testing supplies and extended
waits for test results limited hospitals’ ability to monitor the health of
patients and staff
Hospitals explained that they were unable to keep up with testing demands because they
lacked complete kits and/or the individual components and supplies needed to complete
tests, such as nasal swabs, viral transfer media, and reagents used to detect the virus.
These shortages left hospitals unable to effectively test staff, patients, and others in the community who
reported that they were concerned about possible exposure. One hospital administrator said that
across the industry, “millions [of tests] are needed, and we only have hundreds." Without access to
needed testing materials, some hospitals described dividing the media in COVID-19 kits in half to
double their capacity and resorting to using the transfer media in flu and strep kits to provide testing.
Hospitals described extended waits for COVID-19 test results. Hospitals reported frequently
waiting 7 days or longer for test results. According to one hospital, 24 hours would typically be
considered a long turnaround time for virus testing. Hospitals’ reliance on external laboratories
contributed to delays, particularly as these laboratories became overwhelmed with tests to process from
around the State or country. Hospitals also reported delays related to infrequent specimen pickups,
mailing delays, and labs’ restrictive business hours. Some hospitals described success getting results
more quickly by using commercial labs, whereas others received more timely results from public
sources. Still others experienced inconsistent turnaround times, leaving them unable to predict when
results would arrive or advise patients on how long they should self-quarantine or undertake other
measures while awaiting results.
Testing challenges exacerbated other challenges, including bed availability, PPE supplies,
and staffing shortages. Hospitals reported that to prevent the spread of the virus in the hospital
and community, they were treating symptomatic patients as presumptive positive cases of
COVID-19 (i.e., an individual with symptoms that strongly indicate COVID-19 and tests have ruled out
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 2
similar conditions, but without a positive COVID-19 test result). The scarcity of COVID-19 tests and
length of time it took to get test results back meant presumptive positive patients greatly strained bed
availability, PPE supplies, and staffing, as noted in Exhibit 1.
Exhibit 1: Hospitals reported that the lack of testing supplies and delays in receiving test
results caused additional challenges.
Hospitals reported that some presumptive positive patients remained in the hospital for days while
awaiting test results, which reduced the hospitals’ availability of beds for other patients. One hospital
that was holding presumptive positive patients in intensive care unit beds reported that testing with a
quick turnaround would free up bed availability and increase patient and staff safety. An administrator
at another hospital noted that the sooner the hospital knows whether patients are negative, the faster it
can move them to a lower level of care that consumes fewer resources. As one administrator put it,
"sitting with 60 patients with presumed positives in our hospital isn't healthy for anybody."
Hospitals reported that extended patient stays while awaiting COVID-19 test results also depleted PPE
supplies used by staff in treating those patients during those additional days. One hospital reported
that its staff, at the time of our interview, used (on average) 307 masks per day for its 23 patients with
suspected cases of COVID-19. Another hospital administrator said, "The testing turnaround presents a
challenge, especially for our ‘rule-out’ patients…we have to use a lot of PPE on those rule-outs. And
especially when it’s a negative, we basically used all that PPE for nothing."
The inability to quickly identify confirmed cases exacerbated challenges with hospital staffing. In one
hospital, between 20-25 percent of staff were determined to be presumptively positive for COVID-19.
Due to the lack of quick test results, staff who ultimately were not positive were prevented from
providing clinical services for longer than necessary, causing a substantial strain on staffing availability.
Another hospital noted that it wanted to set up a separate testing clinic to keep potentially infectious
patients from exposing staff, but it did not have enough testing kits and/or related components and
supplies to set up such a clinic.
Delays in receiving test results also made it more challenging for hospital staff to provide patients with
the most appropriate care. One hospital reported that these delays put patients at risk because
physicians were unable to make effective treatment decisions without the test results. Another said that
some patients faced unnecessarily long hospital stays because some long-term-care facilities and
nursing homes will not accept patients without a confirmed negative COVID-19 test.
Testing challenges hampered hospitals’ efforts to reduce community spread, protect
staff, and care for patients. Hospitals reported that their inability to test patients quickly was
affecting their efforts to limit the transmission of COVID-19 within the wider community. Given supply
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 3
shortages and uncertainty about future access, hospitals reported prioritizing testing for their
employees and for patients with more severe symptoms. Prioritized testing meant that many hospitals
reported they were currently unable to conduct widespread testing of patients and community
members to help contain the spread of COVID-19.
Hospitals raised concerns that widespread shortages of PPE put staff and
patients at risk
Hospitals across the country reported that a shortage of PPE was threatening their ability to keep staff
safe while they worked to treat patients with COVID-19. The most commonly needed PPE items
reported were masks (including N95 masks, surgical masks, and face shields), followed by gowns and
gloves.
Hospitals reported that heavier than normal use of PPE contributed to shortages. The
administrator of one hospital stated that before COVID-19, the hospital’s medical center used around
200 masks per day and that it was now using 2,000 per day. Delays in test results led to heavier use of
PPE until a patient’s status was confirmed. Another hospital administrator noted the “fear factor”
associated with COVID-19, which led to all staff wearing masks instead of only a subset. One hospital
administrator reported that some supply distributors limited the quantity of supplies that any one
hospital could order, which meant that even with no COVID-19 patients, the hospital was depleting PPE
faster than it could restock. Even among hospitals that reported that they currently had enough PPE,
some noted that a surge in patients would quickly deplete their supplies. One hospital noted that with
its high “burn” rate (i.e., rate of use), its inventory of PPE would last only 3 more days. Another hospital
administrator expressed a common concern: not wanting to put employees in a position that
“endangers their lives and the lives of their families because [they] do not have PPE.”
Hospitals pointed to the lack of a robust supply chain as delaying or preventing them
from restocking the PPE needed to protect staff. Hospitals reported that the supply chain for
medical equipment had been disrupted because of increased demand for PPE from health care
providers and others around the country. As one administrator said, everyone is “trying to pull [PPE]
from the same small bucket.” Another administrator stated that their hospital’s purchaser was reporting
delays of 3-6 months in being able to replenish key supplies, including surgical and N95 masks.
Another hospital made the point that this competition for supply was unusual in that it involved not
only health care providers, but also the public. An administrator at this hospital reported apprehending
a person trying to steal face masks from the hospital lobby.
Hospital administrators expressed uncertainty about availability of PPE from Federal and
State sources. Some hospitals noted that at the time of our interview they had not received supplies
from the Strategic National Stockpile, or that the supplies that they had received were not sufficient in
quantity or quality. One administrator stated that getting supplies from the stockpile was a major
challenge, saying that the supplies the hospital received “won't even last a day. We need gloves, we
need masks with fluid shields on—N95 masks—and we need gowns. It's the number one challenge all
across the system." One health system reported that it received 1,000 masks from the Federal and State
governments, but it had been expecting a larger resupply. Further, 500 of the masks were for children
and therefore unusable for the health system’s adult staff. One hospital reported receiving a shipment
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 4
of 2,300 N95 masks from a State strategic reserve, but the masks were not useable because the elastic
bands had dry-rotted. Another hospital reported that the last two shipments it had received from a
Federal agency contained PPE that expired in 2010. The shipment contained construction masks that
looked different than traditional masks and did not contain a true N95 seal.
Hospitals noted sharp increases in prices for some equipment. Multiple hospitals reported
concerns that prices of equipment, particularly masks, had increased significantly. One administrator
noted that masks that originally cost 50 cents now cost $6 apiece. Other hospitals reported concerns
about vendors buying up supplies and selling them to the hospital at a higher cost. As one hospital
administrator noted, “We are all competing for the same items and there are only so many people on
the other end of the supply chain.” Another administrator reported being concerned about poor
quality products despite high-prices and “…wonder[ing] if you get what you paid for.”
Hospitals reported that they were not always able to maintain adequate
staffing levels or to offer staff adequate support
Many hospitals reported that they did not have enough staff to meet current or anticipated needs for
COVID-19 patients, which put a strain on existing staff. Some hospitals reported that they were already
struggling with staffing limitations prior to COVID-19, which made any additional demand particularly
challenging. One hospital administrator explained that their hospital would have significant staffing
shortages if faced with a surge of COVID-19 patients because the hospital relies heavily on traveling
nurses. Another administrator stated, "Unlike a disaster where the surge is over in a matter of days,
with this situation we have to prepare for this to last many months. We have to scale up in equipment
and staff, and prepare for this to last a long, long time. This is very challenging for staff."
Hospitals reported a shortage of specialized providers needed to meet the anticipated
patient surge. Several hospitals emphasized a particular need for specialized staff, such as infectious
disease providers, respiratory therapists, and physicians and nurses who can provide intensive and
critical care. Many hospitals also stated that they lacked trained staff that can operate ventilators and
treat patients receiving that level of care. One hospital administrator said his hospital has only one
ventilator and only one respiratory therapist, adding that the therapist can't work 24 hours a day
monitoring the ventilator. Another administrator said, “You can build thousands of ventilators, but you
need an army to manage that equipment and care for those patients.”
Hospitals raised concerns that staff exposure to the virus may exacerbate staffing
shortages and overwork. Several hospitals reported that they would struggle to maintain hospital
operations if even a few staff were exposed to the virus. The administrator for one small, rural hospital
explained that if one patient tested positive for COVID-19 the hospital would have to put 16 staff
members in quarantine, which would essentially halt its operations. Administrators in two hospitals
described how staffing levels in their facilities had been significantly impacted after a large number of
staff had contracted or been exposed to the virus.
Hospital administrators expressed concerns that fear and uncertainty were taking an
emotional toll on staff, both professionally and personally. Hospitals reported that fear of
being infected, and uncertainties about the health and well-being of family members, were impacting
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 5
morale and creating anxiety among staff. As one administrator put it, "The level of anxiety among staff
is like nothing I’ve ever seen.“ Another hospital administrator explained that staff were carrying a heavy
burden both professionally and personally. Professionally, staff were worried about the security of their
jobs and the difficult choices they must make regarding their patients, such as who should get one of a
limited number of tests. They also feared contracting the virus. At one hospital, a staff member who
tested positive exposed others on staff, but the hospital did not have enough kits to test those exposed.
Personally, staff were worried about spreading the virus to their family members and ensuring that their
families were cared for, especially with schools and daycare centers being closed. As one administrator
said, “Health care workers feel like they’re at war right now…[they] are seeing people in their 30s, 40s,
50s dying…This takes a large emotional toll.”
Hospitals also reported substantial challenges maintaining
and expanding capacity to care for patients
The other most prominent concerns reported by hospital administrators centered on maintaining
facility operations while receiving and treating patients with known or suspected cases of COVID-19.
These challenges included concerns about bed availability, particularly specialized beds such as
intensive care unit beds, and supplies, as well as maintaining financial solvency given reductions in
routine patient care and elective surgeries.
Hospitals were concerned about their capacity to treat a surge of patients
who may require special beds and rooms to treat and contain infection
Hospitals anticipated being overwhelmed by a surge in COVID-19 patients, who would need specialty
beds and isolation areas for effective treatment. Specifically, hospitals reported concerns about
potential shortages of intensive care unit beds, negative pressure rooms, and isolation units. Hospitals
also reported that, given the limitations to bed availability, it was challenging to sufficiently separate
COVID-19 and non-COVID-19 patients within their facilities. Separating patients is thought to allow
health care workers to better coordinate and direct needed treatment specific to COVID-19 patients as
well as reduce the spread of infection. One hospital administrator observed that: “Being a rural hospital,
we have to be ready to convert beds to prepare for surge capacity. We still have to take care of our
non-COVID situations. We have to make people feel like we can still take care of them if they have [an]
emergent situation."
Hospitals reported being unable to discharge patients to certain post-acute facilities
while awaiting COVID-19 test results. Many hospitals reported that some post-acute facilities,
such as skilled nursing facilities or facilities with lower-level care, were requiring negative
COVID-19 tests before accepting patients discharged from hospitals. As such, patients who no longer
required acute care were taking valuable bed space while waiting to be discharged. One hospital
reported a case in which a post-acute-care facility refused to take a patient unless the hospital sent
them a week’s worth of masks for the patient and for the staff who would care for the patient, even
though the patient was not positive for COVID-19. Delays in receiving test results contributed to delays
in transferring patients to these lower level facilities and in freeing beds in the hospitals for incoming
COVID-19 patients.
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 6
Hospitals reported concerns about securing other critical supplies,
materials, and logistic support
Hospitals reported they do not have a reliable source for the equipment and supplies they use to
support patient care. One hospital reported that, in addition to beds, it needed to source the materials
that accompany additional beds and did not know where to order them. For example, hospitals
described the supplies that support a patient room, such as intravenous therapy poles, medical gas,
linens, and food. Multiple hospitals also cited a shortage of toilet paper. Hospitals discussed the need
for supportive services, such as sanitation services, staffed mobile field hospitals, and mortuary services,
as well as the construction work and maintenance needed to convert rooms.
Hospitals reported shortages of no-touch, infrared thermometers needed for
temperature screening. One hospital reported an inability to implement a policy to screen all
hospital entrants because it did not have enough no-touch thermometers to allow for timely testing
and avoid long lines at entrances. (No-touch thermometers use infrared technology to rapidly provide
accurate temperature results.) This hospital reported it resorted to only screening patients, staff, and
vendors on a random basis. Similarly, another hospital explained that it was unable to monitor
employee temperatures in a timely manner, given it had a 700-plus person staff and had just a few of
the no-touch thermometers that could be devoted to staff testing rather than patient care.
Hospitals faced shortages of disinfectants and cleaning supplies. Hospitals reported
insufficient inventory of essential cleaning supplies, such as disinfectant wipes, hand sanitizer, and hand
soap. One hospital described being unable to buy disinfectant cleaning supplies and not knowing
when supplies will be available. Another hospital described making disinfectants, such as bleach, out of
on-hand chemicals, such as chlorine.
Isolated or smaller hospitals reported that they have a harder time accessing necessary
supplies. Isolated and smaller hospitals reported that they were facing special challenges maintaining
the supplies they need to continue their operations. One hospital noted that its island location made it
difficult to restock quickly when it runs out of supplies. Another hospital reported that it was not able
to request the amounts of disinfectants and other supplies that it needed from the State. Instead,
products were “divvied up” by the State, and because the hospital is small, it received fewer of the
products and supplies than larger hospitals.
Hospitals cited anticipated shortages of ventilators as a potential
challenge
Many hospitals reported concerns that they would not have enough ventilators if faced with a surge of
COVID-19 patients. One administrator explained the difficulty of predicting whether a surge would
come and how many ventilators would be needed, “[We] just don’t know two weeks down the road
what we will need.” Hospitals pointed to overall supply shortages and the unavailability of ventilators in
other facilities, as well as the scarcity of ventilator components such as tubes.
Some hospitals’ concerns about the supply of ventilators were exacerbated by their small
size. Small hospitals reported that they were able to maintain few, if any, ventilators. Some of these
hospitals described contingency plans to repurpose alternative machines from other hospital
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OEI-06-20-00300 7
departments or to transport patients to other facilities, if needed. However, one hospital with no
ventilators expressed concern that if a patient needs ventilation, neighboring hospitals may not have
the space to take them. Another hospital noted that larger hospitals may be given priority in receiving
ventilators.
Hospitals also explained that potential ventilator shortages would pose difficult
decisions about ethical allocation and liability. As hospitals planned for a surge of patients,
many reported that they were either developing or revising guidelines regarding ventilator utilization
decisions, although at the time of our survey no hospital reported limiting ventilator use. Some
administrators noted that with difficult decisions about ventilator allocation also come concerns about
liability. For example, one hospital administrator described concerns about the liability embedded in
decisions regarding which patients would receive assistance from a ventilator and which would not,
concluding that: “Government needs to provide guidelines on ethics if health resources are limited and
decisions need to be made about which patients to treat. Are physicians liable for their decisions if that
happens?”
Hospitals described increasing costs and decreasing revenues as a threat
to their financial viability
Hospitals reported that the increased costs and loss of revenue were quickly depleting cash reserves
and could be disruptive to ongoing hospital operations. Hospitals reported having essentially ceased
performing elective procedures and many other services, which many hospitals said accounted for a
substantial portion of their revenue. Meanwhile, hospitals explained that their costs have increased as
they prepare for a potential surge of patients by purchasing extra equipment (such as PPE and
ventilators), remodeling rooms for negative pressure, or setting up drive-through clinics and tents.
One administrator explained that having cash on hand was becoming an urgent issue with the specialty
clinic volume down 80 percent, primary care volume down 50 percent, and cancellation of all elective
surgeries. One administrator said their hospital is in a favorable financial position, but it is concerned it
could be overwhelmed if other hospitals close. Another administrator said their hospital is tracking all
of its costs for treating COVID-19 patients or potential cases, so that it can be reimbursed in the future.
Other hospitals reported laying off staff due to financial difficulties, which further exacerbated
workforce shortages and the hospitals’ ability to care for COVID-19 patients and the routine patient
population. One administrator stated that it had been “an absolute financial nightmare for hospitals.”
Hospitals that were part of a larger health system reported that they considered themselves to be
better situated to absorb financial losses compared to smaller independent and rural hospitals. Being
part of a larger health system enabled hospitals to distribute losses from the hardest hit hospitals to the
other hospitals in the system. Smaller, independent hospitals, such as rural hospitals and critical access
hospitals, reported that they were at greater financial risk than those in larger systems and that they
could face more financial uncertainty. As one hospital administrator observed, “There is no mothership
to save us.”
Hospitals reported circumstances in which insurance reimbursements were not covering
hospitals’ costs for providing services in the midst of the COVID-19 crisis. Hospital
administrators reported that insufficient reimbursement for some services and a lack of flexibility in
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billing rules that affect reimbursement amounts have created financial challenges. For example, some
hospitals were using telehealth to provide services without patients having to come to the hospital, but
reported that reimbursement amounts for telehealth services often do not cover the hospitals’ costs. In
another example, hospitals reported facing resistance from health plans to paying for patients’
additional days in the hospital while the patients were awaiting COVID-19 test results. Negative test
results were needed for the patients to be accepted for admission or re-admission at post-acute-care
facilities and nursing homes.
Further, hospitals reported difficulty in getting reimbursed for treating patients in non-traditional
spaces because there were no qualifying billing codes when treating patients in these locations. For
example, to mitigate COVID-19 spread, one hospital relocated speech, occupational, and physical
therapy services off-site. However, the hospital said it was unable to bill for these services because it
does not own the building housing the relocated services, or meet billing requirements.
Hospitals reported that changing and sometimes inconsistent guidance
from Federal, State, and local authorities posed challenges and confused
hospitals and the public
Hospitals reported that it was sometimes difficult to remain current with CDC guidance
when training staff on PPE and safety precautions. To reduce the spread of COVID-19 and
prepare staff for patient surges, hospitals reported providing training regarding proper use of PPE,
procedures for putting on and taking off PPE, and isolation practices. As new information about the
virus becomes available and circumstances on the ground change, the Centers for Disease Control and
Prevention (CDC) has changed its guidance over time. However, some hospital administrators
expressed that it was challenging to stay up to date with CDC guidance and re-educating staff on
changes to the guidance (e.g., who needs PPE, when to remove it, and when to reuse it). Some
hospitals reported that the multiple changes in guidance contributed to a greater sense of confusion,
fear, and distrust among staff that they could rely on hospital procedures to protect them.
Hospitals reported instances of receiving conflicting guidance from different Federal,
State, and local authorities. Hospitals reported receiving conflicting guidance on criteria for
testing, defining elective procedures to delay, use of PPE, and getting supplies from the national
stockpile. For example, on proper use of PPE, one hospital administrator reported that CDC guidelines
at that time called for use of an N95 mask for all patients suspected of COVID-19 infections, while at the
same time, one State said that using a surgical mask and face shield was sufficient for staff treating
patients with COVID-19. The hospital noted “[The inconsistency] makes everyone nervous. It would
have been better if there was coordination and consistency in guidance among the different levels of
government.” Another administrator said, “It’s difficult when a doctor or nurse shows you legitimate
information from legitimate sources and they’re contradictory.”
Hospitals also reported concerns that misinformation had proliferated among the public,
unnecessarily increasing workload on hospitals at a critical time. Many hospital
administrators reported needing to spend time responding to fear, lack of information, and lack of
understanding in their public communities, which they attributed to an absence of clear, accurate, and
consistent information. These hospitals reported having to dispel misinformation and unrealistic
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expectations among patients about testing and other issues, as well as having to work to educate the
community about proper steps to prevent the spread of COVID-19 and when to seek medical attention
versus self-isolating at home. One hospital administrator reported the challenge of taking on a public
health advocacy role with mayors and county commissioners to advocate implementing social
distancing at beaches, restaurants, and the like to slow the spread of COVID-19, in addition to
performing normal duties. Another hospital administrator reported that employers were telling
employees they cannot return to work without testing negative and that the hospital was having a
difficult time educating employers that only certain people can be tested. One administrator stated:
“The misinformation that is out there, and the lack of serious understanding about what we could be
facing, is extraordinary. It is not helping the situation at all. We need to take this seriously."
Hospitals reported using a range of strategies to maintain or
expand their capacity to care for patients and to keep staff
safe
Hospital strategies often attempted to address multiple challenges. These efforts included broad-scale
ideas that involved multiple providers and suppliers across the country, as well as smaller-scale,
community-based efforts that rose in some cases from hospital leadership and staff, other public health
stakeholders, and the general public. For a more detailed list of operational strategies that hospital
administrators shared, see Appendix A.
Hospital administrators turned to alternative practices and
unconventional sources to secure necessary PPE, equipment, and supplies
for their staff
In an attempt to get needed equipment and supplies, hospital administrators turned to
new, sometimes un-vetted, and non-traditional sources. The lack of PPE caused hospitals to
consider new and un-vetted sources for PPE of whose reputability they were sometimes unsure. One
hospital reported that in working with new vendors, some ordered items did not show up, were expired,
or were different than what was ordered. The administrator also stated that the hospital did not have
the ability to evaluate the quality of the equipment in a meaningful way.
Some facilities stated that they turned to non-traditional sources of medical equipment and supplies to
combat supply chain disruptions. For instance, some hospitals considered sources for PPE that they
would not normally use—such as online retailers, home supply stores, paint stores, autobody supply
shops, and beauty salons.
To try to make existing supplies of PPE last, hospitals reported conserving and reusing
PPE. Hospital administrators discussed implementing or considering new procedures to conserve PPE,
including physically securing PPE to prevent theft or misuse, educating staff on appropriate use and
conservation, and limiting PPE use according to patient condition. Other hospitals reported reducing
the extent and frequency of patient interaction to reduce PPE burn; this included doing as much for a
patient as possible in one interaction, having multiple providers see a patient together, or removing
equipment like intravenous pumps from patients’ rooms so that it could be prepped elsewhere without
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PPE. At one facility, staff tested patients at remote sites to, in part, reduce PPE use. Hospitals indicated
that staff performing testing remotely can remain in PPE all day, whereas staff who test inside hospitals
typically change PPE frequently when moving from suspected COVID-19 patients to other patients.
Another hospital described being in ‘war mode’ and abandoning the typical standard of care by only
using N95 masks for certain higher-risk procedures for COVID-19 patients such as aerosolized
procedures, which can send the virus into the air and put health care workers at risk.
Conservation strategies included reusing PPE, which is typically intended to be single-use. To reuse
PPE, some hospitals reported using or exploring ultra-violet (UV) sterilization. Other hospitals reported
bypassing some sanitation processes by having staff place industry masks over N95 masks so that the
N95 mask could be reused. As one administrator characterized the situation, “We are throwing all of
our PPE best practices out the window. That one will come back and bite us. It will take a long time for
people to get back to doing best practices.”
Hospitals also reported turning to non-medical-grade PPE, which they worry may put
staff at risk. Instead of reusing medical-grade equipment, some hospitals reported resorting to
non-medical-grade PPE such as construction masks or handmade masks and gowns, but were unsure
about the guidelines for how to safely do it. For example, one hospital administrator noted that
recommendations were not clear about whether cloth masks were good enough, stating, “But if that’s
what we have, that’s what we’re going to have to use.” One hospital reported using 3D printing to
manufacturer masks, while another hospital reported that its staff had made 500 face shields out of
office supplies.
Other hospitals reported using community resources to make ends meet, including accepting
homemade cloth gowns from a quilter’s guild, asking volunteers to make masks, and asking for
donations on their website. One hospital administrator described a plan for the local distillery to blend
100 liters of the hospital's ultrasound gel with the distillery’s alcohol to produce CDC-compliant hand
sanitizer.
Hospital strategies also focused on ensuring adequate staffing to treat
patients with COVID-19
Hospital administrators reported using strategies aimed at ensuring they had sufficient staff with the
needed skills to treat COVID-19 patients where most needed. For example, some administrators shared
that their hospitals were training certain medical staff, like anesthesiologists, hospitalists, and nursing
staff, to help care for patients on ventilators. Further, hospitals touted partnerships with large health
care systems as beneficial because they can deploy medical staff, like nurses, to other hospitals in the
health care system that may be experiencing a staff shortage.
Hospitals reported providing resources to help reduce employee burden
as well as anxiety and stress
To ease anxiety and reduce outside burdens on staff that could distract them or prevent them from
working, some facilities reported assisting staff to access services such as childcare, laundry pick up and
drop off, grocery services, and hotel accommodations to promote separation from elderly family
members. Hospitals also reported offering or expanding resources to provide employees with
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emotional and psychological support. One hospital shared that it recruited external mental health
clinicians and engaged its own psychiatry staff to help alleviate anxiety among hospital staff.
Some strategies focus on managing patient flow and hospital capacity to
receive and treat patients
Hospital administrators reported using several strategies to manage patient flow as they respond to
their communities’ needs during the COVID-19 pandemic. Strategies included promoting the use of
ambulatory care for patients with less severe symptoms to help relieve the pressure on emergency
departments, and the use of telehealth services when possible to help protect both patients and staff
through social distancing measures. In addition, to help triage patient flow into the hospitals, hospital
administrators described efforts to educate community members about COVID-19 screening or testing
processes to avoid patients entering the hospital if not advised under guidelines.
To address potential bed and facilities shortages, some hospitals reported converting or creating space
to house a surge of additional patients. This included expanding their intensive care units, repurposing
existing space, using tents, and utilizing other network facilities to separate COVID-19 patients when
possible. One hospital administrator explained their strategy: “I’ve emptied the hospital and I’m waiting
for it to come. Which it may or may not.” Some hospital administrators described plans to make use of
other facilities, such as local fairgrounds, vacant college dorms, and closed correctional facilities as
additional space for patient care in the event of a surge.
With an uncertain supply of standard, full-feature ventilators, hospitals
sought new sources and turned to alternative equipment to support
patients
In anticipation of increased needs for ventilators, hospitals tried to obtain additional machines by
renting ventilators, buying single-use emergency transport ventilators, or getting ventilators through an
affiliated facility. Hospitals also discussed sharing supplies of ventilators between hospitals. Where
these options were not available, some hospitals planned to transfer patients in need of a ventilator to a
nearby hospital.
Some hospitals reported converting other equipment to use as ventilators. For example, adapting
anesthesia machines and bilevel positive airway pressure machines. One hospital reported considering
“doubling up on ventilators – that is, adding another hose to the ventilator so that it can push oxygen
to two patients from a single machine.” Another hospital detailed its staff’s efforts at both converting
anesthesia machines and using them to support more than one patient: “Our staff had figured out that
we could transition some anesthesia machines using t-connectors and viral filters to turn them into
ventilators. You jerry-rig the anesthesia machine by using a t-connector, you can support four patients
off one of these.”
Hospitals reported pressing needs for government assistance
to meet COVID-19 challenges
Faced with the magnitude and diversity of challenges described above, hospital officials identified a
range of government assistance that could support their COVID-19 response. One common theme was
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the need for swift action to respond to the COVID-19 crisis. Broadly, the actions they described fall into
five categories: 1) assistance with testing, supplies, and equipment (e.g., PPE); 2) assistance with
workforce allocation; 3) assistance with capacity of facilities; 4) financial assistance; and
5) communication and public information.
The hospital input and suggestions reflect a specific point in time—March 23–27, 2020. We recognize
that the Department of Health and Human Services (HHS) is also getting input from hospitals and other
frontline responders and has already taken and continues to take action to alleviate many hospital
challenges and implement suggestions. The Coronavirus Aid, Relief, and Economic Security (CARES) Act
was signed into law on March 27, 2020, and provides HHS with additional funding and authorities to
combat and respond to the COVID-19 pandemic, including in ways that address challenges and
suggestions raised by the hospitals we surveyed.
1, 2
We present the following hospital suggestions on ways that the government could assist them for
HHS’s and other decision-makers’ consideration as they continue to respond to COVID-19.
Assistance with testing, supplies, and equipment
In discussing potential government assistance related to testing, supplies, and equipment, hospitals
often stated that they were in competition with other providers for limited supplies, and that
government intervention and coordination could help reconcile this problem at the national level to
provide equitable distribution of supplies throughout the country.
Hospitals wanted the government to:
• provide test kits and swabs, or for the government to take steps to ensure that supply chains
can provide hospitals with a sufficient supply of tests;
• make testing faster by allowing more entities to produce tests and related supplies or to
conduct tests;
• help in obtaining a range of supplies, such as N95 masks, surgical masks, gloves, and other
protective gear;
• provide equipment such as ventilators, triage tents, and beds, among others, or take steps to
bolster supply chains to provide needed equipment; and,
• loosen restrictions around the transfer or gifting of equipment and supplies (e.g., when
providers want to send supplies necessary for treatment with patients when transferring them to
another facility).
Assistance with workforce allocation
Given their concerns about staffing shortages, hospitals reported that they needed the government to
enable maximum flexibility among their care-giving workforce.
Hospitals wanted the government to:
• enable reassignment of licensed professionals and realignment of duties within the hospital and
throughout their health care networks;
• provide flexibility with respect to licensed professionals practicing across State lines,
• provide relief from regulations that may restrict using contracted staff or physicians based on
business relationships.
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Assistance with capacity of facilities
Hospitals reported concerns with their capacity to house a surge of COVID-19 patients. They described
a range of government actions that they believe would help them on this front.
Hospitals wanted the government to:
• relax rules around the designation of bed types;
• take steps that enable hospitals to establish surge facilities in non-traditional settings such as
hotels and civic centers; and
• allow more patients to be treated at home by expanding access to telehealth through
flexibilities in the types of services, caregivers, and modalities eligible to receive reimbursement.
Financial assistance
Hospital representatives across all types of hospitals (and in particular small, rural hospitals) reported
that they need financial assistance. Notably, some hospitals reported needing assistance in a matter of
weeks in order to avoid insolvency.
Hospitals wanted the government to:
• speed up Medicare payments by dropping the 14-day wait period;
• increase Medicare payments; and
• offer loans and grants.
Communication and information
Hospitals told us that they thought the Federal Government could play a central role in messaging and
communications to mitigate what they perceived to be conflicting or inconsistent guidance across levels
of government, as discussed in the challenges.
Hospitals wanted the government to:
• provide evidence-based guidance (and as an example, they highlighted the usefulness of CDC’s
guidance on conserving N95 masks);
• provide reliable predictive models and data that would help them plan and prepare; and
• provide a single place to find the information they need, including information on the
COVID-19 disease, guidance from agencies, and instructions for processes they need to follow,
such as how to apply for waivers from certain requirements.
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CONCLUSION
This report provides information about hospitals’ experiences and perspectives in responding to
COVID-19 at a point in time—March 23–27, 2020. The pandemic is fast-moving, as are the efforts to
address it. Since our interviews, some hospital challenges may have worsened and others may have
improved. Hospitals reported that their most significant challenges centered on testing and caring for
patients with known or suspected COVID-19 and keeping staff safe. Hospitals also reported substantial
challenges maintaining or expanding their facilities’ capacity to treat patients with COVID-19.
We recognize that HHS, Congress, and other Federal, State, local, and Tribal entities are taking
substantial action on a continual basis to support hospitals as they work on the frontlines to treat
patients, ensure the safety of the health care workforce, and protect communities. We present this
information for HHS’s and other decision-makers’ consideration as they continue to respond to the
COVID-19 pandemic. In addition, hospitals may find the practical information about other hospitals’
strategies useful as they confront the many challenges they face in fulfilling their mission.
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BACKGROUND
Hospital Response to the COVID-19 Pandemic
The emergence of COVID-19 has created unprecedented challenges for the U.S. hospital system.3
As
frontline responders, hospitals have significant responsibilities for identifying and treating patients with
COVID-19. Hospitals around the country are adapting to the constantly changing face of the
COVID-19 pandemic by adopting both expected and novel strategies to tackle the crisis. (See Appendix
A on pages 21–25 for a list of hospital strategies reported.)
The Emergence of COVID-19
Four main sub-groupings of coronaviruses commonly circulate among humans worldwide, typically
causing mild to moderate upper respiratory tract illnesses, and their incidence usually peaks annually in
the United States during the winter months.4, 5, 6
COVID-19 is a highly contagious coronavirus.7
Common symptoms include fever, tiredness, dry cough, and shortness of breath, and it can be fatal in
some cases.8
The first reported instances of COVID-19 occurred in Wuhan, Hubei Province, China, in December
2019 and January 2020.9
On January 13, 2020, the first patient with COVID-19 was reported outside of
China, and the first patient in the U.S. was reported 7 days later.10
In late-February 2020, a hospital in
California documented the first community spread transmission of COVID-19, meaning the illness was
acquired through an unknown exposure in the community in the U.S.11
On March 11, 2020, the World Health Organization characterized COVID-19 as a pandemic, which refers
to an epidemic that has spread over several countries or continents, usually affecting a large number of
people.12, 13
As of April 3, 2020, CDC reported 239,279 confirmed cases in the U.S. and 5,443 deaths.14
Role of HHS in Emerging Infectious Disease Preparation and
Response
HHS is the lead federal agency responsible for medical support and coordination during public health
emergencies, such as emerging infectious disease (EID) outbreaks. HHS operating divisions involved in
the Federal response to EIDs, including the current COVID-19 response, include the Office of the
Assistant Secretary for Preparedness and Response (ASPR), CDC, CMS, and the Food and Drug
Administration (FDA).15
ASPR coordinates HHS’s response to public health emergencies with other Federal agencies, such as the
Federal Emergency Management Agency. ASPR also maintains the Strategic National Stockpile, which
supplements State and local stocks of life-saving pharmaceuticals and medical supplies for use in a
public health emergency.16
Since 2010, ASPR has managed the Hospital Preparedness Program, which
provides grants to States and localities to distribute to hospitals and health care coalitions for improved
preparedness. Health care coalitions are groups of health care providers and public health entities that
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work together to prepare for, respond to, and recover from emergencies.17, 18
ASPR also created the
Technical Resources, Assistance Center, and Information Exchange to provide information and technical
assistance to health care coalitions, health care providers, and other stakeholders during public health
emergencies.19
Following the Ebola outbreak in 2014, ASPR designated 10 hospitals as Ebola and Other Special
Pathogen Centers.20, 21
ASPR defines “special pathogens” as highly infectious agents that produce
severe disease in humans.22 These centers are to maintain capability to accept patients with suspected
or diagnosed illness from special pathogens within 8 hours of notification and to conduct quarterly
exercises to prepare for an EID outbreak.23 During 2017–2018, all 10 Special Pathogen Centers
participated in on-site readiness consultations conducted by the National Ebola Training and Education
Center, which is a collaborative effort involving ASPR, CDC, and several academic institutions. The
results of these assessments indicate that Special Pathogen Centers have higher levels of operational
readiness to provide care to patients with special pathogens.24
In response to COVID-19, ASPR is working with its partners to develop medical countermeasures and to
provide resources to support the U.S. health care system’s response. On March 24, 2020, ASPR
indicated that it will provide $100 million to support U.S. health care systems in getting ready for an
increase in patients with COVID-19.25
CDC monitors and responds to public health emergencies, such as EIDs, conducts research, and
provides guidance to health care providers, government entities, and the public.26
In response to
COVID-19, CDC recently released interim guidance for U.S. health care facilities on preparing for
community transmission of COVID-19,27 along with strategies for optimizing the supply of N95
respirators,28 and steps health care facilities can take to prepare for COVID-19.29
CMS oversees hospitals participating in Medicare and Medicaid by requiring them to meet Conditions
of Participation, a set of minimum health and safety standards.30, 31
To help to address challenges
presented by COVID-19, CMS has waived some requirements under the emergency authority set forth
in Section 1135 of the Social Security Act.32
In addition, under its 1135 waiver authority and the
Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS expanded the
telehealth benefit for Medicare beneficiaries to allow beneficiaries to “receive a wider range of services
from their doctors without having to travel to a health care facility.”33
FDA is responsible for protecting the public health by ensuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics,
and products that emit radiation.34
FDA is working with hospitals and the medical industry to develop
vaccines, drugs, and diagnostic tests while monitoring the medical supply chain during the
COVID-19 outbreak.35 FDA is also issuing emergency use authorizations for ventilators and other
medical devices to treat patients.36
Personal Protective Equipment
PPE is protective clothing, helmets, goggles, or other garments or equipment designed to protect the
wearer's body from injury or infection. PPE also includes a variety of types of respirators and face
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masks.37
Most relevant to the types of PPE that hospitals are commonly using in treating patients with
known or suspected cases of COVID-19 is the N95 respirator mask, a respiratory protective device
designed to achieve a very close facial fit and very efficient filtration of airborne particles.38
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METHODOLOGY
Data Collection and Scope
We conducted a “pulse survey” (i.e., quick, point-in-time questions) by telephone (or in a few cases, by
email) with administrators from a random sample of Medicare-certified hospitals across the nation and
in some cases, their parent corporations. These conversations focused on three key issues regarding
their COVID-19 response: 1) challenges responding to the COVID-19 pandemic, 2) strategies to mitigate
the challenges, and 3) needs for government assistance.
We conducted the surveys on March 23–27, 2020 with one or more administrators. The positions of
these hospital administrators were typically Chief Executive Officer, Chief Medical Officer, or
representatives from teams and departments dedicated to emergency preparedness or incident
command. In some cases, leadership from the relevant hospital networks participated in the interviews
alongside hospital administrators or on the hospitals’ behalf.
Hospital selection and response
We had previously selected a stratified random sample of 410 hospitals for an October 2018 report
examining hospital preparedness for EIDs.39
We selected the 410 hospitals from
4,489 Medicare-certified hospitals with emergency departments in 2016, located in 47 States, the
District of Columbia, and Puerto Rico. The sample was comprised of two strata: (1) all
10 ASPR-designated Special Pathogen Centers, and (2) 400 other hospitals with emergency
departments.
For this review, we used the same sample, but removed 12 hospitals that were no longer in operation or
no longer providing inpatient care, and 18 hospitals that were under investigation by OIG. This left a
total sample of 380 hospitals that we attempted to survey.
We received responses from 323 of these 380 hospitals, for an 85 percent rate of contact. Among the
hospitals that did not respond, 9 chose not to participate, and we were unable to contact 48 after a
minimum of three attempts during the 5-day data collection period.40
The responding hospitals are located across 46 States, the District of Columbia, and Puerto Rico. Most
survey responses were provided directly by an administrator for a single hospital. However, for
46 sampled hospitals, we spoke with administrators from their parent corporation instead of, or in
addition to, the hospital administrators. We considered the interviews with the administrators from the
parent companies to be responses for each of the hospitals in our sample that were owned by those
companies. These 46 hospitals were spread across 16 hospital networks.
The following two pages provide additional information about the hospitals that responded.
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Exhibit 2: Hospital Respondents, March 23–27, 2020.
Exhibit 3: The 323 hospitals that we interviewed were located in 46 States, as well as the
District of Columbia and Puerto Rico.
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Exhibit 4: Among the 323 hospitals that we interviewed, some are designated as
specialized hospitals.
Limitations
We have three limitations: 1) hospital responses reflect a point in time (March 23–27, 2020), but the
pandemic is fast-moving, as are efforts to address it. Since our interviews, some hospital challenges
may have worsened and others may have improved; 2) we did not independently verify the information
reported by hospital administrators. Rather, we report on hospitals’ experiences and perceptions as
they were conveyed to OIG; and 3) our analysis found some evidence of response bias. Specifically,
larger hospitals appear to be under-represented in the pool of respondents and as a result, their views
may be under-represented.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued
by the Council of the Inspectors General on Integrity and Efficiency.
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APPENDIX A – STRATEGIES REPORTED BY
HOSPITALS
The following are specific strategies reported by hospitals divided by topic areas: 1) securing PPE, other
equipment, and supplies for staff; 2) ensuring adequate staffing to treat patients with COVID‑19;
3) reducing employee anxiety and stress; 4) managing patient flow and hospital capacity; and
5) securing ventilators and alternative equipment to support patients. We note that these strategies are
self-reported by the hospitals and OIG has not validated their effectiveness or safety.
Strategies to secure the necessary PPE, equipment, and
supplies for staff
Seeking Alternative Sources of PPE
To supplement limited supplies, hospitals reported improvising PPE and reaching out to
non-traditional sources or the community to acquire PPE.
• Using non-traditional sources of PPE, such as online retailers, home supply stores, paint stores,
autobody supply shops, and beauty salons.
• Using 3D printers and office supplies to make PPE (e.g., masks).
• Repurposing masks from other industries such as dentists, veterinarians, construction workers,
nail salons, etc.
• Purchasing expired PPE.
• Considering other materials to substitute for needed supplies (e.g., sandwich bags as
thermometer covers, blending ultrasound gel and alcohol from a local distillery to make hand
sanitizer).
• Creating supply by accepting handmade gowns and masks from community volunteers or
local businesses.
Implementing Methods to Extend PPE Usage
To conserve existing PPE, hospitals reported implementing procedures to extend and/or reuse PPE.
• Reusing PPE (e.g., disposable masks, face shields, and gowns).
• Sanitizing PPE (e.g., face shields and masks) between use.
• Reducing the extent and frequency of patient interaction to reduce PPE burn.
• Physically securing PPE to prevent theft or misuse.
• Limiting use of PPE to certain staff or patients (e.g., intensive care unit staff or patients).
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Strategies to ensure adequate staffing to treat patients with
COVID-19
Maintaining Staffing Levels
To keep operations going, hospitals reported “cross-training” staff or bringing on additional medical
staff.
• Supplementing medical staff with contractors, retired providers, nurse aides, and medical and
nursing students.
• Training medical staff to support or play other roles (e.g., anesthesiologists, hospitalists, and
nurses are being trained on how to operate ventilators and care for patients on the machines;
non-Emergency Department physicians are being trained to triage in the Emergency
Department).
Implementing Screening Procedures
To control the spread of COVID-19, hospitals reported implementing procedures to screen and
monitor staff and patients.
• Monitoring the temperature of staff, patients, and visitors who come into the hospital.
• Establishing screening centers outside of the hospital.
Partnering and Collaborating
To aid in their delivery of care, hospitals reported leveraging their partnerships and collaborating with
those in the community.
• Being part of a large health care system enables hospitals to deploy staff to other hospitals
and share supplies (e.g., PPE).
• Rural hospitals working with other rural hospitals to share supplies and pass information
about vendors.
• Working with the local emergency and health departments (e.g., fire department) to prepare
and help with patient flow.
• Coordinating with local health authorities to find proper placement for people that need to
isolate but do not have homes.
• Working with local community businesses and organizations (e.g., factories, fashion schools,
and distilleries) to assist with supplies, such as PPE and cleaning supplies.
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Strategies to help reduce employee anxiety and stress
Providing Social Support and Services
To ease anxiety and reduce outside burdens on staff, hospitals reported providing emotional and
psychological support and other support services.
• Assisting staff to find childcare, grocery, and laundry services.
• Providing hotel accommodations to promote separation from elderly family members.
• Expanding Employee Assistance Program services.
• Recruiting mental health clinicians and psychiatry staff to provide emotional and
psychological support.
Strategies to manage patient flow and hospital capacity
Using Ambulatory Care and Telehealth Services
To limit foot traffic, hospitals reported increasing their use of ambulatory care services and telehealth.
• Using ambulatory care clinics in the community and telehealth to triage patients in the clinic,
in the car, or over the phone to limit Emergency Department visits.
• Establishing hotlines for education and advice.
Social Distancing and Restricting Access
To control the spread of COVID-19, hospitals reported restricting access to the hospital and across
different parts of the hospital.
• Limiting the number of entrances to the hospital.
• Limiting the number of visitors and/or restricting visitors to attend only births and end-of-life
situations.
• Dismissing hospital volunteers.
• Restricting access to common areas (e.g., making cafeterias "grab and go," closing gyms).
• Splitting the Emergency Department into separate areas - one area for patients with
respiratory symptoms and another area for those without respiratory symptoms.
• Constructing temporary walls in the Emergency Department to isolate patients and create
negative pressure space.
• Turning the ambulance bay into a respiratory assessment unit with portable X-rays and
negative air pressure to keep unscreened patients from going through the Emergency
Department.
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Increasing Bed Availability
To address potential bed and facilities shortages, hospitals reported converting or creating space to
house a surge in patients.
• Expanding intensive care units, repurposing existing space or using tents, and utilizing other
network facilities to separate COVID-19 patients.
• Establishing alternate care sites at local fairgrounds and other spacious facilities.
• Converting nonoperational facilities in the community (e.g., prisons and college dorms) into
temporary critical care units.
Conducting Community Outreach and Education
To keep communities informed and reduce public panic, hospitals reported conducting outreach and
education activities to answer questions about COVID-19.
• Sending internal and external hospital communications, such as a daily newsletter; sharing
information on employee health and human resources.
• Holding senior leadership meetings often with other hospitals and communicating with local
and State governments.
• Partnering with local government to educate the public on the COVID-19 screening process,
including indicating which potential patients should go to the emergency department and
when, based on criteria such as symptoms.
• Developing ways for hospital leaders to hear hospital staff concerns, such as through daily
webinars.
Eliminating Elective Surgeries and Other Procedures
To reduce risk of exposure and conserve PPE, hospitals reported eliminating elective surgeries and
reducing other services such as ambulatory services, outpatient services, physical therapy, and
medical imaging.
• Conserving the PPE and blood supply that would be used for elective procedures in
preparation for a COVID-19 patient surge.
• Using surgery units and beds for potential COVID-19 patients.
• Reassigning surgical clinicians and staff to assist with COVID-19 response.
Activating Hospital Command Centers
To coordinate the hospitals' emergency plans, hospitals reported activating their incident command
centers.
• Setting up hospital contingency plans to prepare for patient surge and demand for services
(e.g., using clinic-based physicians to assist in hospital acute care, using a buddy system that
pairs intensive care unit and non-intensive care unit providers together, plans for evacuating
patients, as needed, to alternate settings.
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Managing Financial Viability
To continue providing needed care and retain staff, hospitals reported assessing ways to manage
their cash flow.
• Opening a line of credit to keep payroll going.
• Evaluating pay cuts and layoffs.
• Implementing mandatory and voluntary time off for staff that are not busy or essential, during
which time staff would not be paid but would stay on staff.
• Using flexible staffing and furloughing staff.
• Identifying grants and other funding opportunities.
• Reducing inventory not related to COVID-19.
Strategies to secure ventilators and alternative equipment to
support patients
Securing Ventilators and Alternative Equipment
To address a shortage in ventilators, hospitals sought new sources and alternative equipment to
support patients.
• Renting ventilators, buying single-use emergency transport ventilators, or obtaining
ventilators from an affiliated facility.
• Sharing supplies of ventilators between hospitals.
• Planning to transfer patients in need of ventilator to a nearby hospital.
• Converting medical equipment to use as ventilators (e.g., anesthesia machines and bi-level
positive airway pressure machines).
• Fitting ventilators with additional hoses to connect more than one patient to a single machine.
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APPENDIX B - GLOSSARY OF KEY TERMS
Office of the Assistant Secretary for Preparedness and Response (ASPR): HHS staff division that
leads the nation's medical and public health preparedness for, response to, and recovery from disasters
and public health emergencies. ASPR is assisting organizations to prepare for and respond to the
COVID-19 outbreak.
Centers for Disease Control and Prevention (CDC): HHS operating division tasked with protecting the
public health and safety through the control and prevention of disease, injury, and disability in the U.S.
and internationally. CDC is studying COVID-19 worldwide and helping communities prepare and
respond locally.
Centers for Medicare & Medicaid Services (CMS): HHS operating division that administers the
Medicare program and works in partnership with State governments to administer Medicaid, the
Children's Health Insurance Program, and health insurance portability standards. CMS is issuing clinical
and technical guidance for providers and beneficiaries about COVID-19.
Community spread: Spread of an illness for which the source of the infection is unknown.
Coronavirus disease 2019 (COVID-19): An illness of the respiratory tract that is highly contagious.
Symptoms include a cough, a high temperature (fever), and shortness of breath, and can be fatal in
some cases. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the virus that causes
COVID-19 and is often called the COVID-19 virus; its prior name was the 2019 novel coronavirus (2019-
nCoV).
Critical Access hospital (CAH): Rural primary health care hospital that gives limited outpatient and
inpatient hospital services to people in rural areas. CAHs are designated by CMS, and to qualify these
facilities must meet certain conditions such as: furnishing 24-hour emergency care services 7 days a
week, having no more than 25 inpatient beds, and having an average length of stay of 4 days or less per
patient for acute-care services. CMS is waiving requirements that CAHs limit the number of beds to 25
and length of stay of 4 days.
Emerging infectious disease (EID): Infections that have recently appeared within a population or
those whose incidence or geographic range is rapidly increasing or threatens to increase in the near
future.
Epidemic: Refers to an increase, often sudden, in the number of cases of a disease above what is
normally expected in that population in that area.
Federal Emergency Management Agency (FEMA): Federal agency under the U.S. Department of
Homeland Security that coordinates responses to natural disasters with State and local governments
and provides Federal assistance.
Food and Drug Administration (FDA): HHS operating division that is responsible for protecting the
public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological
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products, medical devices, our nation's food supply, cosmetics, and products that emit radiation. FDA is
working with hospitals and the medical industry to develop vaccines, drugs, and tests while monitoring
the medical supply chain during the COVID-19 pandemic.
Intensive care unit (ICU): Specialized hospital or facility department that provides critical care and life
support for acutely ill and injured patients.
Intravenous (IV) pump: Medical device that delivers fluids, such as nutrients and medications, into a
patient’s body in controlled amounts.
Isolation room: Negatively pressurized room to control the airflow so that the number of airborne
contaminants is reduced to a level that makes the chance of cross-infection to other people within a
health care facility unlikely (also see negative pressure room).
Middle East Respiratory Syndrome (MERS): Illness caused by a virus (more specifically, a coronavirus)
called Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and was first reported in Saudi
Arabia in 2012. Most MERS patients develop severe respiratory illness with symptoms of fever, cough
and shortness of breath and many people who are infected die.
N95 respirator mask: Respiratory protective device designed to achieve a very close facial fit and very
efficient filtration of airborne particles. The 'N95' designation means that when subjected to careful
testing, the respirator blocks at least 95 percent of very small (0.3 micron) test particles. If properly
fitted, the filtration capabilities of N95 respirators exceed those of face masks.
Negative pressure room: Room in a hospital or facility that is used to contain airborne contaminants
within the room.
Outbreak: Carries the same definition as “epidemic,” but usually refers to a more limited geographic
area.
Pandemic: Epidemic that has spread over several countries or continents, usually affecting a large
number of people.
Personal protective equipment (PPE): Protective clothing, helmets, goggles, or other garments or
equipment designed to protect the wearer's body from injury or infection. This includes respirators and
face masks.
Positive COVID-19 test: Test has laboratory confirmation, either from a State or local laboratory or the
CDC.
Powered air purifying respirators (PAPRs): Type of PPE used to safeguard workers against
contaminated air. It includes a battery-powered blower that pulls air through filters then moves filtered
air towards the facepiece. PAPRs are sometimes called positive-pressure masks, blower units, or just
blowers (compare with elastomeric respirators).
Presumptive positive: someone with symptoms that strongly indicate COVID-19 and tests have ruled
out other conditions like the flu, but there hasn’t been an initial positive COVID-19 test result or
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confirmatory test result. This term can also be used when an individual whose initial COVID-19 test has
been positive, but the CDC or other laboratories have not confirmed it.
Pulse survey: Type of short feedback survey, typically narrow in scope and can be administered on an
ongoing basis to track the same topic.
Quarantine: Condition that separates and restricts the movement of people who were exposed to a
contagious disease. If the person in quarantine is determined to have contracted the disease, the
person should seek treatment, as necessary, or go into isolation until they are no longer contagious.
Reagent: Substance that is used to produce a chemical reaction that allows researchers to detect,
measure, produce, or change other substances. For RNA extraction tests that detect the COVID-19
virus, this is an essential component that is lacking in many health care facilities.
Respirator: Masklike device, usually of gauze, worn over the mouth, or nose and mouth, to prevent the
inhalation of noxious substances. There are two main types: air-purifying respirators which remove
contaminants from the air and air-supplying respirators which provide a clean source of air.
"Respirator” is sometimes used interchangeably to refer to “ventilators.” (Also see powered air purifying
respirators and N95 respirators)
Severe Acute Respiratory Syndrome Virus (SARS): Viral respiratory illness caused by a coronavirus
called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003. The
illness spread to more than two dozen countries in North America, South America, Europe, and Asia
before the SARS global outbreak of 2003 was contained.
Single-use (disposable or emergency) ventilator: A small, lightweight ventilator used outside of the
hospital, typically for emergency care situations and intended only for short-term, single patient use,
with no cleaning or calibration needed.
Social distancing: Limits human interaction to lower the risk of human-to-human transmission.
Recommended measures can include keeping 6’ away from others, avoiding social gatherings, and
working from home.
Special Pathogen Centers: 10 hospitals designated by ASPR following the Ebola outbreak in 2014 to
maintain capability to accept patients with suspected or diagnosed illness from special pathogens
within 8 hours of notification and to conduct quarterly exercises to prepare for an EID outbreak. They
receive annual assessments from the National Ebola Training and Education Center, which is a
collaborative effort involving ASPR, CDC, and several academic institutions.
Special pathogens: Highly infectious agents that produce severe disease/illness in humans.
Strategic National Stockpile: Supplements State and local stocks of vaccines, medicines, and supplies
for emergencies.
Surge: When patient volumes challenge or exceed a hospital’s servicing capacity to effectively treat
individuals.
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Telehealth: Use of electronic information and telecommunications technologies to support longdistance clinical health care, patient and professional health-related education, public health and health
administration.
Thermometer (no-touch): No-touch thermometers use infrared technology to rapidly provide
accurate temperature results.
Traveling nurse: Nurses employed on a short-term or periodic basis. They include temporary staff,
independent contractors, and seasonal hires.
Triage: Process of sorting, classifying, and assigning priority to patients based on degree of sickness or
severity of injury.
Ventilator: Machine that supports breathing when a patient is having surgery or cannot breathe on
their own due to a critical illness. The patient is connected to the ventilator with a tube that goes in
their mouth or nose and down into their main airway.
WHO: World Health Organization, a United Nations agency that directs and coordinates international
public health efforts.
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ACKNOWLEDGMENTS AND CONTACT
This report is the result of a large team of OIG staff over a short time period, with the purpose to provide
timely information at an unprecedented time for HHS and the nation.
Rosemary Rawlins Bartholomew, Ben Gaddis, and Camille Harper served as the project leaders for this study.
Key contributors from the Office of Evaluation and Inspections included William Ash, Emily Borgelt, Anna
Brown, Charis Burger, Kristen Calille, Matt DeFraga, Kira Evsanaa, Maria Johnson, Eunji Kim, Anna Lin,
Demetrius Martinez, Conswelia McCourt, Anthony Soto McGrath, Lisa Minich, Petra Nealy, Ivy Ngo, Kenneth
Price, Chelsea Samuel, Karl Mari Santos, Hilary Slover, Jared Smith, Andrea Staples, Malaena Taylor, Savanna
Thielbar, Jesse Valente, John Van Der Schans, Kelly Waldhoff, and Troy Yamaguchi.
Other OIG staff who conducted the study included Deana Baggett, Melissa Baker, Heather Barton, Joanna
Bisgaier, Sara Bodnar, Joe Chiarenzelli, Craig Diena, Scott Englund, Kevin Farber, Caitlin Foster, David Fuchs,
Anne Gavin, Lee Gibson, Kevin Golladay, John Gordon, Vincent Greiber, Samantha Handel Meyer, Nathan
Hauger, Felicia Heimer, Michael Henry, Althea Hosein, Seta Hovagimian, Jonathan Jones, Michael Joseph,
Robert Kirkner, Laura Kordish, Rebecca Laster, San Le, Jay Mazumdar, Sabrina Morello, Christine Moritz,
Lyndsay Patty, Melicia Seay, Meridith Seife, Srishti Sheffner, Ellen Slavin, Peter Taschenberger, Lucio Verani,
Brian Whitley, and Abigail Wydra.
We would also like to acknowledge other significant contributors without whom this effort would not have
been successful. Staff from all OIG components contributed, including the Office of Audit Services, the
Office of Counsel, the Office of Evaluation and Inspections, the Office of Investigations, and the Office of
Management and Policy. Contributions included planning and conducting interviews, data and
administrative support, and report production and distribution.
This report was prepared under the direction of Blaine Collins and Ruth Ann Dorrill, Regional Inspectors
General for Evaluation and Inspections in the San Francisco and Dallas regional offices, and Abby Amoroso
and Amy Ashcraft, Deputy Regional Inspectors General.
Contact
To obtain additional information concerning this report, contact the Office of Public Affairs at
Public.Affairs@oig.hhs.gov. OIG reports and other information can be found on the OIG website at
oig.hhs.gov.
Office of Inspector General
U.S. Department of Health and Human Services
330 Independence Avenues, SW
Washington, DC 20201
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ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the
health and welfare of beneficiaries served by those programs. This statutory mission is carried out
through a nation-wide network of audits, investigations, and inspections conducted by the following
operating components:
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting
audits with its own audit resources or by overseeing audit work done by others. Audits examine the
performance of HHS programs and/or its grantees and contractors in carrying out their respective
responsibilities and are intended to provide independent assessments of HHS programs and
operations. These assessments help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide
HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These
evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and
effectiveness of departmental programs. To promote impact, OEI reports also present practical
recommendations for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of
fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators
working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating
with the Department of Justice and other Federal, State, and local law enforcement authorities. The
investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides general legal services
to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support
for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases
involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity
agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud
alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and
other OIG enforcement authorities.
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ENDNOTES
1 Coronavirus Aid, Relief and Economic Security (CARES) Act of 2020, P.L. No. 116-136 (enacted Mar. 27, 2020).
2 Actions that HHS has taken related to significant hospital challenges and suggestions include, but are not limited to, the
following examples. Pursuant to the CARES Act, CMS will allow hospitals, critical access hospitals, and other Medicare
providers and suppliers to request advance payment for 3 to 6 months of future Medicare claims. On March 30, 2020, CMS
announced an array of regulatory changes to increase hospitals’ and other health care providers’ flexibility in responding to
this pandemic. This includes enabling hospitals to leverage alternative sites (such as ambulatory surgical centers, hotels, and
dormitories) to provide hospital services. CMS also made changes to increase the services that can be provided via telehealth
and to make Medicare payments for services provided via telehealth equal to the traditional payment rates. In addition, CMS
has temporarily waived certain regulations that may restrict how hospitals use physicians or contracted staff due to business or
financial relationships. Specific information about these and many other HHS actions and resources is available at
https://www.hhs.gov/about/news/coronavirus/index.html.
3 The World Health Organization officially named this disease COVID-19 on February 11, 2020. Prior to that, it had been known
as “2019 novel coronavirus” or “2019-nCoV.” WHO, Novel Coronavirus (2019-nCoV) Situation Report-22. Accessed at
https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200211-sitrep-22-ncov.pdf?sfvrsn=fb6d49b1_2 on
March 26, 2020.
4 CDC, Human Coronavirus Types, CDC Fact Sheet. Accessed at https://www.cdc.gov/coronavirus/types.html on April 3, 2020.
5 CDC, Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions: Coronavirus Disease 2019 Basics. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/faq.html on March 26, 2020.
6 Killerby, et al., Human Coronavirus Circulation in the United States 2014-2017, Journal of Clinical Virology, April 2018.
Accessed at https://www.sciencedirect.com/science/article/pii/S1386653218300325 on March 26, 2020.
7 Liu et al., “Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Shenzhen, China, 2020,” Emerging
Infectious Diseases Journal, 26, March 3, 2020. Accessed at https://wwwnc.cdc.gov/eid/article/26/6/20-0239_article on April 2,
2020.
8 CDC, Coronavirus Disease 2019 (COVID-19) Symptoms of Coronavirus. Accessed at https://www.cdc.gov/coronavirus/2019-
ncov/symptoms-testing/symptoms.html on March 29, 2020.
9 Li, Qun, et al., Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. Accessed at
https://www.nejm.org/doi/full/10.1056/NEJMoa2001316 on March 26, 2020.
10 Secon, Holly, et al., A Comprehensive Timeline of the New Coronavirus Pandemic, From China’s First COVD-19 Case to the
Present. Accessed at https://www.businessinsider.com/coronavirus-pandemic-timeline-history-major-events-2020-3 on March
27, 2020.
11 CDC, CDC Confirms Possible Instance of Community Spread of COVID-19 in U.S. Accessed at
https://www.cdc.gov/media/releases/2020/s0226-Covid-19-spread.html on March 2, 2020.
12 World Health Organization, WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11, March 2020.
Accessed at https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-oncovid-19---11-march-2020 on April 3, 2020.
13 An epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that
population in that area. CDC, Principles of Epidemiology in Public Health Practice. Accessed at
https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html on March 27, 2020.
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OEI-06-20-00300 33
14 CDC, Coronavirus Disease 2019 (COVID-19) Cases & Latest Updates, Cases in U.S. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html on April 3, 2020.
15 FEMA, Emergency Support Function #8—Public Health and Medical Services Annex, January 2008. Accessed at
https://www.fema.gov/media-library-data/20130726-1825-25045-
8027/emergency_support_function_8_public_health___medical_services_annex_2008.pdf on March 26, 2020.
16 ASPR, Public Health Emergency Strategic National Stockpile. Accessed at
https://www.phe.gov/about/sns/Pages/default.aspx on April 3, 2020.
17 ASPR, 2017–2022 Health Care Preparedness and Response Capabilities. Accessed at
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf on March 26,
2020.
18 FEMA, Emergency Support Function #8—Public Health and Medical Services Annex, January 2008. Accessed at
https://www.fema.gov/media-library-data/20130726-1825-25045-
8027/emergency_support_function_8_public_health___medical_services_annex_2008.pdf on March 26, 2020.
19 ASPR Technical Resources, Assistance Centers, and Information Exchange (TRACIE): Topic Collection: Coronaviruses (e.g.,
SARS, MERS and COVID-19). Accessed at https://asprtracie.hhs.gov/technical-resources/44/coronaviruses-sars-mers-andcovid-19/27 on March 26, 2020.
20 ASPR designated 9 Special Pathogen Centers in 2015 and added an additional in 2017 for a total of 10.
21 HHS, HHS selects nine regional Ebola and other special pathogen treatment centers. Accessed at
https://www.infectioncontroltoday.com/viral/hhs-selects-nine-regional-ebola-and-other-special-pathogen-treatment-centers
on April 3, 2020.
22 Ibid.
23 ASPR, “Regional Treatment Network for Ebola and Other Special Pathogens,” p. 4. Accessed at
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/RETN-Ebola-Report-508.pdf on March 26, 2020.
24 National Ebola Training & Education Center, Annual Report FY 2018. pp. 3-5. Accessed at https://netec.org/wpcontent/uploads/2019/01/NETEC-Annual-Report-FY2018.pdf on April 3, 2020.
25 CDC, Steps Healthcare Facilities Can Take Now to Prepare for Coronavirus Disease 2019 (COVID-19). Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html on March 26, 2020.
26 CDC, CDC: Mission, Role and Pledge, April 14, 2014. Accessed at https://www.cdc.gov/about/organization/mission.htm on
March 26, 2020.
27 CDC, Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United State.
Accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html on March 26, 2020.
28 CDC, Strategies for Optimizing the Supply of N95 Respirators: Crisis/Alternate Strategies. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html on March 26, 2020.
29 CDC, Steps Healthcare Facilities Can Take Now to Prepare for Coronavirus Disease 2019 (COVID-19). Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html on March 26, 2020.
30 42 CFR pt. 482.
31 Social Security Act, § 1861(e); 42 U.S.C. § 1395x(e); 42 CFR § 488.3(a).
32 42 U.S.C. § 1320b-5.
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33 CMS, Medicare Telemedicine Health Care Provider Fact Sheet, accessed at https://www.cms.gov/newsroom/factsheets/medicare-telemedicine-health-care-provider-fact-sheet on March 26, 2020. The HHS Office of Civil Rights also issued
guidance that allows healthcare providers to use any non-public-facing remote communication product to communicate with
patients. Office of Civil Rights, Notification of Enforcement Discretion for Telehealth Remote Communications During the
COVID-19 Nationwide Public Health Emergency, accessed at https://www.hhs.gov/hipaa/for-professionals/specialtopics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html on April 3, 2020.
34 FDA, What We Do. Accessed at https://www.fda.gov/about-fda/what-we-do on March 31, 2020.
35 FDA, Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions. Accessed at https://www.fda.gov/emergencypreparedness-and-response/coronavirus-disease-2019-covid-19/coronavirus-disease-2019-covid-19-frequently-askedquestions on March 31, 2020.
36 FDA, Coronavirus (COVID-19) Update: Daily Roundup, March 25, 2020. Accessed at https://www.fda.gov/news-events/pressannouncements/coronavirus-covid-19-update-daily-roundup-march-25-2020, on March 2020.
37 FDA, Personal Protective Equipment for Infection Control. Accessed at https://www.fda.gov/medical-devices/generalhospital-devices-and-supplies/personal-protective-equipment-infection-control on March 31, 2020.
38 FDA, N95 Respirators and Surgical Masks (Face Masks). Accessed at https://www.fda.gov/medical-devices/personalprotective-equipment-infection-control/n95-respirators-and-surgical-masks-face-masks on March 31, 2020.
39 OIG, Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak (OEI-06-15-00230),
October 2018.
40 To ensure that the information in this report was released quickly, we did not include six interviews that either took place
after Friday, March 27, 2020 or for which the primary interview notes were added to our database after that date. We included
these 6 hospitals in the total of 48 hospitals that we were unable to contact.
