COVID-19 Crisis Timeline: The Warning and the Surge

After an initial warning, an infectious health crisis, especially a viral one, can surge rapidly from a small outbreak to an overwhelming epidemic or even a pandemic. A surge usually consists of a rapid escalation phase, a peak phase, and a slow de-escalation phase. A surge may include an increase of all categories of patients, emergency room visits, in-patient admissions, and critically ill patients with multi-organ failure requiring ventilation, hemodialysis, and other intensive care measures. There is an accumulative effect of the rapid successive waves of patients admitted into the hospital, with a severe strain on the human and material resources of the hospital. In many health crises, as with the COVID-19 pandemic, the majority of the patients are hospitalized for a long time. Such a long hospitalization slows down the recovery from the crisis significantly. There is a disruptive effect of a health crisis on regular hospital functions and services, such as elective surgery, ambulatory clinics, and care and follow-up of patients with diseases other than the cause of the infectious crisis. This disruption may result in worsening of chronic diseases, such as diabetes, asthma, mental illnesses, and others. It may also result in delay in diagnosis and treatment of various types of cancers and later presentation of cancers at higher stages. Consequently, the disruption places special requirements for resumption of regular services after the crisis and an additional substantial burden on hospital capabilities. This chapter describes the initial COVID-19 crisis at SBH Health System in the Bronx, New York, USA, and shows its unfolding surge over time alongside an overview of the response. While the COVID-19 crisis has unique characteristics, many lessons learned from this crisis can be applied to other crises, especially infectious pandemics. © SBH Health System 2022.

Operationalization of critical care triage during a pandemic surge using protocolized communication and integrated supportive care.

Triage becomes necessary when demand for intensive care unit (ICU) resources exceeds supply. Without triage, there is a risk that patients will be admitted to the ICU in the sequence that they present, disadvantaging those who either present later or have poorer access to healthcare. Moreover, if the patients with the best prognosis are not allocated life support, there is the possibility that overall mortality will increase. Before formulating criteria, principles such as maximizing lives saved and fairness ought to have been agreed upon to guide decision-making. The triage process is subdivided into three parts, i.e., having explicit inclusion/exclusion criteria for ICU admission, prioritization of patients for allocation to available beds, and periodic reassessment of all patients already admitted to the ICU. Multi-dimensional criteria offer more holistic prognostication than only using age cutoffs. Appointed triage officers should also be enabled to make data-driven decisions. However, the process does not merely end with an allocation decision being made. Any decision has to be sensitively and transparently communicated to the patient and family. With infection control measures, there are challenges in managing communication and the psychosocial distress of dying alone. Therefore, explicit video call protocols and social services expertise will be necessary to mitigate these challenges. Besides symptom management and psychosocial management, supportive care teams play an integral role in coordination of complex cases. This scoping review found support for the three-pronged, triage-communication-supportive care approach to facilitate the smooth operationalization of the triage process in a pandemic.