COVID-19, Workforce Autonomy and the Health Supply Chain.

During the COVID-19 pandemic, the rapid surge in demand for critical supplies and public health efforts needed to guard against virus transmission have placed enormous pressure on health systems worldwide. These pressures and the uncertainty they have created have impacted the health workforce in a substantial way. This paper examines the relationship between health supply chain capacity and the impact of the COVID-19 pandemic on Canada's health workforce. The findings of this research also highlight the impact of the pandemic on health workers, specifically the relationship between the health supply chain and the autonomy of the health workforce.

Optimal SARS-CoV-2 vaccine allocation using real-time attack-rate estimates in Rhode Island and Massachusetts.

BACKGROUND: When three SARS-CoV-2 vaccines came to market in Europe and North America in the winter of 2020-2021, distribution networks were in a race against a major epidemiological wave of SARS-CoV-2 that began in autumn 2020. Rapid and optimized vaccine allocation was critical during this time. With 95% efficacy reported for two of the vaccines, near-term public health needs likely require that distribution is prioritized to the elderly, health care workers, teachers, essential workers, and individuals with comorbidities putting them at risk of severe clinical progression. METHODS: We evaluate various age-based vaccine distributions using a validated mathematical model based on current epidemic trends in Rhode Island and Massachusetts. We allow for varying waning efficacy of vaccine-induced immunity, as this has not yet been measured. We account for the fact that known COVID-positive cases may not have been included in the first round of vaccination. And, we account for age-specific immune patterns in both states at the time of the start of the vaccination program. Our analysis assumes that health systems during winter 2020-2021 had equal staffing and capacity to previous phases of the SARS-CoV-2 epidemic; we do not consider the effects of understaffed hospitals or unvaccinated medical staff. RESULTS: We find that allocating a substantial proportion (>75%) of vaccine supply to individuals over the age of 70 is optimal in terms of reducing total cumulative deaths through mid-2021. This result is robust to different profiles of waning vaccine efficacy and several different assumptions on age mixing during and after lockdown periods. As we do not explicitly model other high-mortality groups, our results on vaccine allocation apply to all groups at high risk of mortality if infected. A median of 327 to 340 deaths can be avoided in Rhode Island (3444 to 3647 in Massachusetts) by optimizing vaccine allocation and vaccinating the elderly first. The vaccination campaigns are expected to save a median of 639 to 664 lives in Rhode Island and 6278 to 6618 lives in Massachusetts in the first half of 2021 when compared to a scenario with no vaccine. A policy of vaccinating only seronegative individuals avoids redundancy in vaccine use on individuals that may already be immune, and would result in 0.5% to 1% reductions in cumulative hospitalizations and deaths by mid-2021. CONCLUSIONS: Assuming high vaccination coverage (>28%) and no major changes in distancing, masking, gathering size, hygiene guidelines, and virus transmissibility between 1 January 2021 and 1 July 2021 a combination of vaccination and population immunity may lead to low or near-zero transmission levels by the second quarter of 2021.

COVID-19 in aged care homes: a comparison of effects initial government policies had in the UK (primarily focussing on England) and Australia during the first wave.

BACKGROUND: COVID-19 pandemic has had a major impact globally, with older people living in aged care homes suffering high death rates. OBJECTIVES: We aimed to compare the impact of initial government policies on this vulnerable older population between the UK and Australia during the first wave of attack. METHODS: We searched websites of governments in the UK and Australia and media outlets. We examined the key policies including the national lockdown dates and the distribution of some important resources (personal protective equipment and testing) and the effects of these initial policies on the mortality rates in the aged care homes during the first wave of attack of COVID-19. RESULTS: We found that both countries had prioritized resources to hospitals over aged care homes during the first wave of attack. Both countries had lower priority for aged care residents in hospitals (e.g. discharging without testing for COVID-19 or discouraging admissions). However, deaths in aged care homes were 270 times higher in the UK than in Australia as on 7 May 2020 (despite UK having a population only 2.5 times larger than Australia). The lower fatality rate in Australia may have been due to the earlier lockdown strategy when the total daily cases were low in Australia (118) compared to the UK (over 1000), as well as the better community viral testing regime in Australia. CONCLUSION: In conclusion, the public health policy in Australia aimed towards earlier intervention with earlier national lockdown and more viral testing to prevent new cases. This primary prevention could have resulted in more lives being saved. In contrast, the initial policy in the UK focussed mainly on protecting resources for hospitals, and there was a delay in national lockdown intervention and lower viral testing rate, resulting in more lives lost in the aged care sector.

Ethical Allocation of Scarce Food Resources During Public Health Emergencies.

Escalating demands for limited food supplies at America's food banks and pantries during the COVID-19 pandemic have raised ethical concerns underlying "first-come, first-served" distributions strategies. A series of model ethical principles are designed to guide ethical allocations of these resources to assure greater access among persons facing food insecurity.

Assessment of Disparities Associated With a Crisis Standards of Care Resource Allocation Algorithm for Patients in 2 US Hospitals During the COVID-19 Pandemic.

Importance: Significant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity. Objective: To evaluate whether unanticipated disparities by race or ethnicity arise from a single institution's resource allocation policy. Design, Setting, and Participants: This cohort study included adults (aged ≥18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida. Exposures: Race (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic). Main Outcomes and Measures: The primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome. Results: The cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13). Conclusions and Relevance: In this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning the resource allocation policy. Despite this finding, any policy to guide altered standards of care during a crisis should be monitored to ensure equitable distribution of resources.

When Scarcity Meets Disparity: "Resources Allocation and COVID-19 Patients with Diabetes".

The COVID-19 pandemic raised distinct challenges in the field of scarce resource allocation, a long-standing area of inquiry in the field of bioethics. Policymakers and states developed crisis guidelines for ventilator triage that incorporated such factors as immediate prognosis, long-term life expectancy, and current stage of life. Often these depend upon existing risk factors for severe illness, including diabetes. However, these algorithms generally failed to account for the underlying structural biases, including systematic racism and economic disparity, that rendered some patients more vulnerable to these conditions. This paper discusses this unique ethical challenge in resource allocation through the lens of care for patients with severe COVID-19 and diabetes.

Prone Positioning for Severe Acute Respiratory Distress Syndrome in COVID-19 Patients by a Dedicated Team: A Safe and Pragmatic Reallocation of Medical and Surgical Work Force in Response to the Outbreak.

OBJECTIVE: The aim of this study was to define whether rapidly reallocating health care workers not experienced with PP for performing PP in ICU is feasible and safe. SUMMARY BACKGROUND DATA: In the setting of severe acute respiratory distress syndrome (ARDS), the use of prone and supine positioning procedures (PP) has been associated with improved oxygenation resulting in decreased mortality. Nevertheless, applying PP is time consuming for ICU staffs that are at risk of mental of physical exhaustion, especially with the constant surge of admitted COVID-19 patients with severe ARDS. METHODS: This prospective cohort study conducted at a single regional university hospital between March 27 and April 15, 2020. Among 117 patients admitted to ICU, 67 patients (57.3%) presented with proven SARS-CoV-2 infection with severe ARDS requiring PP. After accelerated simulation training, 109 volunteers including surgeons, physicians, nurses and physiotherapists, multiple dedicated teams performed daily multiple PP following a systematic checklist. Patient demographics and PP data were collected. Patient safety and health care workers safety were assessed. RESULTS: Among 117 patients admitted to ICU, 67 patients (57.3%) required PP. Overall, 53 (79%) were male, with a median age of 68.5 years and median body mass index of 29.3 kg/m. A total of 384 PP were performed. Overall, complication occurred in 34 PP (8.8%) and led to PP cancelation in 4 patients (1%). Regarding health care workers safety, four health care workers presented with potential COVID-19 related symptoms and none was positive. CONCLUSIONS: To overcome the surge of critically ill COVID-19 patients, reallocating health care workers to targeted medical tasks beyond their respective expertise such as PP was safe.

On collaborative reinforcement learning to optimize the redistribution of critical medical supplies throughout the COVID-19 pandemic.

OBJECTIVE: This work investigates how reinforcement learning and deep learning models can facilitate the near-optimal redistribution of medical equipment in order to bolster public health responses to future crises similar to the COVID-19 pandemic. MATERIALS AND METHODS: The system presented is simulated with disease impact statistics from the Institute of Health Metrics, Centers for Disease Control and Prevention, and Census Bureau. We present a robust pipeline for data preprocessing, future demand inference, and a redistribution algorithm that can be adopted across broad scales and applications. RESULTS: The reinforcement learning redistribution algorithm demonstrates performance optimality ranging from 93% to 95%. Performance improves consistently with the number of random states participating in exchange, demonstrating average shortage reductions of 78.74 ± 30.8% in simulations with 5 states to 93.50 ± 0.003% with 50 states. CONCLUSIONS: These findings bolster confidence that reinforcement learning techniques can reliably guide resource allocation for future public health emergencies.

Mobilizing a Whole Community: Policy and Strategy Implications of an Integrated Local System Response to a Global Health Crisis.

The East Toronto Health Partners (ETHP) include more than 50 organizations working collaboratively to create an integrated system of care in the east end of Toronto. This existing partnership proved invaluable as a platform for a rapid, coordinated local response to the COVID-19 pandemic. Months after the first wave of the pandemic began, with the daily numbers of COVID-19 cases finally starting to decline, leaders from ETHP provided preliminary reflections on two critical questions: (1) How were existing integration efforts leveraged to mobilize a response during the COVID-19 crisis? and (2) How can the response to the initial wave of COVID-19 be leveraged to further accelerate integration and better address subsequent waves and system improvements once the pandemic abates?

Organizational Health Literacy: Opportunities for Patient-Centered Care in the Wake of COVID-19.

BACKGROUND AND OBJECTIVES: The coronavirus disease-2019 (COVID-19) pandemic is transforming the health care sector. As health care organizations move from crisis mobilization to a new landscape of health and social needs, organizational health literacy offers practical building blocks to provide high-quality, efficient, and meaningful care to patients and their families. Organizational health literacy is defined by the Institute of Medicine as "the degree to which an organization implements policies, practices, and systems that make it easier for people to navigate, understand, and use information and services to take care of their health." METHODS: This article synthesizes insights from organizational health literacy in the context of current major health care challenges and toward the goal of innovation in patient-centered care. We first provide a brief overview of the origins and outlines of organizational health literacy research and practice. Second, using an established patient-centered innovation framework, we show how the existing work on organizational health literacy can offer a menu of effective, patient-centered innovative options for care delivery systems to improve systems and outcomes. Finally, we consider the high value of management focusing on organizational health literacy efforts, specifically for patients in health care transitions and in the rapid transformation of care into myriad distance modalities. RESULTS: This article provides practical guidance for systems and informs decisions around resource allocation and organizational priorities to best meet the needs of patient populations even in the face of financial and workforce disruption. CONCLUSIONS: Organizational health literacy principles and guidelines provide a road map for promoting patient-centered care even in this time of crisis, change, and transformation. Health system leaders seeking innovative approaches can have access to well-established tool kits, guiding models, and materials toward many organizational health literacy goals across treatment, diagnosis, prevention, education, research, and outreach.

Provision of COVID-19 Convalescent Plasma in a Resource-Constrained State.

BACKGROUND: Arkansas is a rural state of 3 million people. It is ranked fifth for poverty nationally. The first case of coronavirus disease 2019 (COVID-19) in Arkansas occurred on 11 March 2020. Since then, approximately 8% of all Arkansans have tested positive. Given the resource limitations of Arkansas, COVID-19 convalescent plasma (CCP) was explored as a potentially lifesaving, therapeutic option. Therefore, the Arkansas Initiative for Convalescent Plasma was developed to ensure that every Arkansan has access to this therapy. STUDY DESIGN AND METHOD: This brief report describes the statewide collaborative response from hospitals, blood collectors, and the Arkansas Department of Health (ADH) to ensure that CCP was available in a resource-limited state. RESULTS: Early contact tracing by ADH identified individuals who had come into contact with "patient zero" in early March. Within the first week, 32 patients tested positive for COVID-19. The first set of CCP collections occurred on 9 April 2020. Donors had to be triaged carefully in the initial period, as many had recently resolved their symptoms. From our first collections, with appropriate resource and inventory management, we collected sufficient CCP to provide the requested number of units for every patient treated with CCP in Arkansas. CONCLUSIONS: The Arkansas Initiative, a statewide effort to ensure CCP for every patient in a resource-limited state, required careful coordination among key players. Collaboration and resource management was crucial to meet the demand of CCP products and potentially save lives.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Rethinking Trauma Hospital Services in one of Spain's Largest University Hospitals during the COVID-19 pandemic. How can we organize and help? Our experience.

INTRODUCTION: The severe disruptions caused by the SARS-CoV-2 coronavirus have necessitated a redistribution of resources to meet hospitals' current service needs during this pandemic. The aim is to share our experiences and outcomes during the first month of the Covid-19 pandemic, based on the strategies recommended and strategies we have implemented. METHODS: Our experience comes from our work at a referral hospital within the Spanish National Health System. Changes to clinical practice have largely been guided by the current evidence and four main principles: (1) patient and health-care worker protection, (2) uninterrupted necessary care, (3) conservation of health-care resources, (4) uninterrupted formation for residents. Based on these principles, changes in the service organization, elective clinical visits, emergency visits, surgical procedures, and inpatient and outpatient care were made. RESULTS: Using the guidance of experts, we were able to help the hospital address the demands of the Covid-19 outbreak. We reduced to a third of our orthopaedics and trauma hospital beds, provided coverage for general emergency services, and five ICUs, all continuing to provide care for our patients, in the form of 102 trauma surgeries, 6413 phone interviews and 520 emergency clinic visits. Also in the third week, we were able to restart morning meetings via telematics, and teaching sessions for our residents. On the other hand, eight of the healthcare personnel on our service (10.8%) became infected with Covid-19. CONCLUSIONS: As priorities and resources increasingly shift towards the COVID-19 pandemic, it is possible to maintain the high standard and quality of care necessary for trauma and orthopaedics patients while the pandemic persists. We must be prepared to organize our healthcare workers in such a way that the needs of both inpatients and outpatients are met. It is still possible to operate on those patients who need it. Unfortunately, some healthcare workers will become infected. It is essential that we protect those most susceptible to severer consequences of Covid-19. Also crucial are optimized protective measures.