A Systems Approach and Notional Response Model for Preserving the Health System during the COVID-19 Pandemic

During any pandemic, it has long been known that local jurisdictions would need to be self-sufficient with little or no outside assistance, particularly from the federal government. While all eyes have been on California, New York, and Massachusetts, the capacities of health systems in other states have yet to be put to the test. If there are subsequent waves of COVID-19 and other jurisdictions see significant increases in disease spread, the systems used to respond will become critical. Using a review and synthesis approach, this article explores our collective experience and knowledge as it pertains to use of alternate care sites for dealing with the patient surge created by a disease outbreak. Probing the concept of alternate care site (ACS) systems reveals various types of alternate care sites that may be employed during an outbreak. The historical value of ACS models used during outbreak response are discussed. This culminates in the development of a notional response model and list of actions that should be taken by all jurisdictions as we prepare for additional waves of disease.


Introduction
As the COVID-19 outbreak accelerates across the globe, increased attention is being focused on preserving the healthcare infrastructure while meeting excess demands created by the disease. At the time of this writing, the case numbers are reported to be plateauing in the United States (Today, 2020).
The U.S. curve is based most heavily on New York and other hard-hit areas with intense transmission.
There are at least two reasons that emergency planners and health system leaders should not lower their guard: first, the epidemic curves for each region and community will be different; while New York Published by SCHOLINK INC. to free up an additional 343 beds and 43 surgical suites within three hours to accommodate victims (Hick et al., 2006). These strategies, however, are not always generalizable to outbreak scenarios because: a) caring for patients in hallways may amplify disease spread, and b) patients with disease may require more than brief periods of time. The Health Resources and Services Administration (HRSA) released a benchmark for surge capacity during an infectious disease outbreak of a minimum of 500 beds per million residents (Delia & Wood, 2008).

Healthcare Coalitions and the Need for a Systems Approach
A disease outbreak is felt by the whole of society; no single organization can effectively prepare as a solitary endeavor (Agency for Healthcare Research and Quality, 2017;World Health Organization, 2014;World Health Organization, 2009). Planning and preparedness efforts that do not recognize the interdependent nature of all system partners will result in an uncoordinated response (World Health Organization, 2014;World Health Organization, 2009). The COVID-19 response requires unity of effort -from the nation's highest office to individual citizens (White House Office of Intergovernmental Affairs, 2020).
A healthcare coalition represents a systems approach to COVID-19 and is defined as a formal collaboration among hospitals, public health, emergency management, emergency medical services, law enforcement, and non-government organizations that are required to respond to a catastrophic health event (Barbera & Macintyre, 2007, 2009. The goal of the healthcare coalition is to enhance system resiliency, surge capacity, and continuity of operations during such events (World Health Organization, 2014). A systems approach allows for the maintenance of operational capabilities while upholding an acceptable standard of care (World Health Organization, 2009). The total system is, in fact, the solution.
While the images from the 1918 influenza pandemic rightfully strike fear in the hearts of those responsible for surge planning, a prima facie analysis of images of alternate care sites (ACSs) used during the pandemic reveals that a number of persons who occupied beds were potentially capable of caring for themselves, as seen in Image 1. This point is further underscored by Dr. Isaac Starr's first-hand account, who reported that "many seemed to have sought admission chiefly because everybody in the family was sick and no one was left at home who could take care of them" (Staar,

Congress
While not delineated in this manner, the literature suggests an effective response system requires four basic capabilities that will be referred to as:
These capabilities can be addressed through ACS systems with the goal of keeping all who do not require critical care out from hospitals and clinics.

Alternate Care Site Systems (ACSS)
"Alternate care sites" (ACS) refer to any location outside of the normally operating healthcare system that are established for the purpose of addressing the outbreak. This includes any location where persons are monitored by health professionals or their appointees, such as the home care environment.
This allows for a more wholistic consideration of alternate care as part of a larger "system". An ACSS  Joint Commission, 2006). In addition to reducing the strain on hospitals, a major benefit of community-based alternate care site systems is that they allow public health interventions to reach much more of the population sooner (Logan et al., 2014).

Closed ("Shuttered") Hospitals as Alternate Care Sites
A shuttered hospital represents a better option than a school or auditorium because they were designed and engineered for inpatient care, including life safety systems such as fire suppression equipment    **For CCCs, equivalent community settings were also considered, to include safe burial and community-based programs.

A Notional Response Model
Based on the literature, a notional model of a systems approach to a surge during this outbreak has been proposed below. In the model of an alternate care site system (ACSS), shown in Figure 2, hospital capacity has been exceeded and patients enter the ACSS. In this model, an NEHC acts as a primary triage point providing low-acuity (non-disease related) patient care (Church, 2001). A disease treatment unit and two community care centers are established nearby. One CCC is used for isolation of infected

Critical Steps to Take Now
In a March 27, 2020 letter to emergency managers, the FEMA Administrator requested several critical actions be taken immediately (Gaynor, 2020). These include the following: 1. Create a healthcare coalition if one does not already exist. Do this by bringing together emergency managers, public health, first responders, and all communities of interest (Gaynor, 2020).
a) Create an alternate care site committee or team (ACSC) (World Health Organization, 2019).
3. Project requirements for different scenarios (Dayton et al., 2006). Determine the patient number that will be created by each scenario and create a chart of bed availability to each capacity (Dayton et al., 2006). Table 2 represents an example chart to determine enhanced isolation capacity (EIC) needs for a scenario "X".