Real-World Shortages Not Addressed in New COVID-19 Guidance

Andrew D. Bowser

March 20, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Newly updated guidance on treating patients with the novel coronavirus (COVID-19) has been published by the World Health Organization.

While it can't replace clinical judgment or specialist consultation, the new guidance may help strengthen the clinical management of patients when COVID-19 is suspected, according to its authors.

The guidance, adapted from an earlier edition focused on the management of suspected Middle East respiratory syndrome coronavirus (MERS-CoV), covers best practices for triage, infection prevention and control, and optimized supportive care for mild, severe, or critical coronavirus disease 2019 (COVID-19).

"This guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival," the authors wrote in the guidance.

While the WHO guidance does provide solid facts to support best practices for managing COVID-19, providers will also need to look beyond the document to tackle real-world issues, said David M. Ferraro, MD, FCCP, a pulmonary and critical care physician and associate professor of medicine at National Jewish Health in Denver.

For example, while the guidelines address the importance of screening and triage, limited COVID-19 testing may be a barrier to timely diagnoses that might compel more individuals to comply with social distancing recommendations, according to Dr. Ferraro, vice chair of the Fundamental Disaster Management Committee for the Society of Critical Care Medicine (SCCM).

"If we're not providing people with confirmation that they have the virus, they may potentially continue to be spreaders of the disease, because they don't have that absolute proof," Dr. Ferraro said in an interview. "I think that's where we are limited right now, because often we're not able to tell the mild symptomatic people ― or even the asymptomatic people ― that they really need to play a role in preventing further spread."

Likewise, the guidelines provide sound guidance on management of severe or critical COVID-19, according to Dr. Ferraro, yet they don't address the potential for shortages of trained health care personnel to handle more severe cases requiring ventilation. That's clearly an important issue, he said, especially with recent reports that the COVID-19 pandemic has pushed Italian intensive care units (ICUs) to the brink of collapse.

If the pandemic reaches crisis levels in the United States, nearly 1 million people would need ventilatory support, according to a recent report from SCCM on U.S. resource availability for COVID-19. And while there are an estimated 200,000 ventilators available in the United States, it's estimated in that report that only 135,000 patients could be handled at a time, given the shortage of ICU physicians, advanced practice providers, nurses, and respiratory therapists with training in mechanical ventilation.

"If our ICUs get overwhelmed and swarmed, we may have the technology available, but we may not have enough resources and personnel to safely manage the number of patients," Dr. Ferraro said.

The solution to that, according to the SCCM report, is to focus on expanding the pool of trained professionals who may be needed, not only to mechanically ventilate patients with COVID-19, but also to care for other critically ill patients routinely cared for in the ICU. They also suggest adopting a "tiered staffing strategy" in which non-ICU trained health care providers augment the capacity of experienced ICU staff.

With the prospect of untrained health care workers in mind, the WHO guidance could be a valuable resource for those who do have to jump into ICU roles, according to Dr. Ferraro.

The WHO also stresses immediate implementation of appropriate measures for infection prevention and control (IPC). According to their guidance, IPC needs to be initiated right at the point where the patient enters the hospital, with screening done at the first point of contact in the emergency department or outpatient clinics.

If patients are suspected to have COVID-19, they should receive a mask, and should be directed to a separate area where they are kept at least 1 meter apart from other individuals with suspected COVID-19, according to the WHO. (The Centers for Disease Control and Prevention recommends maintaining a distance of 6 feet to prevent spread of illness).

Beyond standard precautions such as hand washing and use of personal protective equipment, health care workers should do a point-of-care risk assessment at every patient contact to determine whether additional precautions are required.

Having standard IPC measures in place is "paramount," according to Dr. Ferraro, for a disease that has no available vaccine, no proven treatments, and a stealthy spread fueled by asymptomatic carriers.

"Those are huge weapons against us, and the only thing we really have to knock this down is really infection prevention control, so that truly is at the cornerstone," he said. "These are things that we must strictly follow."

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