Resource Allocation

The National Academy of Medicine joined eight other national organizations in calling for governors, state health departments, and health system partners to prepare for implementation of crisis standards of care (CSC) during COVID-19 surge. The NAM recommendation comes in response to surge in patients and reports that many intensive care units at hospitals across the country are approaching or over capacity with further case surge anticipated in coming weeks. Additionally, many hospitals that have been hit hardest disproportionately serve communities of color, presenting additional risks of exacerbating existing health inequalities. NAM and other organization recommend the unprecedented step of shifting from conventional standards of care to CSC, prioritizing population health by making difficult decisions about how to allocate scarce resources. However, as the recommendations make clear, failure to take action now is likely to result in even worse outcomes, including more lives lost and last damage to the health care system and health equity.

This Health Affairs blog by DeJong, Lo & Chen focuses on challenges and lessons learned from the FDA’s emergency use authorization (EUA) for monoclonal antibodies as treatment for COVID-19. The treatment shows promise in reducing hospitalization when administered soon after symptom onset (and prior to hospitalization), but it is less clear that it offers benefit among hospitalized patients. One of the most significant problems the authors note is that the federal government moved quickly to purchase and distribute the treatment but lacked a coordinated plan for equitable distribution, resulting in inconsistent access in medically under-resourced areas. Among other problems, cost barriers related to insurance cost-sharing limited access for some patients despite HHS announcements that the government would cover the cost of the treatment. Because communities of color are more likely to be underinsured or uninsured, cost-related burdens are likely to fall more heavily on these communities.

Health Care Workers

This article by Frush et al. describes efforts at a large academic medical system (Stanford Medicine) during the early phase of the pandemic to prioritize workforce protection. Among key efforts identified are activation of a hospital emergency incident control system (HEICS) and creation of a governance structure to oversee clinical response and coordinate operational priorities. The article outlines the structure of the Clinical Operations Resource Team (CORT), which included senior leadership from across the health system, details efforts to enhance the occupational health service, testing for symptomatic health care workers, addressing worker psychological safety and well-being, managing PPE shortages, conducting ongoing surveillance, and other key actions.

Facilities

This letter to the editor from Louie et al. reports an analysis of public health surveillance data comparing symptomatic and asymptomatic COVID-19 infections in long term care facilities (LCTFs) in San Francisco from March–June 2020. Following testing, over 65% of infected health care workers and residents were asymptomatic, despite comparable Ct values (a proxy for viral load). This result is consistent with other data supporting biologic plausibility of the potential of high risk of asymptomatic transmission. This is further evidence of the importance of surveillance and management in LTCF settings, which have experienced particularly high rates of infection and mortality during the pandemic.