Preparing for a Surge of Coronavirus Cases

An outbreak of a novel strain of coronavirus, now called COVID-19, presents an ongoing health threat across the globe. At the time of this writing (February 27, 2020), the initial epidemic in China is threatening to transform into a pandemic, with a surge of cases in Japan, South Korea, Italy, and Iran. Through terrific work by the Centers for Disease Control and Prevention (CDC) and public health officials across the country, we have been able to limit the number of cases in the United States. But if COVID-19 expands worldwide, it seems inevitable that at least some hospitals in the United States will see a surge of patients with the virus.

The Joint Commission has been following the COVID-19 epidemic closely, and in recent days our level of concern has heightened. We are sure that most health care systems are already working to respond to this threat. As information and recommendations about COVID-19 continue to evolve, we want to emphasize our support of the CDC and other public health partners as the appropriate source of information and guidance for health care organizations and providers. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html).

The CDC “Infection Control” web page for health care professionals addresses several areas we think are worth emphasizing (https://www.cdc.gov/coronavirus/2019-ncov/infection-control/).

• •Inquire about symptoms of a respiratory infection, history of travel to areas experiencing transmission of COVID-19, or contact with patients with possible COVID-19 before patient triage or registration (for example, at the time of patient check-in).
• •Attempt to minimize the chance of exposure by trying to screen patients before arrival to a clinical area (for example, asking patients calling for appointments about travel history) and identifying them as early as possible upon arrival (such as by posting signs advising patients to put on a mask if they have respiratory symptoms).
• •If screening at triage is positive and the patient becomes a person under investigation (PUI), this should be communicated directly to the clinicians who will care for the patient, prevention and control services, and other health care facility staff according to a standard protocol.
• •Adhere to standard contact and airborne precautions, including eye protection.
• •Monitor stock and the supply chain to ensure adequate supplies of personal protective equipment.
• •Manage visitor access and movement within the facility.
• •Implement mechanisms and policies to promptly alert key facility staff, including infection control, health care epidemiology, facility leadership, occupational health, clinical laboratory, and frontline staff about known or suspected COVID-19 patients.
• •Identify specific staff to communicate and collaborate with state or local public health authorities.
• •Hand hygiene, hand hygiene, hand hygiene.

Remember also that some patients infected with COVID-19 will present with atypical symptoms (such as nausea, diarrhea, or abdominal pain).¹ Patients who have recently visited a region where cases have been confirmed with symptoms whose etiology remains unknown should still be evaluated for COVID-19 even if they do not have respiratory symptoms.

Because this situation is changing rapidly and advice may change, all organizations should have a person(s) assigned to actively review information and guidance as it becomes available and evaluate the need to modify current practices and communications within their organization. Organizations are also encouraged to review their internal and external communication systems to ensure that those responsible know how to contact their local health authority during the day or night in the event of a suspected case.

This is also a good time to remind everyone of the routine practices that will decrease the risk of transmission of any infectious agent. These should be in place regardless of any new identified infectious threat.

• •Have a clear system notifying patients of their role in preventing the transmission of communicable diseases. Most organizations do this by posting materials provided through the CDC, such as respiratory etiquette, and providing access to hand hygiene products and masks.
• •Ensure that staff at points of entry and intake know how to screen and respond to patients or visitors who may be infectious (for example, those with cough, fever, rash, diarrhea, or vomiting).
• •
  Implement all elements of standard precautions as outlined in the CDC Core Practices, including

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    Hand hygiene
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    Environmental cleaning and disinfection
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    Risk assessment with use of appropriate personal protective equipment (such as gloves, gowns, face masks) based on activities being performed
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    Reprocessing of reusable medical equipment between each patient and when soiled
• •Hand-off communications, both inter- and intrafacility, should include notification of colonization or infection with a potentially transmissible pathogen.
• •Organizations should implement a system for evaluation and management of exposed or ill health care workers and support staff that could expose patients, visitors, or other staff.

Last, our standards require health care organizations to have a plan for dealing with a surge of infectious patients. Specifically, IC.01.06.01 states: “The hospital prepares to respond to an influx of potentially infectious patients.” Based on the recent spread of COVID-19 and the increasing chance that we will see more cases in the United States, we recommend that hospitals review their plans, assess whether they can rapidly and reliably implement their plans as designed, and modify their plans if needed based on their assessment. We recently published a report on conversion of a conference room into a low-acuity inpatient medical unit to respond to an influenza outbreak, and this may be a model for some hospitals.²

If there are severe outbreaks, some communities may even want to consider creating surge hospitals.³ Surge hospitals, so-called because they are designed to treat a surge in the number of patients needing care, contain triage, treatment, and sometimes even surgical capabilities. These temporary facilities were originally established to deal with community-wide events (such as hurricanes) and meant to serve as a stopgap measure to provide medical care until the area's health care organizations could reopen. However, surge hospitals could have a role in pandemics if all hospitals in a community are overwhelmed despite activating their internal surge plans.

The Joint Commission standards were developed with an emphasis on decreasing risk and preparing organizations to respond to this type of emergency. We are confident that accredited organizations who follow routine practices and evolving CDC guidance will be able to provide for the safety of their patients, visitors, and staff.