Successful Health Care Delivery Using Ambulatory Hospitals-Past, Present, and Future.

Crises provide fertile environments for innovation. The novel coronavirus 2019 (COVID-19) pandemic has impacted nearly every country and impacted life across the globe. As a result of the pandemic, health care systems, hospitals, and intensive care units are functioning beyond their capacity, and the interruption of supply chains have resulted in shortages of equipment (ie, ventilators), intensive care beds, medications, testing centers, and powered air purifying respirators (PAPR) for health care workers. Although the current challenges seem to be unprecedented (although it most likely will not eclipse the Spanish Flu pandemic of 1918), there are health care delivery models that were used in the past and may also serve as a model for the current and future pandemics.

The advent of the Mobile Army Surgical Hospital (MASH) in World War II and, later in subsequent years, is credited with the saving of thousands of lives. These “temporary” hospitals (because they could be moved every month if necessary) were deployed to the frontlines to provide life-saving trauma care to injured soldiers near the battlefield. Although many were instrumental in the genesis of these MASH units, Dr. Michael DeBakey helped organize and promote this concept despite initial resistance. These MASH units ultimately resulted in shorter evacuation times, rapid triage, successful resuscitation of the wounded, and a reduction in the number of casualties (Figure ). These MASH units were known for their mobility and adaptability, and individual MASH units provided care for hundreds of patients at a time. These units have been extensively and successfully used in the Korean, Vietnam, Gulf, and Iraqi Wars. The health care delivery provided by these units proffered numerous medical advances and may serve as a platform for health care crises.

Figure

Ambulatory hospitals provided urgent care and saved thousands of lives during wartime crises. (A) MASH unit with rows of ward tents. (B) US Fifth Army, Anzio area, Italy (1944). Obtained from the National Library of Medicine.

According to the American Hospital Association, US hospitals have decreased in number since the 1990s with approximately 6100 hospitals in operation in 2018. These hospitals have 924,107 staffed beds, 97,776 intensive care beds, and collectively have an average occupancy rate of 65% and employ more than 7 million people. Our US health care system functions well, but seasonal influenza outbreaks can provide unique challenges and stress regional bed capacity of hospitals. For example, the 2017-2018 flu season was particularly severe in the United States, accounting for more than 900,000 hospitalizations and 61,099 deaths. Any further challenge during the flu season can prove to be a challenge for the health care delivery system. COVID-19 has provided such a global challenge with areas of higher intensity seen around the world, including Milan, Venice, New York, California, Louisiana, and others.

As a result of the co-occurrence of the seasonal flu and the COVID-19 pandemic, the bed capacity in hospitals is at a crisis level. A potential solution for this shortage would be to establish mobile ambulatory hospitals that could be staffed for cardiopulmonary support services and could be moved throughout the country to provide the necessary health care support. This might use units already available through the Department of Defense or in the future be engineered and mobilized by the government for use and deployment. It would also be important to establish a health care team composed of nursing staff, technicians, and physicians (eg, critical care, pulmonologists, infectious disease specialists, advanced heart failure specialists, etc.) that would be assigned to these mobile ambulatory hospitals. Such a model would require that the dedicated health care team be released from their professional duties in their communities, and state licensure allowances would need to be implemented. This special force of health care personnel would provide efficient expertise in the treatment of any panepidemic.

In summary, previous health care models that have been established during wartime efforts may have utility in the delivery of hospital care for those with COVID-19 or any other future panepidemic.