Looking to the Past, Learning From the Present, and Preparing for the Future: Toward Understanding Critical Care Strain During a Global Pandemic.

In the spring of 1918, an influenza A H1N1 subtype virus spread rapidly across the globe, resulting in one of the deadliest public health crises in human history. The virus ultimately infected up to 40% of the world’s population and killed between 50 million and 100 million people worldwide. In a 2007 perspective piece, Drs. David Morens and Anthony Fauci reflected on this pandemic and commented that in the event of a future similar public health crisis, the most difficult challenge would be “to increase medical capacity and resource availability (eg, hospital beds, medical personnel, drugs, and supplies)…Health-care systems could be rapidly overwhelmed by the sheer number of cases…And the just-in-time nature of our supply chain of necessary medications and equipment for medical care could easily be disrupted by such a global public health catastrophe.”

FOR RELATED ARTICLE, SEE PAGE 619

Their words proved prescient. On January 30, 2020, the World Health Organization declared a global public health emergency due to the novel coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2. With over 38,000,000 cases and nearly 1.1 million deaths worldwide as of October 14, 2020, the pandemic has overwhelmed hospitals and ICUs during local surges across the world. Because a substantial proportion of patients with COVID-19 require ICU admission and mechanical ventilation,5, 6, 7, 8 it is crucial to understand how strain placed on ICUs impacts resource availability and allocation and the burden on health-care workers to inform ongoing pandemic response and future preparedness.

In this issue of CHEST, Wahlster and colleagues contribute to an evidence base for the predictions made over a decade ago. Investigators sought to understand global critical care capacity strain during the pandemic through an international survey of interprofessional critical care clinicians caring for patients with COVID-19. Unsurprisingly, participants around the world frequently reported shortages of necessary resources, particularly ICU nurses and personal protective equipment (PPE). They also reported that critical care delivery changed during the pandemic. In some regions, up to one third of participants reported that limits were placed on administering mechanical ventilation, and more than half reported changes to policies and practices for CPR. Additionally, up to a quarter of respondents in some regions perceived that family involvement in decision-making was less among COVID-19 patients than other ICU patients.

The need to place limitations on mechanical ventilation became an international symbol of the gravity of the pandemic. The lay press was filled with vivid tales of clinicians recounting harrowing experiences of having to choose which patient got the last available ventilator, and medical journals have published countless guides for ventilating multiple patients with a single machine. However, study authors found regional differences in placing limitations on mechanical ventilation. For example, participants from North America—98% of whom were from the United States—were two to three times less likely to report limits on offering mechanical ventilation than any other world region, despite the United States having the highest total case count. Why might this be? One reason is that US participants likely perceive the least risk of actually running out of ventilators. Indeed, during nonpandemic times, the United States has more ICU beds and resources per capita than almost any other country, and lower average occupancy. Another reason is almost surely the “patient as consumer” movement in the United States. US clinicians are unlikely to unilaterally withhold therapies except in the most extreme circumstances. North America was also the only region in which most respondents were more likely to make decisions about CPR based on family or surrogate wishes, rather than by treating physicians—further evidence of how the US health-care system often emphasizes patient autonomy over paternalism.

Also unsurprisingly, participants commonly expressed concern about infecting their families or becoming sick themselves—another common story in the popular media—and more than half of all participants reported emotional distress or burnout. Authors identified several factors associated with this distress, including the volume of COVID-19 patients cared for by an individual, perception of staffing shortages, professional role, female sex, and concerns about inadequate PPE. This latter concern—shortages of PPE—is particularly important because it is potentially modifiable. Given the recent uptick in the number of COVID-19 cases globally and the potential for a prolonged duration of the pandemic, strategies to improve access to PPE could help assuage this primary source of distress. Such strategies include bolstering the supply chain of PPE (eg, through legislation or the Defense Protection Act in the United States) and developing and communicating evidence-based guidelines for disinfecting and reusing PPE.

Additionally, based on our own experiences as ICU clinicians during the pandemic, we suspect there are many other contributors to emotional distress that the authors could not easily capture in a structured survey. For example, widespread restrictive visitation policies created barriers to communication and shared decision-making between clinicians and family members, which is particularly distressing to all parties when patients are critically ill and at the end of life. Furthermore, the relative vacuum of evidence early in the pandemic created uncertainty and undermined confidence in clinical decision-making. Future work should aim to better understand some of these factors to inform creative solutions that improve clinician well-being, which will be essential to maintaining an adequate workforce in both current and future crises.

Over a decade ago, Drs. Morens and Fauci drew on what we had learned from the 1918 influenza pandemic to predict some of the challenges of our current health crisis. The study by Wahlster et al both confirms and builds on their predictions, demonstrating that COVID-19 has both strained the critical care capacity globally and substantially burdened frontline health-care providers, even in the most highly resourced regions of the world. Unfortunately, the end is not yet in sight. Let us continue to learn both from the past and present to simultaneously improve patient outcomes and the experiences of the health-care workers dedicated to their care.