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PURPOSE OF REVIEW: The worldwide SARS-CoV-2 pandemic has taken a heavy toll on ICUs worldwide. This review expounds on lessons learned for ICU preparedness during the pandemic and for future mass casualty events. RECENT FINDINGS: In the 21st century, there have already been several outbreaks of infectious diseases that have led to mass casualties creating ICU strain, providing multiple opportunities for hospitals and hospital systems to prepare their ICUs for future events. Unfortunately, the sheer scale and rapidity of the SARS-CoV-2 pandemic led to overwhelming strain on every aspect of ICU disaster preparedness. Yet, by analyzing experiences of hospitals throughout the first 7 months of the current pandemic in the areas of infection control, equipment preparedness, staffing strategies, ICU spatial logistics as well as acute and postacute treatment, various important lessons have already emerged that will prove critical for successful future ICU preparedness. SUMMARY: Preemptive planning, beginning with the early identification of staffing resources, supply chains and alternative equipment sources, coupled with strong infection control practices that also provide for the flexibility for evolving evidence is of utmost importance. However, there is no single approach that can be applied to every health system.

Background The current coronavirus disease 2019 pandemic is causing significant strain on ICUs worldwide. Initial and subsequent regional surges are expected to persist for months and potentially beyond. As a result of this, as well as the fact that ICU provider staffing throughout the United States currently operate at or near capacity, the risk for severe and augmented disruption in delivery of care is very real. Thus, there is a pressing need for proactive planning for ICU staffing augmentation, which can be implemented in response to a local surge in ICU volumes. Methods We provide a description of the design, dissemination, and implementation of an ICU surge provider staffing algorithm, focusing on physicians, advanced practice providers, and certified registered nurse anesthetists at a system-wide level. Results The protocol was designed and implemented by the University of Pittsburgh Medical Center's Integrated ICU Service Center and was rolled out to the entire health system, a 40-hospital system spanning Pennsylvania, New York, and Maryland. Surge staffing models were developed using this framework to assure that local needs were balanced with system resource supply, with rapid enhancement and expansion of tele-ICU capabilities. Conclusions The ICU pandemic surge staffing algorithm, using a tiered-provider strategy, was able to be used by hospitals ranging from rural community to tertiary/quaternary academic medical centers and adapted to meet specific needs rapidly. The concepts and general steps described herein may serve as a framework for hospital and other hospital systems to maintain staffing preparedness in the face of any form of acute patient volume surge.

This qualitative study uses interviews with capacity management personnel in US acute care hospitals during the 2017-2018 influenza season to examine views regarding hospitals’ responses to high patient volumes and the level of hospital preparedness for future pandemic events., Key Points Question What were US hospitals’ experiences and the views of hospital capacity managers regarding response and preparedness activities during the 2017-2018 influenza epidemic? Findings In this qualitative study using semistructured telephone interviews with 53 key hospital capacity personnel at 53 hospitals throughout the US, perceived strain on hospital resources was almost universally reported. Participants described a range of hospital responses to seasonal influenza but indicated that future pandemic planning was not a high priority. Meaning The findings suggest that, during the 2017-2018 influenza epidemic, there were vulnerabilities in the US health care system, including a lack of planning for future pandemic events, which may have implications for public health planning given the ongoing coronavirus disease 2019 pandemic., Importance The 2017-2018 influenza season in the US was marked by a high severity of illness, wide geographic spread, and prolonged duration compared with recent previous seasons, resulting in increased strain throughout acute care hospital systems. Objective To characterize self-reported experiences and views of hospital capacity managers regarding the 2017-2018 influenza season in the US. Design, Setting, and Participants In this qualitative study, semistructured telephone interviews were conducted between April 2018 and January 2019 with a random sample of capacity management administrators responsible for throughput and hospital capacity at short-term, acute care hospitals throughout the US. Main Outcomes and Measures Each participant’s self-reported experiences and views regarding high patient volumes during the 2017-2018 influenza season, lessons learned, and the extent of hospitals’ preparedness planning for future pandemic events. Interviews were recorded and transcribed and then analyzed using thematic content analysis. Outcomes included themes and subthemes. Results A total of 53 key hospital capacity personnel at 53 hospitals throughout the US were interviewed; 39 (73.6%) were women, 48 (90.6%) had a nursing background, and 29 (54.7%) had been in the occupational role for more than 4 years. Participants’ experiences were categorized into several domains: (1) perception of strain, (2) effects of influenza and influenza-like illness on staff and patient care, (3) immediate staffing and capacity responses to influenza and influenza-like illness, and (4) future staffing and capacity preparedness for influenza and influenza-like illness. Participants reported experiencing perceived strain associated with concerns about preparedness for seasonal influenza and influenza-like illness as well as concerns about staffing, patient care, and capacity, but future pandemic planning within hospitals was not reported as being a high priority. Conclusions and Relevance The findings of this qualitative study suggest that during the 2017-2018 influenza season, there were systemic vulnerabilities as well as a lack of hospital preparedness planning for future pandemics at US hospitals. These issues should be addressed given the current coronavirus disease 2019 pandemic.

Background Our hospital system created system guidelines to standardize care across 24 hospitals for COVID-19 treatment during the pandemic. Guidelines changed over time. Hydroxychloroquine (HCQ) was unrestricted during phase 1, then restricted by pharmacy outside of a randomized clinical trial (RCT) during phase 2 (excepting those ineligible for RCTs). Methods This was a prospective study to assess system-wide adherence to COVID-19 treatment guidelines, and to evaluate patient outcomes. Results Of 261 patients, median age was 67 years (IQR 56–76); 49% (129/261) were male, and 45% (118/261) required ICU care. Overall, 47% (122/261) were in phase 1; HCQ was offered to 57% (69/122) during this phase. The rate of HCQ prescription in phase 2 decreased significantly to 10% (14/136), (p < 0.001). Adherence to COVID-19 treatment protocol was 97% (135/139) during phase 2. Mortality was similar in both phases (22% vs 28%, p=0.32), as was median length of stay (8 vs 7 days, p=0.3). Overall 66 patients (25%) died in the hospital; neither non-adherence (p=1) to system guidelines nor receipt of HCQ (p=0.17) were risk factors for death. Independent predictors of mortality included: new renal replacement therapy (OR 61, 95%CI 6.7–560, p < 0.001), mechanical ventilation (OR 4.9, 95%CI 2.0–11, p < 0.001), abnormal chest X-ray (OR 4.3, 95%CI 1.4–12.6, p =0.009), history of heart failure (OR 3.9, 95%CI 1.5–11, p=0.006), lack of fever on admission (OR 3.5, 95%CI 1.7 -7.6, p =0.001), receipt of corticosteroids (OR 2.7 95%CI 1.1–6.6, p=0.026) and increased age (OR 1.07 per year, 95%CI 1.04–1.1, p < 0.001). Bacterial pneumonia occurred in 8% (21/261), more commonly in those who died (p=0.02). Black patients had a higher race-specific death rate (308 vs 197) per 1000 than white patients (p< 0.001). Conclusion During the COVID-19 pandemic, our health system guidelines and pharmacy restrictions were successful in delivering consistent care across hospitals. Restriction of HCQ for COVID-19 treatment to RCTs reduced its use in phase two. Non-adherence to systemic guidelines was infrequent, and not associated with adverse outcomes. A COVID-19 treatment team of physicians and pharmacists can effectively coordinate therapy across hospitals in the setting of rapidly changing guidelines. Disclosures J. Ryan Bariola, MD, Infectious Disease Connect (Employee)Mayne Pharma (Advisor or Review Panel member)Merck (Research Grant or Support)

Background The 2017–2018 influenza season was characterized by high illness severity, wide geographic spread, and prolonged duration compared with recent years in the United States – resulting in an increased number of emergency department evaluations and hospital admissions. The current study explored how US hospitals perceived the impact of influenza during this time period, including effects on patient volumes, ways in which hospitals responded, and how lessons learned were incorporated into future influenza preparedness. Methods We conducted semi-structured phone interviews with capacity management personnel in short-term acute care hospitals across the United States. A random hospital sample was created using Centers for Medicare and Medicaid Services annual reports. Hospitals self-identified key informants who were involved with throughput and capacity. The interview guide was developed and pilot tested by a team of clinicians and qualitative researchers, with interviews conducted between April 2018 and January 2019. We performed thematic content analysis to identify how hospitals experienced the 2017–2018 influenza season. Results We achieved thematic saturation after 53 interviews. Responses conformed to three thematic domains: impacts on staff and patient care, immediate staffing and capacity responses, and future preparedness (Table 1). Hospitals almost universally reported increased emergency department and inpatient volumes that frequently resulted in strain across the hospital. Strain was created by both increased patient volume and staff shortages due to influenza illness. As strategies to address strain, respondents reported the use of new protocols, new vaccination policies, additional staffing, suspected-influenza treatment areas, and more frequent hospital administration meetings. Many hospitals reported increased diversion time. Despite experiencing high levels of strain, some hospitals reported no changes to their future influenza preparation plans. Conclusion Acute care hospitals experienced significant strain as a result of the 2017–2018 influenza season. Hospitals implemented a range of immediate responses to seasonal influenza, but generally did not report future planning specific to influenza. Disclosures All authors: No reported disclosures.

Background Acute respiratory viral illnesses cause significant morbidity and mortality leading to high healthcare costs. Delayed viral pathogen diagnosis likely contributes to increases in morbidity and mortality. We aimed to analyze: (1) the use of respiratory viral panel (RVP) testing in adults hospitalized to intensive care units (ICUs) with acute respiratory illness (ARI) during flu season; and (2) if RVP testing is associated with improved outcomes. Methods Data from adults hospitalized to the ICU with ARI during the 2015–2016, 2016–2017, and 2017–2018 influenza seasons at 3 hospitals participating in the US Hospitalized Adult Influenza Vaccine Effectiveness Network (HAIVEN) study was analyzed. Details of disease severity, underlying health status, and vaccination status were obtained through enrollment interviews and medical records. Clinical RVP results were recorded. Research swabs for influenza (CDC PCR) were performed in all patients who did not have a clinical sample. Multivariate regression was used to estimate the associations between RVP and in-hospital complications. Results 397 patients were enrolled; 263 (66%) had a clinical RVP done. 25% of patients with ≥ 1 CDC-defined high-risk condition for influenza complications did not have an RVP. 36 (9%) of patients had a positive RVP for flu (1 H1N1, 28 H3, 1 A no subtype, and 6 B). Mean time from onset of symptoms to RVP was 2.25 ± 2.24 days and mean time from ICU admission to RVP was 0.85 ± 1.27 days. 11 (8%) of patients who had only a research swab were positive for flu (1 A no subtype, others H3). 4 (36%) of these patients received oseltamivir. Use of antivirals was significantly more common in patients who had RVPs (68 vs 1%, p Conclusion One-third of patients admitted to the ICU with ARI during the flu season did not have an RVP, including 25% of patients with ≥ 1 high-risk condition for influenza complications. Influenza was present in 8% of patients who did not undergo clinical testing and 64% of these patients did not receive antivirals. There is room for improvement in ordering of RVPs in ICUs. Disclosures All authors: No reported disclosures.

In view of their role in licensing opioid treatment programs (OTPs), state opioid treatment authorities (SOTAs) are in a unique position to influence how OTPs address their patients' alcohol abuse. Using data from a telephone survey of SOTAs from the District of Columbia and states that have at least one OTP (n = 46), this study examines the extent to which SOTAs address alcohol abuse in their respective state policies and guidelines for OTPs. Findings indicate that 27 states have overall measures on how to address patients' problematic alcohol use, 23 states require or recommend alcohol education to be provided to all patients, and 17 states have stipulations that address specific actions to be taken if patients present at daily dosing under the influence of alcohol. Although SOTAs generally rate alcohol of at least moderate importance in formulating regulations, many of their policies and guidelines do not deal with various alcohol-related services and issues.

Alcohol-related problems are especially common among opioid treatment program (OTP) patients, suggesting that educating OTP patients about alcohol and its harmful effects needs to be a priority in OTPs. Using data collected in interviews with a nationwide U.S. sample of OTP directors ( N = 200) in 25 states, we identified factors that differentiate OTPs that provided this education to all OTP patients from those that did not. Findings indicate that these factors include (1) providing this education in a greater variety of ways, (2) having a larger percent of staff knowledgeable about alcohol–related issues, (3) having a director who views alcohol issues as a high priority, and (4) having a written OTP policy.