Medical community recommendations for a better COVID-19 response

We have lost our chance to contain this pandemic and are now facing an unmitigated medical disaster. This administration’s response has actively undermined our ability to care for patients by perpetuating misinformation and downplaying the looming threat this infection poses to the public. Ensuring health security is the fundamental duty and responsibility of government at all levels, and we implore you to prioritize protecting our people over political and economic considerations.

We see ourselves making decisions in the next weeks and months on who will live, and who will die because we don’t have resources sufficient to care for them. We have heard the stories second- and farther-hand from China and Italy and have no reason to think the United States won’t suffer the same fate. We must flatten the curve of this pandemic to save lives.

Here are our recommendations:

1. Establish and empower, with true autonomy to act on medical decisions, a full-time, multidisciplinary team of public health and medical experts (Infectious Disease, Emergency Medicine, Fire/paramedic, Critical Care needed) who staff a central nationwide command center to direct a coordinated national response. This must include:

  • A national call center that receives twice-daily or more updates from current or newly-established state-wide transfer call centers. The purpose of these call centers is to have a centralized place where front-line care providers in each state can call to coordinate transfers of patients to areas with higher levels or greater capacity for delivering care.
  • There should be an ethics team writing recommended guidelines for how to allocate resources when they become limited that is made public. First-come, first-serve cannot be the answer. It will need to be utilitarian in nature.
  • A health care information line for front-line care providers with written, recorded, and video updates that are meticulously kept up to date.
  • Expansion of the CDC information for all to find the latest updates — with up to date national recommendations with translational services keeping all information immediately updated when changes are made. This is the information people need to know how to stay safe and where to go as things get worse.

2. Pass a nationwide stimulus package now to support families who will miss work and school. We will need our communities to pool resources and staff childcare centers in schools that aren’t necessarily licensed. People should have ways to collaborate on childcare sharing in their homes where there are no elderly/at-risk individuals. This is an important call to action for the community that will help keep low-income families supported. This will NOT be perfect, and it will be better than if we don’t do anything. Priority needs to be given in school-based care centers to children of essential workers, including health care workers, environmental service workers, essential service providers, and first-responders.

3. Close schools proactively, with the intent to slow the spread (i.e., “flatten the curve”) so as not to overwhelm the health care system. When and how to do this should be determined at the local and state levels. A priority is to keep food, childcare, and shelter options in place for students who depend on them. We must temporarily lift the current restrictions limiting where school-based food programs may distribute food. Recommendation #2 will need to be in place concurrently to allow workers to find options for childcare.

4. Expansive, safely executed, reliable testing is needed immediately. We need to identify emergency replacements for every step of the supply chain for these tests, corroborate their accuracy, and distribute them rapidly and equitably. In the meantime, we need clear allocation plans so we can identify infected individuals to care for them and take steps to decrease risk to others. Mobile, drive through testing must be instituted and preferably self-testing at-home kits (similar to kits in Seattle supported by The Gates Foundation). Testing needs to happen outside of the ER and hospitals as much as possible.

5. Eliminate all evictions and mortgage foreclosures until COVID-19 has been contained.

6. Establish paid leave support for all vulnerable families.

7. Maximize production of masks, mechanical ventilators, hand sanitizer, viral testing swabs, test reagents, etc. to maintain the supply chain in what will be an unprecedented need. Other medical supplies (intravenous fluids, oxygen masks/tubing, supportive medications, including antibiotics and resuscitation medications) will need to have increased production to maintain supplies to treat this infection. We need tactical and massive increased production of all these resources.

8. Waive patient costs for care given in response to the COVID-19 outbreak.

9. Enable virtual medicine to be used in all venues, decreasing face-to-face transmission within care delivery. This would require lifting Medicare restrictions on non-rural virtual medicine visits [addendum: this is already in process].

10. Establish COVID-19 positive and negative shelters for our houseless populations in as many metropolitan regions as possible. Expand housing options through hotels and mobile homes as necessary.

11. Establish clear and data-driven social isolation recommendations. No one should leave their homes in impacted regions except for medical care, essential supplies, essential work services, and compelling other reasons that are clearly defined. Virtual work options should be encouraged for all businesses, whenever possible.

12. Hospitals must be able to test outpatients, inpatients, and emergency room patients commercially, rather than transporting tests and running them centrally. If private labs are being used for COVID-19 testing, they must be required to report the outcomes of all tests to local health authorities and the CDC.

13. A tracking method at the state level for people self quarantined must be instituted for public health surveillance and follow up.

14. We need guidelines for nursing, retirement, and group homes, including optimized social isolation and sanitation processes, separation of COVID-19 positive patients into units, or even separate nursing homes to minimize transmission.

15. Health care workers, including first-responders, are at high risk for infection and death according to China’s experience. We immediately need sufficient and appropriate personal protective attire/equipment and comprehensive testing availability for all at-risk health care workers.

16. Maximize oxygen supplies by stockpiling/making oxygen as rapidly as possible. Hospitals in impacted areas have run out, and this will be a core life-sustaining support. [addendum: we understand getting approval for home oxygen through distributors must also be liberated as this has been limited by billing issues in some areas]

17. Each state should make and maintain a record of all available ventilators with the capability to transport them to the areas with the greatest need. Anesthesia ventilators can be used in the ICUs if the ORs aren’t being used. Firefighter transfer vents may also be used.

18. We should strive to have available hand sanitizer and masks available at the entrance to all open businesses. Priority for these resources must go to medical care delivery.

19. Temporary ventilators of new designs that may be urgently manufactured, preferably with built-in oxygen concentration if possible, will be needed in the near future — we should contract with innovators to create these now.

20. Medical workforce expansion plans need to be created and implemented.

21. State medical boards must work together for emergent and free licensing for medical personal, so medical providers can cross states lines for patient care.

22. Xenophobia is fomenting racist language and behavior against patients and providers. All leaders, at every level, should speak out against it so that it does not lead to violence and compromise.

23. We need to protect our incarcerated populations in all detention facilities, ideally separating COVID-19 positive individuals from negative. Comprehensive infection control will be nearly impossible, and consideration should be given for allowing appropriate detainees/inmates to leave facilities.

24. Enact consumer protections for all necessary goods and services immediately, especially those to deliver health care. All prices for medications, supplies, and insurance costs should be frozen at the prices as of March 13, 2020, or earlier.

Maxine Dexter is a pulmonary and critical care physician. Smitha R. Chadaga is a hospitalist.

Image credit: Shutterstock.com

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