Where are the ventilators?

“We can’t wait until capacity has already been overloaded before requesting extra machines – we have to act now based on the best available data. If we don’t, the surge in COVID-19 patients May result in rationing care and unnecessary deaths.”

By Andrew Iliff, HGHI | March 20, 2020

As hospitals face a growing wave of COVID-19 patients, health professionals are managing a severe shortage of critical medical equipment including swabs, masks, gloves, and other PPE because production and supply chains struggle to keep up with the massive surge in need.

Physicians anticipate an equivalent surge in need for ventilators – machines that help patients whose lungs have been overwhelmed by the disease continue to breathe while they fight the infection. In the absence of effective drugs to treat the coronavirus, ventilators are one of the most critical tools doctors have to care for very sick patients. Other respiratory support options, like BiPAP machines, are inadequate for treating COVID-19, and risk releasing virus particles into the air right there in the hospital where they are being used.

Projections show that existing ventilator capacity — approximately 62,000 units nationally, based on a 2010 study, many of which are already being used by other patients — will soon be maxed out, as current estimates suggest that between 1% and 2% of COVID-19 patients require ventilation. Experts estimate that we may need at least twice as many ventilators over the next three months in a mild scenario, and as much as eight times as many should we not be able to slow down the spread of the disease.

“In order to staff appropriately and take care of sick patients, hospitals and physicians need to understand what ventilators and other measures are available and how quickly they can be deployed,” says Jose Figueroa, MD, MPH, an Assistant Professor of Health Policy and Management at the Harvard T.H. Chan School of Public Health and Affiliated Faculty at the Harvard Global Health Institute.

“Hospitals in cities like Seattle, NYC and Boston urgently need additional capacity and the support of the federal government. We can’t wait until capacity has already been overloaded before requesting extra machines,” Figueroa urges. “We have to act now based on the best available data. If we don’t, the surge in COVID-19 patients may result in rationing care and unnecessary deaths.”

But how can hospitals increase the number of ventilators that are available to treat COVID-19 patients?

HHS has reportedly ordered more, and while the WSJ reports that manufacturers have already exhausted their standing inventory, they have pledged to ramp up production. In addition, companies including GE, Ford, and Tesla have proposed shifting from manufacturing cars to ventilators. This approach raises some concerns: Ventilators are sensitive and complex medical devices, and it is unclear how quickly or successfully car factories can be turned into ventilator factories. Also, the turnaround time on production is typically around 8 weeks, by which time ventilator demand will likely already exceeded supply, and manufacturers may face component and supply chain obstacles due to the global pandemic.

Fortunately, the federal government has stockpiled ventilators in anticipation of just such an emergency – nearly 13,000 according to Anthony Fauci, Director of NIAID. (Alex Azar, Secretary of Health and Human Services, declined to specify the number citing national security concerns). A 2018 study of pandemic preparedness found that this stockpile “could arrive within 24-36 hours of the federal decision to deploy them.”

According to the Center for Health Security, requests involve several steps: hospitals place requests through their incident command system to the local health department and emergency management agency. The approval of the governor is sought before an official request is made to HHS to CDC. Alternatively, in times of emergency, the federal government could proactively allocate ventilators and other resources based on anticipated need.

As of March 20, it is unclear if this capacity is being tapped, possibly due to delays in the requesting process. On Sunday, March 15, Azar said that he had only received “one request for just several ventilators.”

There are other reasons why hospitals may hesitate to order new machines, or even request them from the federal government. Although projections of need are clear, hospital leaders may adopt a “wait and see” approach, only supplementing capacity when the need occurs. High-acuity ventilators cost between $25,000 and $50,000, depending on the model. While new machines will be used in the short- and (likely) medium-term, once the epidemic subsides extra ventilators will likely sit idle.

Also, ventilators are useless without trained personnel to operate them safely and effectively, and many hospitals anticipate their staff being stretched to capacity. However, with many hospitals also canceling elective surgical procedures, anesthesiologists and other specialists should be available to support additional ventilator capacity.

HGHI research assistants Tynan Friend, Luke Testa and Benjamin Jacobson contributed to this story.

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