COVID-19 and surge capacity in U.S. hospitals


Requirements for COVID-19 preparation

To prepare for the increased number of seriously and critically ill patients, individual hospitals and regions must perform a needs assessment. The fundamental disease process of COVID-19 is a contagious viral pneumonia; treatment hinges on four major categories of intervention: spatial isolation (including physical space, beds, partitions, droplet precautions, food, water, and sanitation), oxygenation (including wall and portable oxygen, nasal canulae, and masks), mechanical ventilation (including ventilator machines, tubing, anesthetics, and reliable electrical power) and personnel (including physicians, nurses, technicians, and adequate personal protective equipment).10 In special circumstances and where available, extra corporeal membrane oxygenation may be considered.10 The necessary interventions are summarized in Table 1.

Table 1. Resources needed to care for COVID-19 patients

Emergency, critical care, nursing, and medical leadership should consider what sort of space, personnel, and supplies will be needed to care for a large volume of patients with contagious viral pneumonia at the same time as other hospital patients. Attention should also be given to potential need for morgue expansion. Hospitals must be proactive in procuring supplies and preparing for demands on beds and physical space. Specifically, logistics coordinators should start stockpiling ventilators, oxygen, respiratory equipment, and personal protective equipment. Reallocating supplies from other regions of the hospital such as operating rooms and ambulatory surgery centers may be considered. These resources, particularly ventilators and ventilator supplies, are already in disturbingly limited supply, and they are likely to be single most important limiting factor for survival rates. To prevent regional shortages, stockpiling efforts should ideally be aided by state and federal governments. The production and acquisition of ventilators should be immediately and significantly increased.

Hospitals must additionally prepare for demands for physical space and beds. Techniques to maximize space and bed availability (see Table 2) include discharging patients who do not require hospitalization, and canceling elective procedures and admissions. Additional methods would be to utilize unconventional preexisting spaces such as hallways, operating rooms, recovery rooms, hallways, closed hospital wards, basements, lobbies, cafeterias, and parking lots. Administrators should also consider establishing field hospitals or field wards, such as tents in open spaces and nearby roads. Medical care performed in unconventional environments will need to account for electricity, temperature control, oxygen delivery, and sanitation.

Table 2. Techniques to increase hospital bed availability


To minimize unnecessary loss of life and suffering, hospitals must expand their surge capacities in preparation for the predictable rise in demand for health care resources related to COVID-19. Numerous hospitals, particularly those that serve low-income and underserved communities, operate with a narrow financial margin.11 Independently preparing for the surge capacity needed to face COVID-19 may be infeasible for several hospitals. As a result, many health care systems will rely on government aid during this period for financial and material support. To maximize preparedness and response, hospitals should ask for and receive aid from the Federal Emergency Management Agency (FEMA), American Red Cross, state governments, and the military; these resources should be mobilized now.

Dr. Blumenberg, Dr. Noble, and Dr. Hendrickson are based in the department of emergency medicine & toxicology, Oregon Health and Science University, Portland.


1. Coronavirus disease 2019 (COVID-19) situation report – 60. 2020 Mar 19.

2. Coronavirus disease 2019 (COVID-19) Cases in the U.S. CDC. 2020 Apr 8.

3. Li Q et al. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020 Jan. doi: 10.1056/NEJMoa2001316.

4. Anderson RM et al. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020 Mar. doi: 10.1016/S0140-6736(20)30567-5.

5. Fraser C et al. Factors that make an infectious disease outbreak controllable. Proc Natl Acad Sci U S A. 2004;101(16):6146-51. doi: 10.1073/pnas.0307506101.

6. Mackenzie J and Balmer C. Italy locks down millions as its coronavirus deaths jump. Reuters. 2020 Mar 9.

7. Health care system surge capacity recognition, preparedness, and response. Ann Emerg Med. 2012;59(3):240-1. doi: 10.1016/j.annemergmed.2011.11.030.

8. Pitts SR et al. A cross-sectional study of emergency department boarding practices in the United States. Acad Emerg Med. 2014;21(5):497-503. doi: 10.1111/acem.12375.

9. Health at a Glance 2019. OECD; 2019. doi: 10.1787/4dd50c09-en.

10. Murthy S et al. Care for critically ill patients with COVID-19. JAMA. 2020 Mar. doi: 10.1001/jama.2020.3633.

11. Ly DP et al. The association between hospital margins, quality of care, and closure or other change in operating status. J Gen Intern Med. 2011;26(11):1291-6. doi: 10.1007/s11606-011-1815-5.


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