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Day to day, hospitals provide all kinds of services to help us get better and stay healthy, but during an outbreak, hospitals are the front line of the emergency. In this episode of Crash Course Outbreak Science, we'll look at how hospitals and other healthcare facilities adapt in the face of an outbreak, from resources needs, the roles of healthcare workers, and costs.

This episode of Crash Course Outbreak Science was produced by Complexly in partnership with Operation Outbreak and the Sabeti Lab at the Broad Institute of MIT and Harvard—with generous support from the Gordon and Betty Moore Foundation.

Sources:
https://apps.who.int/iris/bitstream/handle/10665/151281/9789241548939_eng.pdf?sequence=1
https://link.springer.com/article/10.1186/s12889-019-7707-z
https://militaryhealth.bmj.com/content/166/1/37.full
https://academic.oup.com/heapol/article/35/8/1084/5856261?login=true
https://www.chathamhouse.org/2021/04/trade-policy-and-medical-supplies-during-covid-19/case-study-1-medical-goods-shortages
https://www.cdc.gov/vhf/ebola/treatment/index.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5234495/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4702360/
https://apps.who.int/iris/bitstream/handle/10665/332441/Policy-brief%2036-1997-8073-eng.pdf
https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-4012-y
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5234495/
https://gh.bmj.com/content/bmjgh/5/9/e003317.full.pdf
https://pubmed.ncbi.nlm.nih.gov/32914175/
https://www.who.int/whr/2003/en/Chapter7.pdf
https://www.kff.org/coronavirus-covid-19/issue-brief/community-health-centers-role-in-delivering-care-to-the-nations-underserved-populations-during-the-coronavirus-pandemic/

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We can think of every hospital as really two hospitals.

It might sound strange…. But in a way, it’s true!

In ordinary times, hospitals treat patients, conduct surgeries, provide therapies and perform other roles to help us get better and stay healthy. But when outbreaks happen, hospitals become the front line of an emergency. On top of their usual roles, the wave of new infections changes the resources they need, the way they provide care and the kinds of jobs people do there.

By considering what changes are needed during outbreaks and how to plan for them, we can come up with strategies that make hospitals more resilient against shocks like these. So in this episode, we’re going to explore how hospitals and other healthcare facilities can adapt to the challenges that arise during an outbreak, and the decisions that need to be made to get there. I’m Pardis Sabeti, and this is Crash Course Outbreak Science! [Theme Music].

Hospitals have two main goals: treating people who are unwell, and stopping others from becoming unwell. The same is true of other facilities like individual clinics, community health centers, nursing homes and pharmacies, which make up the healthcare system. We’ll be talking mostly about hospitals this episode, but keep in mind that lots of what we’ll say applies to other kinds of facilities too, and that the healthcare system is made up of all of them.

Whether there’s an outbreak or not, healthcare facilities need well organized resources and healthcare workers to perform their roles. As an example, consider clinical diagnostics from our last episode. To test blood samples, a hospital laboratory would need chemical reactants to conduct tests, skilled technicians who can operate equipment like centrifuges, and logistics operations to get blood samples from the clinic to the lab and return the test results back to the right patients.

And to get and maintain workers and resources, healthcare facilities need to be able to cover their respective costs. Broadly speaking, the ability of well-managed resources and healthcare workers to treat as many patients as possible is called a healthcare facility’s capacity. During an outbreak we want the healthcare system to have enough capacity to keep performing or adapt its usual role in providing care and also meeting the new, added care needs caused by the outbreak.

When it does we consider it resilient. From surgery to sanitization, allocating beds to community outreach, there is a lot to consider about the running of a hospital, and more than we could cover here! But by broadly considering what happens to resources and workers during an outbreak, we have a starting point to branch out and find strategies that can help improve resilience.

We’ll start with a closer look at why we need additional resources during an outbreak. By definition, outbreaks involve many more people than usual being infected by a disease. Some of those people will become sick enough to need medical attention which means more patients who need helping.

What’s more, with so many potentially infected people coming into the hospital, it’s a top priority to prevent staff, and other patients from being infected. Finally, we need to organise our supplies and the information we’ve gathered to make effective decisions and coordinate with others. So, we should see what resources a hospital might need to overcome these obstacles.

Let’s go to the Thought Bubble. During an outbreak, it’s likely that extra patients will create a need for more hospital beds. Hospitals would also need more supplies for treatments, depending on the infectious disease responsible.

For an outbreak of a respiratory disease, like Legionnaires’ disease, we’d need a bigger supply of ventilators to support patients whose breathing is struggling, while for an ebola outbreak, we’d need rehydration salts and blood pressure medication to treat severely ill patients. Meanwhile, pathogens from infected patients might spread through the air, on surfaces, from bodily fluids or direct contact with others. Cleaning supplies like disinfectants can help keep the hospital's environment free of pathogens.

It’s also where personal protective equipment or PPE, comes in. PPE is the equipment used by healthcare workers to minimize the risk of being infected by pathogens. It consists of things you wear like gloves, face shields, gowns and masks, and also supplies like hand sanitizer.

By supplying staff with enough PPE, hospitals can limit the spread of disease to others and keep their staff healthy. Finally there’s information and communications technology or ICT, like computers and phones. ICT can help manage data during an outbreak, tracking the stocks of other supplies we mentioned.

Importantly, we can also record information about our patients like when they arrived, what symptoms they had, what medicines they were given and their condition over time. As we saw in our first episode, if we don’t know exactly what disease might be driving an outbreak in its early stages, this kind of data can help us find out, provided we can share it with others. Which brings us to communication.

Remember, the healthcare system consists of lots of different facilities. So communication networks help them share resources like patient records and test data to measure how the outbreak is evolving and even exchange physical resources like medicine or staff. Thanks, Thought Bubble!

We’ll look at how different groups come together to lead a response to outbreaks in future episodes. But all in all, it’s clear that there are lots of resources that help increase a hospital’s capacity during an outbreak. Similarly, other kinds of healthcare facilities will have their resource needs changed too.

Community health centers and pharmacies, for example, might need to set up physical barriers like plastic screens at the point where patients pick up their medicines from staff, to block pathogens that spread through droplets in the air. That protects both the patients and staff. Healthcare facilities use different strategies to make sure they have resources like these or are able to get them quickly.

One way is to stockpile them. In some cases, extra supplies like medicines and PPE can be stored safely and replaced from time to time based on their shelf life. But that could also require increasing the hospital’s storage capacity, like refrigerators for medicines like antibiotics, or physical space for accommodating more hospital beds in a crisis.

Another way to get resources to hospitals is to anticipate what resources hospitals may need and ensure we have an effective supply chain to get them the moment an outbreak hits. That involves establishing relationships with distributors beforehand and making sure arrangements are in place to deliver extra resources if needed. Of course, even with the supplies they need, hospitals require people to actually use them effectively.

Healthcare workers are at the heart of delivering care at a hospital, from janitorial staff, nurses, and lab technicians, to surgeons, community counselors, doctors and many more. Much like physical resources, an outbreak requires a larger workforce to provide the capacity for treatments, testing, and the operations of the hospital. One way to get more staff is to hire more doctors and nurses!

Alternatively, if an outbreak is localized to one area, staff can be brought in from less affected hospitals to temporarily increase their capacity. Hospitals can ask retired healthcare workers to come back for a time, and request or even train volunteers from the community to undertake certain roles, like vaccinating patients. As well as bringing in more staff, we can also request more of their time.

That means asking them to work longer hours, changing contracts from part-time to full-time and re-arranging work schedules to try and increase capacity. But people aren’t machines! When asking healthcare workers to work longer and under extreme circumstances, it’s vital to ensure they’re properly supported and motivated.

Without that, workers might not be able to maintain high quality of care or burn out, and a hospital can quickly lose capacity! For example, in 2014, during early stages of an Ebola outbreak in Liberia, the recommended infection prevention and control strategies for healthcare facilities weren’t made clear at the national level. Without a clear plan or consistent information, it was difficult to control the outbreak, and some healthcare workers became infected.

As stories of such cases spread, naturally, many staff were afraid to return to work, for fear of catching the disease. With fewer healthcare workers willing to work under such conditions, healthcare capacity was reduced, making it harder to tackle the outbreak. Finally, there’s the consideration of how each worker’s time is spent.

Hospitals almost always triage patients as they come in, deciding which cases need to be addressed first based on how severe the patient’s case is. This process is especially important during an outbreak, since a significant amount of a hospital’s workforce capacity will need to focus on infected patients. For example, appointments for minor medical issues could be rescheduled, so that doctors can focus on attending to potential cases of the infectious disease.

When hospitals are near their individual capacity, community healthcare centers can take on some of these cases, preserving the collective capacity of the healthcare system. They can also help reduce the overall caseload through preventative measures such as community testing and contact tracing to stop more people from becoming infected. And if we really need the space, we can create makeshift hospitals from existing infrastructure, like hotels and stadiums.

A key part of building resilience in this way is by making decisions about what kinds of care will be prioritised during a serious outbreak before one happens, rather than trying to come up with decisions once an outbreak is already underway. We’ve mentioned that for both physical resources and healthcare workers, response capacity can be increased by simply having, or quickly getting, more of them when an outbreak happens. While that sounds perfectly sensible, in practice all these approaches are limited by their costs and a hospital’s budget.

To navigate the trade-offs and limitations that health systems face, we have to turn to economics. In many countries, like Iceland and Costa Rica, the healthcare systems are mostly public, meaning they’re funded largely by taxes and social contributions. For the most part patients themselves don’t pay for their treatment and nearly anyone in the country can receive treatment from a public healthcare facility.

In other countries, like the US, private healthcare also plays a big role, with patients paying for some of their treatment, usually in the form of medical insurance, which funds the hospital. Most countries have some mixture of private and public healthcare systems. In either case, a hospital can increase its resources and staffing when its funding is steady, reliable and sufficient.

That lets them buy more than they need under ordinary conditions. Another way for facilities to increase capacity is by creating a reserve of money, or securing a loan at short notice in the event of an outbreak. In privately run hospitals, the decision between these options would likely be made by the management and owners, while for public hospitals, financing tends to be determined by local or national governments.

For example, in response to the Covid-19 pandemic,. Lithuania drew on reserves of government money called the National Health Insurance Fund to provide more equipment to hospitals. Both economics and politics play a role in these decisions because there are lots of competing uses for money.

Individual hospitals need to balance their budgets between outbreak preparedness and other routine expenses like drugs and medicines, or expensive, one-off purchases like MRI scanners. Governments use tax spending for all sorts of purposes like building physical infrastructure, social security, and education, which as we’ve seen in previous episodes, can also reduce the likelihood and impacts of outbreaks in the first place. While it might feel like there should be a scientific, objective formula for how much spending we need to shore up the resilience of healthcare systems, in practice, it comes down to considering what we value and whether the extra capacity afforded by that money is as valuable as the other uses we have for it.

For now, we’ll point out that, wherever money can be more readily found, healthcare systems can be more resilient. Unfortunately, as we’ve seen in previous episodes, that means that economic inequalities can often lead to inequalities in terms of who receives care and prevention during an outbreak, whether that’s between rich and poorer countries or even neighborhoods in a single city with better or worse infrastructure. But that doesn’t have to be the case.

Healthcare can be provided on smaller scales, such as community health clinics, or in coordination with other parts of the healthcare system, so that individual communities have their needs met whether there’s an outbreak or not. In future episodes, we’ll see how individual institutions like public health bodies and governments, and community members coordinate in all scales of society to try and ensure that healthcare can be distributed more evenly. Even when healthcare systems are made resilient, there’s still an important question left to answer.

How do we know when an outbreak is happening, and what’s causing it? Join us in the next episode to find out, when we talk about epidemiology! We at Crash Course and our partners Operation Outbreak and the Sabeti Lab at the Broad Institute at MIT and Harvard want to acknowledge the Indigenous people native to the land we live and work on, and their traditional and ongoing relationship with this land.

We encourage you to learn about the history of the place you call home through resources like native-land.ca and by engaging with your local Indigenous and Aboriginal nations through the websites and resources they provide. Thanks for watching this episode of Crash Course Outbreak Science, which was produced by Complexly in partnership with Operation Outbreak and the Sabeti Lab at the Broad Institute of MIT and Harvard— with generous support from the Gordon and Betty Moore Foundation. If you want to help keep Crash Course free for everyone, forever, you can join our community on Patreon.