Surge Strategies Research Articles

Experiences and Lessons Learned From Surging the Governmental Public Health Workforce During the COVID-19 Pandemic.

During the COVID-19 pandemic, the United States relied on the public health workforce to control the spread of COVID-19 while continuing to provide foundational public health services. Facing longstanding staffing shortages, state, tribal, local, and territorial (STLT) public health agencies (PHAs) used various strategies and supports to surge the workforce in response to the pandemic. The study explored (1) the types of strategies and supports STLT PHAs used to surge the public health workforce during the pandemic, (2) assessments of surge strategies and supports, and (3) approaches to using the range of surge strategies available. We conducted 27 semi-structured interviews in 2023 and performed thematic analysis. Interviewees included STLT public health officials, leaders of organizations that directly supported the COVID-19 workforce surge, and public health workforce experts indirectly involved in the workforce surge. To surge the workforce, interviewees relied on partnerships, staffing agencies, the National Guard, the Centers for Disease Control and Prevention Foundation's COVID-19 Corps, the Medical Reserve Corps, and other strategies. Interviewees valued strategies that rapidly engaged staff and volunteers at no cost to their PHA and flexible funding from the federal government to support surge efforts but noted shortcomings in the strategies and supports available. Interviewees described using multiple strategies simultaneously but noted challenges in implementing these strategies due to inadequate planning and insufficient staff and resources. The study underscores the need for STLT PHAs to establish mechanisms to surge the workforce as part of ongoing planning for emergency preparedness. Focus areas include building administrative and hiring capacity within STLT PHAs and sustaining partnerships and contractual agreements that helped fill staffing gaps during the pandemic. To support efforts to build workforce capacity to meet future surge management needs, STLT PHAs should consider creative solutions to attract and retain staff, as well as opportunities to engage students in public health work.

Expanding access to HIV services during the COVID-19 pandemic\u2014Nigeria, 2020

BackgroundTo accelerate progress toward the UNAIDS 90-90-90 targets, US Centers for Disease Control and Prevention Nigeria country office (CDC Nigeria) initiated an Antiretroviral Treatment (ART) Surge in 2019 to identify and link 340,000 people living with HIV/AIDS (PLHIV) to ART. Coronavirus disease 2019 (COVID-19) threatened to interrupt ART Surge progress following the detection of the first case in Nigeria in February 2020. To overcome this disruption, CDC Nigeria designed and implemented adapted ART Surge strategies during February–September 2020.MethodsAdapted ART Surge strategies focused on continuing expansion of HIV services while mitigating COVID-19 transmission. Key strategies included an intensified focus on community-based, rather than facility-based, HIV case-finding; immediate initiation of newly-diagnosed PLHIV on 3-month ART starter packs (first ART dispense of 3 months of ART); expansion of ART distribution through community refill sites; and broadened access to multi-month dispensing (MMD) (3–6 months ART) among PLHIV established in care. State-level weekly data reporting through an Excel-based dashboard and individual PLHIV-level data from the Nigeria National Data Repository facilitated program monitoring.ResultsDuring February–September 2020, the reported number of PLHIV initiating ART per month increased from 11,407 to 25,560, with the proportion found in the community increasing from 59 to 75%. The percentage of newly-identified PLHIV initiating ART with a 3-month ART starter pack increased from 60 to 98%. The percentage of on-time ART refill pick-ups increased from 89 to 100%. The percentage of PLHIV established in care receiving at least 3-month MMD increased from 77 to 93%. Among PLHIV initiating ART, 6-month retention increased from 74 to 92%.ConclusionsA rapid and flexible HIV program response, focused on reducing facility-based interactions while ensuring delivery of lifesaving ART, was critical in overcoming COVID-19-related service disruptions to expand access to HIV services in Nigeria during the first eight months of the pandemic. High retention on ART among PLHIV initiating treatment indicates immediate MMD in this population may be a sustainable practice. HIV program infrastructure can be leveraged and adapted to respond to the COVID-19 pandemic.

Surging critical care capacity for COVID-19: Key now and in the future

The COVID-19 pandemic has shocked health systems worldwide, with visible impacts on intensive care units and emergency departments. The concept of “surge capacity” should be analyzed within this context as this crisis could be seen as an opportunity to improve the knowledge base of intensive care units and emergency departments.We reflected, based on our experience from work at the frontlines, on health service planning and with epidemiological data, about the importance of surging critical care capacity for COVID, now and as lessons for the future. We summarize and relate virus clinical characteristics, epidemiological patterns and critical care surge capacity as important factors to consider for effective health systems response. Some practical aspects are described, but also the role that mathematical models can play to improve intensive care units surge capacity by considering its importance as a predictor of needs according to epidemiological patterns. Also, in the transitional phase, we consider the importance of coexisting COVID-19 and non-covid-19 health care services, and the importance of a new surge capacity for postponed activities. In this new transitional phase, also emergency departments will have to adapt their surge capacity for a rebound effect due to delayed visits from non-COVID-19 health conditions during the pandemic.Health systems and society must remain vigilant for potential resurgence of cases as measures are relaxed to restart the economy and a new normal. Emergency departments and intensive care units have to develop surge strategies to deal together with COVID-19 and non-COVID-19 flow of patients.

A spiking neural program for sensorimotor control during foraging in flying insects

Foraging is a vital behavioral task for living organisms. Behavioral strategies and abstract mathematical models thereof have been described in detail for various species. To explore the link between underlying neural circuits and computational principles, we present how a biologically detailed neural circuit model of the insect mushroom body implements sensory processing, learning, and motor control. We focus on cast and surge strategies employed by flying insects when foraging within turbulent odor plumes. Using a spike-based plasticity rule, the model rapidly learns to associate individual olfactory sensory cues paired with food in a classical conditioning paradigm. We show that, without retraining, the system dynamically recalls memories to detect relevant cues in complex sensory scenes. Accumulation of this sensory evidence on short time scales generates cast-and-surge motor commands. Our generic systems approach predicts that population sparseness facilitates learning, while temporal sparseness is required for dynamic memory recall and precise behavioral control. Our work successfully combines biological computational principles with spike-based machine learning. It shows how knowledge transfer from static to arbitrary complex dynamic conditions can be achieved by foraging insects and may serve as inspiration for agent-based machine learning.

Personal Protective Equipment: Challenges and Strategies to Combat COVID-19 in India: A Narrative Review

The current outbreak of the coronavirus disease (COVID-19) has become a pandemic. All COVID-19-affected countries in the world are implementing containment interventions and trying their best to fight against the disease to halt the further spread of the infection and to reduce mortality. The public health workforce and healthcare staff in clinical settings are playing a crucial role in the early detection of cases, contact tracing and treatment of patients. The availability of personal protective equipment (PPE) and their consistent, proper use by healthcare providers and public health professionals is a crucial factor in combating any infectious disease in a crisis. The requirement of PPE has exponentially increased, as more and more countries are experiencing the COVID-19 pandemic. The rapid spread of the pandemic has created a temporary shortage of PPE in many countries, including India. The lack of PPE has affected the morale of healthcare workers (HCWs) and other frontline warriors in fighting the coronavirus disease, as more than 22,000 health workers in 56 countries have suffered from COVID-19. Some of them have succumbed to it across all countries, including India (WHO). We have reviewed the available literature to understand the challenges in ensuring adequate availability and consistent use of PPE and the strategies for the rational use of PPE in India. Our study reveals that India has responded swiftly to enhance the accessibility of PPE and put in place strategies for the judicious use of PPE to reduce the incidence of the COVID-19 infection to a bare minimum in healthcare settings. In the present article, we report the current status of COVID-19 among HCWs. We have reviewed the challenges and the surge strategies adopted by India to produce or procure good-quality PPE and supply it to all service delivery points in adequate quantities.

Accountability to Population Health in the COVID-19 Pandemic: Designing Health Care Delivery Within a Social Responsibility Framework.

Accountability to Population Health in the COVID-19 Pandemic: Designing Health Care Delivery Within a Social Responsibility Framework.

Triage: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Pandemics and disasters can result in large numbers of critically ill or injured patients who may overwhelm available resources despite implementing surge-response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. The Triage topic panel reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel. The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This article provides 11 suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage. Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.

Absorbing Citywide Patient Surge During Hurricane Sandy: A Case Study in Accommodating Multiple Hospital Evacuations

Hospital evacuations have myriad effects on all elements of the health care system. We seek to (1) examine the effect of patient surge on hospitals that received patients from evacuating hospitals in New York City during Hurricane Sandy; (2) describe operational challenges those hospitals faced pre- and poststorm; and (3) examine the coordination efforts to distribute patients to receiving hospitals. We used a qualitative, interview-based method to identify medical surge strategies used at hospitals receiving patients from evacuated health care facilities during and after Hurricane Sandy. We identified 4 hospital systems that received the majority of evacuated patients and those departments most involved in managing patient surge. We invited key staff at those hospitals to participate in on-site group interviews. We interviewed 71 key individuals. Although all hospitals had emergency preparedness plans in place before Hurricane Sandy, we identified gaps. Insights gleaned included improvement opportunities in these areas: prolonged increased patient volume, an increase in the number of methadone and dialysis patients, ability to absorb displaced staff, the challenges associated with nursing homes that have evacuated and shelters that have already reached capacity, and reimbursements for transferred patients. Our qualitative, event-based research identified key opportunities to improve disaster preparedness. The specific opportunities and this structured postevent approach can serve to guide future disaster planning and analyses.

A Separate Peace: Explaining War, Crime, Violence, and Security During and After the Surge in Iraq

In response to the 2006 peak in violence following the U.S. invasion and occupation of Iraq, American politicians debated whether to Surge additional troops or partition the nation into sectarian enclaves. There is little social scientific work that locates the Iraq conflict and the results of these debates in relation to broader theoretical frameworks or nationally representative data that can illuminate how Iraqis experienced the violence that swept through their communities. The Surge and partition strategies drew from an ethnic war theory that postulated deeply entrenched and unchanging sectarian divisions, while we propose that an endogenous conflict theory better explains how the troop Surge that was ultimately implemented helped consolidate and perpetuate an unequal and unstable “separate peace” that preceded a renewal of violence. We analyze multi-level, nationally representative survey data collected in Iraq from the peak in violence in 2007 through the transitory peace of 2009. Sunni communities reported more unnecessary attacks on civilians by U.S./Coalition troops during the Surge, while Shia communities reported lower levels of war violence and higher levels of perceived security. In striking contrast with ethnic war theory expectations, the few Sunni living in predominately Shia communities in 2008-2009 perceived greater security than the far more numerous Sunni living in predominately Sunni communities. Iraqi Prime Minister Maliki gained support through 2009 from the few Sunni as well as growing numbers of Shia living in the increasing number of predominately Shia communities. It was the Shia who gained the most and felt most secure during and after the Surge of U.S. forces, while the Sunni who lived overwhelmingly in predominately Sunni communities benefited less and felt less secure. This unequal and unstable “separate peace” was the context in which violence returned to Iraq in 2013.

Going Viral

The objective of this study was to assess hospital and emergency department (ED) pediatric surge strategies utilized during the 2009 H1N1 influenza pandemic as well as compliance with national guidelines. Electronic survey was sent to a convenience sample of emergency physicians and nurses from US EDs with a pediatric volume of more than 10,000 annually. Survey questions assessed the participant's hospital baseline pandemic and surge preparedness, as well as strategies for ED surge and compliance with Centers for Disease Control and Prevention (CDC) guidelines for health care personal protection, patient testing, and treatment. The response rate was 54% (53/99). Preexisting pandemic influenza plans were absent in 44% of hospitals; however, 91% developed an influenza plan as a result of the pandemic. Twenty-four percent reported having a preexisting ED pandemic staffing model, and 36% had a preexisting alternate care site plan. Creation and/or modifications of existing plans for ED pandemic staffing (82%) and alternate care site plan (68%) were reported. Seventy-nine percent of institutions initially followed CDC guidelines for personal protection (use of N95 masks), of which 82% later revised their practices. Complete compliance with CDC guidelines was 60% for patient testing and 68% for patient treatment. Before the H1N1 pandemic, greater than 40% of the hospitals in our study did not have an influenza pandemic preparedness plan. Many had to modify their existing plans during the surge. Not all institutions fully complied with CDC guidelines. Data from this multicenter survey should assist clinical leaders to create more robust surge plans for children.

Compressor Instability: Stall, Surge and their Control

Every compressor has a stall line. In the vicinity of the stall line, the flow field is inherently unsteady due to the interactions between adjacent rows of blades, formation of small stall cells, flow separation and the viscous effects including shock-boundary layer interactions. These factors may aggravate to a state of local breakdown of flow or a total breakdown of flow or with a disastrous flow reversal. This paper starts with an overview on the previous researches about compressor stall and surge. Subsequently, it describes the effects of these instabilities in overall engine performance and design with/ without any control. The main objectives of this paper are to review the phenomenon of instability and methodology to suppress the rotating stall and surge by enlarging the stable operating range of compressor with the application of various control systems. This paper surveys research developments in this field and also tries to find an improved solution to increase the engine performance by applying various surge control strategies. Finally, the paper focuses on some recommendations towards a better design of compressor especially for aircraft power plant.

The triage dilemma: opening Pandora's box... ever so slowly

I applaud the eff orts by Michael Christian and colleagues [1] in taking on the diffi cult dilemmas surrounding triage management and training tied to surge capacity and resource allocation within intensive care settings during pandemics. Studies on triage protocols arose primarily from critical care professionals awakened to those respon sibilities during severe acute respiratory syndrome and then re-challenged during the current H1N1 pandemic [2-4]. In reality, intensive care units with their professional staff and high-tech equipment represent a major limiting factor for most communities. Th e most plausible scenario for a viral pathogen of greater severity and lethality is that emergency departments and hospital wards will be deluged with critical care patients, the challenge being how to provide ‘opportunities for survival’ by transferring some semblance of critical care services and expertise to these ‘non-critical care’ settings. Discipline-directed triage management protocols will only be as important as the manner in which these tertiary level algorithms can be integrated into a larger system-wide triage scheme that begins at the primary triage care level and ends with whatever additional resources a regional support system can mobilize. Many ‘uncomfortable but real’ decisions that have not, to date, been operationalized at the local level will be made. Triage management requires an infrastructure, such as health emergency operations centers (HEOCs), where central triage committees, operationalized ethical resources, palliative care guidance, data collection and analysis, and communication capacities provide high-level situational awareness for simultaneously initiating triage and modifying protocols at all health facilities and their individual triage teams [5]. While attempts to provide independent hospital-centric plans are noble, they do not solve what ultimately requires an integrated populationbased system-wide solution [6]. Triage is an imperfect but necessary ‘art and science’ whether based on good clinical judgment or informed by protocols that attempt to direct resources to those most likely to benefi t. Critical care studies opened Pandora’s box. What follows requires much more input from other disciplines and society itself. Although it may fi rst seem like one is trespassing professional boundaries, the investment in integrated preparedness and eff ective surge strategies, including system-wide triage, is crucial to minimize the need for rationing at all levels of care.

Emergency Department Surge Capacity: Recommendations of the Australasian Surge Strategy Working Group

For more than a decade, emergency medicine (EM) organizations have produced guidelines, training, and leadership for disaster management. However, to date there have been limited guidelines for emergency physicians (EPs) needing to provide a rapid response to a surge in demand. The aim of this project was to identify strategies that may guide surge management in the emergency department (ED). A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations and identified underlying assumptions from disaster epidemiology and clinical practice. The group then characterized surge strategies from their corpus of experience; examined them through available relevant published literature; and collated these within domains of space, staff, supplies, and system operations. These recommendations detail 22 potential actions available to an EP working in the context of surge, along with detailed guidance on surge recognition, triage, patient flow through the ED, and clinical goals and practices. The article also identifies areas that merit future research, including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies, and measurement of strategy impacts on throughput, cost, and quality of care.