April 2, 2020 Advisory Board's take: Amid a pandemic, don’t panic: follow these steps before splitting ventilators

Federal health officials in an open letter to U.S. health care workers on Tuesday said hospitals may split one ventilator between two COVID-19 patients to keep up with demand for the life-saving technology—though the practice should be used only "as an absolute last resort," the letter said.

Background

While companies like Ford and General Electric are ramping up production to the tune of 50,000 ventilators in the next 100 days, experts say the production timeline lags current projections for COVID-19's peak. Even if there is a surge of ventilators ready for purchase, the United States lacks a centralized allocator of critical supplies, forcing hospitals and state and federal governments to compete for available ventilators.  

New guidelines recommends ventilator splitting as 'last resort'

In response to the situation, Surgeon General Jerome Adams and Assistant Secretary for Health Brett Giroir in the letter released Tuesday said that, in "order to meet the growing demand" of mechanical ventilators, hospitals will have to optimize their use by canceling elective surgeries, using equipment from regions that are not experiencing outbreaks, and transitioning anesthesia machines and other devices for mechanical support.

In addition to these measures, the guidelines said that providers may turn to a "crisis standard of care strategy": Splitting a single mechanical ventilator between two patients. The patients sharing the ventilator must either not have COVID-19 or both have COVID-19.

The practice of ventilator splitting has been used very rarely and the safety of the practice remains undetermined. In fact last week, some groups representing critical care providers cautioned against the practice, saying "it cannot be done safely with current equipment."

Given the safety concerns, Adams and Giroir said the strategy "should only be considered as an absolute last resort" and only "if a hospital cannot provide clinically proven, reliable, and safe methods to manage acute respiratory failure."

The officials in the guidelines said the decision to split ventilators "must be made on an individual institution, care-provider, and patient level."

The officials noted that several institutions are currently developing and testing protocols for the practice and evaluating its use in hospitals that are currently overwhelmed with COVID-19 patients. Moreover, some hospitals have "preliminarily implemented" the practice, the officials wrote. At least one hospital in New York, for instance, has already started splitting ventilators between patients, Politico reports. In addition, some hospitals in Italy tried the strategy when they were overrun with COVID-19 patients (Weixel, The Hill, 3/31; Roubein, Politico, 3/31; Reuters/New York Times, 3/30; HHS letter, 3/31).

Advisory Board's take

Amid a pandemic, don’t panic: follow these steps before splitting ventilators

Colleen Keenan, Consultant and Ari Prescott, Senior Analyst

Prevailing wisdom tells us that if you’re disaster planning during a disaster, you’re probably too late. The Trump administration’s recent announcement that hospitals can split a single ventilator as "an absolute last resort" sounds like it’s too late.

The practice is rarely used and stems largely from scant scientific evidence, including a study conducted on four adult sheep. That's why it's important to stress that despite the greenlight from the federal government, ventilator-splitting must remain a hospital’s last resort.

Before hospitals get to that option, there's two things providers can do to procure ventilators.

First, contact alternative ventilator manufacturers. Calling ventilator manufacturers is not new advice, but consider the smaller players who produce different types of ventilators. University of Chicago Medical Center, Johns Hopkins Medicine, Massachusetts General Hospital, and the Veterans Administration have all placed orders for Sea-Long Medical Systems’ helmet-like, noninvasive ventilator. The device is FDA-approved and costs $162.

Hillrom is another company that’s increasing access to noninvasive ventilator options by quintupling production of their Life2000 noninvasive, portable ventilator. The device can be used across acute care settings for patients with mild to moderate respiratory needs, which can free up invasive ventilators for those most in need. The Life2000 is FDA-approved and manufactured in the United States.

Hospitals should also stay abreast of ventilator models in development. In Maryland, engineers are creating ventilator prototypes using FDA-approved breast pumps. The prototypes cost about $500 to build but still require biomedical testing and clinical review. While the device is not on the market, hospitals should cast a wide net to understand what is being developed in their own communities.

Second, partner with other hospitals to advocate not for yourself—but for the community. When local hospitals compete for ventilators, some will benefit at the expense of others. Hospitals will be better off banding together and sharing inventory data to care for community members.

Federal guidance to split ventilators is intended to be a hospital’s last resort. To avoid such dire straits, make sure that you’re thinking outside the box to look for alternative sources of ventilators and breaking down barriers to serve the community.

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