The COVID-19 pandemic is far from over

COVID-19 continues to devastate communities across the U.S., with 100,000 deaths and climbing. Health care workers have rushed to the frontlines without hesitation to respond to the needs of our patients. Fortunately, due to social distancing and other public health measures, the coronavirus caseload may be plateauing and even decreasing. As a nation, we have largely avoided the overt rationing of care seen in Italy. Despite these successes, the COVID pandemic is far from over. The burden of COVID-19 is forecasted to extend for months; it has become clear that as a nation, we will not experience a rapid descent of the curve. In this context, leading hospitals have an ethical obligation to prepare to do even more.

Patients with severe COVID-19 should be treated at specialized tertiary care centers

Severe COVID-19 infection leads to acute respiratory distress syndrome (ARDS), a complex lung condition that typically mandates transfer to a specialty tertiary care hospital. These are the nation’s leading academic hospitals and are full of the brightest and most skilled physicians, nurses, respiratory therapists, operational staff, supply chains, and environmental services. Under ideal treatment conditions at these centers with optimal supportive care maneuvers such as prone positioning, mortality for the severe form of ARDS can be reduced by over 50 percent.

However, not all patients receive this treatment. Well-documented racial disparities plague ARDS outcomes, and are likely contributing to the terrible racial disparities in COVID-19 mortality between African-Americans and whites in the U.S. Despite heroic efforts, smaller community hospitals, which serve vulnerable populations with a fraction of the resources, are being overwhelmed by COVID-19.

Large tertiary care hospitals should become COVID-19 centers of excellence

We call on larger, tertiary hospitals to take a leadership role in reducing COVID-19 mortality, particularly among low-resource communities and marginalized populations, by:

1. Collaborating with community hospitals to coordinate transfers of high-acuity patients, without regard to ability to pay, and

2. Coordinating with emergency medical services (EMS) to direct ambulances with severely ill COVID patients directly to their hospital systems.

Tertiary care hospitals are also the principal sites receiving allocations of remdesivir and investigating other promising experimental therapies and are best positioned to deliver effective medications to as many COVID-19 patients as possible. During this pandemic crisis, there is an ethical obligation to perform the greatest good for the greatest number, which means utilizing tertiary care hospital capacity for those who stand to benefit the most from specialty care.

COVID-19 care should be prioritized over elective procedures

We recognize that lost revenue from COVID-19 has put hospitals across the country under significant financial strain, and tertiary care centers are not immune to this pressure. The deferred “elective” surgeries and procedures are often both medically necessary and time-sensitive, and often can only be performed at the nation’s leading hospitals. The pressure to “get back to business as normal” is immense. Yet, it is important to remember that academic hospitals pay no taxes in exchange for providing substantial community benefits. In this century, there has been no greater time when high-risk communities could benefit from our sustained medical support.

A moral choice confronts the nation’s leading hospitals

The moral stakes could not be higher. If tertiary care hospitals do not shoulder the burden that community hospitals caring for the poor and uninsured cannot, they might have better balance sheets, but they will save fewer lives and further compound the unacceptable racial disparities in COVID-19 already seen in New York, Chicago, and Louisiana. The white and well-insured will still have access to the best hospitals, while underinsured minority patients will be forced into overwhelmed hospitals unable to provide state of the art care.

We cannot afford to lose lives to the pandemic because of a rush to return to the pre-COVID status quo. With coordinated action and leadership from tertiary hospitals, we can save lives and our moral compass.

William F. Parker is a pulmonary physician. Monica E. Peek is an internal medicine physician. Brian H. Williams is a surgeon.

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