HHS Inspector General Report Covid 19 Oei-06!20!00300

U.S.
Department of Health and Human Services
Office of Inspector General
Hospital Experiences Responding

to the COVID-19 Pandemic:
Results of a National Pulse
Survey March 23–27, 2020
Christi A. Grimm
Principal Deputy Inspector General
April 2020, OEI-06-20-00300
1
Hospital Experiences Responding to the COVID-19
Pandemic: Results of a National Pulse Survey
March 23–27, 2020
Purpose of the Review
This review provides the Department of Health and Human Services (HHS) and other decision-makers (e.g., State
and local officials and other Federal agencies) with a national snapshot of hospitals’ challenges and needs in
responding to the coronavirus 2019 (COVID-19) pandemic. This is not a review of HHS response to the
COVID-19 pandemic. We have collected this information as an aid for HHS as it continues to lead efforts to
address the public health emergency and support hospitals and other first responders. In addition, hospitals
may find the information about each other’s strategies useful in their efforts to mitigate the challenges they are
facing.
The hospital input that we describe reflects their experiences and perspectives at a point in time—March 23–27,
2020. The pandemic is fast-moving, as are the efforts to address it. We recognize that HHS, Congress, and other
government entities across the Federal, State, local, and Tribal levels are taking substantial actions on a continual
basis to support hospitals in responding to COVID-19. HHS has already taken and continues to take actions
related to each of the challenges that hospitals identified in our survey, and the Coronavirus Aid, Relief, and
Economic Security (CARES) Act provides the basis for additional actions. We present this information for HHS’s
and other decision-makers’ consideration as they continue to respond to the COVID-19 pandemic.
Key Takeaway
Hospitals reported that their most significant challenges centered on testing and caring for patients with known
or suspected COVID-19 and keeping staff safe. Hospitals also reported substantial challenges maintaining or
expanding their facilities’ capacity to treat patients with COVID-19. Hospitals described specific challenges,
mitigation strategies, and needs for assistance related to personal protective equipment (PPE), testing, staffing,
supplies and durable equipment; maintaining or expanding facility capacity; and financial concerns.
How OIG Did This Review

This information is based on brief telephone interviews (“pulse surveys”) conducted March 23–27, 2020, with
hospital administrators from 323 hospitals across 46 States, the District of Columbia, and Puerto Rico, that were
part of our random sample. Our rate of contact was 85 percent. Interviews focused on three key questions:
1. What are your most difficult challenges in responding to COVID-19?

2. What strategies is your hospital using to address or mitigate these challenges?
3. How could government best support hospitals responding to COVID-19?
Respondent hospitals included Special Pathogen Centers, critical access hospitals, and a range of hospitals
nation-wide of various sizes and characteristics. At the time of our surveys, most hospitals reported they were
treating patients with confirmed or suspected COVID-19, but some were not currently treating any patients with
confirmed or suspected COVID-19. (See Methodology on pages 18–20 for additional information.)
Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp

Findings at a Glance: Hospital Challenges
Severe Shortages of Testing Supplies and Extended Waits for Results
Hospitals reported that severe shortages of testing supplies and extended waits for test results limited
hospitals’ ability to monitor the health of patients and staff. Hospitals reported that they were unable
to keep up with COVID-19 testing demands because they lacked complete kits and/or the individual
components and supplies needed to complete tests. Additionally, hospitals reported frequently
waiting 7 days or longer for test results. When patient stays were extended while awaiting test results,
this strained bed availability, personal protective equipment (PPE) supplies, and staffing.
Widespread Shortages of PPE

Hospitals reported that widespread shortages of PPE put staff and patients at risk. Hospitals reported
that heavier use of PPE than normal was contributing to the shortage and that the lack of a robust
supply chain was delaying or preventing them from restocking PPE needed to protect staff. Hospitals
also expressed uncertainty about availability of PPE from Federal and State sources and noted sharp
increases in prices for PPE from some vendors.
Difficulty Maintaining Adequate Staffing and Supporting Staff

Hospitals reported that they were not always able to maintain adequate staffing levels or offer staff
adequate support. Hospitals reported a shortage of specialized providers needed to meet the
anticipated patient surge and raised concerns that staff exposure to the virus may exacerbate staffing
shortages and overwork. Hospital administrators also expressed concern that fear and uncertainty
were taking an emotional toll on staff, both professionally and personally.
Difficulty Maintaining and Expanding Hospital Capacity to Treat Patients

Capacity concerns emerged as hospitals anticipated being overwhelmed if they experienced a surge of
patients, who may require special beds and rooms to treat and contain infection. Many hospitals
reported that post-acute-care facilities were requiring negative COVID-19 tests before accepting
patients discharged from hospitals, meaning that some patients who no longer required acute care
were taking up valuable bed space while waiting to be discharged.
Shortages of Critical Supplies, Materials, and Logistic Support

Hospitals reported that shortages of critical supplies, materials, and logistic support that accompany
more beds affected hospitals’ ability to care for patients. Hospitals reported needing items that
support a patient room, such as intravenous therapy (IV) poles, medical gas, linens, toilet paper, and
food. Others reported shortages of no-touch infrared thermometers, disinfectants, and cleaning
supplies. Isolated and smaller hospitals faced special challenges maintaining the supplies they needed
and restocking quickly when they ran out of supplies.

Findings at a Glance: Hospital Challenges (continued)
Anticipated Shortages of Ventilators
Anticipated shortages of ventilators were identified as a big challenge for hospitals. Hospitals
reported an uncertain supply of standard, full-feature ventilators and in some cases used alternatives
to support patients, including adapting anesthesia machines and using single-use emergency
transport ventilators. Hospitals anticipated that ventilator shortages would pose difficult decisions
about ethical allocation and liability, although at the time of our survey no hospital reported limiting
ventilator use.
Increased Costs and Decreased Revenue

Hospitals described increasing costs and decreasing revenues as a threat to their financial viability.
Hospitals reported that ceasing elective procedures and other services decreased revenues at the
same time that their costs have increased as they prepare for a potential surge of patients. Many
hospitals reported that their cash reserves were quickly depleting, which could disrupt ongoing
hospital operations.
Changing and Sometimes Inconsistent Guidance

Hospitals reported that changing and sometimes inconsistent guidance from Federal, State, and local
authorities posed challenges and confused hospitals and the public. Hospitals reported that it was
sometimes difficult to remain current with Centers for Disease Control and Prevention (CDC) guidance
and that they received conflicting guidance from different government and medical authorities,
including criteria for testing, determining which elective procedures to delay, use of PPE, and getting
supplies from the national stockpile. Hospitals also reported concerns that public misinformation has
increased hospital workloads (e.g., patients showing up unnecessarily, hospitals needing to do public
education) at a critical time.

Findings at a Glance: Hospital Strategies
Secure Necessary PPE, Equipment, and Supplies
To secure the necessary PPE, equipment, and supplies, hospitals reported turning to new, sometimes
un-vetted, and non-traditional sources of supplies and medical equipment. To try to make existing
supplies of PPE last, hospitals reported conserving and reusing single-use/disposable PPE, including
using or exploring ultra-violet (UV) sterilization of masks or bypassing some sanitation processes by
having staff place surgical masks over N95 masks. Hospitals also reported turning to
non-medical-grade PPE, such as construction masks or handmade masks and gowns, which they
worried may put staff at risk.
Ensure Adequate Staffing

To ensure adequate staffing to treat patients with COVID-19, hospitals were training medical staff such
as anesthesiologists, hospitalists, and nursing staff to help care for patients on ventilators.
Support Staff
To support staff, some hospitals reported assisting staff to access services such as childcare, laundry,
grocery services, and hotel accommodations to promote separation from elderly family members.
Manage Patient Flow and Hospital Capacity

To manage patient flow and hospital capacity, some hospitals were providing ambulatory care for
patients with less severe symptoms, offering telehealth services when possible, and setting up
alternate facilities such as fairgrounds, vacant college dorms, and closed correctional facilities as
additional spaces for patient care.
Secure Ventilators and Alternative Equipment to Support Patients

In anticipation of increased needs for ventilators, hospitals tried to obtain additional machines by
renting ventilators, buying single-use emergency transport ventilators, or getting ventilators through
an affiliated facility. Some hospitals reported converting other equipment, such as anesthesia
machines, to use as ventilators.

Findings at a Glance: Hospital Requests for Assistance
The hospital input and suggestions in this report reflect a specific point in time—March 23–27, 2020. We
recognize that HHS is also getting input from hospitals and other frontline responders and has already
taken and continues to take actions toward each of these suggestions. For example, on March 28, 2020,
the Centers for Medicare & Medicaid Services (CMS) announced the availability of advanced payments to
hospitals and other providers, and on March 30, 2020, CMS announced an array of regulatory changes to
increase hospitals’ and other health care providers’ flexibility in responding to this pandemic, including
changes to support facility capacity and workforce, among many others.
We present hospitals’ suggestions for ways that the government could assist them for HHS’s and other
decision-makers’ consideration as they continue to respond to COVID-19. We note that authorities for
some of the assistance sought by hospitals may reside with entities outside of HHS (e.g., other Federal
agencies or States).
Testing, Supplies, and Equipment

Many hospitals noted that they were competing with other providers for limited supplies, and that
government intervention and coordination could help reconcile this problem nationally. For example,
hospitals wanted the government to ensure that they have access to test kits and swabs, make tests
faster by allowing more entities to conduct and produce tests, and help hospitals obtain PPE supplies
and other equipment such as ventilators.
Workforce Allocation
Hospitals requested that government allow reassignment of licensed professionals and realignment of
duties as needed, provide flexibility with respect to licensed professionals practicing across State lines,
and provide relief from regulations that may restrict using contracted staff or physicians based on
business relationships.
Capacity of Facilities
Hospitals asked for relaxed rules around bed designations, the ability to establish surge facilities in
non-traditional settings, and expanded flexibilities in telehealth, such as the types of services,
caregivers, and modalities eligible to receive reimbursement.
Financial Assistance
All types of hospitals, and especially small rural hospitals, requested financial assistance, including
faster and increased Medicare payments, and loans and grants.
Communication and Information

Hospitals sought centralized communication and public information, including evidence-based
guidance, reliable data and predictive models, and a central repository for all COVID-19-related
guidance, data, and information.

TABLE OF CONTENTS
FINDINGS 1
Hospitals reported that their most significant challenges centered on testing and caring for 1
patients with COVID-19 and keeping staff safe
Hospitals also reported substantial challenges maintaining and expanding capacity to 5
care for patients
Hospitals reported using a range of strategies to maintain or expand their capacity to care for 9
patients and to keep staff safe
Hospitals reported pressing needs for government assistance to meet COVID-19 challenges 11
CONCLUSION 14
BACKGROUND 15
METHODOLOGY 18
APPENDICES 21
A. Strategies Reported By Hospitals 21
B. Glossary of Key Terms 26
ACKNOWLEDGMENTS AND CONTACT 30
ABOUT THE OFFICE OF INSPECTOR GENERAL 31
ENDNOTES 32
FINDINGS
Hospitals reported that their most significant challenges
centered on testing and caring for patients with COVID-19
and keeping staff safe
Hospitals across the country reported facing similar challenges, regardless of which stage of the process
they were in—treating patients with coronavirus 2019 (COVID-19), testing patients who were potentially
infected, or preparing to treat COVID-19 patients in the near future. The most commonly reported
challenges centered on hospitals’ efforts to confirm cases of COVID-19, to keep health care staff safe,
and to provide needed services to patients requiring hospital care for a wide array of medical reasons,
including COVID-19. Challenges included difficulties related to testing, lack of personal protective
equipment (PPE), and staffing, including specialized staffing.
Hospitals reported that severe shortages of testing supplies and extended

waits for test results limited hospitals’ ability to monitor the health of
patients and staff
Hospitals explained that they were unable to keep up with testing demands because they
lacked complete kits and/or the individual components and supplies needed to complete
tests, such as nasal swabs, viral transfer media, and reagents used to detect the virus.
These shortages left hospitals unable to effectively test staff, patients, and others in the community who
reported that they were concerned about possible exposure. One hospital administrator said that
across the industry, “millions [of tests] are needed, and we only have hundreds." Without access to
needed testing materials, some hospitals described dividing the media in COVID-19 kits in half to
double their capacity and resorting to using the transfer media in flu and strep kits to provide testing.
Hospitals described extended waits for COVID-19 test results. Hospitals reported frequently
waiting 7 days or longer for test results. According to one hospital, 24 hours would typically be
considered a long turnaround time for virus testing. Hospitals’ reliance on external laboratories
contributed to delays, particularly as these laboratories became overwhelmed with tests to process from
around the State or country. Hospitals also reported delays related to infrequent specimen pickups,
mailing delays, and labs’ restrictive business hours. Some hospitals described success getting results
more quickly by using commercial labs, whereas others received more timely results from public
sources. Still others experienced inconsistent turnaround times, leaving them unable to predict when
results would arrive or advise patients on how long they should self-quarantine or undertake other
measures while awaiting results.
Testing challenges exacerbated other challenges, including bed availability, PPE supplies,
and staffing shortages. Hospitals reported that to prevent the spread of the virus in the hospital
and community, they were treating symptomatic patients as presumptive positive cases of
COVID-19 (i.e., an individual with symptoms that strongly indicate COVID-19 and tests have ruled out
Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020
OEI-06-20-00300 1
similar conditions, but without a positive COVID-19 test result). The scarcity of COVID-19 tests and
length of time it took to get test results back meant presumptive positive patients greatly strained bed
availability, PPE supplies, and staffing, as noted in Exhibit 1.
Exhibit 1: Hospitals reported that the lack of testing supplies and delays in receiving test
results caused additional challenges.
Hospitals reported that some presumptive positive patients remained in the hospital for days while
awaiting test results, which reduced the hospitals’ availability of beds for other patients. One hospital
that was holding presumptive positive patients in intensive care unit beds reported that testing with a
quick turnaround would free up bed availability and increase patient and staff safety. An administrator
at another hospital noted that the sooner the hospital knows whether patients are negative, the faster it
can move them to a lower level of care that consumes fewer resources. As one administrator put it,
"sitting with 60 patients with presumed positives in our hospital isn't healthy for anybody."
Hospitals reported that extended patient stays while awaiting COVID-19 test results also depleted PPE
supplies used by staff in treating those patients during those additional days. One hospital reported
that its staff, at the time of our interview, used (on average) 307 masks per day for its 23 patients with
suspected cases of COVID-19. Another hospital administrator said, "The testing turnaround presents a
challenge, especially for our ‘rule-out’ patients…we have to use a lot of PPE on those rule-outs. And
especially when it’s a negative, we basically used all that PPE for nothing."
The inability to quickly identify confirmed cases exacerbated challenges with hospital staffing. In one
hospital, between 20-25 percent of staff were determined to be presumptively positive for COVID-19.
Due to the lack of quick test results, staff who ultimately were not positive were prevented from
providing clinical services for longer than necessary, causing a substantial strain on staffing availability.
Another hospital noted that it wanted to set up a separate testing clinic to keep potentially infectious
patients from exposing staff, but it did not have enough testing kits and/or related components and
supplies to set up such a clinic.
Delays in receiving test results also made it more challenging for hospital staff to provide patients with
the most appropriate care. One hospital reported that these delays put patients at risk because
physicians were unable to make effective treatment decisions without the test results. Another said that
some patients faced unnecessarily long hospital stays because some long-term-care facilities and
nursing homes will not accept patients without a confirmed negative COVID-19 test.
Testing challenges hampered hospitals’ efforts to reduce community spread, protect

staff, and care for patients. Hospitals reported that their inability to test patients quickly was
affecting their efforts to limit the transmission of COVID-19 within the wider community. Given supply
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shortages and uncertainty about future access, hospitals reported prioritizing testing for their
employees and for patients with more severe symptoms. Prioritized testing meant that many hospitals
reported they were currently unable to conduct widespread testing of patients and community
members to help contain the spread of COVID-19.
Hospitals raised concerns that widespread shortages of PPE put staff and
patients at risk
Hospitals across the country reported that a shortage of PPE was threatening their ability to keep staff
safe while they worked to treat patients with COVID-19. The most commonly needed PPE items
reported were masks (including N95 masks, surgical masks, and face shields), followed by gowns and
gloves.
Hospitals reported that heavier than normal use of PPE contributed to shortages. The
administrator of one hospital stated that before COVID-19, the hospital’s medical center used around
200 masks per day and that it was now using 2,000 per day. Delays in test results led to heavier use of
PPE until a patient’s status was confirmed. Another hospital administrator noted the “fear factor”
associated with COVID-19, which led to all staff wearing masks instead of only a subset. One hospital
administrator reported that some supply distributors limited the quantity of supplies that any one
hospital could order, which meant that even with no COVID-19 patients, the hospital was depleting PPE
faster than it could restock. Even among hospitals that reported that they currently had enough PPE,
some noted that a surge in patients would quickly deplete their supplies. One hospital noted that with
its high “burn” rate (i.e., rate of use), its inventory of PPE would last only 3 more days. Another hospital
administrator expressed a common concern: not wanting to put employees in a position that
“endangers their lives and the lives of their families because [they] do not have PPE.”
Hospitals pointed to the lack of a robust supply chain as delaying or preventing them
from restocking the PPE needed to protect staff. Hospitals reported that the supply chain for
medical equipment had been disrupted because of increased demand for PPE from health care
providers and others around the country. As one administrator said, everyone is “trying to pull [PPE]
from the same small bucket.” Another administrator stated that their hospital’s purchaser was reporting
delays of 3-6 months in being able to replenish key supplies, including surgical and N95 masks.
Another hospital made the point that this competition for supply was unusual in that it involved not
only health care providers, but also the public. An administrator at this hospital reported apprehending
a person trying to steal face masks from the hospital lobby.
Hospital administrators expressed uncertainty about availability of PPE from Federal and
State sources. Some hospitals noted that at the time of our interview they had not received supplies
from the Strategic National Stockpile, or that the supplies that they had received were not sufficient in
quantity or quality. One administrator stated that getting supplies from the stockpile was a major
challenge, saying that the supplies the hospital received “won't even last a day. We need gloves, we
need masks with fluid shields on—N95 masks—and we need gowns. It's the number one challenge all
across the system." One health system reported that it received 1,000 masks from the Federal and State
governments, but it had been expecting a larger resupply. Further, 500 of the masks were for children
and therefore unusable for the health system’s adult staff. One hospital reported receiving a shipment
OEI-06-20-00300 3
of 2,300 N95 masks from a State strategic reserve, but the masks were not useable because the elastic
bands had dry-rotted. Another hospital reported that the last two shipments it had received from a
Federal agency contained PPE that expired in 2010. The shipment contained construction masks that
looked different than traditional masks and did not contain a true N95 seal.
Hospitals noted sharp increases in prices for some equipment. Multiple hospitals reported
concerns that prices of equipment, particularly masks, had increased significantly. One administrator
noted that masks that originally cost 50 cents now cost $6 apiece. Other hospitals reported concerns
about vendors buying up supplies and selling them to the hospital at a higher cost. As one hospital
administrator noted, “We are all competing for the same items and there are only so many people on
the other end of the supply chain.” Another administrator reported being concerned about poor
quality products despite high-prices and “…wonder[ing] if you get what you paid for.”
Hospitals reported that they were not always able to maintain adequate
staffing levels or to offer staff adequate support
Many hospitals reported that they did not have enough staff to meet current or anticipated needs for
COVID-19 patients, which put a strain on existing staff. Some hospitals reported that they were already
struggling with staffing limitations prior to COVID-19, which made any additional demand particularly
challenging. One hospital administrator explained that their hospital would have significant staffing
shortages if faced with a surge of COVID-19 patients because the hospital relies heavily on traveling
nurses. Another administrator stated, "Unlike a disaster where the surge is over in a matter of days,
with this situation we have to prepare for this to last many months. We have to scale up in equipment
and staff, and prepare for this to last a long, long time. This is very challenging for staff."
Hospitals reported a shortage of specialized providers needed to meet the anticipated

patient surge. Several hospitals emphasized a particular need for specialized staff, such as infectious
disease providers, respiratory therapists, and physicians and nurses who can provide intensive and
critical care. Many hospitals also stated that they lacked trained staff that can operate ventilators and
treat patients receiving that level of care. One hospital administrator said his hospital has only one
ventilator and only one respiratory therapist, adding that the therapist can't work 24 hours a day
monitoring the ventilator. Another administrator said, “You can build thousands of ventilators, but you
need an army to manage that equipment and care for those patients.”
Hospitals raised concerns that staff exposure to the virus may exacerbate staffing
shortages and overwork. Several hospitals reported that they would struggle to maintain hospital
operations if even a few staff were exposed to the virus. The administrator for one small, rural hospital
explained that if one patient tested positive for COVID-19 the hospital would have to put 16 staff
members in quarantine, which would essentially halt its operations. Administrators in two hospitals
described how staffing levels in their facilities had been significantly impacted after a large number of
staff had contracted or been exposed to the virus.
Hospital administrators expressed concerns that fear and uncertainty were taking an
emotional toll on staff, both professionally and personally. Hospitals reported that fear of
being infected, and uncertainties about the health and well-being of family members, were impacting
OEI-06-20-00300 4
morale and creating anxiety among staff. As one administrator put it, "The level of anxiety among staff
is like nothing I’ve ever seen.“ Another hospital administrator explained that staff were carrying a heavy
burden both professionally and personally. Professionally, staff were worried about the security of their
jobs and the difficult choices they must make regarding their patients, such as who should get one of a
limited number of tests. They also feared contracting the virus. At one hospital, a staff member who
tested positive exposed others on staff, but the hospital did not have enough kits to test those exposed.
Personally, staff were worried about spreading the virus to their family members and ensuring that their
families were cared for, especially with schools and daycare centers being closed. As one administrator
said, “Health care workers feel like they’re at war right now…[they] are seeing people in their 30s, 40s,
50s dying…This takes a large emotional toll.”
Hospitals also reported substantial challenges maintaining

and expanding capacity to care for patients
The other most prominent concerns reported by hospital administrators centered on maintaining
facility operations while receiving and treating patients with known or suspected cases of COVID-19.
These challenges included concerns about bed availability, particularly specialized beds such as
intensive care unit beds, and supplies, as well as maintaining financial solvency given reductions in
routine patient care and elective surgeries.
Hospitals were concerned about their capacity to treat a surge of patients

who may require special beds and rooms to treat and contain infection
Hospitals anticipated being overwhelmed by a surge in COVID-19 patients, who would need specialty
beds and isolation areas for effective treatment. Specifically, hospitals reported concerns about
potential shortages of intensive care unit beds, negative pressure rooms, and isolation units. Hospitals
also reported that, given the limitations to bed availability, it was challenging to sufficiently separate
COVID-19 and non-COVID-19 patients within their facilities. Separating patients is thought to allow
health care workers to better coordinate and direct needed treatment specific to COVID-19 patients as
well as reduce the spread of infection. One hospital administrator observed that: “Being a rural hospital,
we have to be ready to convert beds to prepare for surge capacity. We still have to take care of our
non-COVID situations. We have to make people feel like we can still take care of them if they have [an]
emergent situation."
Hospitals reported being unable to discharge patients to certain post-acute facilities

while awaiting COVID-19 test results. Many hospitals reported that some post-acute facilities,
such as skilled nursing facilities or facilities with lower-level care, were requiring negative
COVID-19 tests before accepting patients discharged from hospitals. As such, patients who no longer
required acute care were taking valuable bed space while waiting to be discharged. One hospital
reported a case in which a post-acute-care facility refused to take a patient unless the hospital sent
them a week’s worth of masks for the patient and for the staff who would care for the patient, even
though the patient was not positive for COVID-19. Delays in receiving test results contributed to delays
in transferring patients to these lower level facilities and in freeing beds in the hospitals for incoming
COVID-19 patients.
OEI-06-20-00300 5
Hospitals reported concerns about securing other critical supplies,
materials, and logistic support
Hospitals reported they do not have a reliable source for the equipment and supplies they use to
support patient care. One hospital reported that, in addition to beds, it needed to source the materials
that accompany additional beds and did not know where to order them. For example, hospitals
described the supplies that support a patient room, such as intravenous therapy poles, medical gas,
linens, and food. Multiple hospitals also cited a shortage of toilet paper. Hospitals discussed the need
for supportive services, such as sanitation services, staffed mobile field hospitals, and mortuary services,
as well as the construction work and maintenance needed to convert rooms.
Hospitals reported shortages of no-touch, infrared thermometers needed for

temperature screening. One hospital reported an inability to implement a policy to screen all
hospital entrants because it did not have enough no-touch thermometers to allow for timely testing
and avoid long lines at entrances. (No-touch thermometers use infrared technology to rapidly provide
accurate temperature results.) This hospital reported it resorted to only screening patients, staff, and
vendors on a random basis. Similarly, another hospital explained that it was unable to monitor
employee temperatures in a timely manner, given it had a 700-plus person staff and had just a few of
the no-touch thermometers that could be devoted to staff testing rather than patient care.
Hospitals faced shortages of disinfectants and cleaning supplies. Hospitals reported

insufficient inventory of essential cleaning supplies, such as disinfectant wipes, hand sanitizer, and hand
soap. One hospital described being unable to buy disinfectant cleaning supplies and not knowing
when supplies will be available. Another hospital described making disinfectants, such as bleach, out of
on-hand chemicals, such as chlorine.
Isolated or smaller hospitals reported that they have a harder time accessing necessary
supplies. Isolated and smaller hospitals reported that they were facing special challenges maintaining
the supplies they need to continue their operations. One hospital noted that its island location made it
difficult to restock quickly when it runs out of supplies. Another hospital reported that it was not able
to request the amounts of disinfectants and other supplies that it needed from the State. Instead,
products were “divvied up” by the State, and because the hospital is small, it received fewer of the
products and supplies than larger hospitals.
Hospitals cited anticipated shortages of ventilators as a potential

challenge
Many hospitals reported concerns that they would not have enough ventilators if faced with a surge of
COVID-19 patients. One administrator explained the difficulty of predicting whether a surge would
come and how many ventilators would be needed, “[We] just don’t know two weeks down the road
what we will need.” Hospitals pointed to overall supply shortages and the unavailability of ventilators in
other facilities, as well as the scarcity of ventilator components such as tubes.
Some hospitals’ concerns about the supply of ventilators were exacerbated by their small
size. Small hospitals reported that they were able to maintain few, if any, ventilators. Some of these
hospitals described contingency plans to repurpose alternative machines from other hospital
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departments or to transport patients to other facilities, if needed. However, one hospital with no
ventilators expressed concern that if a patient needs ventilation, neighboring hospitals may not have
the space to take them. Another hospital noted that larger hospitals may be given priority in receiving
ventilators.
Hospitals also explained that potential ventilator shortages would pose difficult
decisions about ethical allocation and liability. As hospitals planned for a surge of patients,
many reported that they were either developing or revising guidelines regarding ventilator utilization
decisions, although at the time of our survey no hospital reported limiting ventilator use. Some
administrators noted that with difficult decisions about ventilator allocation also come concerns about
liability. For example, one hospital administrator described concerns about the liability embedded in
decisions regarding which patients would receive assistance from a ventilator and which would not,
concluding that: “Government needs to provide guidelines on ethics if health resources are limited and
decisions need to be made about which patients to treat. Are physicians liable for their decisions if that
happens?”
Hospitals described increasing costs and decreasing revenues as a threat

to their financial viability
Hospitals reported that the increased costs and loss of revenue were quickly depleting cash reserves
and could be disruptive to ongoing hospital operations. Hospitals reported having essentially ceased
performing elective procedures and many other services, which many hospitals said accounted for a
substantial portion of their revenue. Meanwhile, hospitals explained that their costs have increased as
they prepare for a potential surge of patients by purchasing extra equipment (such as PPE and
ventilators), remodeling rooms for negative pressure, or setting up drive-through clinics and tents.
One administrator explained that having cash on hand was becoming an urgent issue with the specialty
clinic volume down 80 percent, primary care volume down 50 percent, and cancellation of all elective
surgeries. One administrator said their hospital is in a favorable financial position, but it is concerned it
could be overwhelmed if other hospitals close. Another administrator said their hospital is tracking all
of its costs for treating COVID-19 patients or potential cases, so that it can be reimbursed in the future.
Other hospitals reported laying off staff due to financial difficulties, which further exacerbated
workforce shortages and the hospitals’ ability to care for COVID-19 patients and the routine patient
population. One administrator stated that it had been “an absolute financial nightmare for hospitals.”
Hospitals that were part of a larger health system reported that they considered themselves to be
better situated to absorb financial losses compared to smaller independent and rural hospitals. Being
part of a larger health system enabled hospitals to distribute losses from the hardest hit hospitals to the
other hospitals in the system. Smaller, independent hospitals, such as rural hospitals and critical access
hospitals, reported that they were at greater financial risk than those in larger systems and that they
could face more financial uncertainty. As one hospital administrator observed, “There is no mothership
to save us.”
Hospitals reported circumstances in which insurance reimbursements were not covering

hospitals’ costs for providing services in the midst of the COVID-19 crisis. Hospital
administrators reported that insufficient reimbursement for some services and a lack of flexibility in
OEI-06-20-00300 7
billing rules that affect reimbursement amounts have created financial challenges. For example, some
hospitals were using telehealth to provide services without patients having to come to the hospital, but
reported that reimbursement amounts for telehealth services often do not cover the hospitals’ costs. In
another example, hospitals reported facing resistance from health plans to paying for patients’
additional days in the hospital while the patients were awaiting COVID-19 test results. Negative test
results were needed for the patients to be accepted for admission or re-admission at post-acute-care
facilities and nursing homes.
Further, hospitals reported difficulty in getting reimbursed for treating patients in non-traditional
spaces because there were no qualifying billing codes when treating patients in these locations. For
example, to mitigate COVID-19 spread, one hospital relocated speech, occupational, and physical
therapy services off-site. However, the hospital said it was unable to bill for these services because it
does not own the building housing the relocated services, or meet billing requirements.
Hospitals reported that changing and sometimes inconsistent guidance

from Federal, State, and local authorities posed challenges and confused
hospitals and the public
Hospitals reported that it was sometimes difficult to remain current with CDC guidance
when training staff on PPE and safety precautions. To reduce the spread of COVID-19 and
prepare staff for patient surges, hospitals reported providing training regarding proper use of PPE,
procedures for putting on and taking off PPE, and isolation practices. As new information about the
virus becomes available and circumstances on the ground change, the Centers for Disease Control and
Prevention (CDC) has changed its guidance over time. However, some hospital administrators
expressed that it was challenging to stay up to date with CDC guidance and re-educating staff on
changes to the guidance (e.g., who needs PPE, when to remove it, and when to reuse it). Some
hospitals reported that the multiple changes in guidance contributed to a greater sense of confusion,
fear, and distrust among staff that they could rely on hospital procedures to protect them.
Hospitals reported instances of receiving conflicting guidance from different Federal,

State, and local authorities. Hospitals reported receiving conflicting guidance on criteria for
testing, defining elective procedures to delay, use of PPE, and getting supplies from the national
stockpile. For example, on proper use of PPE, one hospital administrator reported that CDC guidelines
at that time called for use of an N95 mask for all patients suspected of COVID-19 infections, while at the
same time, one State said that using a surgical mask and face shield was sufficient for staff treating
patients with COVID-19. The hospital noted “[The inconsistency] makes everyone nervous. It would
have been better if there was coordination and consistency in guidance among the different levels of
government.” Another administrator said, “It’s difficult when a doctor or nurse shows you legitimate
information from legitimate sources and they’re contradictory.”
Hospitals also reported concerns that misinformation had proliferated among the public,
unnecessarily increasing workload on hospitals at a critical time. Many hospital
administrators reported needing to spend time responding to fear, lack of information, and lack of
understanding in their public communities, which they attributed to an absence of clear, accurate, and
consistent information. These hospitals reported having to dispel misinformation and unrealistic
OEI-06-20-00300 8
expectations among patients about testing and other issues, as well as having to work to educate the
community about proper steps to prevent the spread of COVID-19 and when to seek medical attention
versus self-isolating at home. One hospital administrator reported the challenge of taking on a public
health advocacy role with mayors and county commissioners to advocate implementing social
distancing at beaches, restaurants, and the like to slow the spread of COVID-19, in addition to
performing normal duties. Another hospital administrator reported that employers were telling
employees they cannot return to work without testing negative and that the hospital was having a
difficult time educating employers that only certain people can be tested. One administrator stated:
“The misinformation that is out there, and the lack of serious understanding about what we could be
facing, is extraordinary. It is not helping the situation at all. We need to take this seriously."
Hospitals reported using a range of strategies to maintain or

expand their capacity to care for patients and to keep staff
safe
Hospital strategies often attempted to address multiple challenges. These efforts included broad-scale
ideas that involved multiple providers and suppliers across the country, as well as smaller-scale,
community-based efforts that rose in some cases from hospital leadership and staff, other public health
stakeholders, and the general public. For a more detailed list of operational strategies that hospital
administrators shared, see Appendix A.
Hospital administrators turned to alternative practices and

unconventional sources to secure necessary PPE, equipment, and supplies
for their staff
In an attempt to get needed equipment and supplies, hospital administrators turned to
new, sometimes un-vetted, and non-traditional sources. The lack of PPE caused hospitals to
consider new and un-vetted sources for PPE of whose reputability they were sometimes unsure. One
hospital reported that in working with new vendors, some ordered items did not show up, were expired,
or were different than what was ordered. The administrator also stated that the hospital did not have
the ability to evaluate the quality of the equipment in a meaningful way.
Some facilities stated that they turned to non-traditional sources of medical equipment and supplies to
combat supply chain disruptions. For instance, some hospitals considered sources for PPE that they
would not normally use—such as online retailers, home supply stores, paint stores, autobody supply
shops, and beauty salons.
To try to make existing supplies of PPE last, hospitals reported conserving and reusing
PPE. Hospital administrators discussed implementing or considering new procedures to conserve PPE,
including physically securing PPE to prevent theft or misuse, educating staff on appropriate use and
conservation, and limiting PPE use according to patient condition. Other hospitals reported reducing
the extent and frequency of patient interaction to reduce PPE burn; this included doing as much for a
patient as possible in one interaction, having multiple providers see a patient together, or removing
equipment like intravenous pumps from patients’ rooms so that it could be prepped elsewhere without
OEI-06-20-00300 9
PPE. At one facility, staff tested patients at remote sites to, in part, reduce PPE use. Hospitals indicated
that staff performing testing remotely can remain in PPE all day, whereas staff who test inside hospitals
typically change PPE frequently when moving from suspected COVID-19 patients to other patients.
Another hospital described being in ‘war mode’ and abandoning the typical standard of care by only
using N95 masks for certain higher-risk procedures for COVID-19 patients such as aerosolized
procedures, which can send the virus into the air and put health care workers at risk.
Conservation strategies included reusing PPE, which is typically intended to be single-use. To reuse
PPE, some hospitals reported using or exploring ultra-violet (UV) sterilization. Other hospitals reported
bypassing some sanitation processes by having staff place industry masks over N95 masks so that the
N95 mask could be reused. As one administrator characterized the situation, “We are throwing all of
our PPE best practices out the window. That one will come back and bite us. It will take a long time for
people to get back to doing best practices.”
Hospitals also reported turning to non-medical-grade PPE, which they worry may put
staff at risk. Instead of reusing medical-grade equipment, some hospitals reported resorting to
non-medical-grade PPE such as construction masks or handmade masks and gowns, but were unsure
about the guidelines for how to safely do it. For example, one hospital administrator noted that
recommendations were not clear about whether cloth masks were good enough, stating, “But if that’s
what we have, that’s what we’re going to have to use.” One hospital reported using 3D printing to
manufacturer masks, while another hospital reported that its staff had made 500 face shields out of
office supplies.
Other hospitals reported using community resources to make ends meet, including accepting
homemade cloth gowns from a quilter’s guild, asking volunteers to make masks, and asking for
donations on their website. One hospital administrator described a plan for the local distillery to blend
100 liters of the hospital's ultrasound gel with the distillery’s alcohol to produce CDC-compliant hand
sanitizer.
Hospital strategies also focused on ensuring adequate staffing to treat

patients with COVID-19
Hospital administrators reported using strategies aimed at ensuring they had sufficient staff with the
needed skills to treat COVID-19 patients where most needed. For example, some administrators shared
that their hospitals were training certain medical staff, like anesthesiologists, hospitalists, and nursing
staff, to help care for patients on ventilators. Further, hospitals touted partnerships with large health
care systems as beneficial because they can deploy medical staff, like nurses, to other hospitals in the
health care system that may be experiencing a staff shortage.
Hospitals reported providing resources to help reduce employee burden

as well as anxiety and stress
To ease anxiety and reduce outside burdens on staff that could distract them or prevent them from
working, some facilities reported assisting staff to access services such as childcare, laundry pick up and
drop off, grocery services, and hotel accommodations to promote separation from elderly family
members. Hospitals also reported offering or expanding resources to provide employees with
OEI-06-20-00300 10
emotional and psychological support. One hospital shared that it recruited external mental health
clinicians and engaged its own psychiatry staff to help alleviate anxiety among hospital staff.
Some strategies focus on managing patient flow and hospital capacity to

receive and treat patients
Hospital administrators reported using several strategies to manage patient flow as they respond to
their communities’ needs during the COVID-19 pandemic. Strategies included promoting the use of
ambulatory care for patients with less severe symptoms to help relieve the pressure on emergency
departments, and the use of telehealth services when possible to help protect both patients and staff
through social distancing measures. In addition, to help triage patient flow into the hospitals, hospital
administrators described efforts to educate community members about COVID-19 screening or testing
processes to avoid patients entering the hospital if not advised under guidelines.
To address potential bed and facilities shortages, some hospitals reported converting or creating space
to house a surge of additional patients. This included expanding their intensive care units, repurposing
existing space, using tents, and utilizing other network facilities to separate COVID-19 patients when
possible. One hospital administrator explained their strategy: “I’ve emptied the hospital and I’m waiting
for it to come. Which it may or may not.” Some hospital administrators described plans to make use of
other facilities, such as local fairgrounds, vacant college dorms, and closed correctional facilities as
additional space for patient care in the event of a surge.
With an uncertain supply of standard, full-feature ventilators, hospitals

sought new sources and turned to alternative equipment to support
patients
In anticipation of increased needs for ventilators, hospitals tried to obtain additional machines by
renting ventilators, buying single-use emergency transport ventilators, or getting ventilators through an
affiliated facility. Hospitals also discussed sharing supplies of ventilators between hospitals. Where
these options were not available, some hospitals planned to transfer patients in need of a ventilator to a
nearby hospital.
Some hospitals reported converting other equipment to use as ventilators. For example, adapting
anesthesia machines and bilevel positive airway pressure machines. One hospital reported considering
“doubling up on ventilators – that is, adding another hose to the ventilator so that it can push oxygen
to two patients from a single machine.” Another hospital detailed its staff’s efforts at both converting
anesthesia machines and using them to support more than one patient: “Our staff had figured out that
we could transition some anesthesia machines using t-connectors and viral filters to turn them into
ventilators. You jerry-rig the anesthesia machine by using a t-connector, you can support four patients
off one of these.”
Hospitals reported pressing needs for government assistance

to meet COVID-19 challenges
Faced with the magnitude and diversity of challenges described above, hospital officials identified a
range of government assistance that could support their COVID-19 response. One common theme was
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the need for swift action to respond to the COVID-19 crisis. Broadly, the actions they described fall into
five categories: 1) assistance with testing, supplies, and equipment (e.g., PPE); 2) assistance with
workforce allocation; 3) assistance with capacity of facilities; 4) financial assistance; and
5) communication and public information.
The hospital input and suggestions reflect a specific point in time—March 23–27, 2020. We recognize
that the Department of Health and Human Services (HHS) is also getting input from hospitals and other
frontline responders and has already taken and continues to take action to alleviate many hospital
challenges and implement suggestions. The Coronavirus Aid, Relief, and Economic Security (CARES) Act
was signed into law on March 27, 2020, and provides HHS with additional funding and authorities to
combat and respond to the COVID-19 pandemic, including in ways that address challenges and
suggestions raised by the hospitals we surveyed.1, 2
We present the following hospital suggestions on ways that the government could assist them for
HHS’s and other decision-makers’ consideration as they continue to respond to COVID-19.
Assistance with testing, supplies, and equipment

In discussing potential government assistance related to testing, supplies, and equipment, hospitals
often stated that they were in competition with other providers for limited supplies, and that
government intervention and coordination could help reconcile this problem at the national level to
provide equitable distribution of supplies throughout the country.
Hospitals wanted the government to:
• provide test kits and swabs, or for the government to take steps to ensure that supply chains
can provide hospitals with a sufficient supply of tests;
• make testing faster by allowing more entities to produce tests and related supplies or to
conduct tests;
• help in obtaining a range of supplies, such as N95 masks, surgical masks, gloves, and other
protective gear;
• provide equipment such as ventilators, triage tents, and beds, among others, or take steps to
bolster supply chains to provide needed equipment; and,
• loosen restrictions around the transfer or gifting of equipment and supplies (e.g., when
providers want to send supplies necessary for treatment with patients when transferring them to
another facility).
Assistance with workforce allocation

Given their concerns about staffing shortages, hospitals reported that they needed the government to
enable maximum flexibility among their care-giving workforce.
• enable reassignment of licensed professionals and realignment of duties within the hospital and
throughout their health care networks;
• provide flexibility with respect to licensed professionals practicing across State lines,
• provide relief from regulations that may restrict using contracted staff or physicians based on
business relationships.
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Assistance with capacity of facilities
Hospitals reported concerns with their capacity to house a surge of COVID-19 patients. They described
a range of government actions that they believe would help them on this front.
• relax rules around the designation of bed types;

• take steps that enable hospitals to establish surge facilities in non-traditional settings such as
hotels and civic centers; and
• allow more patients to be treated at home by expanding access to telehealth through
flexibilities in the types of services, caregivers, and modalities eligible to receive reimbursement.
Financial assistance
Hospital representatives across all types of hospitals (and in particular small, rural hospitals) reported
that they need financial assistance. Notably, some hospitals reported needing assistance in a matter of
weeks in order to avoid insolvency.
• speed up Medicare payments by dropping the 14-day wait period;

• increase Medicare payments; and
• offer loans and grants.
Communication and information

Hospitals told us that they thought the Federal Government could play a central role in messaging and
communications to mitigate what they perceived to be conflicting or inconsistent guidance across levels
of government, as discussed in the challenges.
• provide evidence-based guidance (and as an example, they highlighted the usefulness of CDC’s
guidance on conserving N95 masks);
• provide reliable predictive models and data that would help them plan and prepare; and
• provide a single place to find the information they need, including information on the
COVID-19 disease, guidance from agencies, and instructions for processes they need to follow,
such as how to apply for waivers from certain requirements.
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CONCLUSION
This report provides information about hospitals’ experiences and perspectives in responding to
COVID-19 at a point in time—March 23–27, 2020. The pandemic is fast-moving, as are the efforts to
address it. Since our interviews, some hospital challenges may have worsened and others may have
improved. Hospitals reported that their most significant challenges centered on testing and caring for
patients with known or suspected COVID-19 and keeping staff safe. Hospitals also reported substantial
challenges maintaining or expanding their facilities’ capacity to treat patients with COVID-19.
We recognize that HHS, Congress, and other Federal, State, local, and Tribal entities are taking
substantial action on a continual basis to support hospitals as they work on the frontlines to treat
patients, ensure the safety of the health care workforce, and protect communities. We present this
information for HHS’s and other decision-makers’ consideration as they continue to respond to the
COVID-19 pandemic. In addition, hospitals may find the practical information about other hospitals’
strategies useful as they confront the many challenges they face in fulfilling their mission.
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BACKGROUND
Hospital Response to the COVID-19 Pandemic
The emergence of COVID-19 has created unprecedented challenges for the U.S. hospital system.3 As
frontline responders, hospitals have significant responsibilities for identifying and treating patients with
COVID-19. Hospitals around the country are adapting to the constantly changing face of the
COVID-19 pandemic by adopting both expected and novel strategies to tackle the crisis. (See Appendix
A on pages 21–25 for a list of hospital strategies reported.)
The Emergence of COVID-19

Four main sub-groupings of coronaviruses commonly circulate among humans worldwide, typically
causing mild to moderate upper respiratory tract illnesses, and their incidence usually peaks annually in
the United States during the winter months.4, 5, 6 COVID-19 is a highly contagious coronavirus.7
Common symptoms include fever, tiredness, dry cough, and shortness of breath, and it can be fatal in
some cases.8
The first reported instances of COVID-19 occurred in Wuhan, Hubei Province, China, in December
2019 and January 2020.9 On January 13, 2020, the first patient with COVID-19 was reported outside of
China, and the first patient in the U.S. was reported 7 days later.10 In late-February 2020, a hospital in
California documented the first community spread transmission of COVID-19, meaning the illness was
acquired through an unknown exposure in the community in the U.S.11
On March 11, 2020, the World Health Organization characterized COVID-19 as a pandemic, which refers
to an epidemic that has spread over several countries or continents, usually affecting a large number of
people.12, 13 As of April 3, 2020, CDC reported 239,279 confirmed cases in the U.S. and 5,443 deaths.14
Role of HHS in Emerging Infectious Disease Preparation and

Response
HHS is the lead federal agency responsible for medical support and coordination during public health
emergencies, such as emerging infectious disease (EID) outbreaks. HHS operating divisions involved in
the Federal response to EIDs, including the current COVID-19 response, include the Office of the
Assistant Secretary for Preparedness and Response (ASPR), CDC, CMS, and the Food and Drug
Administration (FDA).15
ASPR coordinates HHS’s response to public health emergencies with other Federal agencies, such as the
Federal Emergency Management Agency. ASPR also maintains the Strategic National Stockpile, which
supplements State and local stocks of life-saving pharmaceuticals and medical supplies for use in a
public health emergency.16 Since 2010, ASPR has managed the Hospital Preparedness Program, which
provides grants to States and localities to distribute to hospitals and health care coalitions for improved
preparedness. Health care coalitions are groups of health care providers and public health entities that
OEI-06-20-00300 15
work together to prepare for, respond to, and recover from emergencies.17, 18 ASPR also created the
Technical Resources, Assistance Center, and Information Exchange to provide information and technical
assistance to health care coalitions, health care providers, and other stakeholders during public health
emergencies.19
Following the Ebola outbreak in 2014, ASPR designated 10 hospitals as Ebola and Other Special
Pathogen Centers.20, 21 ASPR defines “special pathogens” as highly infectious agents that produce
severe disease in humans.22 These centers are to maintain capability to accept patients with suspected
or diagnosed illness from special pathogens within 8 hours of notification and to conduct quarterly
exercises to prepare for an EID outbreak.23 During 2017–2018, all 10 Special Pathogen Centers
participated in on-site readiness consultations conducted by the National Ebola Training and Education
Center, which is a collaborative effort involving ASPR, CDC, and several academic institutions. The
results of these assessments indicate that Special Pathogen Centers have higher levels of operational
readiness to provide care to patients with special pathogens.24
In response to COVID-19, ASPR is working with its partners to develop medical countermeasures and to
provide resources to support the U.S. health care system’s response. On March 24, 2020, ASPR
indicated that it will provide $100 million to support U.S. health care systems in getting ready for an
increase in patients with COVID-19.25
CDC monitors and responds to public health emergencies, such as EIDs, conducts research, and
provides guidance to health care providers, government entities, and the public.26 In response to
COVID-19, CDC recently released interim guidance for U.S. health care facilities on preparing for
community transmission of COVID-19,27 along with strategies for optimizing the supply of N95
respirators,28 and steps health care facilities can take to prepare for COVID-19.29
CMS oversees hospitals participating in Medicare and Medicaid by requiring them to meet Conditions
of Participation, a set of minimum health and safety standards.30, 31 To help to address challenges
presented by COVID-19, CMS has waived some requirements under the emergency authority set forth
in Section 1135 of the Social Security Act.32 In addition, under its 1135 waiver authority and the
Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS expanded the
telehealth benefit for Medicare beneficiaries to allow beneficiaries to “receive a wider range of services
from their doctors without having to travel to a health care facility.”33
FDA is responsible for protecting the public health by ensuring the safety, efficacy, and security of
human and veterinary drugs, biological products, medical devices, our nation's food supply, cosmetics,
and products that emit radiation.34 FDA is working with hospitals and the medical industry to develop
vaccines, drugs, and diagnostic tests while monitoring the medical supply chain during the
COVID-19 outbreak.35 FDA is also issuing emergency use authorizations for ventilators and other
medical devices to treat patients.36
Personal Protective Equipment

PPE is protective clothing, helmets, goggles, or other garments or equipment designed to protect the
wearer's body from injury or infection. PPE also includes a variety of types of respirators and face
OEI-06-20-00300 16
masks.37 Most relevant to the types of PPE that hospitals are commonly using in treating patients with
known or suspected cases of COVID-19 is the N95 respirator mask, a respiratory protective device
designed to achieve a very close facial fit and very efficient filtration of airborne particles.38
OEI-06-20-00300 17
METHODOLOGY
Data Collection and Scope
We conducted a “pulse survey” (i.e., quick, point-in-time questions) by telephone (or in a few cases, by
email) with administrators from a random sample of Medicare-certified hospitals across the nation and
in some cases, their parent corporations. These conversations focused on three key issues regarding
their COVID-19 response: 1) challenges responding to the COVID-19 pandemic, 2) strategies to mitigate
the challenges, and 3) needs for government assistance.
We conducted the surveys on March 23–27, 2020 with one or more administrators. The positions of
these hospital administrators were typically Chief Executive Officer, Chief Medical Officer, or
representatives from teams and departments dedicated to emergency preparedness or incident
command. In some cases, leadership from the relevant hospital networks participated in the interviews
alongside hospital administrators or on the hospitals’ behalf.
Hospital selection and response

We had previously selected a stratified random sample of 410 hospitals for an October 2018 report
examining hospital preparedness for EIDs.39 We selected the 410 hospitals from
4,489 Medicare-certified hospitals with emergency departments in 2016, located in 47 States, the
District of Columbia, and Puerto Rico. The sample was comprised of two strata: (1) all
10 ASPR-designated Special Pathogen Centers, and (2) 400 other hospitals with emergency
departments.
For this review, we used the same sample, but removed 12 hospitals that were no longer in operation or
no longer providing inpatient care, and 18 hospitals that were under investigation by OIG. This left a
total sample of 380 hospitals that we attempted to survey.
We received responses from 323 of these 380 hospitals, for an 85 percent rate of contact. Among the
hospitals that did not respond, 9 chose not to participate, and we were unable to contact 48 after a
minimum of three attempts during the 5-day data collection period.40
The responding hospitals are located across 46 States, the District of Columbia, and Puerto Rico. Most
survey responses were provided directly by an administrator for a single hospital. However, for
46 sampled hospitals, we spoke with administrators from their parent corporation instead of, or in
addition to, the hospital administrators. We considered the interviews with the administrators from the
parent companies to be responses for each of the hospitals in our sample that were owned by those
companies. These 46 hospitals were spread across 16 hospital networks.
The following two pages provide additional information about the hospitals that responded.
OEI-06-20-00300 18
Exhibit 2: Hospital Respondents, March 23–27, 2020.
Exhibit 3: The 323 hospitals that we interviewed were located in 46 States, as well as the
District of Columbia and Puerto Rico.
OEI-06-20-00300 19
Exhibit 4: Among the 323 hospitals that we interviewed, some are designated as
specialized hospitals.
Limitations
We have three limitations: 1) hospital responses reflect a point in time (March 23–27, 2020), but the
pandemic is fast-moving, as are efforts to address it. Since our interviews, some hospital challenges
may have worsened and others may have improved; 2) we did not independently verify the information
reported by hospital administrators. Rather, we report on hospitals’ experiences and perceptions as
they were conveyed to OIG; and 3) our analysis found some evidence of response bias. Specifically,
larger hospitals appear to be under-represented in the pool of respondents and as a result, their views
may be under-represented.
Standards
We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued
by the Council of the Inspectors General on Integrity and Efficiency.
OEI-06-20-00300 20
APPENDIX A – STRATEGIES REPORTED BY
HOSPITALS
The following are specific strategies reported by hospitals divided by topic areas: 1) securing PPE, other
equipment, and supplies for staff; 2) ensuring adequate staffing to treat patients with COVID‑19;
3) reducing employee anxiety and stress; 4) managing patient flow and hospital capacity; and
5) securing ventilators and alternative equipment to support patients. We note that these strategies are
self-reported by the hospitals and OIG has not validated their effectiveness or safety.
Strategies to secure the necessary PPE, equipment, and

supplies for staff
Seeking Alternative Sources of PPE
To supplement limited supplies, hospitals reported improvising PPE and reaching out to
non-traditional sources or the community to acquire PPE.
• Using non-traditional sources of PPE, such as online retailers, home supply stores, paint stores,
autobody supply shops, and beauty salons.
• Using 3D printers and office supplies to make PPE (e.g., masks).
• Repurposing masks from other industries such as dentists, veterinarians, construction workers,
nail salons, etc.
• Purchasing expired PPE.
• Considering other materials to substitute for needed supplies (e.g., sandwich bags as
thermometer covers, blending ultrasound gel and alcohol from a local distillery to make hand
sanitizer).
• Creating supply by accepting handmade gowns and masks from community volunteers or
local businesses.
Implementing Methods to Extend PPE Usage

To conserve existing PPE, hospitals reported implementing procedures to extend and/or reuse PPE.
• Reusing PPE (e.g., disposable masks, face shields, and gowns).
• Sanitizing PPE (e.g., face shields and masks) between use.
• Reducing the extent and frequency of patient interaction to reduce PPE burn.
• Physically securing PPE to prevent theft or misuse.
• Limiting use of PPE to certain staff or patients (e.g., intensive care unit staff or patients).
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Strategies to ensure adequate staffing to treat patients with
COVID-19
Maintaining Staffing Levels
To keep operations going, hospitals reported “cross-training” staff or bringing on additional medical
staff.
• Supplementing medical staff with contractors, retired providers, nurse aides, and medical and
nursing students.
• Training medical staff to support or play other roles (e.g., anesthesiologists, hospitalists, and
nurses are being trained on how to operate ventilators and care for patients on the machines;
non-Emergency Department physicians are being trained to triage in the Emergency
Department).
Implementing Screening Procedures

To control the spread of COVID-19, hospitals reported implementing procedures to screen and
monitor staff and patients.
• Monitoring the temperature of staff, patients, and visitors who come into the hospital.
• Establishing screening centers outside of the hospital.
Partnering and Collaborating

To aid in their delivery of care, hospitals reported leveraging their partnerships and collaborating with
those in the community.
• Being part of a large health care system enables hospitals to deploy staff to other hospitals
and share supplies (e.g., PPE).
• Rural hospitals working with other rural hospitals to share supplies and pass information
about vendors.
• Working with the local emergency and health departments (e.g., fire department) to prepare
and help with patient flow.
• Coordinating with local health authorities to find proper placement for people that need to
isolate but do not have homes.
• Working with local community businesses and organizations (e.g., factories, fashion schools,
and distilleries) to assist with supplies, such as PPE and cleaning supplies.
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Strategies to help reduce employee anxiety and stress
Providing Social Support and Services
To ease anxiety and reduce outside burdens on staff, hospitals reported providing emotional and
psychological support and other support services.
• Assisting staff to find childcare, grocery, and laundry services.
• Providing hotel accommodations to promote separation from elderly family members.
• Expanding Employee Assistance Program services.
• Recruiting mental health clinicians and psychiatry staff to provide emotional and
psychological support.
Strategies to manage patient flow and hospital capacity

Using Ambulatory Care and Telehealth Services
To limit foot traffic, hospitals reported increasing their use of ambulatory care services and telehealth.
• Using ambulatory care clinics in the community and telehealth to triage patients in the clinic,
in the car, or over the phone to limit Emergency Department visits.
• Establishing hotlines for education and advice.
Social Distancing and Restricting Access

To control the spread of COVID-19, hospitals reported restricting access to the hospital and across
different parts of the hospital.
• Limiting the number of entrances to the hospital.
• Limiting the number of visitors and/or restricting visitors to attend only births and end-of-life
situations.
• Dismissing hospital volunteers.
• Restricting access to common areas (e.g., making cafeterias "grab and go," closing gyms).
• Splitting the Emergency Department into separate areas - one area for patients with
respiratory symptoms and another area for those without respiratory symptoms.
• Constructing temporary walls in the Emergency Department to isolate patients and create
negative pressure space.
• Turning the ambulance bay into a respiratory assessment unit with portable X-rays and
negative air pressure to keep unscreened patients from going through the Emergency
Department.
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Increasing Bed Availability
To address potential bed and facilities shortages, hospitals reported converting or creating space to
house a surge in patients.
• Expanding intensive care units, repurposing existing space or using tents, and utilizing other
network facilities to separate COVID-19 patients.
• Establishing alternate care sites at local fairgrounds and other spacious facilities.
• Converting nonoperational facilities in the community (e.g., prisons and college dorms) into
temporary critical care units.
Conducting Community Outreach and Education

To keep communities informed and reduce public panic, hospitals reported conducting outreach and
education activities to answer questions about COVID-19.
• Sending internal and external hospital communications, such as a daily newsletter; sharing
information on employee health and human resources.
• Holding senior leadership meetings often with other hospitals and communicating with local
and State governments.
• Partnering with local government to educate the public on the COVID-19 screening process,
including indicating which potential patients should go to the emergency department and
when, based on criteria such as symptoms.
• Developing ways for hospital leaders to hear hospital staff concerns, such as through daily
webinars.
Eliminating Elective Surgeries and Other Procedures

To reduce risk of exposure and conserve PPE, hospitals reported eliminating elective surgeries and
reducing other services such as ambulatory services, outpatient services, physical therapy, and
medical imaging.
• Conserving the PPE and blood supply that would be used for elective procedures in
preparation for a COVID-19 patient surge.
• Using surgery units and beds for potential COVID-19 patients.
• Reassigning surgical clinicians and staff to assist with COVID-19 response.
Activating Hospital Command Centers

To coordinate the hospitals' emergency plans, hospitals reported activating their incident command
centers.
• Setting up hospital contingency plans to prepare for patient surge and demand for services
(e.g., using clinic-based physicians to assist in hospital acute care, using a buddy system that
pairs intensive care unit and non-intensive care unit providers together, plans for evacuating
patients, as needed, to alternate settings.
OEI-06-20-00300 24
Managing Financial Viability
To continue providing needed care and retain staff, hospitals reported assessing ways to manage
their cash flow.
• Opening a line of credit to keep payroll going.
• Evaluating pay cuts and layoffs.
• Implementing mandatory and voluntary time off for staff that are not busy or essential, during
which time staff would not be paid but would stay on staff.
• Using flexible staffing and furloughing staff.
• Identifying grants and other funding opportunities.
• Reducing inventory not related to COVID-19.
Strategies to secure ventilators and alternative equipment to

support patients
Securing Ventilators and Alternative Equipment
To address a shortage in ventilators, hospitals sought new sources and alternative equipment to
support patients.
• Renting ventilators, buying single-use emergency transport ventilators, or obtaining
ventilators from an affiliated facility.
• Sharing supplies of ventilators between hospitals.
• Planning to transfer patients in need of ventilator to a nearby hospital.
• Converting medical equipment to use as ventilators (e.g., anesthesia machines and bi-level
positive airway pressure machines).
• Fitting ventilators with additional hoses to connect more than one patient to a single machine.
OEI-06-20-00300 25
APPENDIX B - GLOSSARY OF KEY TERMS
Office of the Assistant Secretary for Preparedness and Response (ASPR): HHS staff division that
leads the nation's medical and public health preparedness for, response to, and recovery from disasters
and public health emergencies. ASPR is assisting organizations to prepare for and respond to the
COVID-19 outbreak.
Centers for Disease Control and Prevention (CDC): HHS operating division tasked with protecting the
public health and safety through the control and prevention of disease, injury, and disability in the U.S.
and internationally. CDC is studying COVID-19 worldwide and helping communities prepare and
respond locally.
Centers for Medicare & Medicaid Services (CMS): HHS operating division that administers the
Medicare program and works in partnership with State governments to administer Medicaid, the
Children's Health Insurance Program, and health insurance portability standards. CMS is issuing clinical
and technical guidance for providers and beneficiaries about COVID-19.
Community spread: Spread of an illness for which the source of the infection is unknown.
Coronavirus disease 2019 (COVID-19): An illness of the respiratory tract that is highly contagious.
Symptoms include a cough, a high temperature (fever), and shortness of breath, and can be fatal in
some cases. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is the virus that causes
COVID-19 and is often called the COVID-19 virus; its prior name was the 2019 novel coronavirus (2019-
nCoV).
Critical Access hospital (CAH): Rural primary health care hospital that gives limited outpatient and
inpatient hospital services to people in rural areas. CAHs are designated by CMS, and to qualify these
facilities must meet certain conditions such as: furnishing 24-hour emergency care services 7 days a
week, having no more than 25 inpatient beds, and having an average length of stay of 4 days or less per
patient for acute-care services. CMS is waiving requirements that CAHs limit the number of beds to 25
and length of stay of 4 days.
Emerging infectious disease (EID): Infections that have recently appeared within a population or
those whose incidence or geographic range is rapidly increasing or threatens to increase in the near
future.
Epidemic: Refers to an increase, often sudden, in the number of cases of a disease above what is
normally expected in that population in that area.
Federal Emergency Management Agency (FEMA): Federal agency under the U.S. Department of
Homeland Security that coordinates responses to natural disasters with State and local governments
and provides Federal assistance.
Food and Drug Administration (FDA): HHS operating division that is responsible for protecting the
public health by ensuring the safety, efficacy, and security of human and veterinary drugs, biological
OEI-06-20-00300 26
products, medical devices, our nation's food supply, cosmetics, and products that emit radiation. FDA is
working with hospitals and the medical industry to develop vaccines, drugs, and tests while monitoring
the medical supply chain during the COVID-19 pandemic.
Intensive care unit (ICU): Specialized hospital or facility department that provides critical care and life
support for acutely ill and injured patients.
Intravenous (IV) pump: Medical device that delivers fluids, such as nutrients and medications, into a
patient’s body in controlled amounts.
Isolation room: Negatively pressurized room to control the airflow so that the number of airborne
contaminants is reduced to a level that makes the chance of cross-infection to other people within a
health care facility unlikely (also see negative pressure room).
Middle East Respiratory Syndrome (MERS): Illness caused by a virus (more specifically, a coronavirus)
called Middle East Respiratory Syndrome Coronavirus (MERS-CoV) and was first reported in Saudi
Arabia in 2012. Most MERS patients develop severe respiratory illness with symptoms of fever, cough
and shortness of breath and many people who are infected die.
N95 respirator mask: Respiratory protective device designed to achieve a very close facial fit and very
efficient filtration of airborne particles. The 'N95' designation means that when subjected to careful
testing, the respirator blocks at least 95 percent of very small (0.3 micron) test particles. If properly
fitted, the filtration capabilities of N95 respirators exceed those of face masks.
Negative pressure room: Room in a hospital or facility that is used to contain airborne contaminants
within the room.
Outbreak: Carries the same definition as “epidemic,” but usually refers to a more limited geographic
area.
Pandemic: Epidemic that has spread over several countries or continents, usually affecting a large
number of people.
Personal protective equipment (PPE): Protective clothing, helmets, goggles, or other garments or
equipment designed to protect the wearer's body from injury or infection. This includes respirators and
face masks.
Positive COVID-19 test: Test has laboratory confirmation, either from a State or local laboratory or the
CDC.
Powered air purifying respirators (PAPRs): Type of PPE used to safeguard workers against
contaminated air. It includes a battery-powered blower that pulls air through filters then moves filtered
air towards the facepiece. PAPRs are sometimes called positive-pressure masks, blower units, or just
blowers (compare with elastomeric respirators).
Presumptive positive: someone with symptoms that strongly indicate COVID-19 and tests have ruled
out other conditions like the flu, but there hasn’t been an initial positive COVID-19 test result or
OEI-06-20-00300 27
confirmatory test result. This term can also be used when an individual whose initial COVID-19 test has
been positive, but the CDC or other laboratories have not confirmed it.
Pulse survey: Type of short feedback survey, typically narrow in scope and can be administered on an
ongoing basis to track the same topic.
Quarantine: Condition that separates and restricts the movement of people who were exposed to a
contagious disease. If the person in quarantine is determined to have contracted the disease, the
person should seek treatment, as necessary, or go into isolation until they are no longer contagious.
Reagent: Substance that is used to produce a chemical reaction that allows researchers to detect,
measure, produce, or change other substances. For RNA extraction tests that detect the COVID-19
virus, this is an essential component that is lacking in many health care facilities.
Respirator: Masklike device, usually of gauze, worn over the mouth, or nose and mouth, to prevent the
inhalation of noxious substances. There are two main types: air-purifying respirators which remove
contaminants from the air and air-supplying respirators which provide a clean source of air.
"Respirator” is sometimes used interchangeably to refer to “ventilators.” (Also see powered air purifying
respirators and N95 respirators)
Severe Acute Respiratory Syndrome Virus (SARS): Viral respiratory illness caused by a coronavirus
called SARS-associated coronavirus (SARS-CoV). SARS was first reported in Asia in February 2003. The
illness spread to more than two dozen countries in North America, South America, Europe, and Asia
before the SARS global outbreak of 2003 was contained.
Single-use (disposable or emergency) ventilator: A small, lightweight ventilator used outside of the
hospital, typically for emergency care situations and intended only for short-term, single patient use,
with no cleaning or calibration needed.
Social distancing: Limits human interaction to lower the risk of human-to-human transmission.
Recommended measures can include keeping 6’ away from others, avoiding social gatherings, and
working from home.
Special Pathogen Centers: 10 hospitals designated by ASPR following the Ebola outbreak in 2014 to
maintain capability to accept patients with suspected or diagnosed illness from special pathogens
within 8 hours of notification and to conduct quarterly exercises to prepare for an EID outbreak. They
receive annual assessments from the National Ebola Training and Education Center, which is a
collaborative effort involving ASPR, CDC, and several academic institutions.
Special pathogens: Highly infectious agents that produce severe disease/illness in humans.
Strategic National Stockpile: Supplements State and local stocks of vaccines, medicines, and supplies
for emergencies.
Surge: When patient volumes challenge or exceed a hospital’s servicing capacity to effectively treat
individuals.
OEI-06-20-00300 28
Telehealth: Use of electronic information and telecommunications technologies to support long-
distance clinical health care, patient and professional health-related education, public health and health
administration.
Thermometer (no-touch): No-touch thermometers use infrared technology to rapidly provide

accurate temperature results.
Traveling nurse: Nurses employed on a short-term or periodic basis. They include temporary staff,
independent contractors, and seasonal hires.
Triage: Process of sorting, classifying, and assigning priority to patients based on degree of sickness or
severity of injury.
Ventilator: Machine that supports breathing when a patient is having surgery or cannot breathe on
their own due to a critical illness. The patient is connected to the ventilator with a tube that goes in
their mouth or nose and down into their main airway.
WHO: World Health Organization, a United Nations agency that directs and coordinates international
public health efforts.
OEI-06-20-00300 29
ACKNOWLEDGMENTS AND CONTACT
This report is the result of a large team of OIG staff over a short time period, with the purpose to provide
timely information at an unprecedented time for HHS and the nation.
Rosemary Rawlins Bartholomew, Ben Gaddis, and Camille Harper served as the project leaders for this study.
Key contributors from the Office of Evaluation and Inspections included William Ash, Emily Borgelt, Anna
Brown, Charis Burger, Kristen Calille, Matt DeFraga, Kira Evsanaa, Maria Johnson, Eunji Kim, Anna Lin,
Demetrius Martinez, Conswelia McCourt, Anthony Soto McGrath, Lisa Minich, Petra Nealy, Ivy Ngo, Kenneth
Price, Chelsea Samuel, Karl Mari Santos, Hilary Slover, Jared Smith, Andrea Staples, Malaena Taylor, Savanna
Thielbar, Jesse Valente, John Van Der Schans, Kelly Waldhoff, and Troy Yamaguchi.
Other OIG staff who conducted the study included Deana Baggett, Melissa Baker, Heather Barton, Joanna
Bisgaier, Sara Bodnar, Joe Chiarenzelli, Craig Diena, Scott Englund, Kevin Farber, Caitlin Foster, David Fuchs,
Anne Gavin, Lee Gibson, Kevin Golladay, John Gordon, Vincent Greiber, Samantha Handel Meyer, Nathan
Hauger, Felicia Heimer, Michael Henry, Althea Hosein, Seta Hovagimian, Jonathan Jones, Michael Joseph,
Robert Kirkner, Laura Kordish, Rebecca Laster, San Le, Jay Mazumdar, Sabrina Morello, Christine Moritz,
Lyndsay Patty, Melicia Seay, Meridith Seife, Srishti Sheffner, Ellen Slavin, Peter Taschenberger, Lucio Verani,
Brian Whitley, and Abigail Wydra.
We would also like to acknowledge other significant contributors without whom this effort would not have
been successful. Staff from all OIG components contributed, including the Office of Audit Services, the
Office of Counsel, the Office of Evaluation and Inspections, the Office of Investigations, and the Office of
Management and Policy. Contributions included planning and conducting interviews, data and
administrative support, and report production and distribution.
This report was prepared under the direction of Blaine Collins and Ruth Ann Dorrill, Regional Inspectors
General for Evaluation and Inspections in the San Francisco and Dallas regional offices, and Abby Amoroso
and Amy Ashcraft, Deputy Regional Inspectors General.
Contact
To obtain additional information concerning this report, contact the Office of Public Affairs at
[email protected]. OIG reports and other information can be found on the OIG website at
oig.hhs.gov.
Office of Inspector General

U.S. Department of Health and Human Services
330 Independence Avenues, SW
Washington, DC 20201
OEI-06-20-00300 30
ABOUT THE OFFICE OF INSPECTOR GENERAL
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the
health and welfare of beneficiaries served by those programs. This statutory mission is carried out
through a nation-wide network of audits, investigations, and inspections conducted by the following
operating components:
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting
audits with its own audit resources or by overseeing audit work done by others. Audits examine the
performance of HHS programs and/or its grantees and contractors in carrying out their respective
responsibilities and are intended to provide independent assessments of HHS programs and
operations. These assessments help reduce waste, abuse, and mismanagement and promote economy
and efficiency throughout HHS.
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide
HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These
evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and
effectiveness of departmental programs. To promote impact, OEI reports also present practical
recommendations for improving program operations.
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of
fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators
working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating
with the Department of Justice and other Federal, State, and local law enforcement authorities. The
investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil
monetary penalties.
The Office of Counsel to the Inspector General (OCIG) provides general legal services
to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support
for OIG’s internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases
involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty
cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity
agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud
alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and
other OIG enforcement authorities.
OEI-06-20-00300 31
ENDNOTES
1 Coronavirus Aid, Relief and Economic Security (CARES) Act of 2020, P.L. No. 116-136 (enacted Mar. 27, 2020).
2 Actions that HHS has taken related to significant hospital challenges and suggestions include, but are not limited to, the
following examples. Pursuant to the CARES Act, CMS will allow hospitals, critical access hospitals, and other Medicare
providers and suppliers to request advance payment for 3 to 6 months of future Medicare claims. On March 30, 2020, CMS
announced an array of regulatory changes to increase hospitals’ and other health care providers’ flexibility in responding to
this pandemic. This includes enabling hospitals to leverage alternative sites (such as ambulatory surgical centers, hotels, and
dormitories) to provide hospital services. CMS also made changes to increase the services that can be provided via telehealth
and to make Medicare payments for services provided via telehealth equal to the traditional payment rates. In addition, CMS
has temporarily waived certain regulations that may restrict how hospitals use physicians or contracted staff due to business or
financial relationships. Specific information about these and many other HHS actions and resources is available at
https://www.hhs.gov/about/news/coronavirus/index.html.
3The World Health Organization officially named this disease COVID-19 on February 11, 2020. Prior to that, it had been known
as “2019 novel coronavirus” or “2019-nCoV.” WHO, Novel Coronavirus (2019-nCoV) Situation Report-22. Accessed at
https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200211-sitrep-22-ncov.pdf?sfvrsn=fb6d49b1_2 on
March 26, 2020.
4 CDC, Human Coronavirus Types, CDC Fact Sheet. Accessed at https://www.cdc.gov/coronavirus/types.html on April 3, 2020.
5CDC, Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions: Coronavirus Disease 2019 Basics. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/faq.html on March 26, 2020.
6Killerby, et al., Human Coronavirus Circulation in the United States 2014-2017, Journal of Clinical Virology, April 2018.
Accessed at https://www.sciencedirect.com/science/article/pii/S1386653218300325 on March 26, 2020.
7 Liu et al., “Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2, Shenzhen, China, 2020,” Emerging
Infectious Diseases Journal, 26, March 3, 2020. Accessed at https://wwwnc.cdc.gov/eid/article/26/6/20-0239_article on April 2,
2020.
8CDC, Coronavirus Disease 2019 (COVID-19) Symptoms of Coronavirus. Accessed at https://www.cdc.gov/coronavirus/2019-

ncov/symptoms-testing/symptoms.html on March 29, 2020.
9Li, Qun, et al., Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. Accessed at
https://www.nejm.org/doi/full/10.1056/NEJMoa2001316 on March 26, 2020.
10Secon, Holly, et al., A Comprehensive Timeline of the New Coronavirus Pandemic, From China’s First COVD-19 Case to the
Present. Accessed at https://www.businessinsider.com/coronavirus-pandemic-timeline-history-major-events-2020-3 on March
27, 2020.
11CDC, CDC Confirms Possible Instance of Community Spread of COVID-19 in U.S. Accessed at
https://www.cdc.gov/media/releases/2020/s0226-Covid-19-spread.html on March 2, 2020.
12World Health Organization, WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11, March 2020.
Accessed at https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-
covid-19---11-march-2020 on April 3, 2020.
13An epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that
population in that area. CDC, Principles of Epidemiology in Public Health Practice. Accessed at
https://www.cdc.gov/csels/dsepd/ss1978/lesson1/section11.html on March 27, 2020.
OEI-06-20-00300 32
14CDC, Coronavirus Disease 2019 (COVID-19) Cases & Latest Updates, Cases in U.S. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html on April 3, 2020.
15FEMA, Emergency Support Function #8—Public Health and Medical Services Annex, January 2008. Accessed at
https://www.fema.gov/media-library-data/20130726-1825-25045-
8027/emergency_support_function_8_public_health___medical_services_annex_2008.pdf on March 26, 2020.
16ASPR, Public Health Emergency Strategic National Stockpile. Accessed at
https://www.phe.gov/about/sns/Pages/default.aspx on April 3, 2020.
17ASPR, 2017–2022 Health Care Preparedness and Response Capabilities. Accessed at
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf on March 26,
2020.
18FEMA, Emergency Support Function #8—Public Health and Medical Services Annex, January 2008. Accessed at
https://www.fema.gov/media-library-data/20130726-1825-25045-
8027/emergency_support_function_8_public_health___medical_services_annex_2008.pdf on March 26, 2020.
19ASPR Technical Resources, Assistance Centers, and Information Exchange (TRACIE): Topic Collection: Coronaviruses (e.g.,
SARS, MERS and COVID-19). Accessed at https://asprtracie.hhs.gov/technical-resources/44/coronaviruses-sars-mers-and-
covid-19/27 on March 26, 2020.
20 ASPR designated 9 Special Pathogen Centers in 2015 and added an additional in 2017 for a total of 10.
21HHS, HHS selects nine regional Ebola and other special pathogen treatment centers. Accessed at
https://www.infectioncontroltoday.com/viral/hhs-selects-nine-regional-ebola-and-other-special-pathogen-treatment-centers
on April 3, 2020.
22 Ibid.
23 ASPR, “Regional Treatment Network for Ebola and Other Special Pathogens,” p. 4. Accessed at
https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/RETN-Ebola-Report-508.pdf on March 26, 2020.

24National Ebola Training & Education Center, Annual Report FY 2018. pp. 3-5. Accessed at https://netec.org/wp-
content/uploads/2019/01/NETEC-Annual-Report-FY2018.pdf on April 3, 2020.
25CDC, Steps Healthcare Facilities Can Take Now to Prepare for Coronavirus Disease 2019 (COVID-19). Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html on March 26, 2020.
CDC, CDC: Mission, Role and Pledge, April 14, 2014. Accessed at https://www.cdc.gov/about/organization/mission.htm on
26
March 26, 2020.

27CDC, Interim Guidance for Healthcare Facilities: Preparing for Community Transmission of COVID-19 in the United State.
Accessed at https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html on March 26, 2020.
28CDC, Strategies for Optimizing the Supply of N95 Respirators: Crisis/Alternate Strategies. Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html on March 26, 2020.
29CDC, Steps Healthcare Facilities Can Take Now to Prepare for Coronavirus Disease 2019 (COVID-19). Accessed at
https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/steps-to-prepare.html on March 26, 2020.
30 42 CFR pt. 482.

31 Social Security Act, § 1861(e); 42 U.S.C. § 1395x(e); 42 CFR § 488.3(a).
32 42 U.S.C. § 1320b-5.
OEI-06-20-00300 33
33CMS, Medicare Telemedicine Health Care Provider Fact Sheet, accessed at https://www.cms.gov/newsroom/fact-
sheets/medicare-telemedicine-health-care-provider-fact-sheet on March 26, 2020. The HHS Office of Civil Rights also issued
guidance that allows healthcare providers to use any non-public-facing remote communication product to communicate with
patients. Office of Civil Rights, Notification of Enforcement Discretion for Telehealth Remote Communications During the
COVID-19 Nationwide Public Health Emergency, accessed at https://www.hhs.gov/hipaa/for-professionals/special-
topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html on April 3, 2020.
34 FDA, What We Do. Accessed at https://www.fda.gov/about-fda/what-we-do on March 31, 2020.

35FDA, Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions. Accessed at https://www.fda.gov/emergency-
preparedness-and-response/coronavirus-disease-2019-covid-19/coronavirus-disease-2019-covid-19-frequently-asked-
questions on March 31, 2020.
36FDA, Coronavirus (COVID-19) Update: Daily Roundup, March 25, 2020. Accessed at https://www.fda.gov/news-events/press-
announcements/coronavirus-covid-19-update-daily-roundup-march-25-2020, on March 2020.
37FDA, Personal Protective Equipment for Infection Control. Accessed at https://www.fda.gov/medical-devices/general-

hospital-devices-and-supplies/personal-protective-equipment-infection-control on March 31, 2020.
38FDA, N95 Respirators and Surgical Masks (Face Masks). Accessed at https://www.fda.gov/medical-devices/personal-
protective-equipment-infection-control/n95-respirators-and-surgical-masks-face-masks on March 31, 2020.
39OIG, Hospitals Reported Improved Preparedness for Emerging Infectious Diseases After the Ebola Outbreak (OEI-06-15-00230),
October 2018.
40 To ensure that the information in this report was released quickly, we did not include six interviews that either took place
after Friday, March 27, 2020 or for which the primary interview notes were added to our database after that date. We included
these 6 hospitals in the total of 48 hospitals that we were unable to contact.
OEI-06-20-00300 34

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Department of Health and Human Services

Office of Inspector General

Hospital Experiences Responding

How OIG Did This Review

1. What are your most difficult challenges in responding to COVID-19?

Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp

Widespread Shortages of PPE

Difficulty Maintaining Adequate Staffing and Supporting Staff

Difficulty Maintaining and Expanding Hospital Capacity to Treat Patients

Shortages of Critical Supplies, Materials, and Logistic Support

Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp

Increased Costs and Decreased Revenue

Changing and Sometimes Inconsistent Guidance

Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp

Ensure Adequate Staffing

Manage Patient Flow and Hospital Capacity

Secure Ventilators and Alternative Equipment to Support Patients

Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp

Testing, Supplies, and Equipment

Communication and Information

Full report: oig.hhs.gov/oei/reports/oei-06-20-00300.asp

Hospitals reported that severe shortages of testing supplies and extended

Testing challenges hampered hospitals’ efforts to reduce community spread, protect

Hospitals reported a shortage of specialized providers needed to meet the anticipated

Hospitals also reported substantial challenges maintaining

Hospitals were concerned about their capacity to treat a surge of patients

Hospitals reported being unable to discharge patients to certain post-acute facilities

Hospitals reported shortages of no-touch, infrared thermometers needed for

Hospitals faced shortages of disinfectants and cleaning supplies. Hospitals reported

Hospitals cited anticipated shortages of ventilators as a potential

Hospitals described increasing costs and decreasing revenues as a threat

Hospitals reported circumstances in which insurance reimbursements were not covering

Hospitals reported that changing and sometimes inconsistent guidance

Hospitals reported instances of receiving conflicting guidance from different Federal,

Hospitals reported using a range of strategies to maintain or

Hospital administrators turned to alternative practices and

Hospital strategies also focused on ensuring adequate staffing to treat

Hospitals reported providing resources to help reduce employee burden

Some strategies focus on managing patient flow and hospital capacity to

With an uncertain supply of standard, full-feature ventilators, hospitals

Hospitals reported pressing needs for government assistance

Assistance with testing, supplies, and equipment

Hospitals wanted the government to:

Assistance with workforce allocation

Hospitals wanted the government to:

Hospitals wanted the government to:

• relax rules around the designation of bed types;

Hospitals wanted the government to:

• speed up Medicare payments by dropping the 14-day wait period;

Communication and information

Hospitals wanted the government to:

The Emergence of COVID-19

Role of HHS in Emerging Infectious Disease Preparation and

Personal Protective Equipment

Hospital selection and response

Strategies to secure the necessary PPE, equipment, and

Implementing Methods to Extend PPE Usage

Implementing Screening Procedures