As of June 5, 2020, over 6.7 million individuals worldwide have been infected with COVID-19 with more than 1.9 million (28%) cases in the United States (US). Managing this pandemic has put considerable strain on healthcare systems with many regions experiencing a surge in critically ill patients that exceeds the capacity of the system. The first confirmed case of COVID-19 in the US was identified in Washington state on January 21, 2020, the first COVID-19 outbreak in a long-term care facility (LTCF) in King County, WA identified on Institute of Health Metrics and Evaluation has been instrumental in forecasting the projected need for medical resources across the US, which has been critical for surge planning. As shown in Figure 2 , initial estimates on March 25, 2020 were that Washington State would need a mean of 3000 hospital beds for COVID patients at the peak of the outbreak. These projections were revised on April 12, 2020, suggesting the state had already peaked with less than 1000 beds required. This is dramatic evidence of "flattening the curve" (Figure 3 ) As a result, the healthcare systems in Western Washington, where the largest number of cases have been concentrated, have been able to function without compromising patient care or access to emergency care.
Despite this success, until there is an effective vaccine, there are likely to be intermittent outbreaks, especially among vulnerable populations. There is also risk of a second peak of infections as physical distancing orders are relaxed or with seasonal changes later in the year.
The objective of this study was to identify the key factors that contributed to the "flattening of the curve" and an effective healthcare system disaster response in western WA. This report seeks to both capture the lessons learned, but also provide guidance to governmental leaders and healthcare systems in managing the pandemic over time. Our goal is to support the ability of the healthcare systems to meet the needs of patients suffering from COVID-19, maintain access for common medical emergencies, and support the care of patients with chronic health conditions including those requiring surgical intervention. to provide a detailed description of the response in their area and asked to identify the key factors they believe contributed to an effective healthcare system response in western WA.
These responses were collected and reviewed by 3 members of the panel (SM, EB, JL) who formed a steering committee. Qualitative analysis revealed six overarching themes which reflected the topics reported by the panel. A white paper was then drafted organizing the input received into 6 key elements and was sent back to all panelists for review and feedback. There was uniform consensus on the key elements and additional detail was provided to the steering committee as needed.
The lessons learned in each of the 6 domains were then organized by the steering committee into a set of 11 consensus recommendations which are designed to provide guidance for the ongoing response to manage future outbreaks in a community. All panel members approved these recommendations.
The six themes identified as key factors in supporting the healthcare system response to the COVID-19 pandemic in western WA were: 
The early cluster of patients at the Kirkland LTCF provided immediate evidence for the need of a regional approach to surveillance and coordination of care. The cluster lead to a crisis at the LTCF where large numbers of staff and residents had become symptomatic and the local hospital had difficulty locating sufficient ventilators. 2 This occurred while large amounts of capacity remained within other local healthcare systems.
The King County DMCC has served to coordinate and distribute patients across the healthcare system since the initial outbreak. However, the DMCC was designed to manage patient distribution in discrete mass casualty events and had to adapt to meet the ongoing needs of this pandemic. This led to the creation of the Western Washington Regional The WRC monitors EMS and public health data to identify outbreaks within the LTCFS and when clusters of patients are identified, the WRC coordinates with EMS and regional hospitals in order to balance patient placement. The WRC also assists hospitals at maximum capacity to decompress by transferring groups of COVID-19 or non-COVID-19 patients to other hospitals.
The WRC has the capabilities to coordinate this distribution statewide and across states if needed. The primary goal of the WRC is to ensure that any single hospital is not overburdened and to maintain community standards of care and capacity for both COVID-19 and non COVID-19 patients requiring acute care. Though existing relationships between the DMCC, NWHRN, and the Washington Hospital Association were leveraged to create the coordination for the WRC, the NWHRN is now initiating routine regional and statewide exercises, primarily in the form of virtual tabletop drills to mature this coordination.
NWHRN and the WRC also partnered with Microsoft to build the Emergency Response platform for improved surveillance of health system variables prone to constraint in the pandemic. The WA DOH has recently adopted the platform and launched it as WAHealth. This solution allows the WRC to visualize resource impacts including beds, staffing, ventilators, PPE, and number of COVID-19 patients across all hospitals. The WRC is working to extend this platform to include LTCFs and EMS.
Early diagnostic testing is critical to identify COVID-19 cases and slow transmission. As the initial outbreak was unfolding in China and the first viral sequence was published, the UW Virology lab quickly designed and obtained RT-PCR primers and probes and moved rapidly into initial test validation. State public health laboratories will almost always have the first validated assay in the state, and receive early, confirmed positive specimens for a novel pathogen. Thus, close partnering with state laboratories for early validation helps amplify regional testing capacity.
As early CDC testing criteria were restrictive, communities with early clusters had difficulty in obtaining testing for the virus. Having established communication between laboratory directors and infectious disease physicians was critical to support early stage coordination of testing criteria. The ability of reference laboratories to scale and invest resources was also critical. UW Laboratory Medicine supported this rapid investment and expansion of resources to provide 24/7 testing operations including: additional qPCR machines, additional instrumentation, couriers to facilitate transport, and volunteers from research and clinical labs across the UW campus. Development of diverse, redundant supply chains and validation techniques was necessary to support continued availability of laboratory consumables. Purchase agreements, financial arrangements (leases, hiring, contracts) and approval processes were modified to meet the need. The result, for UW Virology, was an initial testing capacity of 1000 samples per day which has steadily increased over 6 weeks to a capacity of 7500 samples per day.
Moving forward, it will be essential that the worlds of academia and public health labs collaborate and leverage their respective roles to accomplish population-based testing and surveillance. In King County, the Seattle Flu Study and PHSKC have recently announced the initiation of the Seattle Coronavirus Assessment Network (SCAN), an innovative disease surveillance platform that will allow cross-sectional community surveillance. 6
LTCFs, such as skilled nursing facilities (SNFs), are high risk settings for severe outbreaks.
Many lack the infrastructure and supplies necessary to respond to a pandemic. An effective response starts with (1) A centralized reporting system is critical for an effective response. Focus must be given to identify distressed LTCFs, identify PPE supply chain challenges, infection prevention education, managing staffing shortages, and support for diagnostic and clinical assistance. A central coordination system must match the urgent needs of a LTCF with pre-determined local, county and state resources identified as the support network. This includes work to monitor safe staffing levels and to coordinate augmentation of staffing from a regional resource pool when staffing ratios become unsafe. Existing public health data and active surveillance activities such as phone calls to LTCFs experiencing increased EMS utilization were utilized to facilitate this coordination early in the pandemic. However, LTCFs are now required to report these data to the Washington State Department of Health.
Our region's response in support of the LTCFs has included major health systems, the NWHRN and PHSKC. Health systems and PHSKC have developed strike teams which provide on-site support for infection prevention, triage, containment, testing, and clinical management of patients not requiring hospitalization. Their work includes conservation guidelines for PPE, training for testing of residents and staff, protocols for increased surveillance and outbreak management. To support these efforts, PHSKC facilitates weekly calls between agencies and statewide webinars are conducted in conjunction with SNF associations in the state. This provides a forum for local experts to educate, train and provide real time situational awareness.
In addition to residents of SNFs, the COVID-19 pandemic presents challenges for other vulnerable communities.
Many diseases including COVID-19, disproportionately impact those who are socially and economically disadvantaged. 7 Data from US health departments reveal a disturbing, disproportionate impact of COVID-19 on racial and ethnic minorities, including Latinos and Black Americans. 8 Preliminary analyses within the UW Medicine system comparing COVID-19 rates across race, ethnicity, and language demonstrate higher positive results among tests performed for COVID-19 among racial/ethnic minorities and limited English proficiency (LEP) populations. PHSKC surveillance data mirror these findings. There are likely multiple factors responsible for these findings including: lack of culturally relevant messaging and education, living in multi-generational households, more likely to work in essential jobs resulting in inability to physically distance. PHSKC has worked to engage racially and linguistically diverse communities and has convened nine taskforces and a community advisory group to collaborate across sectors and provide tools and resources to support physical distancing and reduce the risk of disease transmission.
Seattle has the third largest homeless population of any large city in the US with a recent estimate of more than 11,000 people experiencing homelessness in King County. 9 This population suffers from a high rate of comorbid physical and mental health conditions. As such, shelters and other congregate settings must consider opportunities for physical distancing and prevention in settings that are normally crowded. 10,11 To address this King County has rapidly added shelter locations by using empty public spaces, some of which were closed because of the pandemic. The result was significant decompression of existing shelter spaces and greater physical distancing.
and is amenable to outpatient treatment, self-isolation may be attainable, however with the closure of most public spaces, resources for hygiene are limited. Strategies include opening public restrooms in parks and deploying hand washing stations.
In King County, people living homeless have been designated a priority population for COVID-19 testing. Discharging patients to a congregate setting without appropriate testing can lead to a rapid outbreak. Developing a robust system for I&Q is critical. This requires a close relationship and open communication with community partners. PHSKC has developed a number of locations and a call center to facilitate access to I&Q services.
During outbreaks, jails and prisons must work quickly to establish I&Q units and consider methods to decrease inmate population density. Jail and prison leaders need to work with arresting agencies and correctional partners to decrease arrests and provide physical distancing within facilities. This may include work with courts and judges to pursue alternatives to secure detention. [12] [13] [14] Jails also face challenges pertaining to the release of inmates. Since release from jail is a criminal justice and not a healthcare process, there is no mandatory health evaluation at release.
Thus, release from jail can occur any time of day or night making the release of individuals with pending test results problematic. The King County jail has used an I&Q call center to obtain housing for individuals released and unable to self-isolate.
It has become evident worldwide that effective physical distancing at the community level can A recent analysis of mobility data by Unacast demonstrated that between February 26 and April 14, King County has seen a >70% reduction in non-essential visits and a 40-55% reduction in average mobility. 16 An analysis of cell phone mobility reported in the New York Times reveals a > 60% reduction in mobility across western Washington. 17 Automobile traffic in the Seattle area has also seen significant reductions. Continued emphasis of physical distancing will be critical in preventing a resurgence of disease activity. 18
As Washington State and the nation contemplate the next phase of our pandemic response, many questions remain unanswered. We still do not know the true burden of infection, the level or duration of immunity post-infection or the extent of immunity in the community. Supply chains remain fragile and inconsistent, leading to the need for continuous re-assessment of new PPE and COVID-19 sample collection capacity. Due to the work of the UW Virology laboratory, western WA has achieved good access to testing, but needs to continue to scale and ensure an adequate supply chain to ensure widespread testing availability and access for vulnerable populations in congregate settings. Ongoing work is needed to ensure comprehensive COVID-19 preparedness and response capacity in LTCFs.
The aggressive physical distancing practices put into place were aimed at reducing the incidence of new infections so that hospitals, emergency departments and clinics could provide care in a safe and effective way. This has been effective, and this time has allowed us to transform the way care is delivered. Surge capacity was rapidly built, clinic visits moved to tele-health, and non-urgent care for many has been delayed, especially for those awaiting surgical procedures. How long many of these changes will continue remains unknown, but it is clear that healthcare systems can change rapidly when needed.
When the number of new cases in In Washington State declines sufficiently and relaxing distancing measures and back-to-work policies are considered, it will be critical to have widespread access to COVID-19 testing, healthcare system capacity to manage a future surge in patients, adequate supplies of PPE, and robust public health capacity to conduct rapid case and contact tracing and effective isolation and quarantine of ill and exposed persons. The vast majority of the population remain susceptible, making a resurgence likely if these conditions are not adequately met.
The six key themes identified in this report provide a road map for navigating future outbreaks.
A strength of this report is that the lessons' learned were identified by a multidisciplinary group of experts on the front lines of the healthcare disaster response. Limitations include the lack of literature available to guide these recommendations and uncertainty regarding the long-term trajectory for this disease. While we believe these recommendations will be applicable in communities across the US, they may not all be generalizable to healthcare settings with more limited resources. It is our hope that the key factors and recommendations identified in this report will help other states and nations in supporting their healthcare system disaster response.
• A robust healthcare coalition with engagement of stakeholders and active regional disaster preparedness establishes relationships that facilitate communication and rapid response to a crisis in the healthcare system • Regional Medical Operations Centers are vital for ensuring early identification of outbreaks, coordination of regional care and ensuring healthcare assets are levelloaded • Establishing lines of communication and sharing of data with local public health, healthcare coalitions, healthcare systems and EMS are essential for optimal coordination of regional assets and identification of disease clusters • State level adoption of a data platform which tracks (at a minimum) bed capacity, staffing impacts and equipment (PPE and ventilators) is essential • Early preparation is key for laboratories with the capability of establishing their own tests for emerging pathogens; at a minimum, obtaining primers and probes early can save valuable time.
• Collaboration between academic, state, county, and public health laboratory resources is critical for initiating and scaling clinical pathogen testing • Academic laboratories capable of rapidly developing their own tests are a valuable resource for the US health care system and should be encouraged to participate in the early stages of an emerging pandemic.
• A centralized, local coordination center to aid LTCFs and congregate living environments should be established to identify distressed facilities and coordinate resources, education and training.
• Public health, local healthcare systems and coalitions should coordinate to identify strategies that support local LTCFs in times of disaster by providing support, consultation, and resources
• Public health, local healthcare systems and coalitions must make targeted efforts to reach out and provide resources for vulnerable populations including non-English speaking residents, homeless residents, and jail inmates. These include plans for surveillance and testing, resources to support physical distancing, and safe isolation and quarantine.
• When rates of COVID-19 transmission increase, community-wide physical distancing is necessary to decrease the number of ill persons and prevent the health care system from being overwhelmed. All hospital bed requirement. The IHME published an initial estimate of total hospital beds required for COVID-19 patients in Washington State on March 25,2020 (light pink line, shaded pink area represents confidence intervals). New projections were published on April 12, 2020 which incorporated all hospital bed us up to that date (dark pink line) showing a significant reduction compared to initial projections. http://www.healthdata.org/covid/data-downloads (Accessed April 17, 2020) Figure 4 . Western Washington Regional COVID Coordination Center (WRC). The WRC has 4 pillars of activity including 2 surveillance pillars provide situational awareness of hospital resources and COVID-19 status in congregate settings and two coordination pillars which include coordination of resources and support for long term care facilities and distribution of patients across area hospitals to level-load the system. PPE, personal protective equipment; EMS, emergency medical services Precis This study captures the lessons learned from the first outbreak of COVID-19 in the US. Six themes were identified to inform future planning including: stakeholder coordination, regional medical operations center, creating capacity for viral testing, effecitve physical distancing, and support for long-term care facilities and vulnerable populations.