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Use of Alternative Medical Care Facilities in the COVID-19 Pandemic

Eric Toner, MD, and Richard Waldhorn, MD | April 7, 2020

A number of cities in the United States are preparing alternative care facilities (ACFs) to augment surge capacity in response to the COVID-19 pandemic. But in some instances, it seems the use case or strategy for these facilities is unclear. We published papers on this topic in 2006 and 2008, during the height of concerns about an imminent H5N1 influenza pandemic.1,2 Most of the recommendations in those papers are still relevant and applicable to the current coronavirus pandemic. Here we provide our recommendations for how ACFs can best be used in the immediate response to COVID-19.

Establish ACFs in All Communities

We recommend that all cities and towns immediately start working rapidly to establish and make plans for staffing ACFs. Time is of the essence, because constructing and outfitting a facility cannot happen overnight. Some towns may wish to jointly establish ACFs, or states may establish regional facilities. COVID-19 epidemiology models forecast that hospitals across the United States may be stretched to their limits, if not completely overwhelmed. Some cities are experiencing it now; the rest of the country can expect to see it in the coming weeks. Even with successful social distancing, it is unlikely that any location will be completely spared, and it is hard to predict which communities will see the greatest mismatch between patient demand and medical capacity.

The ACFs should be established jointly by the local or state governments and the local hospitals in collaboration with local healthcare coalitions. They may be established in a variety of spaces, including gymnasiums, conference halls, hotels, and, in some cases, tents. The choice of the space as well as the size and configuration should be determined by the anticipated demand as well as the specific purpose of the ACF. That purpose is likely to vary from location to location.

Possible Uses for ACFs

ACFs have been proposed to serve a variety of functions, including:

  • Overflow from hospitals, providing a full range of care
  • Patient isolation and alternative to home care for COVID-19–infected patients
  • Quarantine of contacts of confirmed cases
  • Primary triage and rapid patient screening
  • Limited supportive care for noncritical infected patients
  • Expanded ambulatory care
  • Care for recovering, noninfected patients

The first of these proposed functions is not practical. It is not possible to recreate all the capabilities of a hospital in an ACF. Hospitals require extraordinary amounts of large, sophisticated, and expensive equipment and infrastructure. To build an ACF with these capabilities would be to build a new hospital. The only full hospital model to augment surge capacity being attempted right now is the deployment of the Navy hospital ships Comfort and Mercy to New York and California, and defining their exact mission and integration into the local surge capacity effort remains challenging.

Each of the others make some sense and could be useful for some communities. We would not expect that any location would create ACFs to address all these functions. Which functions are needed must be determined locally.

  • Patient isolation and alternative to home care for infected patients
    There are many people in society who may not be able to effectively home isolate if they become ill with COVID-19. They may live in a crowded apartment with others, be medically frail with no one to care for them, or even be homeless. An ACF could be a resource for medically supervised isolation for people with limited healthcare needs.
  • Quarantine of contacts of confirmed cases
    Close contacts of confirmed or suspected COVID-19 patients should undergo 2 weeks of home quarantine, but as with home isolation, this may not be possible for many people. An ACF could provide shelter with some separation between individuals, along with medical monitoring for emerging symptoms.
  • Primary triage and rapid patient screening
    Most COVID-19 patients will not need hospital care and should not be seen in an overcrowded emergency department (ED). ACFs could provide a space for initial screening and triage of potential COVID-19 patients. An ACF used for this purpose would need to be located physically close to the hospital ED so that unstable patients can be admitted as quickly as possible.
  • Limited supportive care for noncritical infected patients
    Although some hospitalized COVID-19 patients will require intensive care, the majority will not. These patients may need only low-flow oxygen, intravenous fluids, and some common medications and treatments. This could conceivably be done in a well-equipped ACF. However, some COVID-19 patients suddenly deteriorate, so there needs to be the capability of rapid transfer to a nearby hospital ICU.
  • Expanded ambulatory care
    In addition, there may be a need for an alternative to overwhelmed EDs and urgent care centers as well as closed physician offices for all non-COVID patients who need minor medical care but cannot access it because of the pandemic.
  • Care for recovering, noninfected patients
    In order to free up hospital space for COVID-19 patients, many hospitals are trying to discharge medically stable non–COVID-19 patients early. Some of these patients may not yet be well enough to go home but do not need the full services of a hospital. ACFs could provide basic medical care for such patients.

Different Functions Require Different Plans

Each potential ACF function, or subgroup of functions, listed above requires a different layout, staffing pattern, and type of medical resources. The size of patient spaces, the barriers between them, and the medical resources (eg, oxygen) needed will vary depending on the intended use. The degree of proximity to the hospital will also vary depending on the intended function. In some smaller locations, such as a gymnasium, only 1 function is likely to be possible; however, in a very large space, like a convention center, separate parts of the facility can be used for different functions if the functions are sufficiently segregated.


Some functions will be fairly resource-intensive, requiring extensive coverage by physicians, nurse practitioners, or physician assistants (eg, expanded ambulatory care). Others may require much less coverage (eg, patient isolation and alternative to home care for infected patients). The ratio of nursing personnel to patients will also be different, depending on the functions. Volunteers may be more useful in some functions than in others. Where the staffing will come from is an important limiting factor, and the availability of staffing may dictate the kinds of functions that can be offered.

The Challenge of Asymptomatic Transmission

Because a substantial portion of COVID-19 transmission is from people with no symptoms at the time, every ACF, regardless of its intended function, could and likely will become “infected” unless rapid COVID-19 testing becomes much more widely available than it is now. Therefore, every ACF, whether intended for COVID-19 patients of not, must adhere to strict infection control practices and have contingency plans for how to respond to an outbreak within the facility.


ACFs can be an essential part of the response to the pandemic, and every community should be preparing them now. But form follows function, and those planning these facilities should have a clear notion of what the precise purpose of the facility will be.



  1. Lam C, Waldhorn R, Toner E, Inglesby TV, O’Toole T. The prospect of using alternative medical care facilities in an influenza pandemic. Biosecur Bioterror 2006;4(4):384-390.
  2. Waldhorn R. What role can alternative care facilities play in an influenza pandemic? Biosecur Bioterror 2008;6(4):357-358.