The coronavirus surge is coming, America’s hospitals are struggling to prepare, and the eventual demand for intensive care unit beds for Covid-19 cases could far exceed what US hospitals will be able to provide.
Researchers at the Imperial College London wrote in a devastating new analysis that even stringent mitigation measures of case isolation, home quarantine, and social distancing “would still result in an 8-fold higher peak demand on critical care beds over and above the available surge capacity in ... the US.”
America’s hospitals do not appear ready. Tom Frieden, former CDC director under President Barack Obama, told me that in “any place there is community transmission,” hospitals should cancel elective surgeries so they can make more beds available to Covid-19 patients. Surgeon General Jerome Adams has made a similar plea.
But when Vox asked more than a dozen hospitals in major metro areas across the country where there is community transmission, we found that guidance is not being uniformly adopted. Hospitals are trying to balance the needs of the coronavirus pandemic with the needs of their regular patients, making it more difficult to expand their capacity ahead of a surge in coronavirus cases.
States are starting to take drastic steps to try to increase the number of hospital beds available, but there are limits on what they can do. New York Gov. Andrew Cuomo said Monday he would order the National Guard and building developers to convert existing facilities — dormitories and former nursing homes, for example — into makeshift hospitals. That order is expected to add 9,000 new beds to the 53,000 already available in the state. Maryland Gov. Larry Hogan issued a similar order the same day, adding 6,000 beds to the 9,000 existing beds in his state. Governors are urging the Trump administration to get the Army Corps of Engineers and the US military involved to set up temporary hospitals.
Complicating matters further is a shortage of basic medical supplies — masks, gloves, gowns, etc. — that hospital staff need to care for patients and protect themselves. The strain on health care workers will only get worse if nurses and doctors get sick because they lacked protective gear and then are unable to work.
I’ve spoken with nurses at major US hospitals who are certain they have already been exposed to the coronavirus because of these shortages and some lax protocols in the early coronavirus panic.
“We just need supplies,” Melissa Tizon, a spokesperson for the Providence St. Joseph hospital system, which has facilities in Seattle, the worst-hit US city so far, told me. “That’s the main thing we need to care for our patients.”
America has been, from the start, lagging behind in our response to the coronavirus pandemic. The next few weeks, and this test of our ability to dramatically expand US health care capacity, will determine how the outbreak goes from here.
America does not have enough ICU beds for the coronavirus outbreak
America has about 924,000 hospital beds, about 98,000 of which can be used for people who need intensive care, according to the American Hospital Association. The number of Covid-19 cases that will require ICU care could expand far beyond what the US is currently capable of providing.
The Imperial College London projections are just one set of estimates among many (based largely on modeling for influenza outbreaks instead of the current facts on the ground), but they paint a grim picture. The short version is that even the most aggressive mitigation strategies — general social distancing, quarantines, closing schools — will not be enough to prevent US hospitals from being overwhelmed eventually unless we commit to such drastic measures until a vaccine becomes available.
For people 60 and older, between 17 percent and 25 percent of cases are expected to require hospitalization; of those, 25 percent or more will require intensive care (as many as 70 percent for patients 80 and older), according to this analysis. The ability of hospitals to provide that care will be imperative if we are to protect those most vulnerable populations.
Frieden suggested hospitals could, for starters, attempt to turn operating rooms into temporary ICUs. Tizon, with the Providence hospitals in Washington, told me they were running predictive modeling on how many critical cases they can expect and that they are evaluating which other areas of the hospitals could be converted into ICUs.
“We are definitely taking steps to significantly increase our capacity to accommodate a rise in critical care patients,” Mona Locke, a spokesperson for the Swedish Medical Center in Seattle, told me. But she acknowledged they were still crunching numbers and could not be more specific: “Everything is fluid.”
Other hospitals told me they were adapting their existing surge capacity plans for the current crisis, but added that an extreme surge in Covid-19 cases would require help from federal and state authorities.
“We have ventilators for our current patients and for our surge plan,” a spokesperson for the Los Angeles County-USC Medical Center said in an email. “However, like all hospitals, if an extreme surge of patients presents, LAC+USC will depend on external resources from state and federal agencies.”
This is where the steps already being taken in New York and Maryland to set up temporary facilities could be useful. And the US military, though limited practically and legally in what it can do, could help to expand America’s health care capacity, as Vox’s Alex Ward reported:
The military also has thousands of physicians who could help treat patients. Dr. Angela Rasmussen, an infectious disease expert at Columbia University, told me the military could create new hospitals if needed — as New York Gov. Andrew Cuomo called on the Army Corps of Engineers to do — or repurpose current ones, for example by converting parts of hospitals into intensive care units.
But it will still be a race to increase hospital beds and ICUs quickly enough to meet the steadily rising number of coronavirus cases here in the US. And at the same time, hospitals must continue to care for the patients they already have.
Hospitals are not uniformly postponing elective surgeries, as public health officials have urged
Frieden told me that hospitals in areas where there is community transmission (which means the virus is spreading naturally among residents, not being brought in from other places) should postpone elective surgeries. Adams made a similar plea on Twitter over the weekend.
Hospital & healthcare systems, PLEASE CONSIDER STOPPING ELECTIVE PROCEDURES until we can #FlattenTheCurve!— U.S. Surgeon General (@Surgeon_General) March 14, 2020
Each elective surgery you do:
1) Brings possible #Coronavirus to your facilities
2) Pulls from PPE stores
3) Taxes personnel who may be needed for #COVIDー19 response https://t.co/WAUTXF5Vyc
That is easier said than done. While “elective” surgeries might sound like plastic surgery or something less urgent, any procedure that can be scheduled in advance falls under that category. So elective surgeries can include heart surgeries, removing kidney stones, cancer treatments, and more.
That’s why hospitals have bristled at these broad recommendations, asking government leaders to trust them to evaluate their situations and needs. The letter sent over the weekend to the Surgeon General by the major hospital associations explained their position:
We agree that the crisis as it develops may require the curtailment of the least critical or time-sensitive hospital services, but any curtailment must be nuanced to meet the needs of all severely ill patients. Our patients will be best served by carefully evaluating and prioritizing gradients of “elective” care to ensure that the most time-sensitive medically necessary care can be delivered by physicians and hospitals.
Based on Vox’s reporting, hospitals in Covid-19 hotspots are generally making the decision to postpone elective surgeries. The Seattle hospitals I have been in contact with said they were postponing most or all of their elective surgeries with the hope of freeing up their staff and facilities to treat coronavirus patients.
“The decision to postpone elective surgeries will free up staff from operating rooms, and they can hopefully be moved where they are most needed,” Locke at Swedish hospitals in Seattle told me. “This may allow Swedish to admit more medical patients as it decreases surgical patients. This is a delicate balance between the communities’ medical needs and surgical needs.”
Mount Sinai and New York-Presbyterian hospitals in New York City have delayed elective surgeries, as have the George Washington University hospital system in Washington, DC, Massachusetts General in Boston, and the LAC-USC medical system in Los Angeles.
But other hospitals where the virus is now starting to circulate in the community have not yet taken that step. Some hospitals in Denver, Chicago, and DC — all places where there are suspected cases of community transmission — have not postponed elective surgeries, according to their responses to our inquiries and internal communications reviewed by Vox. All of them said they were constantly reviewing their caseloads and the potential need for a delay in those procedures.
These are difficult decisions. One of the paramount public health concerns during a pandemic is how other patients will be affected as resources are taken away from them and directed to the current emergency. But the push and pull on elective surgeries compounds hospitals’ struggles to get ready for the crisis.
US hospitals do not have enough gear for their nurses and doctors
Another huge problem for US hospitals is basic protective gear, particularly masks for health care workers who are interacting with Covid-19 patients, as well as gloves, gowns, and more. I’ve heard that worry from hospitals and nurses, as have other reporters. From BuzzFeed News’s Rosalind Adams:
One of the nation’s top cancer hospitals has informed its staff it has a shortage of masks and other personal protective equipment, even as at least five employees and three patients have been diagnosed with COVID-19.
The hospital, Memorial Sloan Kettering Cancer Center in New York, has only a week’s supply of masks on hand, according to a transcript of a staff meeting last Friday afternoon. The shortage, Kreg Koford, senior vice president of supply chain and sustaining care, told employees, is due to production and distribution delays in China, where most personal protective equipment, or PPE, is manufactured.
As of late last week, Premier Inc., a major supplier to US hospitals, reported it had seen demand for surgical masks double from what they usually see: 55 million versus the typical annual demand of between 22 million and 25 million of the N95 masks that are the standard for health care workers.
“Most hospitals have only a couple weeks of supply,” the company wrote in an update on the supply chain.
Making more masks will be a challenge, as NPR reported: Chinese factories, where many such masks are made, only produce about 600,000 of those masks on average every day due to the difficulty in procuring the necessary materials.
One nurse at a large hospital in a major US city, who asked for anonymity to avoid retribution from their employer, shared with me one concerning story about the mask shortage. A patient was brought into the hospital’s ICU unit; the patient tested negative for flu but did not meet the CDC’s guidelines for coronavirus testing. The nurses were therefore not required to wear a mask when they interacted with the patient after that negative test.
It was later revealed one of the patient’s family members had recently been in Wuhan, China, and been confirmed to have Covid-19. After that information was revealed, then the patient was finally scheduled for a test and masks were used again. But there were several hours in between the negative flu test and the discovery that the patient could be a Covid-19 case when protective gear was not used.
The patient ended up coughing most of the night, potentially exposing nurses and other patients in the ICU ward. Yet even after the nurse gave notice about the potential exposure, their superiors said they could continue to work and did not need to wear a mask “because we’re on shortage.” Nurses were instructed that, even if they had confirmed exposure, they should come into work unless they have symptoms.
“They’re not protecting us. They’re taking away our masks,” the nurse said. “The one thing we are all worried about is we are shedding the virus to the most vulnerable populations.”
The US is trying to ramp up production of medical masks, with the federal government contracting with the company 3M to make tens of millions, but 3M faces the same challenges as Chinese manufacturers: a shortage of raw materials. The Trump administration has also considered, but not yet followed through on, utilizing the Defense Production Act in order to compel private manufacturers to increase their production of these needed supplies.
The entire health system is in a scramble to respond to the Covid-19 outbreak. Perfect processes can’t be expected. But as the scale of the problem becomes apparent, and the virus continues to spread, US hospitals are playing catch-up in a crisis.