As the number of confirmed coronavirus cases in the United States continues to rise and a flood of cases in other countries show the potential danger in a surge of infected patients, hospitals across the country are preparing for the worst.
Dr. Jeffrey Smith, chief operating officer for Cedars-Sinai, the esteemed Los Angeles medical center, told Yahoo News that his hospital is already starting to scale up its coronavirus response, although Los Angeles has only around 40 confirmed cases. That number is expected to increase rapidly in coming days, and Smith said Cedars-Sinai was sharing its best practices with other hospitals in the region.
He emphasized that containment measures including social distancing and cancellation of public events are crucial to avoiding a large spike in cases that could overwhelm the health care system.
Epidemiologists recognize that the coronavirus is likely to eventually infect a large swath of the population, and that older people in particular are likely to get sick, and some will die. The emphasis now is on slowing the spread to extend that outcome over weeks and months, giving hospitals and clinics time to prepare and avoiding a sudden surge in cases that could exceed their capacity.
“The social engineering methods that we’re putting in place — canceling schools, canceling large gatherings — to decrease the rate of spread, that’s really important to avoid a big rapid spike in cases, including critically ill cases that could tax our entire health system, including the availability of ventilators, patient rooms and critical-care resources,” said Smith.
According to Centers for Disease Control projections from last month reviewed by the New York Times, 2.4 million to 21 million people in the United States could require hospitalization, with as many as 200,000 to 1.7 million people dying in an epidemic that could last for a few months or over a year.
On Thursday, Cedars-Sinai set up a screening area in the parking lot outside the emergency room. This is also when they started to see an increase in patients with respiratory problems — coughing and shortness of breath — that along with fever are the presenting symptoms of COVID-19. Smith said that that allows them to keep the infected away from the general intake of those dealing non-coronavirus-related illnesses.
In order to protect staff members, patients who are suspected of having the virus are given masks to reduce the spread of droplets that could transmit the disease. Smith said that the mask supplies are an “ongoing challenge.”
“We’ve been working with local and federal officials to gain access to potential stockpiles to make sure we have an adequate supply,” said Smith. “One of the things that we’ve done is we’re managing the distribution of the personal protective equipment very tightly so that people aren’t hoarding or potentially stealing it. We make sure the people who need to have the equipment really do have it and we want to make sure that it is being used in the appropriate circumstances but not being overused by the patients where it’s not necessary.”
The CDC has already allowed hospitals to relax their protocols for use of protective masks — allowing medical personnel to use regular surgical masks in some situations, owing to a shortage of the more protective N95 masks. Health and Human Services Secretary Alex Azar said up to 5 million of the masks in the National Strategic Stockpile could be past their expiration dates.
The hospital is also keeping a log of every staff member who enters or exits the room of a suspected coronavirus patient, to ensure that quarantines are imposed when necessary, and only when necessary. Smith said they’re attempting to secure additional staffing, but there are problems outside the hospital’s control, including school closures, which put pressure on staff members to find childcare.
At present, tests take 24 to 48 hours for results, and the hospital is only testing patients who are most at risk. To avoid its emergency department being overrun, Cedars-Sinai is screening patients by phone and if their symptoms suggest they are infected, they are referred to a central testing area — at a clinic the hospital commandeered to further reduce the potential for transmission of the virus.
Experts warn that the U.S. needs to prepare for a worst-case scenario similar to the experience of Italy, where the health system is running out of hospital beds for patients sick with COVID-19. While most coronavirus infections are mild and do not require hospitalization, severely affected patients may require weeks on a ventilator in an intensive care unit. Care for patients with non-coronavirus-related ailments may suffer.
The Center for Health Security at the Johns Hopkins University estimated last month that the U.S. has a total of 160,000 ventilators deployed in health care facilities, with at least an additional 8,900 in the national stockpile. In an interview Thursday night, Seema Verma, administrator of the White House Centers for Medicare and Medicaid Services, refused to answer questions about whether the country had enough ventilators.
“The stockpile is there and we hope that it is adequate,” Verma told CNN on Friday. “But I think it is important to know that’s why we’re focusing so much on the prevention of this and trying to mitigate the spread — so we don’t create a situation where our whole health care system is unduly stressed.”
Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University, called Verma’s comments “stunning” and “nonsense.”
“We are so incredibly underprepared for a major onslaught to hospitals, which is basically now inevitable,” Redlener said. “We have to look at Italy and see what happened and I think we’re actually in worse shape. We don’t have enough hospital beds, we don’t have enough ICU beds. And by the way, even if we had the 100,000-plus ventilators that we actually need, we don’t have the staff to operate them.”
The potential deluge of patients is something that worries Smith, who said that social distancing and bans on large gatherings are critical in avoiding the breakdown of the health care system.
“We are really concerned when we talk to colleagues in Italy or other European countries to hear about some of the hard choices they’ve had to make in rationing care in certain circumstances,” said Smith. “We’re working really hard to make sure we’re able to provide care for all patients and that’s going to require a significant community-wide effort. We’re not even close to that point yet and we’re working hard never to get there but that would be our concern: At some point, we’d have to make some very difficult ethical decisions about who would benefit from care.”
Some areas of the country could already be dealing with the worst: New York Times columnist Nicholas Kristoff said Friday night that a Seattle-area hospital sent out a note to staff that it was suspending elective surgery along with a warning that "our local COVID-19 trajectory is likely to be similar to that of Northern Italy.” Kristoff added that the hospital is down to a four-day supply of gloves.
Smith said there are plans in place at Cedars-Sinai if the surge comes, including co-locating coronavirus patients in certain areas of the hospital, canceling elective surgeries that would free up staffers from departments and further reducing outpatient care not related to the virus. He said they have an adequate number of ventilators now and are working to make sure they have a line to governmental caches if necessary. They’re also taking precautions with visitors, blocking anyone showing signs of coronavirus, which can be distressing for those wanting to spend time with loved ones, particularly those who are older or otherwise physically compromised.
Concerns of a systemic breakdown due to a spike in patients is shared widely. An analysis published by Harvard’s T.H. Chan School of Public Health on the potential demand faced by U.S. hospitals found that, in order to accommodate an outbreak similar to the one in Wuhan, the U.S. would likely need three times the number of unoccupied intensive care unit beds that are typically available here now.
“Plans are urgently needed to mitigate the effect of COVID-19 outbreaks on the local health care system in U.S. cities,” the authors of the analysis concluded.
“I think cities need to act to reduce social distance, promptly isolate cases and/or quarantine contacts before hospital capacity is reached, because by the time maximum capacity is needed, it means in the next 5 to 7 days the hospitals are going to expect double the number of severe patients,” Ruoran Li, a graduate student at the T.H. Chan School of Public Health and one of the authors of the analysis, said in an email to Yahoo News. “So prepare now to avoid surprises.”
According to the Wall Street Journal, some major health systems, such as the Ohio-based Cleveland Clinic, have contingency plans in place to increase bed capacity to accommodate a potential influx of coronavirus patients, including suspending elective procedures and using either a nearby hotel or field hospital to set up additional hospital beds.
On Thursday, the University of Iowa Hospitals and Clinics announced new measures to address growing numbers of coronavirus infections as an example of steps many hospitals may need to take. These include arranging video visits for patients with flu or coronavirus-like symptoms, and dedicated screening clinics in which patients can be tested after their video consultations. New visitor restrictions have also been put in place at all University of Iowa health care facilities, limiting visitors to two “healthy” adults per patient and prohibiting any visitors who exhibit flu-like symptoms and urging people with various other symptoms to postpone visits. Additional measures to conserve personal protective equipment for staff, such as face masks, gloves and hand sanitizer, have also been implemented.
Worst-case scenarios may be avoided, if government leaders, health care professionals and everyday citizens take appropriate measures. Joe DeRisi, professor of biochemistry and biophysics at University of California-San Francisco, told Yahoo News, “The introduction of human behavior modifications [social distancing], possible drugs, and even vaccines may alter the course of this pandemic significantly, thus making any sort of predictions a constant moving target.”
While Cedars-Sinai is financially stable, Smith said other hospitals are likely to need government intervention because the things they do to make money — elective procedures and outpatient appointments — are being cut to make time for the costly fight against the pandemic. That’s the reality for Cedars-Sinai and every other hospital treating this disease: If experts are correct and social distancing prevents a spike in cases that overwhelms the system — obviously desirable — the U.S. could still be dealing with coronavirus infections for months to come, as infections spread more gradually, but inexorably, through the population.
“This certainly is very stressful for our caregivers, although we’re highly trained and skilled and take care of sick patients all the time, our staff is worried about their families,” said Smith. “Already, especially among our leadership and epidemiology staff and others who have been caring for these patients and making sure we have these systems in place, we’re getting exhausted already, so managing that energy level is really going to be important. Spreading that burden and taking care of each other is going to be really important throughout this.”
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