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Will December's COVID-19 Crush Overwhelm Hospitals?

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Dec. 8, 2020 -- At the University Medical Center in El Paso, TX, a tent city is rising from the parking lot to handle the massive influx of COVID-19 patients.

In Wisconsin, an alternate care facility has opened at State Fair Park near Milwaukee to take overflow hospital patients from across the state, and the Mayo Clinic Health System has paused non-emergency procedures to free up staff for coronavirus cases.

Rhode Island became the first state to declare that all of its hospitals are “at capacity” this week and has turned to field hospitals, and medical centers across the country are hauling in mobile refrigerated morgues to store coronavirus deaths.

As the nation enters a frightening new phase of the COVID-19 crisis, hospitals and care facilities are grappling with tremendous spikes in new patients, and the CDC reported the coronavirus hospitalization rate is at an all-time high.

A record 102,148 coronavirus patients were hospitalized in the U.S. as of Monday, according to the Covid Tracking Project, which monitors CDC and hospital data across the country.

“The overall weekly hospitalization rate is at its highest point in the pandemic, with steep increases in individuals aged 65 years and older,” the CDC noted in its weekly “COVIDView” summary of cases. “Hospitalization rates for the most recent week are also expected to increase as additional data are reported.”

Infectious disease specialists say these ominous trends and projections suggest the worst is yet to come. A new surge in infections could further swamp hospitals across the country before the expected rollout of new vaccines begins in the weeks ahead.

“I think it is inevitable that this is just going to get worse before it gets better,” says Amesh Adalja, MD, an emerging infectious diseases specialist with the Johns Hopkins University Center for Health Security.

“People traveled a lot for Thanksgiving, [so] we will start to see the results of that, possibly by the end of this week, as people start getting into their incubation period and start developing symptoms and get tested.”

Leana Wen, MD, an emergency doctor and public health policy professor at George Washington University, agrees. She fears the next few weeks will bring a dangerous new peak in COVID-19 cases and hospitals will face the brunt of it.

“However bad things look right now … they’re going to get much worse,” she says, noting COVID-19 spikes have followed every major holiday this year -- the Fourth of July, Labor Day, and Memorial Day. “And there was unprecedented travel over Thanksgiving, the weather was colder than during the other holidays. So chances are there were more people congregating indoors, compared to previous holidays.”

Wen notes other factors are at work. What she calls “pandemic fatigue” is driving some Americans to let their guard down and not wear masks and social distance. Colder temperatures are driving Americans to spend more time indoors. And the holidays are a time for shopping, gift giving, and get-togethers with family and friends -- all of which can speed up the spread of COVID-19.

Even worse, the head of the CDC said in October that small household gatherings are a major source of new cases.

“Also, what we’re seeing now is a surge upon a surge upon a surge ... because every time there was a surge we never came back down to a low enough baseline,” she adds. “And now there is explosive spread that’s happening all across the country at exactly the worst time.”

What all of this means is hospitals and health care workers, already stretched thin, will need to brace for a new crush of patients they may not be able to handle.

The surge is leading some hospitals to take drastic measures. In Reno, NV, one hospital has set up an area in its parking garage where 1,400 patients could be treated. In Kansas, hospital chapels and cafeterias are being used to treat COVID-19 patients.

“Our hospitals are already getting overwhelmed,” Wen notes. “I’m extremely concerned what this is going to look like later in December.”

Shortage of Specialized Health Care Workers

It’s impossible to predict how hospitals will cope with the rise in COVID-19 patients. On one hand, medical centers are better prepared now to handle spikes in patients needing hospitalization than they were earlier this year, Adalja says.

On the other, Wen notes, the U.S. is not used to such a rise in infectious disease rates or hospitalization rates.

This past spring, hospitals in hot spots like New York City were unprepared to handle the huge influx in patients and faced widespread shortages of ventilators, ICU beds, and personal protective equipment for health care workers, such as masks and gowns.

This time around, the biggest problem will be a lack of qualified nurses, doctors, and health care workers trained to handle COVID-19, infectious disease experts say. It’s not just that the number of patients is increasing, either. The country’s largest nurses union reported in September that more than 1,700 health care workers have died from COVID-19 since the pandemic began. The CDC reported on Nov. 2 that it has tracked more than 200,000 cases of coronavirus among health care workers, according to the Journal of the American Medical Association.

“You can build new beds and get field hospitals, you can get more ventilators,” Wen explains. “But you cannot build new respiratory therapists and ICU nurses and doctors. That’s the single biggest challenge that we face -- a lack of health care workers.

“One estimate is that 1 in 5 hospitals are already facing a critical shortage of health care workers. Without them we don’t have a functional health care system.”

To meet the demand, hospitals in Illinois, Iowa, Florida, and other states are cross-training doctors and nurses to provide the specialized care COVID-19 patients need.

In addition, children’s hospitals in Colorado, Oregon, Ohio, and elsewhere are being converted to temporary care facilities for coronavirus patients.

The problem is that caring for COVID-19 patients requires doctors and nurses with specialized expertise, which takes years of training. What’s more, not all medical facilities are equipped to handle patients infected with the deadly virus.

“You can’t just use another doc or RN for this -- it’s not the same,” she says.

“Let’s say you have a doc or nurse who trained in internal medicine or pediatrics [retrained to] manage patients who are critically ill on ventilators. Yes, they can learn how, to some extent, but the care the patients receive is not going to be the optimal care.”

That highly specialized COVID-19 care has been a key factor in lowering the death rate of patients hospitalized since the start of the pandemic, studies show.

Although coronavirus cases have exploded in recent weeks, with new infections topping 1 million a week, a fewer people who get the virus are dying from it than 6 months ago. Data from the CDC shows that deaths dropped from 6.7% in April to 1.9% in September.

Wen fears this progress could be overwhelmed by a new surge in hospitalizations and shortages of specialized health care workers.

“We have been able to reduce mortality rates because of the exceptional care that’s provided by specialists, and that’s not the same if we literally run out of these specially trained individuals,” Wen says.

That’s already starting to happen in some states, where hospitals are turning to teams of traveling nurses, who travel from one hotspot to another.

Last week, the Wall Street Journal reported traveling nurses -- for whom hospitals pay as much as double to staff up -- are in demand across the country.

In New York, Gov. Andrew Cuomo has called on health care officials to recruit recently retired doctors and nurses with ICU training and infectious disease specialties.

Even so, these stopgap measures have not been enough for some medical centers, which have begun postponing non-emergency medical care or elective surgeries and limiting hospitalizations to only the sickest patients.

“We’re already seeing the rationing of care right now" because hospitals are crushed with the volume of patients, Wen says. “If a nurse who normally sees 10 patients is now seeing 20, if an ER doc who normally sees 30 patients is now seeing 60 ... just by definition, they’re going to have less time to spend with patients and the quality of care is going to suffer.”

She adds that she’s heard that some rural hospitals are facing such a crush that that they can no longer send COVID-19 patients who need high levels of care to urban medical centers. The pandemic is having a terrible trickle-down effect. In Kansas, health care officials say larger city hospitals are turning away more than 100 patients a month from smaller local hospitals.

“Many hospitals are already telling their patients that they are at capacity,” Wen says. “Rural hospitals are already facing a crush so that they have nowhere to send their patients who need higher levels of care. And urban hospitals have to take care of their own patients from their own area, and now they’re also dealing with the onslaught of patients from rural areas too.”

Hospice Facilities Also Facing Challenges

Hospitals aren’t the only health care facilities facing challenges. Hospice centers are also overwhelmed.

Robin Turner, MD, medical director of Duke University Health System’s homecare and hospice program, has seen firsthand the growing pressures COVID-19 has placed on facilities.

“Even from the beginning of the pandemic, when our cases were low here in Durham, there was significant need to plan for the surge,” he says.

“I think that the increase in COVID cases will continue to put stresses on hospices because the spread is community-based currently. This will continue to stress our staffing, and we don’t have a lot of back of staffing in the home health/hospice model.”

How Hospitals Are Coping

Adalja says hospitals across the country are responding to the surge in COVID-19 cases in four primary ways that are already impacting patients with coronavirus and other health conditions:

Postponing non-emergency care. Many hospitals have been forced to postpone elective surgeries and non-emergency services for non-COVID-19 patients to free up bed space, staffing, personal protective equipment, and ventilators that some patients might need after an operation.

“That’s the first thing you do,” he says, “You have to look and see which non-emergency procedures and processes can be eliminated in the hospital.”

Adjusting staffing. Hospitals are reassessing their staffing. That involves not only moving health care workers from certain departments to others, but also taking into account how to handle staff infections. In certain states, including North Dakota and Massachusetts, hospitals have elected to allow asymptomatic workers continue to care for patients.

“Your staff lives in the community, which also means that some percentage of your staff is going to be infected,” he explains. “So do you change those policies ... to allow asymptomatic health care workers to work in COVID units despite being positive? You have to think about that in order to make sure that you have enough resiliency in your staff to be able to handle that.”

Partnering with other hospitals. Small, independent and rural medical centers that do not have specialized health care workers on staff have faced the challenge of working with other facilities and incorporating telemedicine approaches to handle the influx of patients.

“If you’re a small hospital,” he notes, “you have to look and see what you can do in terms of other hospitals that you might want to partner with so that you can [handle] capacity and have transfer agreements in place for ICU beds or telemedicine, if you don’t have access to specialty doctors in critical care or infectious disease.”

Stocking up on equipment and supplies. Hospitals across the country have also struggled to maintain adequate supplies of equipment and critical medicines. Among them: the antiviral drug remdesivir, recently approved by the FDA to treat certain patients with COVID-19, as well as monoclonal antibody therapies, the anti-inflammatory dexamethasone, and sedatives for ICU patients.

“All of that is a part of what you have to think about,” Adalja notes.

It’s also important to note that hospitals don’t admit every patient with COVID-19. Many recover from the virus at home, sometimes with supplemental oxygen and home health care assistance.

But if the December surge in patients grows high enough, hospitals may have no choice but to turn away coronavirus patients who merit and need hospital care.

Adalja and Wen both agree there are reasons for hope, even in the face of the frightening prospect of a new surge in cases.

Hospitals are better prepared today than last winter and spring when the virus first emerged.

“We do know more about the disease now and we have new tools, and we’re better than we were back then ... because of the knowledge that we have today,” Adalja says. “We’re much better at taking care of these patients, we understand more who needs to be admitted, who doesn’t need to be admitted, we’re much better at using mechanical ventilators in the most judicious way.”

Secondly, the FDA has approved new drugs in recent months to help some COVID-19 patients recover.

“We have new tools like dexamethasone, which we know can decrease mortality,” Adalja notes. “We have drugs like remdesivir that may perhaps decrease lengths of stay in the hospital or get people better faster. We’re much better at anticipating complications and diagnosing people.”

Finally, new vaccines are also on the way, with the CDC this week approving a schedule that could allow for 100 million Americans to be vaccinated by March of next year.

In the meantime, hospitals will face tough times as they grapple with what many predict will be the worst period of the pandemic.

“Even though there’s great news about a vaccine, the vaccine is not going to do us much good this winter,” Wen says. “So at this point we just have to get through.”

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Sources

The New York Times: "As Hospitalizations Soar, El Paso Brings In New Mobile Morgues,” "Cuomo Fears ‘Nightmare of Overwhelmed Hospitals’ as Virus Cases Spike." 

Wisconsin Department of Health Services: "COVID-19: Alternate Care Facility at State Fair Park." 

Wisconsin Public Radio: "State-Run 'Alternate Care Facility' Has 15 COVID-19 Patients, As Wisconsin Hospitals Near Capacity." 

The Providence Journal: "Rhode Island hospitals are full. Covid field hospital opening today." 

CDC: “COVIDView.”

Twitter.com/Covid19Tracking

The Covid Tracking Project.

Amesh Adalja, MD, Johns Hopkins University Center for Health Security.

Leana Wen, MD, FAAEM, emergency doctor, public health policy professor. George Washington University.

KSB: “COVID Hub.”

Modern Healthcare: “As COVID-19 cases threaten capacity, children's hospitals resist taking adults.”

Wall Street Journal: “Soaring Covid-19 Hospitalizations Again Put Traveling Nurses in Demand.”

Journal of Hospital Medicine: “Trends in COVID-19 Risk-Adjusted Mortality Rates.”

STAT News: "Data show hospitalized Covid-19 patients are surviving at higher rates, but surge in cases could roll backgains,” “‘People are going to die’: Hospitals in half the states are facing a massive staffing shortage as Covid-19 surges.”

Robin Turner, MD, FAAHPM, medical director, Duke University Health System homecare and hospice program.

CNN: “CDC optimistic coronavirus vaccines will be released by end of the year.”

National Nurses United: “Sins of Omission.”

KBIA: “Kansas Hospitals Are Declining 100 Rural Coronavirus Patients A Month As Capacity Continues To Swell.”

Journal of the American Medical Association: “Health Care Workers Deserve Better Protections From Coronavirus Disease 2019.”

Medical News Today: “COVID-19: Hospital support staff hit harder than doctors and nurses.”

Christian Science Monitor: “Out of space, hospital moves COVID-19 patients to parking garage.”

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