A Blog by Jonathan Low


Apr 11, 2020

Which US Areas Are Most Vulnerable To Hospitals Being Overwhelmed By Covid-19?

There are more than most experts would have thought possible. And they're not always where expected.

Which is why experts are concerned about claiming the danger is over too soon. JL

Amy Brittain and colleagues report in the Washington Post:

More than half of the nation’s population lives in areas less prepared than New York City. The analysis key metrics: hospital beds, ICU beds and ventilator usage in a year-long scenario in which the coronavirus sickens 20% of U.S. adults, and 20% of those infected require hospitalization. Under that scenario, 11 million adults would need hospitalization for two weeks, and 2.5 million require intensive care. 30% of the adult population live in areas where the number of ICU beds would not be enough. For ventilator availability, half the adult population lives in regions where demand would exceed supply
If a health official wanted to know how many intensive-care beds there are in the United States, Jeremy Kahn would be the person to ask. The ICU physician and researcher at the University of Pittsburgh earns a living studying critical-care resources in U.S. hospitals.
Yet even Kahn can’t give a definitive answer. His best estimate is based on Medicare data gathered three years ago.
“People are sort of in disbelief that even I don’t know how many ICU beds exist in each hospital in the United States,” he said, noting that reporting varies hospital to hospital, state to state. “And I’m sort of like, ‘Yep, the research community has been dealing with this problem for years.’ ”
Amid the covid-19 pandemic, pinpointing the number and location of ICU beds, ventilators and doctors with specialized training is critical for local, state and federal officials trying to forge an effective response. But the pandemic has revealed a dearth of reliable data about the key parts of the nation’s health-care system now under assault. That leaves decision-makers operating in the dark as the virus — which has now killed more than 16,000 people in the United States — surges, spreading from urban areas like New York City and New Orleans into the rest of America.
Given the limitations, The Washington Post assembled data to analyze the availability of the critical-care resources needed to treat severely ill patients who require extended hospitalization. The Post conducted a stress test of sorts on available resources, which revealed a patchwork of possible preparedness shortcomings in cities and towns where the full force of the virus has yet to hit and where people may not be following isolation and social distancing orders.

Are your hospitals at risk of being overwhelmed by covid-19 patients?

Hospital referral regions are the service areas for major, regional hospitals defined by analysis of patient billing data. The 306 regions across the country are made up of multiple Zip codes and regularly cross county and state lines.

If 2 in 10 adults are infected:

Available bedsNo.Virus patients would need less than two thirds of available beds.
ICU bedsMaybe.Virus patients would need more than two thirds of ICU beds.
Mechanical ventilatorsYes.Virus patients would need more than the available supply of mechanical ventilators.
This scenario is based on estimates of pre-pandemic resources and doesn't include recent changes.

Montgomery, AL, compared to other hospital regions:

Hospital beds: ABOUT 285 PER 100,000 PEOPLE
Per capita, in eachof 306 hospital regionsFewerMore
ICU beds: ABOUT 41 PER 100,000 PEOPLE
Mechanical ventilators used: ABOUT 13 PER 100,000 PEOPLE
Mechanical ventilators used represent estimates of the highest number of mechanical ventilator patients.
More than half of the nation’s population lives in areas that are less prepared than New York City, where in early April officials scrambled to add more ICU beds and find extra ventilators amid a surge of covid-19 patients.
The analysis draws on key metrics: total hospital beds, ICU beds and ventilator usage, as recorded in data sets assembled by Definitive Healthcare, an analytics company that mines government filings, including those of the Centers for Medicare and Medicaid Services (CMS), as well as commercial insurance claims. Locations of these critical-care resources were mapped by hospital referral zones, or areas where residents receive their hospital care, as determined by Dartmouth College.
As the virus has spread, researchers globally are continuing to model outcomes that reflect varying assumptions about the disease, including the number of infections in different countries, the availability of testing and the impact of social distancing.
To compare available resources across the country, The Post examined a year-long scenario in which the coronavirus would sicken 20 percent of U.S. adults, and about 20 percent of those infected would require hospitalization. Under that scenario, about 11 million adults would need hospitalization for nearly two weeks, and almost 2.5 million would require intensive care. This level of hospitalization is considered by Harvard researchers to be a conservative outcome for the pandemic, while others have described it as severe.
In The Post’s scenario — which does not predict deaths or the effects of social distancing — about 76 million people, or 30 percent of the nation’s adult population, live in areas where the number of available ICU beds would not be enough to satisfy the demand of virus patients. The scenario for ventilator availability is even more dire: Nearly half of the adult population lives in regions where the demand would exceed the supply. Strict adherence to social distancing is likely to reduce those numbers by an unknown amount.
Pennsylvania Task Force 1 member Greg Rogalski walks in late March among the beds of a federal medical station for covid-19 patients set up at Temple University’s Liacouras Center in Philadelphia. (Matt Rourke/AP)
Informed planning by emergency officials, experts said, is greatly hampered by gaps in knowledge about health-care resources.
“We need to know where our weapons are. We need to coordinate all of that,” said Retsef Levi, a Massachusetts Institute of Technology professor leading a health-care data initiative called the COVID-19 Policy Alliance. “This is a war.”
Kahn likened the task of evaluating the current readiness of the U.S. health-care system to peering into a dark room.
“We’re outside of it, and we’re all looking through different keyholes and seeing different aspects of it,” he said. “But there’s no way to just open the door and turn on the lights, because of how fragmented the data are. And that is a really, really depressing thing at all times, let alone during a pandemic, that we don’t have an ability to look at these things.”
Owensboro — a small city in western Kentucky on the south bank of the Ohio River — offers a case study of what could unfold amid a coronavirus outbreak. In the projected scenario, covid-19 patients would occupy all of the available ICU beds in the region, which is served by the 352-bed Owensboro Health Regional Hospital and one smaller hospital. The region would need 75 percent more ventilators than it has ever used in the past.
“We’ve never seen something like this, something this big,” said Vicki Wheatley, a 63-year-old retiree who lives in Hawesville, a small town near Owensboro.
For Owensboro and some other hospital regions, The Post also evaluated the availability of health-care professionals — the doctors, nurses and respiratory therapists who are specially trained to care for critically ill patients in the ICU, and whose ranks around the country will probably thin as they become ill and are quarantined. National certification boards provide only aggregate data about critical-care professionals. The Post used the CMS list of medical providers to identify thousands of those specialists and where they work, but the list does not include all specialties.
Number of beds at each hospital
Owensboro Hospital Region
147,801 people
Critical-care physicians: AT LEAST 5, ACCORDING TO LOCAL HOSPITALS
Per capita, in each of the 306 hospital regions
Critical-care nurse practitioners: AT LEAST 3, ACCORDING TO LOCAL HOSPITALS
Hospital beds: ABOUT 297 PER 100,000 PEOPLE
ICU beds: ABOUT 35 PER 100,000 PEOPLE
Mechanical ventilators used: ABOUT 10 PER 100,000 PEOPLE
Michael Muzoora is one of just five critical-care physicians at Owensboro Health. Before covid-19, the 43-year-old pulmonologist split his time between the ICU and his office practice, where he treats patients who suffer from respiratory issues such as asthma and chronic lung disease.
Now, Muzoora is preparing to shift all of his time and energy to the 32-bed ICU at Owensboro Health. At night, the hospital relies on physicians 200 miles away in Cincinnati to peer into patients’ rooms through tele-ICU technology and provide bedside instructions to hospital nurses or physician assistants.
A typical day for Muzoora in the ICU once meant treating 10 to 15 patients. Now, he is trying to imagine the chaos in New York City hospital rooms unfolding in his own workplace.
“I’ve thought about what it would be like,” Muzoora said. “It certainly brings up the question of how you prioritize if you’re overrun. Even with the best intentions, you just won’t be able to do everything.”

‘Micro-geographies’ of vulnerability

Scientists around the world are scrambling to understand how the coronavirus has spread rapidly in some geographic areas while leaving others less affected.
In Italy, the hardest-hit region was not a booming metropolis, but Bergamo, a city with a population of about 120,000.
Bergamo, as the ground zero of the Italian outbreak, was beset by ICU bed and ventilator shortages. “We think Italy may be the most comparable area to the United States, at this point, for a variety of reasons,” Vice President Pence said April 1 in a CNN interview.
Researchers at MIT have studied Bergamo to look for factors that may have left the area uniquely vulnerable to covid-19.
The MIT research group, the COVID-19 Policy Alliance, has mapped high-risk areas in the United States where sudden spikes could inundate hospitals as the surge in northern Italy did.
In their U.S. analysis, MIT researchers considered several risk factors, including elderly population, high blood pressure and obesity.
Highlighted risk of covid-19 deaths
The orange and red areas of higher risk may have more hospitalizations and deaths for people who are infected. Risk is higher with age and existing health problems such as diabetes, high blood pressure and obesity. Most urban areas are relatively low-risk because there are so many young and healthy people.
Localized risk score based on older and sicker people
Circles are scaled by county population
Source: County-level health data from MIT covidalliance.com
The takeaway, the researchers said, is that across the nation, “micro-geographies” of individual Zip codes or small towns have the potential to generate surges of covid-19 patients that could overwhelm even the most-
prepared hospitals.
“It could create a load on a hospital that can crush a hospital,” said Levi, the professor leading the research alliance.
Levi said nursing home populations should be prioritized for virus testing across the country, because outbreaks in such close quarters can rapidly sicken dozens of people, who then flood into area hospitals. The deadly outbreak at the Life Care Center nursing home in Kirkland, Wash., which was linked to more than 100 illnesses and 40 deaths, provided an early U.S. case study for the MIT team. Now, in Louisiana, officials have identified at least 40 clusters of cases in long-term care facilities.
In Seattle, critical-care physician Nick Johnson is on a team of health-care providers responsible for drafting a covid-19 “surge plan” at Harborview Medical Center, which is part of UW Medicine and serves as the only Level 1 trauma center in Washington state. The hospital also regularly accepts emergency transfers from Montana, Idaho, Wyoming and Alaska.
Nurses wait for cars at a drive-up coronavirus testing station at Harborview Medical Center in Seattle. (Ted S. Warren/AP)
Harborview recorded the first death of a covid-19 patient in the United States and also treated several of the Kirkland nursing home patients.
“Our hospital was running at over 100 percent capacity all the time, pretty much before this happened,” Johnson said. “And we’ve done a lot of things really early and aggressively to cancel elective surgeries and to try to free up space. But the system’s already pretty taxed.”
By The Post’s analysis, the general Seattle region would need all of its available ICU beds — plus a 15 percent increase — to handle an outbreak in which 20 percent of the population is infected with the coronavirus and 20 percent of those people need hospitalization. But the demand for ICU beds could be lower because the curve of infections in Washington appears to be flattening, according to officials.
Number of beds at each hospital
Seattle Hospital Region
3,051,857 people
Critical-care physicians: AT LEAST 206, ACCORDING TO FEDERAL RECORDS
Per capita, in each of the 306 hospital regions
Critical-care nurse practitioners: AT LEAST 55, ACCORDING TO FEDERAL RECORDS
Hospital beds: ABOUT 152 PER 100,000 PEOPLE
ICU beds: ABOUT 33 PER 100,000 PEOPLE
Mechanical ventilators used: ABOUT 12 PER 100,000 PEOPLE
Johnson said Harborview’s surge plan could double its ­existing 89 ICU beds by converting other hospital rooms into ­critical-care units. The plan would boost ICU staffing by teaming up surgeons and other doctors with ICU experience with nurses and respiratory therapists under the direction of critical-care physicians.
“I think of a critical-care doctor in the ICU as sort of being the quarterback of the team,” Johnson said. “We rely on and count on a lot of different people to contribute to the care of these really complicated patients. But it’s our job to sort of maintain the broad view and situational awareness over what’s happening with the entire patient.”
The Society of Critical Care Medicine estimates that there are nearly 29,000 critical-care specialized physicians like Johnson who are trained to work in ICUs in the United States. Yet about half of all acute-care hospitals have no specialists dedicated to their ICUs. Because of the demands of treating covid-19 patients, the lack of dedicated physicians “will be strongly felt” through a lack of high-quality care, the society said in a statement.
The society also projects that the nurses, respiratory therapists and physician assistants specially qualified to work with ICU patients may be in short supply as patient demand increases and the ranks of medical workers are thinned by illness and quarantine.
“We want to protect our health-care workers. They’re our greatest resource,” said Megan Brunson, president of the American Association of Critical-Care Nurses. “And I would say that is one of my greatest concerns. If people ask me what keeps me up at night, that definitely would be it.”
Experts say experienced critical-care physicians and nurses are essential to executing techniques that can save lives. One example is prone ventilation — sometimes known as “proning” — for acute respiratory distress syndrome. Patients are carefully placed on their stomachs, sometimes for hours, allowing gravity to do the heavy work of alleviating fluid buildup in the back of the lungs.
Early studies out of China and Italy have shown that proning has helped some covid-19 patients.
“It’s mostly executed by the ICU nurses,” Johnson said. “The doctors are sort of asked to collaborate and to provide some general oversight and help with safety, but it definitely can be done by experienced teams of nurses.”

‘Drilling and preparing’

On paper, Iowa City is well prepared for this pandemic.
The region has more critical-care physicians per capita than nearly anywhere else in the country and ranks well in ICU bed and ventilator capabilities, according to The Post’s review.
Health officials in Iowa City said they have several factors working in their favor. The University of Iowa Hospitals and Clinics attracts top academic researchers who specialize in critical care. The major medical center has 190 ICU beds — almost six times the number at Owensboro Health, for comparison, while serving a population about twice that served by the Kentucky hospital.
“I feel confident in my people and the work that we’re doing to prepare as best we can for what is to come,” said Theresa Brennan, the chief medical officer at the University of Iowa.
Number of beds at each hospital
Sioux City
Des Moines
Iowa City Hospital Region
357,105 people
Critical-care physicians: AT LEAST 101, ACCORDING TO FEDERAL RECORDS
Per capita, in each of the 306 hospital regions
Critical-care nurse practitioners: AT LEAST 27, ACCORDING TO FEDERAL RECORDS
Hospital beds: ABOUT 410 PER 100,000 PEOPLE
ICU beds: ABOUT 88 PER 100,000 PEOPLE
Mechanical ventilators used: ABOUT 22 PER 100,000 PEOPLE
Brennan said the hospital ranks high nationally by statistics that show how often it accepts patients transferred from other facilities for more-
advanced care. She said the mission will not change, even if the pandemic drives up the number of patients. As of Wednesday, 16 covid-19 patients were hospitalized there.
“If we have a bed and a patient needs that bed and can’t be cared for in one of our hospitals in Iowa or beyond, we would take that patient,” she said.
Brennan said her hospital already had a substantial stockpile of personal protective equipment accumulated after it was named a “Prevention Epicenter” by the Centers for Disease Control and Prevention four years ago. In the wake of the devastating Ebola outbreak in West Africa, the agency granted the University of Iowa $2.2 million to support research and outbreak preparedness efforts. There are 11 such centers in the country.
So what has the hospital been doing as a prevention epicenter in the four years between the Ebola epidemic and the emergence of the coronavirus pandemic?
Lynn Rhinehart, a guest services staff member, checks Stephanie Silva’s temperature at a screening checkpoint outside the University of Iowa Hospitals and Clinics. (Rebecca F. Miller/The Gazette/AP)
“Drilling and preparing for it,” said Jorge Salinas, an infectious-disease physician working on the effort. “You may be preparing and training for 10 years and nothing happens. But if you don’t do that, when these pandemics do occur, you will not be prepared.”
Ebola is clearly not the same as covid-19, Salinas noted, adding that Ebola is far more deadly but not as easy to contract. But he said the frequent drills and stockpile of supplies, including masks, gowns and gloves, will prove useful during the hospital’s treatment of covid-19 patients.
Salinas said the pandemic has exposed the long-standing flaws in the nation’s “individualistic” health-care system, where hospitals look out for themselves. Electronic health-monitoring systems vary hospital to hospital. Supply tallies are kept in-house and generally not shared. To counter this in Iowa, he said, all hospitals have begun sharing daily information with state officials.
“The name of the game is solidarity,” Salinas said. “If we try to be individualists, we will fail.”

‘We’re in the center of no place’

In Lubbock, Tex., Cynthia Jumper does not hesitate to talk about the limitations of treating patients in this remote part of West Texas.
“We’re in the center of no place,” said Jumper, a physician and professor of medicine at the Texas Tech University Health Sciences System. “Dallas and Albuquerque are 300 miles away.”
She is a native of Lubbock, recalling a slogan from the 1970s: “Lucky me! I live in Lubbock.” So far, Jumper believes her beloved hometown is prepared for the pandemic. As of Tuesday, there were 191 reported covid-19 cases in Lubbock County.
She said she is more concerned for the rural community hospitals that sometimes refer patients to her 476-bed hospital, with 104 ICU beds. She pointed to Monahans, a town 175 miles south with about 8,000 residents.
Number of beds at each hospital
Ft. Worth
El Paso
Lubbock Hospital Region
737,207 people
Critical-care physicians:
Per capita, in each of the 306 hospital regions
Critical-care nurse practitioners: AT LEAST 6, ACCORDING TO FEDERAL RECORDS
Hospital beds: ABOUT 457 PER 100,000 PEOPLE
ICU beds: ABOUT 106 PER 100,000 PEOPLE
Mechanical ventilators used: ABOUT 32 PER 100,000 PEOPLE
“We have a lot of smaller hospitals around us,” she said. “If our hospital’s full, what is a guy in Monahans, Texas, with two ICU beds and one ventilator going to do?”
If need be, Jumper said, rural facilities without critical-care physicians can turn to telemedicine, where physicians can consult remotely. She said she has offered her cellphone number to rural providers.
Back in western Kentucky, 64-year-old Marshall Prunty also knows the limitations of practicing in a rural setting. He works
at a community hospital in Muhlenberg County. The facility has only 55 hospital beds. A rich history of coal mining and tobacco farming have led to high rates of chronic obstructive pulmonary disease, Prunty said.
Prunty is a “hospitalist,” a primary physician for hospitalized patients. He also regularly sees patients in the hospital’s six-bed ICU. And, when he is not there, he gives his number to the nurse and says to call if there is any trouble.
“Probably on average we may have three patients in there,” he said, noting that they have three ventilators and are trying to secure more.
Prunty said he lacks training in certain critical-care techniques that could be deployed in hospitals staffed with highly specialized physicians. He has no experience, for instance, using prone ventilation.
“You know, as the pandemic might progress, and we’re having more and more patients with covid-19, I think the plan is to probably transfer [the patients] unless they’re just minor illnesses,” Prunty said.
He said he would send patients an hour’s drive north to the area’s only major medical center, Owensboro Health — the hospital where pulmonologist Muzoora and his four critical-care colleagues would be entrusted with handling the surge.
At Owensboro Health, the full force of the pandemic has yet to strike. As of Wednesday, 10 covid-19 patients were hospitalized there. Staff members believe, however, that they have just days before they face the onslaught.
“You’ve got to dust off all of your policies and procedures, and get your teams up and running. Everybody is set and ready to go,” said Francis DuFrayne, Owensboro’s chief medical officer.
“And now . . . we’re really just waiting.”


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