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U.S. Hospitals Prepare for Coronavirus, With the Worst Still to Come U.S. Hospitals Prepare for Coronavirus, With the Worst Still to Come
(7 days later)
WASHINGTON — One Seattle-area hospital has already seen patient care delayed by the stringent infection-control practices that the government recommended for suspected coronavirus cases. Another in Chicago switched Thursday morning into “surge” mode, setting up triage tents in its ambulance bay and dedicating an entire floor to coronavirus patients. At least one is already receiving emergency supplies from the federal government’s stockpile.WASHINGTON — One Seattle-area hospital has already seen patient care delayed by the stringent infection-control practices that the government recommended for suspected coronavirus cases. Another in Chicago switched Thursday morning into “surge” mode, setting up triage tents in its ambulance bay and dedicating an entire floor to coronavirus patients. At least one is already receiving emergency supplies from the federal government’s stockpile.
With the bow wave of coronavirus infections still to come, hospitals across the country are trying to prepare for a flood of critically ill patients who will strain their capacities like nothing they have seen in at least a generation. Even with some time to prepare, administrators fear they will not be ready.With the bow wave of coronavirus infections still to come, hospitals across the country are trying to prepare for a flood of critically ill patients who will strain their capacities like nothing they have seen in at least a generation. Even with some time to prepare, administrators fear they will not be ready.
Staffing shortages could hinder care if doctors and nurses become infected. There may not be enough ventilators or bed space for a crush of seriously ill patients.Staffing shortages could hinder care if doctors and nurses become infected. There may not be enough ventilators or bed space for a crush of seriously ill patients.
“Our hospitals are already stretched to capacity,” said C. Ryan Keay, the medical director of the emergency department at Providence Regional Medical Center in Everett, Wash., near Seattle, which is dealing with the largest outbreak in the country. “We’re a hospital that is always full, so it doesn’t take much to tip us over the edge.”“Our hospitals are already stretched to capacity,” said C. Ryan Keay, the medical director of the emergency department at Providence Regional Medical Center in Everett, Wash., near Seattle, which is dealing with the largest outbreak in the country. “We’re a hospital that is always full, so it doesn’t take much to tip us over the edge.”
The novel coronavirus could result in 10 million to 34 million hospital visits, based on statistics from other countries, according to the Harvard Global Health Institute. About one-fifth of those patients will require intensive care. With 2.8 hospital beds per 1,000 people, the United States has fewer than Italy’s 3.2 beds per 1,000, China’s 4.3 and South Korea’s 12.3.The novel coronavirus could result in 10 million to 34 million hospital visits, based on statistics from other countries, according to the Harvard Global Health Institute. About one-fifth of those patients will require intensive care. With 2.8 hospital beds per 1,000 people, the United States has fewer than Italy’s 3.2 beds per 1,000, China’s 4.3 and South Korea’s 12.3.
The estimated 45,000 intensive care unit beds in the United States would be swamped by even a moderate outbreak of about 200,000 in need of I.C.U. admission.The estimated 45,000 intensive care unit beds in the United States would be swamped by even a moderate outbreak of about 200,000 in need of I.C.U. admission.
“I am very, very worried,” said Ashish K. Jha, who directs the Harvard Institute.“I am very, very worried,” said Ashish K. Jha, who directs the Harvard Institute.
The strain is already playing out in unexpected ways. Since admitting the first known case in the United States, Dr. Keay’s hospital has followed Centers for Disease Control and Prevention protocols for sanitizing facilities used by multiple patients with suspected coronavirus infection, which resulted in slower treatment.The strain is already playing out in unexpected ways. Since admitting the first known case in the United States, Dr. Keay’s hospital has followed Centers for Disease Control and Prevention protocols for sanitizing facilities used by multiple patients with suspected coronavirus infection, which resulted in slower treatment.
“If somebody had to go in for a chest X-ray, as most of these patients do, the X-ray room would need to be down for 30 minutes afterward to reverse the airflow and sanitize,” Dr. Keay said. “If you have lots of patients, that becomes a huge issue and delay.”“If somebody had to go in for a chest X-ray, as most of these patients do, the X-ray room would need to be down for 30 minutes afterward to reverse the airflow and sanitize,” Dr. Keay said. “If you have lots of patients, that becomes a huge issue and delay.”
Another unanticipated development: More moderate forms of breathing support, such as nebulizers and Bipap machines, should spare ventilators for the worse cases, but those technologies cannot be used on coronavirus patients because they risk releasing particles into the air.Another unanticipated development: More moderate forms of breathing support, such as nebulizers and Bipap machines, should spare ventilators for the worse cases, but those technologies cannot be used on coronavirus patients because they risk releasing particles into the air.
Hospitals can take steps to increase their capacity, for instance by canceling some elective procedures or repurposing facilities meant to care for psychiatric patients. The most critical action, however, is outside hospitals’ control: slowing the spread of the virus through hygiene and social distancing, so cases spread out and the health system can treat patients who need care.Hospitals can take steps to increase their capacity, for instance by canceling some elective procedures or repurposing facilities meant to care for psychiatric patients. The most critical action, however, is outside hospitals’ control: slowing the spread of the virus through hygiene and social distancing, so cases spread out and the health system can treat patients who need care.
Most hospitals maintain disaster preparedness plans for multiple situations, such as mass casualties and novel infectious diseases. Those contingency plans are typically for a surge in capacity of up to 20 percent, hospital executives said. Some experts believe that hospitals could increase their capacity by resorting to more extreme measures, such as sending patients home earlier than planned or renting space at nearby facilities to set up makeshift hospital rooms.Most hospitals maintain disaster preparedness plans for multiple situations, such as mass casualties and novel infectious diseases. Those contingency plans are typically for a surge in capacity of up to 20 percent, hospital executives said. Some experts believe that hospitals could increase their capacity by resorting to more extreme measures, such as sending patients home earlier than planned or renting space at nearby facilities to set up makeshift hospital rooms.
The American Hospital Association has lobbied the Trump administration for flexibility to further stretch capacity by allowing physicians to practice in states where they are not licensed and waiving requirements that Medicare enrollees stay at a hospital for three days before moving to a long-term care facility.The American Hospital Association has lobbied the Trump administration for flexibility to further stretch capacity by allowing physicians to practice in states where they are not licensed and waiving requirements that Medicare enrollees stay at a hospital for three days before moving to a long-term care facility.
“This is an unusual case where we have a new disease, no immunity and no vaccine,” said Nancy Ann Foster, the American Hospital Association’s vice president for patient safety. “As we watch it in other countries, we realize it has the potential to spread quite easily.”“This is an unusual case where we have a new disease, no immunity and no vaccine,” said Nancy Ann Foster, the American Hospital Association’s vice president for patient safety. “As we watch it in other countries, we realize it has the potential to spread quite easily.”
Rush University Medical Center, the largest hospital in Chicago, put its surge protocols into effect Thursday morning for the first time in its 183-year history. The hospital has treated four confirmed cases of coronavirus and expects an onslaught in the coming weeks.Rush University Medical Center, the largest hospital in Chicago, put its surge protocols into effect Thursday morning for the first time in its 183-year history. The hospital has treated four confirmed cases of coronavirus and expects an onslaught in the coming weeks.
“We made the decision to surge because of the concern we’re seeing nationally and internationally,” said Omar B. Lateef, the hospital’s chief executive. “The W.H.O. is making statements about the risks of inaction, so we felt a responsibility to do something.”“We made the decision to surge because of the concern we’re seeing nationally and internationally,” said Omar B. Lateef, the hospital’s chief executive. “The W.H.O. is making statements about the risks of inaction, so we felt a responsibility to do something.”
Rush officials estimate that new triage tents outside — with chairs spaced 6 feet apart, the distance the World Health Organization recommends for separating infected individuals — and additional beds inside will increase the hospital’s emergency department capacity by 40 percent.Rush officials estimate that new triage tents outside — with chairs spaced 6 feet apart, the distance the World Health Organization recommends for separating infected individuals — and additional beds inside will increase the hospital’s emergency department capacity by 40 percent.
“We have to accept that this is a tremendous challenge for the health care system,” Dr. Lateef said. “If we allow uncontrolled spread, we will be overwhelmed. But if we practice mitigation, then hospitals can handle it.”“We have to accept that this is a tremendous challenge for the health care system,” Dr. Lateef said. “If we allow uncontrolled spread, we will be overwhelmed. But if we practice mitigation, then hospitals can handle it.”
The federal government and states maintain stockpiles of emergency supplies that hospitals can tap into when patient volume surges. The Trump administration has already fulfilled one request from Washington State for additional N95 respirator masks, which health care providers use to protect themselves from the virus, a Department of Health and Human Services spokeswoman confirmed.The federal government and states maintain stockpiles of emergency supplies that hospitals can tap into when patient volume surges. The Trump administration has already fulfilled one request from Washington State for additional N95 respirator masks, which health care providers use to protect themselves from the virus, a Department of Health and Human Services spokeswoman confirmed.
The stockpile also includes ventilators, a supply that could become crucial in fighting the severe respiratory infections that can result from the virus.The stockpile also includes ventilators, a supply that could become crucial in fighting the severe respiratory infections that can result from the virus.
Updated June 16, 2020 Updated June 22, 2020
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.
The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
One study, published in 2010, estimated that American hospitals had stockpiled 160,000 ventilators. If the coronavirus pandemic follows the pattern of the 1918 flu, American patients would need more than 740,000. The experiences in Italy and Iran have heightened fears of a shortage in the United States.One study, published in 2010, estimated that American hospitals had stockpiled 160,000 ventilators. If the coronavirus pandemic follows the pattern of the 1918 flu, American patients would need more than 740,000. The experiences in Italy and Iran have heightened fears of a shortage in the United States.
“The biggest, most dreadful thing we might face is rationing or triaging who gets ventilators,” said Gabe Kelen, the director of the Office of Critical Event Preparedness at Johns Hopkins University. “I really hope we never have to make these kinds of life-and-death decisions.”“The biggest, most dreadful thing we might face is rationing or triaging who gets ventilators,” said Gabe Kelen, the director of the Office of Critical Event Preparedness at Johns Hopkins University. “I really hope we never have to make these kinds of life-and-death decisions.”
Johns Hopkins University, which has five hospitals in the Baltimore area and has treated coronavirus cases, could surge its capacity by as much as 50 percent if it went into what Dr. Kelen described as crisis mode. That would mean housing some patients in hallways and canceling elective procedures.Johns Hopkins University, which has five hospitals in the Baltimore area and has treated coronavirus cases, could surge its capacity by as much as 50 percent if it went into what Dr. Kelen described as crisis mode. That would mean housing some patients in hallways and canceling elective procedures.
Johns Hopkins ordered extra ventilators weeks ago, as staff began to see the virus spreading across the world. But Dr. Kelen still worries about access to protective gear for his staff.Johns Hopkins ordered extra ventilators weeks ago, as staff began to see the virus spreading across the world. But Dr. Kelen still worries about access to protective gear for his staff.
“We are astoundingly concerned as to whether there is enough personal protective equipment,” he said. “It will not take us very long to completely run out. When I’m on calls with other hospitals, this is the biggest concern I hear. We’re running out, and we haven’t even hit a spike yet.”“We are astoundingly concerned as to whether there is enough personal protective equipment,” he said. “It will not take us very long to completely run out. When I’m on calls with other hospitals, this is the biggest concern I hear. We’re running out, and we haven’t even hit a spike yet.”
Robert Kadlec, the assistant secretary for preparedness and response at the Department of Health and Human Services, conceded the problem in congressional testimony on Thursday: “We did not consider a situation like this today. We thought about vaccines. We thought about therapeutics. We never thought about respirators being our first and only line of defense for health care workers.”Robert Kadlec, the assistant secretary for preparedness and response at the Department of Health and Human Services, conceded the problem in congressional testimony on Thursday: “We did not consider a situation like this today. We thought about vaccines. We thought about therapeutics. We never thought about respirators being our first and only line of defense for health care workers.”
Other providers fear hospitals will not be able to treat patients who come in for typical aches and pains seen in the emergency room.Other providers fear hospitals will not be able to treat patients who come in for typical aches and pains seen in the emergency room.
“Our numbers are going to go up, the wait times are going to go up,” said Mahshid Abir, a physician at the University of Michigan, where a coronavirus case has been treated. “I’m concerned about the person who comes in with chest pains or is in the waiting room with heart failure. What is going to happen to care for those patients? How is that going to get compromised?”“Our numbers are going to go up, the wait times are going to go up,” said Mahshid Abir, a physician at the University of Michigan, where a coronavirus case has been treated. “I’m concerned about the person who comes in with chest pains or is in the waiting room with heart failure. What is going to happen to care for those patients? How is that going to get compromised?”
Abby Goodnough contributed reporting.Abby Goodnough contributed reporting.