Overrun by critically ill coronavirus patients, Italy’s hospitals are choosing who gets lifesaving breathing machines and who does not. It’s a scenario that could soon repeat in the United States, experts warn.
Overrun by critically ill coronavirus patients, Italy’s hospitals are choosing who gets lifesaving breathing machines and who does not.
It’s a scenario that could soon repeat in the United States, experts warn.
“The capacity in northern Italy hospitals is a preview of a movie that is about to play in the United States,” said Marty Makary, a Johns Hopkins University surgeon and health policy expert. “The best two indicators of what things will be like in the U.S. are the number of COVID-related deaths in Italy and the number of ICU beds.”
U.S. hospitals are on the cusp of too many severely ill patients without enough intensive care unit beds and ventilators to keep those patients breathing. It’s why states, municipalities and businesses are desperately trying to delay new infections through social distancing measures such as school closings and work-from-home mandates.
The federal government has not publicly released estimates on demands COVID-19 might place on hospitals. In an earlier report on a moderate flu pandemic, the U.S. projected 200,000 Americans would need the most extreme level of care: a bed in a hospital intensive care unit. If the pandemic worsens to levels of the 1918 Spanish flu pandemic, 2.9 million would need ICU care, according to the report.
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However, there are fewer than 100,000 ICU beds in the United States, according to a recent analysis by Johns Hopkins Center for Health Security.
The center recommended hospitals be able to convert a full 30% of available beds to COVID-19 patients within a week's notice. It recommend expediting discharges, converting single rooms to doubles and converting lobby waiting rooms and classrooms.
Hospitals also might struggle to keep up with demand for ventilators – mechanical breathing machines needed to keep people with severe pneumonia and respiratory failure alive. During a pandemic, the demand for ventilators "could quickly overwhelm" the nation's stockpile of ventilators, the Johns Hopkins Center reported last month.
A 2010 survey reported U.S. hospitals had 62,188 full-featured mechanical ventilators on hand, but the numbers varied widely by state. Hospitals in Washington, the state hit hardest by the epidemic, had 12.8 ventilators per 100,000 people, the second-lowest per-capita supply, ahead of only Idaho.
Washington, D.C., had the largest supply based on population, followed by West Virginia, which this week became the last state to report a coronavirus case.
Although the survey is a decade old and hospitals have added ventilators to their stockpile, "we figure that supply is less than 100,000 in this country," said Timothy Myers, a respiratory therapist and chief business officer of the American Association for Respiratory Care, which contributed to the survey.
"The number of ventilators pretty much mirrors the number of ICU beds in this country," Myers said. "The problem is a lot of these patients are being ventilated for numerous days. Some are off in three to four days. Others are on for several weeks. That is where you get the supply-demand issue."
The American Hospital Association estimates 960,000 Americans could need mechanical help to breathe during the coronavirus pandemic.
But even if hospitals pull out-of-date ventilators from storage and repurpose other machines to pitch in, there would only be enough devices and trained experts to treat 135,000 patients at a time, according to a paper the Society of Critical Care Medicine released Friday.
“We are being creative,” said Dr. Lewis Kaplan, the society’s president and a doctor at the University of Pennsylvania. The alternative, Kaplan said, is making decisions about who is assigned a machine. “We would like not to be in that space.”
Those who distribute and manufacture ventilators also are scrambling.
Chinese parts suppliers are coming back online, said Cheston Turbyville, a vice president for Vyaire Medical, which manufactures ventilators in Palm Springs, California. Vyaire has sped up its hiring to meet demand, he said, and gives priority to shipments directly to hospitals that need them.
Demand from hospitals has drained the supplies of several large companies that rent ventilators, said Robert Preville, the CEO of KWIPPED.com, which matches businesses to equipment-rental companies. His company received more than 20 requests for ventilator-rental quotes last week for up to 200 ventilators per quote.Iran has become 'a tragic natural experiment' during coronavirus crisis
Hospitals in Italy and Iran are struggling to keep pace with round-the-clock demands of caring for a flood of patients, and both countries rank second and third, respectively, in total deaths.
Three weeks ago, Italy reported just seven deaths. By Tuesday night, more than 2,500 had died and the country was fast approaching the grim benchmark of more than 3,100 deaths in Wuhan and Hubei, China.
Political leaders have put all of Italy under quarantine. It hasn't been enough. Doctors there have described in interviews and on social media heart-wrenching decisions on who gets ventilators and who does not. It's a life-or-death call.
Former Food and Drug Administration Commissioner Scott Gottlieb, among the first U.S. public health officials to call for more aggressive, systematic COVID-19 testing, also cited Iran as an example of what can happen when a nation is unprepared for a pandemic.
"Iran is, in some respects, a tragic natural experiment," Gottlieb said. "They're not doing much of anything, and it probably is out of the sense of helplessness that they really don't have the capacity to implement mitigation tools. So it's just coursing through their population now largely unchecked. And so they're going to have a terrible public health outcome."
Efforts by the U.S. Centers of Disease Control and Prevention initially focused on delaying spread of the virus in the United States through travel restrictions and screening passengers returning from regions where the virus was endemic.
But with the respiratory virus circulating in major metro areas from Seattle to suburban New York, the strategy shifted to social distancing, with schools closing nationwide and cities shutting down bars and gathering spots. San Francisco Bay Area municipalities are urging people to stay at home other than for essential errands such as buying food.
The idea is to "flatten the curve" of new infections and prevent a peak of cases so large it might overwhelm hospitals. Not only do hospitals have a limited supply of ICU beds and ventilators, facilities also face challenges of keeping doctors, nurses and therapists healthy enough to care for the sick.
"A patient needs a bed and a respirator," said Makary, of Johns Hopkins. "What folks may not appreciate is the patient also needs nursing, a respiratory therapist and good (hospital) cleaning systems. ... This is the largest workforce crisis in our generation."
Myers, of the respiratory association, said his group's survey revealed nearly 110,000 respiratory therapists work at hospitals. It is crucial to ensure those therapists remain healthy so they can treat patients. When doctors, nurses or therapists become infected, it further compromises care.
"If the health care team starts dwindling because of positive health care tests, that will become problematic," Myers said.Do hospitals have enough supplies? Yes, unless there's a wave of patients
Hospital industry officials say health care leaders are preparing for more patients quickly.
Nancy Foster is the American Hospital Association's vice president for quality and patient safety. She said hospitals plan for a surge of patients, whether for an outbreak, a natural disaster or a man-made disaster.
"People have thought about whether anything needs to be adapted to reflect what we know about this COVID-19 strain," Foster said. "People are preparing to make those adjustments."
Hospitals also want help from Congress. The American Hospital Association requested $1 billion for a laundry list of COVID-19 needs – including training, infection control, equipment purchases and construction of isolation units "to assess potentially large numbers of persons under investigation for COVID-19 infection." Senate Republicans are working on a far-reaching legislative package to help Americans and industries harmed by coronavirus epidemic.
USA TODAY contacted 32 hospitals within 19 “major medical centers” around the country to ask about supplies, staffing and space for COVID-19. Of those, 12 responded in some form.
None of the hospitals provided specific answers about mask, gown or respirator supplies or addressed specific questions about requiring overtime for staff or canceling time off.
Twenty hospitals did not respond or declined to participate.
Most hospitals that responded to USA TODAY's survey said they now have adequate supplies of face masks, respirators, gowns and other personal protective gear for patients and health care workers.
But some worried about the prospect of quickly dwindling supplies should they see a wave of infected people.
Brigham and Women's Hospital in Boston is conserving personal protective gear and sending N-95 masks to the health system's high-risk locations, said Elaine St. Peter, a senior media relations specialist. N-95 masks fit more tightly around a user's face and provide more protection from airborne particles than a looser-fitting surgical mask.
"We have a sufficient supply of PPE (personal protective equipment) on hand to manage normal operations," St. Peter said, "and anticipate we may be challenged if there is an influx of patients."
The Mayo Clinic is adopting conservation strategies across its three hospitals because of sporadic supply disruption, said Dr. Pritish Tosh, an infectious diseases specialist.
The ECRI Institute, a nonprofit that advises medical facilities on safety and quality, has tracked purchasing of its member hospitals. The survey covers 10% to 15% of all hospitals in the United States, said Marcus Schabacker, ECRI’s president and CEO.
Hospitals have tripled purchases of N-95 respirator masks since late 2019, a significant increase that is “not normal” compared to typical equipment buying during flu season, Schabacker said. Purchasing of surgical masks has jumped 50%, while sales of gloves and gowns have increased at lower levels.
Hospitals are worried about equipment supply but also don't want to incite panic buying.
"One of the questions on everyone’s mind (is) this issue of masks: how many are available, are they experiencing a shortage, do they expect it?" said Suzet McKinney, CEO and executive director at the Illinois Medical District. "But when the general public hears 'shortage,' they get scared and start trying to purchase up all the masks they can find. That has a negative consequence on the health system."A dire warning: 'If health care workers go down, we’re all in trouble'
The equipment is essential to protect health care workers and the public. If a doctor or nurse inhales droplets from a coronavirus patient who sneezes or coughs, they might become infected.
The Mayo Clinic didn't specify its conservation strategies, but other hospitals are changing policies on when and how workers use gowns and gloves. Some hospitals are relaxing "contact isolation" rules that require health care workers be in gowns and gloves when treating a patient with certain infections, said Dr. Jennifer Hanrahan, chief of infectious diseases at University of Toledo.
Doctors and nurses who treat "contact isolation" patients use and dispose of gloves, gowns and masks every time they leave the patient's room. But if fewer patients are placed in isolation – or if hospitals congregate several patients with the same types of infections – it might be a strategy to use less disposable gear, Hanrahan said.
"As an infectious disease physician, if I'm doing regular rounds in a hospital, I might put on one of those isolation gowns 10 to 15 times per day," Hanrahan said, adding that nurses might require more protective equipment for frequent trips in and out of rooms.
"In a scenario where you have unlimited supplies, you can do whatever you want. The long-term goal is to make sure there are appropriate (equipment supplies) for people who are at the highest risk. And those are going to be people who are taking care of patients with severe pneumonia who are in the hospital for a longer period of time."
Doctors, nurses and other health workers must be equipped with protective gear and properly trained on how to use the equipment. A National Nurses United survey of more than 6,500 nurses in 48 states released last week found fewer than 1 in 3 nurses reported their hospital had a plan on how to isolate coronavirus patients. The survey also found a large share of nurses were not properly trained on how to use N-95 masks.
As COVID-19 cases accelerate across the United States, experts say protecting health care workers will become critically important. The CDC and King County, Washington, public health officials are recruiting traveling nurses to fill in for nurses who are exposed to the virus and become quarantined and to help with community testing efforts, nurse.org reported.
Dr. Richard Waldhorn is a contributing scholar at Johns Hopkins Center for Health Security and a clinical professor of medicine at Georgetown University School of Medicine. He said hospitals must protect and train health care workers to ensure enough workers are there for this crisis.
"If health care workers go down, we’re all in trouble," Waldhorn said. "Preventing the hospital from becoming a disease amplifier – often they’re the worst place to go. You can’t have them contributing to the problem, that’s on scrupulous training within the hospital."
Contributing: Erin Mansfield and Katie Wedell, USA TODAY Network