By Rose Hoban
Yesterday, state health officials announced the first deaths of North Carolina patients who had acquired the novel coronavirus, known as COVID-19. Both patients were reportedly older, and each had preexisting, underlying health problems.
But it’s clear that not every patient with the disease is older. Mecklenburg County published data on its positive tests and found that, as of March 23, 52 percent of positive results were people between the ages of 20 and 39.
Also in the numbers: One in five of the Mecklenburg County cases had been hospitalized at some point.
As the number of patients with coronavirus increases and hospitalizations among those patients increases, the question of how many beds and how many intensive care unit beds will be available to accommodate them is becoming more pressing.
Hospital leaders report they’re scrambling to get ready, to get beds opened, to get supplies in place, to get staff trained.
But at some point, the surge of patients will come and the question is, how much capacity will North Carolina have to care for them?
Scaling back for the surge
When inquiring about the number of ICU beds North Carolina has, the answer often comes back that there is no one number.
When first queried, Doug Allred, the communications director at the Cone Health, said there were 100 ICU beds across that system. A few minutes later, he emailed with an update that Cone could “flex” to 125 ICU beds.
But some of those beds are already full with people who have everyday problems, such as heart attacks, car accidents, kidney failure and other serious illnesses.
“We can’t ignore the normal processes that we normally go through to take care of these patients, we just have to continue to provide the care that we normally give, while we wait on what’s gonna come down the road from COVID-19,” said James Wyatt, the chief medical officer at Cone. “We do want people to know that nothing else is being ignored, we’re just trying to prepare while doing the same things we normally would do.”
Wyatt detailed how his institution has scaled back on elective and non-urgent cases to free up equipment, save on personal protective equipment that would have been used on those patients, and free up operating rooms – which contain ventilators – that might be used for ICU beds during a surge.
That’s the case everywhere.
David Weber, the associate chief medical officer at UNC Health, detailed similar preparations for his institution. Changes UNC is making include preparing whole floors of the hospital to become care units for patients with COVID-19, using spaces in the post-surgical recovery units for other critical care patients, using 24-hour observation beds, and even using tents outside to triage and treat the usual bumps and bangs that bring people into emergency departments.
Weber said he’s trying to make as much space as possible because he pointed out that with the closure and downsizing of many rural hospitals, there are fewer beds overall.
“The U.S., compared to years ago, has less open beds and on a normal busy week, you know, most of our hospitals, including UNC, would be running between 90 and 100 percent occupancy,” he said.
That’s why most, if not all hospitals in the state, have eliminated elective procedures and pushed to discharge patients. But that’s going slower than some would like. One place patients often go after hospital discharge is skilled nursing facilities, for longer-term recovery. But many of those facilities, filled with vulnerable patients, are not taking new patients.
According to the North Carolina Healthcare Association, which represents hospitals around the state, the state has the ability to flex up to 3,514 licensed ICU beds around the state.
“We have more licensed beds than operational beds,” said NCHA vice president Cody Hand, explaining the numbers. “Licensed beds are what the state has permitted us to have under our license, operational beds are those that are staffed and running.
“In many cases, licensed beds can scale up and be operational in a matter of hours,” he said. “That’s also contingent on finding nurses and doctors to staff them.”
When asked if all of this would be enough, Hand had a sobering answer.
“The assumption is that we don’t have enough if we don’t change the pattern of infection,” he said. “We’ve seen all the modeling and none of it looks good and none of it indicates we have enough.”
Like Hand, others around the country are attempting to create mathematical models to estimate the surge of patients.
One model from the Kaiser Family Foundation estimates that some 3.4 million North Carolinians are at higher risk of being hospitalized or having a bad outcome if they contract coronavirus. That’s because they’re over the age of 60 or have an underlying condition that puts them at higher risk, such as diabetes or heart disease.
Another mathematical model created by economists, statisticians and engineers in Silicon Valley predict that if North Carolina does not enact more stringent measures to restrict the transmission of coronavirus, sometime in early April, hospitals could be overwhelmed by about two or three times more patients than there are beds.
Models and belly buttons
Even before coronavirus hit, public health leaders have been planning for patient surges using mathematical models that take into account the rate of infection, the number of patients, the number and distribution of beds, how long patients would be in those beds, and how many patients might require ICU care.
“Models are like belly buttons, everyone’s got one,” said Mark Holmes from the Sheps Center for Health Services Research at UNC Chapel Hill.
Holmes’ center published a report Wednesday looking at the number of rural ICU beds versus urban ICU beds which noted that while rural ICU beds have, on average, fewer patients in them, there are fewer of those beds overall.
Especially as rural hospitals have trimmed beds in recent years, they’ve gotten used to being able to ship more serious cases to larger urban centers.
“During a large increase in acute patients, those upstream hospitals will be much less likely to accommodate such transfers, meaning more patients will need to stay in the rural hospital,” the report noted.
The Healthcare Association’s Cody Hand said that hospitals, which in normal times can be fiercely competitive, are cooperating to create networks to allow for movement of patients to the most appropriate places.
“We’re actually currently planning for 25 to 50 percent surge capacity,” he said. “A lot depends on where our pockets of infection are. We have facilities in suburban North Carolina that could handle quite a few more people.”
Gov. Roy Cooper also mentioned that the state is exploring all options, including military bases, National Guard facilities, mobile hospitals and even shuttered health care buildings.
State Health and Human Services Sec. Mandy Cohen told reporters on Wednesday that her team is looking at all options. They’re exploring many variables, including how quickly hospitals in other states filled up and of how quickly the disease is spreading, and are continually running the numbers.
“I don’t have a better answer yet on when this peaks, what will that look like,” she said. “What I can say is North Carolina was later in the course of seeing our first case, later in the course of seeing our hundredth case, is at a trajectory that is lower than what we’re seeing in other states, but we want to be modeling this out so that we can be best prepared.”
“These are data models with a lot of assumptions that are challenging to make with the limited information that we have.”