U.S. Hospitals Prepare for Coronavirus, With the Worst Still to Come

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.

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.”

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.

“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.

“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.

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.

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.”

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.”

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.”

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.

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.”

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.

“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.”

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, which has treated a coronavirus case. “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.

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