RICHMOND — At Mary Washington Hospital in Fredericksburg, instead of cars, geriatric recliners and IV poles fill parking spots in the garage next to the emergency department — a makeshift field hospital for a possible overflow of patients.
VCU Medical Center hurriedly packed up students’ belongings last week to convert dorm rooms into a hospital for patients who do not have COVID-19 and free up beds in the main hospital for those who do. The medical center has asked the state for emergency permission to add 460 beds on various campuses.
And on Wednesday, Gov. Ralph Northam ordered hospitals to cease non-urgent surgeries and made a call out to all medical professionals — from students to retirees — to volunteer for the state’s Medical Reserve Corps to relieve anticipated medical staffing shortages. The state is also working with the Army Corps of Engineers to identify sites for building up hospital capacity.
It’s all part of an effort to keep Virginia’s health care system from being overrun by COVID-19 patients like New York City and Italy before it.
And while state officials say they are planning and encouraging social distancing to prevent the worst-case scenario, they have kept those plans mostly under wraps as some projections anticipate a shortage of intensive care beds, tens of thousands of sickened Virginians needing hospitalization and a climbing death toll in the coming months.
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In Italy, doctors without enough ventilators — the machines that keep people with respiratory failure breathing — have decided who would live and who would die, often opting to save younger patients, according to news reports.
In New York City, one hospital was using one ventilator for two patients, the New York Times reported Thursday, and New York Gov. Andrew Cuomo has tweeted that the state’s 11,000 ventilators will fall far short of the 30,000 it expects to need.
COVID-19 tests, masks and other protective equipment are also in short supply globally, putting health care workers in danger and making containing the virus especially difficult.
On Friday, President Donald Trump invoked the Defense Production Act to compel General Motors to manufacture ventilators. The company said in a release that it is ramping up production and plans to work up to producing 10,000 per month.
Still, experts who have projected how COVID-19 is likely to spread say the U.S. health care system will be strained in the coming days and weeks.
Virginia, a state of more than 8.5 million people, has 2,000 ventilators on hand, according to Cotton Puryear, spokesman for the Virginia COVID-19 Unified Command Joint Information Center. The Virginia Department of Health referred questions from the Richmond Times-Dispatch on March 16 and March 24 to the joint information center, which is run by the Virginia Department of Emergency Management and includes spokespeople from different state agencies, which responded Friday.
A middle-of-the-road projection that assumes 40% of the U.S. population will become infected with the coronavirus over the next six months predicts that hospital emergency rooms and critical care units would be overwhelmed, according to Dr. Ashish Jha, director of the Harvard Global Health Institute.
“Even when you have a lot of capacity creation, we would not be anywhere near where we need to be,” Jha said on a webcast Thursday, referring to hospitals’ actions like at VCU Health to free up space by canceling elective procedures and adding bed space.
The state has requested an additional 350 ventilators from the national stockpile, but has not received an answer, Puryear said.
“In addition to those assets, the regional health care coalitions that function as part of the Virginia Healthcare Emergency Management Program (VHEMP) have ventilators that can be deployed to hospitals,” said Julian Walker, spokesman for the Virginia Hospitals and Healthcare Association, in a statement. “While ventilator usage varies by region, at this point only a fraction of the ventilators in Virginia are in use to support patient care.”
While other state officials, like those in New York, have publicly discussed projections of how many intensive care beds and ventilators will be needed depending on how many people are infected by the virus, Virginia has not released that information.
In news briefings, Northam and Health Secretary Daniel Carey have stopped short of giving specific numbers on current available resources or projections, instead saying that state officials are in the process of planning and urging the public to stay home and away from other people to slow the spread of the virus.
“You need to stay at home,” Northam said at a briefing Friday. “That is the only way that we can slow the spread of this virus to give our medical system time to build its capacity to save lives. … If we don’t stay home … we will see our hospitals overwhelmed.”
State epidemiologist Dr. Lilian Peake said in an interview Friday that state officials are looking to different entities, such as the University of Virginia and individual hospital systems, that are doing scientific modeling to project possible numbers of infected people and needed resources, but that the state does not have one model it’s relying on.
Projections from the Institute for Health Metrics and Evaluation at the University of Washington in Seattle, which has done a state-by-state data analysis factoring in strict adherence to social distancing and public health measures, predict that Virginia will reach its peak in outbreak severity on May 2 and, on that day, will need 512 intensive care unit beds — 183 more than the 329 they predict to be open — according to the data used by IHME.
The projections also say Virginia will need 276 ventilators and can anticipate 1,543 COVID-19 deaths by Aug. 4.
Loudoun County’s Pandemic Response Plan, which was updated this month, says previous severe pandemic modeling used by the VDH estimated that Virginia could see 2,700 to 6,300 deaths, 12,000 to 28,500 hospitalizations and 1.08 million to 2.52 million people become sick.
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At Friday’s briefing, Carey addressed questions from reporters about bed capacity and projections, saying that state officials are aware of different projections and are involved in helping health systems implement their emergency plans and working to call in backup from the Federal Emergency Management Agency, the Army Corps of Engineers and the Virginia National Guard.
“Our first and foremost goal is to encourage how to bend that curve so that those statistics and those potential realities don’t come to pass,” said Carey, reiterating the importance of social distancing.
Kaiser Health News analyzed hospital bed data from fiscal years 2018 and 2019 throughout the U.S. and found that millions of Americans — and 7 million people over age 60 — live in counties or cities with no ICU beds. In Virginia, 76 of 133 localities reported having no ICU beds, but Kaiser noted the state’s situation is more difficult to analyze because of its independent cities with hospitals that likely serve neighboring counties.
KHN focused on older people because experts believe they — along with people who have chronic health conditions — are more susceptible to the severe and fatal cases of COVID-19, although the CDC has reported that nearly 40% of COVID-19 hospitalizations in the U.S. have been younger than 55.
A Richmond Times-Dispatch analysis of KHN’s data, dividing the state into eight regions instead of cities and counties, found that in Virginia, there were about 1,000 people who are 60 or older for every ICU bed in the state as of 2019.
The Richmond area, which has the most beds, had about 770 seniors for every ICU bed. In Northern Virginia, which had the most reported coronavirus cases in the state as of Friday, there were about 1,250 seniors per ICU bed.
Northern Virginia, the Richmond area and Hampton Roads accounted for more than 90% of confirmed coronavirus cases as of Friday. They skew younger than all other regions of the state and are home to about 70% of the state’s ICU beds. About 1 in 5 people living in those three regions are 60 or older. Across the rest of the state, where a lower number of beds means a smaller outbreak could overwhelm the system, it’s between 1 in 4 and 1 in 3.
In James City County, which has the highest rate of infection in the state, 1 in 3 residents are 60 or older. The county is home to 26 ICU beds, according to the Kaiser data.
As of Saturday’s positive test count, Virginia had between two and three ICU beds for every diagnosed case of COVID-19. But in Northern Virginia, the 392 confirmed cases already slightly outnumber ICU beds in the region.
Most people who test positive for COVID-19 do not require hospitalization, and even fewer require an ICU bed.
The state health department reported that, as of Saturday, there had been 99 cumulative hospitalizations related to COVID-19 out of 739 confirmed cases.
But Dr. Laurie Forlano, deputy commissioner for population health for the VDH, said in an interview that the department relies on hospitals to report hospitalizations. She said there tends to be a lag in reporting and — because it’s cumulative — the number does not represent current hospitalizations.
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The state also has shirked repeated questions about how it will approach offering guidance to hospitals on criteria for rationing health care should the need outstrip the supply, as it did in Italy and as it threatens to in New York.
“Part of the pandemic flu plan from years ago did anticipate the possibility of [the need for rationing]. We have taken that plan and we are in the midst of evaluating that,” Carey said at the Friday briefing in response to a question about statewide rationing criteria. “I would really focus on the most important thing we can do is … make sure we’re doing everything we can to at least slow the spread of this disease. That’s where our focus needs to be. At the same time, we are doing our contingency planning, and we are in the midst of that.”
Having a predetermined set of standards and state-level planning is vital when it comes to pandemic preparation, according to Mary Faith Marshall, director of the Program in Biomedical Ethics at UVa’s School of Medicine and an expert in ethical issues during a pandemic.
“When you’re doing pandemic planning, you always want to use the worst-case scenario,” said Marshall, who helped the Minnesota Department of Health craft its resource scarcity plan a decade ago.
Marshall said any rationing decisions should be made by multidisciplinary teams — not bedside health care practitioners — and those decisions should be free from discrimination and focused on the likelihood of the patient surviving at least a year.
“When you think about this criteria, you don’t discriminate based on age, based on citizenship, for example, or necessarily disability,” Marshall said. “We don’t want to know who the patient is.”
A National Academy of Medicine discussion paper published earlier this month laid out the steps health care providers should take before considering rationing equipment — such as a ventilator — including substituting, adapting or reusing equipment. The paper said that, if no other alternative exists, the equipment can be removed from one patient and given to another patient who is believed to have a higher chance of benefiting from the care.
Marshall believes the leaders of Virginia’s hospitals have been on top of preparing for the worst.
“People are just working around the clock,” Marshall said. “They’re putting their all into it.”
Another important part of the equation is transparency and accountability, according to Marshall and papers on the issue.
“There is fear, there is anxiety and there is misinformation,” Marshall said. “Good communication is really important.”