Big red flag

Rising ICU bed use 'a big red flag'

States proceed with reopening plans despite warnings local hospitals may struggle to handle a new coronavirus outbreak.

By NOLAN D. MCCASKILL

Intensive care units in Montgomery, Ala., are overflowing with Covid-19 patients, pushing them into emergency departments that are not primed to care for them. And Alabama’s capital city could be a harbinger for other parts of the country.

ICU beds are also starting to fill up in places like Minnesota’s Twin Cities; Omaha, Neb.; and the entire state of Rhode Island, according to local health officials and epidemiologists tracking such data, a warning sign of possible health care problems down the road. The availability of ICU beds is one measure of a hospital’s ability to care for its most vulnerable patients — people with severe illness who require more staff to treat them and may need life-support equipment such as a ventilator to breathe. And it's served as a metric for whether the local health care system is able to handle a coronavirus outbreak, albeit a constantly shifting one.

Some state leaders deny there are problems, saying they are prepared to convert regular hospital beds to ICU beds, if necessary. In the meantime, they are pressing ahead with reopening plans.

But Paul Biddinger, director of Harvard's School of Public Health Emergency Preparedness Research, Evaluation and Practice Program, says it's “a big red flag that when you see increasing numbers of ICU patients with Covid.”

“Our greatest fear about not being able to blunt the peak of illness, not being able to flatten the curve, is that ... people will be exposed to the virus, become ill and potentially die because too many people became sick too quickly and it overwhelmed the health care system," Biddinger tells POLITICO.

Minnesota’s most populous counties, Hennepin and Ramsey — where Minneapolis and St. Paul are located — are each projected to have a shortage of dozens of ICU beds in the next three weeks, according to the health care intelligence firm Leavitt Partners, which is led by President George W. Bush’s former Health and Human Services Secretary Mike Leavitt. Ramsey County is also at risk of exceeding its hospital bed capacity, meaning hospitals there would have no additional space to convert for ICU patients.

Nevertheless, Gov. Tim Walz (D-Minn.) signed an executive order Wednesday allowing outdoor dining at bars and restaurants and salons and barbershops to open, beginning on Monday.

Jan Malcolm, Minnesota’s health commissioner, told reporters the same day that despite mixed data indicators, the state is seeing “relative stability in the growth pattern” and expects to hit its peak in late June or July.

“We do see some more accelerating and concerning signs like the rate of increase in ICU capacity,” Malcolm acknowledged. “Even though we have planned for this and have surge capacity available in the state, the fact that a couple of our hospitals have already gone into that surge space at this point in the curve is important to note and gives us reason to be really, really watching these data.”

Leavitt Partners’ Torch Insight Covid-19 Burden Index tool projects hospital and ICU bed capacity across states, metro areas, counties and individual hospitals, based off the assumption that people continue behaving the same way.

The tool can inform public officials and health care leaders that, “If things don’t change, this is what I need to be ready for at the extreme in three weeks,” said David Muhlestein, chief strategy and chief research officer of Leavitt Partners, the group behind the burden index tool.

“The concern is that somebody will say, ‘Oh, we think it’s going to go down so we’re not going to prepare for the worst-case scenario,’ and then the worst-case scenario happens,” Muhlestein said in an interview.

The projections are an additional warning sign as local leaders nationwide seek to avoid what occurred in Montgomery, where the Democratic mayor is still sounding the alarm after gaining national attention last week for warning that “you’re in trouble” if you need an ICU bed in the city.

Mayor Steven Reed told NPR this week that hospital leaders are telling him to “sound the alarm and to let people know we’re still in the middle of a pandemic and that we are in a health crisis.”

Minnesota saw its largest single-day spike in Covid-19-related ICU bed use earlier this week, jumping from 207 people hospitalized in the ICU on Sunday to 248 by Monday. There were 260 ICU hospitalizations on Wednesday, the highest since the pandemic began.

And more than 90 percent of beds are in use in hospitals in the metro and southeast regions of the state. The percentage of ICU beds in use are 1 to 3 percentage points shy of 90 percent in the metro, northeast and southeast regions.

Kristen Ehresmann, the Minnesota Department of Health director of infectious disease, epidemiology, prevention and control, told reporters Tuesday that the state was also hearing that hospitals were at or near ICU capacity at the end of last week and having isolated staffing concerns. But she downplayed the rapid increase in hospitalizations.

“This level of ICU use has not been unexpected,” she said, noting that the state tracks Covid-19 admissions and the availability of ICU beds and ventilators. “This past weekend, the overall picture for ICU bed availability on May 25 showed 87 percent of the ICU beds in the metro were in use. Other regions of the state had more availability. For comparison, it isn’t unusual for ICU beds to be 95 percent full during flu season.”

But as Biddinger pointed out, the novel coronavirus that causes Covid-19 is much less predictable than flu season.

“Across the country, it is common for intensive care unit beds to be full, especially during flu season, but that’s with relatively predictable patterns of illness,” said Biddinger, who also serves as medical director of emergency preparedness at Massachusetts General Hospital. “With Covid, it’s not nearly as predictable, and the potential of a Covid outbreak is much more severe than the peak of a traditional flu season.”

Biddinger said the lower the peak of hospitalizations, the more likely it is that people who need ICU care will be able to access it.

Monday’s death of George Floyd, a black man who died after a white Minneapolis police officer pushed his knee into Floyd’s neck and ignored pleas that he couldn’t breathe, has sparked protests and could also lead to additional spread of the virus. Demonstrators have been photographed and recorded in large crowds, many not wearing masks. Peaceful protests Wednesday ended with looted stores and burned buildings.

Malcolm said there’s a “very, very real risk that the pandemic poses to” protesters and anyone they interact with, given “the importance of the degree of community spread that we have today.”

She made a “plea for people to be careful and to be mindful of those health guidelines and the importance of distancing and masking” while protesting.

In Nebraska, where driving tests resumed at DMVs on Wednesday, a state legislator clashed with the state’s chief medical officer after he told reporters that a slight uptick in Covid-19 patients over the past week wasn’t affecting hospital bed or ICU availability.

Chief Medical Officer Gary Anthone downplayed the hospital situation in the Omaha and Douglas County area this week, despite warnings from an infectious disease expert at the University of Nebraska Medical Center that bed availability is meaningless without proper personnel, and that the health care system could be overwhelmed.

Anthone acknowledged an increase in Covid-19 patients over the last week but insisted the situation has “been very stable.”

“We have seen an increase in the number of patients hospitalized, but it hasn’t really affected the bed availability generally or the actual ICU bed availability. We are at a 29 percent bed availability,” he told reporters Tuesday.

He said he has been in close contact with chief medical officers of major hospitals in the area, adding that “everybody feels like they’re being able to handle the situation” without issue.

“Right now, it appears to be more of an ICU availability issue than a general bed or a ventilator issue,” he said. “So we’re working very closely with them to come to that right balance as far as how we manage the Covid situation.”

State Sen. Megan Hunt tweeted that ICU availability “is a big deal, because it’s not just COVID patients who need ICU care.”

“We need to try to keep people from getting infected and hospitalized, not say ‘We still have beds available for you to pay for,’” she said.

According to data tracked by a group of public health and crisis experts at covidexitstrategy.com, Rhode Island's health care system has the lowest percentage of ICU availability in the country, at 19 percent. Nineteen states have more than 40 percent of ICU beds available, and 29 states have between 21 percent and 40 percent of their ICU beds open.

Leavitt Partners project that hospitals across Rhode Island will have no more than 10 available ICU beds in three weeks. Still, the state is poised to enter its next phase of reopening on Monday.

Rhode Island’s health department questioned covidexitstrategy.com's data, which rates the state’s hospital bed and ICU capacity as “extremely low,” with less than 20 percent availability in each metric.

“We have adequate hospital capacity in Rhode Island,” said Joseph Wendelken, the health department’s public information officer. “A third of our non-ICU beds are open, two-thirds of our ICU beds are open, and 87 percent of our ventilators are not currently being used. Additionally, we have developed surge hospital sites that could open up, if needed.”

At a briefing Tuesday, Rhode Island Gov. Gina Raimondo indicated a willingness to shut the state down again if there’s another virus outbreak.

“The reality is every other country who’s gotten into trouble, there was an outbreak in one community, which led to a shutdown of the whole state,” she said. “If I have to shut down our economy again, it’s our whole economy.”