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Hospital officials rushing to boost capacity for COVID-19 patients

  • Signs showing appreciation to healthcare workers were posted around the road entries to Dartmouth-Hitchcock Medical Center in Lebanon, N.H., Friday, March 27, 2020. (Valley News - James M. Patterson) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com. James M. Patterson

Granite State News Collaborative
Published: 4/2/2020 3:20:06 PM
Modified: 4/2/2020 3:19:56 PM

Images of hospitals and caregivers immersed by a wave of seriously ill patients in New York City and other COVID-19 hot spots raise important questions about the capacity and preparedness of health care facilities in rural areas.

“I’m very worried about what’s going to happen to the critically ill people in rural areas when the infection becomes more widespread there,” Ashish Jha, the director of the Harvard Global Health Institute, said in a webcast Thursday.

New Hampshire officials have similar concerns. “The whole fear is that the health care system will be overwhelmed,” said Jake Leon, the spokesman for the New Hampshire Department of Health and Human Services.

About 500,000 Granite Staters live in rural areas, according to the U.S. Department of Agriculture, and 13 of the state’s acute care hospitals have been designated by Medicare as “critical access” facilities which serve rural areas. Large hospitals in Manchester and Lebanon provide specialty care to residents throughout the state.

Local health caregivers say they’re ready.

“We are prepared to take care of anyone who has a more complicated disease or needs a more thorough evaluation,” Dartmouth-Hitchcock Health’s Chief Clinical Officer Edward Merrens said in a video made March 24 and posted on the D-H website. D-H officials did not respond to requests for additional comments.

“New Hampshire hospitals are ready to meet the needs of all patients in the state including situations involving high threat infectious diseases such as COVID-19 and influenza,” said Vanessa Stafford, vice president for communications for the New Hampshire Hospital Association.

So far, northern New England has not seen a surge in COVID-19 cases similar to that in some not-so-distant cities, though New Hampshire and Vermont together had tallied 15 deaths as of Monday. And experts remain concerned about a likely sharp increase in the need for intensive care beds and the ventilators that keep alive the sickest and most vulnerable COVID-19 patients.   

“The capacity of ICU care in rural areas in America is really quite limited,” Jha said. “And when people get very sick and need ICU care it’s going to be very, very hard to provide all the ICU care they need.”

“Based on what we are hearing from Seattle and New York City, we are getting ready for anything from incredibly busy to more extreme scenarios in which we have to ration mechanical ventilators,” said Tim Lahey, an infectious disease physician and professor at the University of Vermont’s Larner School of Medicine.

Mechanical ventilators that supply oxygen to patients otherwise unable to breathe make up the last line of defense for the sickest and most vulnerable COVID patients. “If you have respiratory failure and you don’t get a ventilator, you die,” Jha said.

But ventilators are in short supply. Ventilator need could exceed supply by factors ranging from 1.4 to 31, according to an article published March 23 by the New England Journal of Medicine. The authors cited a February report by the Johns Hopkins Center for Health Security that estimated a nationwide inventory of 62,000 advanced ventilators usable to treat the sickest patients as well as another 98,000 basic ventilators. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said on March 15 that an additional 12,700 ventilators were available in the Centers for Disease Control Strategic National Stockpile.

State officials are counting and adding to ventilator supplies. A coalition of hospitals, including D-H, that serve Vermont has 170 critical care ventilators, of which 99 were available Tuesday, according to Stephanie Brackin, an information manager at the Vermont COVID-19 Joint Information Center. In New Hampshire, according to Leon, “if the State used every ventilator and every piece of equipment that can be converted into a ventilator, there would be about 1,000 ventilators available for patients requiring hospitalization during a surge.” An additional 45 ventilators have been requested at from federal agencies. Both states’ tallies appear to include D-H units. D-H officials did not provide data on ventilator availability. 

Jha warned that if the number of critically ill COVID patients exceeds ventilator availability, “we’re going to ration care so that some people will live and some people will die and so we should have some systematic approach for doing that.”

Such triage decisions seem inevitable, he added: “We’ve got to do absolutely everything in our power to make sure that doesn’t come up.” 

New Hampshire has other capacity concerns. The state has about 1.1 million adult residents, including 219,000 age 65 or older, and is served by hospital networks based in Lebanon and Manchester, according to a model by the Harvard Global Health Institute. 

HGHI tallied 252 beds in intensive care units and a total of 2,598 hospital beds in the Granite State. Stafford said the inventory of currently staffed ICU beds is slightly higher: 280. 

HGHI developed a model that estimated in a “best case” scenario that about 20% of New Hampshire adults, or 214,000 individuals, would be infected by COVID-19, nearly 45,000 would require hospitalization and the spread of illness would be slowed – by “flattening the curve,” as public health leaders say – to extend over an 18-month period. 

Even under this “optimistic” forecast, which takes into account measures already undertaken by hospitals to free up general and ICU beds by postponing elective surgery and otherwise reducing usage by non-COVID patients, peak demand for intensive care beds would exceed the available supply by 17%.

Failing to flatten the curve would have dire consequences. 

In its worst-case scenario, HGHI estimates that more than 640,000 adults would be infected with the novel coronavirus in New Hampshire, more than 134,000 would require hospitalization and the virus would spread rapidly to peak in about six months. 

Under these pessimistic assumptions, demand for hospitals beds for COVID-19 patients would reach five times the available supply – even after measures to reduce non-COVID usage. Worse still, at the peak of the pandemic more than 17 sick patients would stand in line for each of the 181 available intensive care beds in the state’s hospitals.

Stafford did not comment on the Institute projections but said that the hospitals “have plans in place in case of an event, like COVID-19, to provide additional temporary beds to treat a surge in patients.” She added: “Planning is also underway to procure beds and locations to meet an increased demand” for intensive care beds. That effort could include “establishment of flex facilities,” she said.

Public health experts acknowledge that modeling for a previously unknown virus will be inexact, often wrong, and will need to be revised, but that it nonetheless sounds an important warning that action needs to be taken. Tara Kirk Sell, a senior scholar at the Johns Hopkins Center for Health Security, said,  “When a model tells us something that’s very alarming, it tells us that there’s probably some actions that we need to take now.”

Jha said it is too late to build or buy enough ventilators or new intensive care capacity to cover a rapidly surging virus.

New Hampshire officials are rushing to make other preparations. “We’re not at the apex of the crisis here,” Leon said. “We’re going to continue to see more cases.”

Leon said the state aims to have ready this week eight flex sites with a total capacity of 1,700 to 1,900 beds that could be activated to provide more in-patient or out-patient care. That capacity could be used by less severely ill COVID patients or to reduce exposure to the virus for non-COVID patients. Sites have been lined up at Southern New Hampshire University in Manchester and New Hampshire Technical Institute in Concord. Upper Valley officials are working to include one near Dartmouth-Hitchcock Medical Center, likely in a Dartmouth College athletic facility.

Jha stressed the importance of ongoing efforts at physical or social distancing: “The closer we are to fewer interactions, the more the virus slows down.”

Stafford, New Hampshire Hospital Association spokeswoman, agreed: “By practicing social distancing, diligently hand washing, and not utilizing the Emergency Department unless there is a true emergency, such as significant difficulty breathing, residents can help preserve precious hospital resources for those that truly need them,”

“We want to give our hospitals a shot,” Jha added. “The more we spread it out, the more time we have for testing therapies, the more time we have to have a vaccine.”

 

Rick Jurgens can be reached at rickndiane2@gmail.com or 802-281-6641.

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org. 


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