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As COVID-19 Patients Increase, Hospitals Prepare For Surge

The COVID-19 triage tent next to the UNC Rex Hospital emergency department.
Jason deBruyn

Leaders at health systems around the state say a combination of better medical care and larger stockpiles of protective gear mean they can handle surges in COVID-19 patients more effectively today than they could three months ago.

But those same leaders warn that the additional capacity still has a limit, and they worry for the health of North Carolina residents if current trends continue.

"We're in a much better place than we were when we began this," said Dr. West Paul, chief clinical officer at New Hanover Regional Medical Center in Wilmington. "That being said, if you look at our hospitalizations, they continue to go up."

A hospital's ability to accommodate growing numbers of patients is about more than how many beds it has, Paul said: It's about "staff, stuff and space."

"We need more capacity right now, because sometimes it's just not simply if your hospital is full or not. Sometimes it is, 'My ICU is full or my operating rooms can't get the patient through because of (not enough) floor staff.' So there's a lot of flow we have to deal with," Paul said.

A survey of hospital systems across the state by a network of reporters shows that while capacity is holding steady now, health care leaders are preparing to handle an influx of patients.

However, hospital leaders expect that influx to be more manageable as health care systems have worked together to increase patient capacity and shared access to personal protective equipment, which, three months ago was hard to get.

Dr. Abhi Mehrotra in the UNC Hospitals Emergency Department.
Credit UNC Health

Stockpiles Of Protective Gear And Medical Equipment Have Grown

Reporting by the network shows the state doesn't track hospital staffing, but the N.C. Department of Health and Human Services says records show the state has adequate supplies of PPE, including gloves, gowns, respirators, procedure masks and face shields.

A shipment that includes 15 pallets carrying more than 30,000 gowns was in customs as of Thursday. Hospitals will share that protective equipment with smaller health providers thanks in part to a group purchasing initiative set up by a subsidiary of the N.C. Healthcare Association, the lobbying group for the state's hospitals, a spokeswoman said.

When the coronavirus pandemic first hit the United States, health systems in North Carolina feared they did not own enough PPE to protect their workers or other patients, something that could have led to an unmanageable surge in COVID-19 cases.

North Carolina hospitals didn't see an early surge like those in the northeast, particularly New York. As supply chains snapped back closer to normal, it allowed health systems and the state to beef up stockpiles of PPE, put new policies in place to better triage coronavirus patients and learn from treatment missteps in other areas.

In addition to more PPE, fewer COVID-19 patients are being put on ventilators, seen as an important treatment option early in the pandemic. Ventilators tax the lungs, and studies have shown them to be counterproductive in some patients, according to new research. Doctors now use ventilators more sparingly, public health experts say, and mortality rates have dropped.

"What we have done is drastically improve medical care," said Dr. Myron Cohen, the UNC School of Medicine associate vice chancellor for global health and medical affairs. "And the drastically improved medical care leads itself to much lower mortality than we saw early in the epidemic and to people getting out of the hospital much more quickly than they did early in the epidemic.

Governor Roy Cooper in a candid photo wearing his black face mask where he gives coronavirus briefings.
Credit Courtesy Governor Roy Cooper Twitter
Governor Roy Cooper

Experts Worried By Recent Trends

As a result, health leaders around the state agree they are much better prepared now than they were three months ago to face an influx of patients.

"Yes, (the statewide stay at home order) bought us time. This absolutely helped. We were able to prepare. We were to put plans in place," Paul said.

However, these experts worry that they might see the original scenario become reality.

"We are in a markedly different place now than we were in mid to late March," said Dr. Chris DeRienzo, WakeMed Health and Hospitals chief quality and medical staff officer.

Still, he added that, "It certainly is concerning to see the slow rise in hospitalizations."

When Gov. Roy Cooper pushed North Carolina into Phase 1 of reopening on May 8, the state's hospitals were seeing about 500 COVID-19 patients on a daily basis. This figure counts all patients on a given day.

When Cooper stepped the state into Phase 2 on May 22, ending his statewide stay-at-home order, hospitals had fewer than 600 patients per day. That number has now increased to about 900. 

On the ground, hospitals reported a noticeable difference after restrictions were eased.

"If you look at our curve of admissions for COVID patients," said Paul, from NHRMC, "when we sheltered at home when the government gave the order, within two weeks, our numbers went down, went down rather dramatically and plateaued."

The hospital saw a spike in hospitalizations two weeks after those restrictions were lifted, he said.

Cooper cited these trends in his announcement that he would keep the state in Phase 2 of reopening and require wearing face masks in public.

"Our cautious approach is like a dimmer switch, rather than an on/off switch," Cooper said at a briefing Wednesday. "Over the past weeks and months, even as we've slowly turned the dimmer switch up and eased restrictions, we've seen community spread of the virus increase in North Carolina. We're adding this new requirement because we don't want to go backward."

What's more, a group of public health experts say the recent rise in COVID-19 hospitalizations has had an uneven impact across the state. Researchers from Duke University and the University of North Carolina at Chapel Hill found that counties surrounding Greenville, Charlotte and Raleigh "are experiencing more substantial tightening of near-term capacity than other regions."

At Mission hospitals, which service Asheville and several largely rural communities in the Western North Carolina mountains, the number of COVID-19 patents went from fewer than six hospitalized patients a few months ago to as many as 20 patients per day at the start of June, said Dr. William Hathaway, chief medical officer with the North Carolina Division of HCA Health and Mission Health in a June 1 press conference in Buncombe County.

"About half of these patients tend to be located in our Intensive Care Unit, and a smattering of those are on ventilators," he said.

Mission's main hospital is in Asheville, with regional hospitals located in Jackson, Macon, McDowell, Mitchell and Transylvania counties.

"While unfortunate, and certainly disappointing and tragic for the families and patients involved, I would not say that this is unexpected at this point in time," Hathaway said. 

"Given the increased mobility we have seen in our community as we open up the economy, we will continue to expect to see additional cases of COVID-19."

But other areas' hospitalization trends, the authors of the Duke and UNC study said, "are somewhat more threatening now than they were a month ago," and hospitals reached by reporters indicated the concerns are still there.

A spokeswoman for Novant Health, which has hospitals in Brunswick, Forsyth and Mecklenburg counties, said the health system has seen an increase in COVID-19 patients in recent weeks, although many of the new cases are more mild.

"We're well aware of the current environment, with a mix of protests and businesses reopening, and will continue to carefully monitor the modeling," spokeswoman Megan Rivers said.

Rivers said Novant has increased its bed capacity by 60% and has reinforced its supply chain.

"Novant Health has extensive surge planning in place and stands ready to activate, as needed," Rivers said.

Rivers said everyone can do their part to ensure hospitals have enough room for critical patients if they continue following the basic guidelines of physical distancing, wearing masks and washing their hands.

"This not only helps mitigate the spread of COVID-19, but ensures hospitals are able to conserve valuable resources like PPE and continue providing care to all who need it," she said.

Cohen, the UNC infectious disease specialist, echoed the importance of people taking steps to protect themselves and others while in public, similar to how health care staff have adapted to treat patients.

"I think, unequivocally, the risk to health care workers has gone down as we've learned the rules," he said.

However, he said he worries the general public still hasn't taken those rules to heart.

"Masks, masks and more masks need to be emphasized," he said in a media briefing Wednesday, adding that handwashing and social distancing also play important roles.

Solutions To Capacity Issues

During a typical emergency, such as a hurricane, hospitals have the ability to work together to move less-critical patients to other facilities — thus making more room where it is needed most.

But with COVID-19, all hospitals in the state are dealing with the same emergency.

"It's not nearly as easy as it would have been before," Paul said. "COVID, it's not the hurricane scenario. Every hospital is grappling with this right now. So no, it's much more difficult."

Paul said it isn't impossible, though, and hospitals are communicating to figure out what can be done.

"As we've increased a number of patients, we have already looked at outside hospitals, 'What do you have available? What could we transfer?'" he said. "So we've got those plans in place if we need it."

Paul added that hospitals also have to have their own solutions.

"We need to maximize our capacity," he said, explaining that could mean anything from setting up triage facilities outdoors to opening a new hospital tower earlier than planned, which is what NHRMC is doing in the coming weeks.

However, the best-laid plans may not be enough, he said.

"Planning is one thing," Paul said. "Being in the actual event is another, and we are finding even with the best plans we've made, we are having to adapt to the new reality. 

"We've got normal sick patients who are coming through our organization, we still have trauma patients, we still have all of the work that we did, plus COVID patients. So now we're adapting our plans."

This story was jointly reported and edited by Kate Martin and Frank Taylor, of Carolina Public Press; Jordan Schrader, of The News & Observer; Nick Ochsner, of WBTV; Emily Featherston, of WECT; Tyler Dukes, of WRAL; and Jason deBruyn, of WUNC-FM.

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