CLEVELAND, Ohio — Long lines outside drive-through coronavirus testing sites in Cuyahoga County are an undeniable indication of a stark reality: Our health care system has a limited capacity.
As the coronavirus pandemic worsens, the stock of medical supplies and available hospital beds and health care workers will only dwindle.
That means choices about who has access will only get harder.
At some point, the decision won’t be who gets tested; it will be who gets help to breathe.
When testing started in Ohio 11 days ago, public and hospital officials took steps to ration the precious few COVID-19 tests, even as they speedily ramped up capacity from zero to thousands.
They prioritized those who had traveled to a high-risk country or had been exposed to someone who had tested positive for COVID-19. And health care workers — nurses, doctors and medical aids — who have the most contact with infected and exposed patients.
Others, even with fevers and chills and coughs, were told to self-quarantine and treat their symptoms at home.
That message was frightening to some.
“It’s scary,” said Sharona Hoffman, a professor of law and bioethics and the co-director of the Law-Medicine Center at Case Western Reserve University. “This is scary.”
It will be a marking point in people’s lives, just like it was for people who lived through the 1918 Spanish flu pandemic or the less severe but still significant 1957 influenza outbreak, Hoffman said.
There aren’t enough resources to test otherwise healthy people with symptoms to ease their concerns, Dr. Cindy Zelis, University Hospitals vice president of ambulatory operations, said Tuesday.
“You can’t just carte blanche test,” Zelis said. “You can’t test for the ‘worried well.’ There’s not enough supply.”
Limiting testing
Right now, the Clinic and UH combined can test about 1,500 people per day. MetroHealth began testing Tuesday but hasn’t shared its capacity.
Even with ramped up capacity, the systems were showing signs of buckling this week. Just days after the drive-through testing began at two sites, hospitals were overwhelmed with demand, and patients, even those with physician’s orders for a test, were waiting for hours, and sometimes turned away.
By Tuesday night, the Clinic announced it would reserve testing only for patients at the highest risk, which includes those in the hospital and patients 61 and older with a doctor’s order for the test, to preserve a limited supply of Italian-manufactured testing swabs, it said.
At MetroHealth, tests also are being reserved for hospitalized patients who are critically ill.
In these moments, people may feel like, “I am not going to get something I need so that someone else can get it,” said Jessica Berg, dean of the Case Western Reserve University Law school and professor of Bioethics and Public Health.
But really, the decisions are population health-based in order to “keep the most people as healthy as possible.”
When there’s not enough tests to go around the question that must be answered is, “Does it make sense for everyone to have access?”
The answer is “no,” Berg said. The question then becomes, “Who needs it the most?”
Ohio Department of Health Director Amy Acton has estimated that 100,000 Ohioans already have the virus.
Lack of supply
Shortages of other supplies are already being seen as well.
The state, for instance, last week called for veterinarians and dentists who had extra protective gear, like N95 surgical masks and respirators, to consider sending them to Emergency Management Agencies.
And, on Tuesday, Gov. Mike DeWine ordered hospitals to postpone elective surgeries to conserve personal protective equipment and make sure health care workers are at the ready for those in dire need of care.
DeWine, in his now-daily press briefing, said he had concerns about shortages of that protective gear and of ventilators, which are needed for patients with severe respiratory distress due to the virus. The Ohio Hospital Association (OHA) estimated the state would need the country’s entire stock of protective gear to meet the expected need.
The governor’s order to postpone elective surgeries goes into effect at the end of the day Wednesday.
That means some people will have to forgo surgeries that might improve their health or that they’ve waited a long time for, Hoffman said.
“If you are the person being told ‘Sorry, no elective surgery,’” Hoffman said. “It’s not easy.”
Overwhelming the system
It’s becoming more clear that our health care system isn’t built to handle a million people or more who are gravely ill. There’s not enough hospital beds, ventilators or staff to care for those patients, Hoffman said.
In Northeast Ohio, the Clinic system has 3,000 adult hospital beds with the ability to increase that capacity by 200 in 72 hours by using equipment in storage. The hospital system also has at least 550 ventilators on hand.
The UH system has a 3,116-maximum bed capacity and 429 ventilators.
MetroHealth has 750 beds, 200 of which can be used for intensive care, along with 60 adult ventilators.
Hospitals already are at about 75% capacity, which is normal for this time of year, maybe a little elevated due to a tough flu season, said Mike Abrams, CEO of the OHA.
“We can safely surge another 25% without doing anything extraordinary,” Abrams said.
Capacity can be expanded in some ways: nursing home wings or even local hotels could be transformed to care for non-infectious hospital patients. Triage can be done in tents outside hospital buildings.
“There’s no scenario now by which we won’t have a surge,” Acton said Tuesday.
Decisions made now to promote physical distancing and self-quarantine are hung on hopes of tamping down the demand on hospitals by two-thirds. And in the best circumstance, cut the number of deaths in half, she said.
When the inevitable happens, Acton said, “You’re going to hear a lot about bed capacity…It’s not about beds. Our National Guard and others will be setting up tents and things with beds.”
As of 2018, the Cleveland area had 7,230 total hospital beds with about 64% occupied. That would leave about 2,630 beds open for additional patients, including 880 beds in intensive care units where many coronavirus patients are treated, according to data obtained by ProPublica from the American Hospital Association and the American Hospital Directory.
Without coronavirus patients, there are only 310 available beds on average in intensive care units, which is 3.2 times less than what is needed to care for all severe cases, according to ProPublica’s estimates.
Even harder decisions are going to be made as the weeks go on, as the pool of health care workers diminishes and cases spike.
Already, the CDC has changed its guidelines for health care workers exposed to the coronavirus. Those who are exposed while not wearing personal protective equipment and are not showing symptoms are now being told to return to work.
“As the virus continues to spread throughout our communities, it is important to return personnel to work as soon as possible so we can continue caring for our patients,” the Clinic said in a statement.
Making tough decisions
In the best circumstances, decisions to ration health care, especially urgently, should be cooperative and clearly explained to the public, bioethics experts said.
In some ways, it is easier to have the governor say, “This is what we are going to do,” Hoffman said. That way, others can explain that they are following orders. But those folks making the decisions must be connected with and consulting those who understand the reality on the ground, she said.
There’s no set of agreed-upon “rules” or standards for rationing: who makes the rules or whether it should happen collectively or institution-by-institution, Hoffman said.
Berg said it’s best for those recommendations to come from national associations and professional groups.
“It’s always best to do things at a higher level with a lot of input and to be very, very open about what the decisions were and why they were made,” Berg said.
Institutions like hospitals may find it hard to be transparent about how they will make choices about who gets the benefit of equipment — such as a ventilator. But it is necessary to share how the decisions will be made so people don’t think there’s a secret group of people making the decisions, Hoffman said.
Explaining the choices to the public, as far ahead of time as possible also helps, Berg said.
A person might not like it when a decision comes down and adversely affects them or a loved one, Berg said. “But you understand it better.”
Experts agree that choices about who gets access to equipment should not be put on nurses or doctors, Berg said, because that “is not a fair burden to put on individuals.”
No matter who is responsible, people need to keep in mind that “these are horrible decisions to have to make.”
“You’re going to have to play God, and nobody wants to do that,” Berg said.
Hoffman, who spent time studying the aftermath of Hurricane Katrina at the CDC, said health care workers were forced to watch people in their care die because of decisions they made.
“It’s terribly traumatic and some people don’t recover from that,” Hoffman said. “If you feel you caused someone to die, that is very, very difficult,” she said.
The decisions of who gets critical care are endlessly debated and extremely controversial, Berg said.
In some cases, like in hard-hit Italy, life-saving measures have been extended to younger and healthier patients more likely to recover, Hoffman said. Even older patients might agree with that rationale.
But, “if you are gasping for breath,” she said, “You might not feel that way in the moment.”
COVID-19 is a respiratory illness with symptoms including fever, cough and shortness of breath. It has sickened thousands and killed 7,400 globally, according to the World Health Organization. There is not yet a vaccine for COVID-19, nor are there any medications approved to treat it, according to the Centers for Disease Control and Prevention.
Plain Dealer Reporter Brie Zeltner contributed to this story.
Latest COVID-19 statistics, as of 1 p.m. Wednesday:
Countries, territories and areas with confirmed cases: 151
U.S. states reporting cases: 50 and Washington, D.C., Puerto Rico, Guam and U.S. Virgin Islands
Total cases in U.S.: 7,038
Total deaths in U.S.: 97
Worldwide information is from the WHO, and U.S. numbers are from the CDC.
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