At the present rate of COVID-19 inflection growth Alaska hospitals will be short of Intensive Care Unit beds and ventilators by mid-September, a panel of physicians and health experts told a legislative committee last Tuesday.
Anchorage hospitals are already feeling strain, although there is still available capacity.
What’s causing the sharp rise in infections that Alaskans, particularly young people, are not paying enough attention to basic precautions like physical distancing and wearing of face masks. Although the Municipality of Anchorage has mandated wearing of face masks while in public indoor spaces there is no statewide mandate. Compliance with state COVID-19 recommendations including spacing in restaurants is spotty outside Anchorage.
The key problem is a sense of complacency because of state officials’ reliance on a web-based “dashboard” on numerical indicators of hospital capacity that is actually misleading, Dr. Nick Papacostas, Alaska Chapter president of the American College of Emergency Room Physicians, told the House Health and Social Services Committee.
The indicators show ample capacity of intensive care units, ventilators and general hospital beds, but the reality is that pressures on medical staffs at hospitals mean the number of COVID-19 patients can be placed in ICU beds is actually lower, Dr. Papacostas said.
“The state dashboard may show us in the ‘green’ in capacity while we’re actually in the red zone because of staffing,” he said.
In the case of ventilators, the numbers may show units available but pediatric and neonatal units (for children and infants) are included, so the capacity is artificially inflated in terms of ventilators available for adults, Dr. Papacostas said.
Staffing issues are a factor with ventilators too, because it takes a team of skilled nurses and technicians to support patients using ventilators, he said. Alaska’s COVID-19 numbers are still small, but the rising week-over-week increases in infections is already resulting in increased hospitalizations, so the trend is worrisome, he said.
“We’re also seeing an increasing number of patients with risk factors (other health complications) so they get sicker and come back,” after being initially discharged, Papacostas said.
Dr. Thomas Hennessy, epidem at the University of Alaska Anchorage’s College of Heath, agreed that hospital staffing amid the COVID crisis is a problem not generally unrecognized.
“Having ventilators without the skilled people to run them is akin to having a bunch of airplanes full of important cargo need to get someplace urgently, but not having pilots,” Dr. Hennessy said.
Dr. Hennessy said the worsening of COVID-19 numbers for Alaska was expected following the relaxation of restrictions but the trend has now quickened to the point that the ability to do “contact tracing,” to identify others that a person testing positive for the virus may have infected, has been exhausted in Anchorage.
“This is alarming because it’s a sign that the public heath response is being overwhelmed,” he told the legislative committee.
Not being able to do contact tracing means the virus is spreading undetected at unknown rates. “A case reported today is an exposure to the virus that happened two weeks ago. A person that is hospitalized today was exposed a month ago,” Dr. Hennessy said.
Meanwhile, the university is closely tracking hospital capacity. At the rate of infections in early June the modeling showed 16 to 20 weeks of available ICU and ventilator capacity. By early July infections increased to the point that capacity would be absorbed in eight weeks, or by September 20 according to the university’s models, Dr. Hennessy said.
Capacity modeling had also resulted in dire predictions in March when Alaskans first started being infected, but what slowed the curve then was an aggressive response by state and local officials to close schools and businesses, and there was broad public support for the measures.
It’s not too late to do this again, Dr. Hennessy said, but state and local officials must act quickly. On a far larger scale, states like Florida, Texas and California are experiencing an explosion of infections and hospitalizations following rapid reopening of their economies. “We can see where we are headed,” Dr. Hennessy said.
“We need a return of the bold leadership now to stem the rising tide of cases. We've never been closer to exceeding our healthcare capacity at any point in this pandemic,” he told the legislators.
Jared Kosin, CEO of the Alaska State Hospital and Nursing Home Association said his members are still reporting ICU and “medical” bed occupancy at normal levels. Anchorage hospitals were at 61 percent of the 92 ICU beds occupied and 79 percent of 62 medical beds occupied, but these rates are normal for now. Capacity varies because patients are always being admitted and discharged. ICU capacity use in Anchorage peaked at 67 percent last week and medical bed occupancy peaked at 89 percent.
However, “hospital capacity is functioning at normal levels,” Kosin said. “There are no major concerns at this moment, but this is not a normal moment,” with COVID-19 he told the legislators.
“The unusual thing is the growing pipeline of likely hospitalizations coming based on the high COVID case counts,” Kosin said.
What would put hospitals under stress is an increase to a consistent patient load in Anchorage hospitals to 80 percent occupancy of ICU beds and 90 percent occupancy of medical beds. To reach that would require increases to 18 hospitalizations in ICU units and 63 hospitalizations to medical beds, Kosin said.
Getting to this point is probable given the current trends. Last Sunday, “we had 36 people with COVID in hospitals, 26 in Anchorage. A month ago, we had four people in hospitals. Two weeks later it had grown to 16. Seven days later it was 21. Two days ago (from July 28) we had 36,” he said.
“Will we hit the stress point? How can we not at this rate,” Kosin told legislators.
When Anchorage hospitals come under stress it affects other parts of the state and particularly rural Alaska, Dr. Ellen Hodges, medical director of the Yukon-Kuskokwim Health Corporation in Bethel, told the legislative committee.
YKHC serves 48 villages and 28,000 people in the Yukon-Kuskokwim region of Southwest Alaska through a network of village clinics and one hospital in Bethel.
Capacity for COVID treatment is limited. “We have no ICU beds,” Dr. Hodges told legislators. Gravely ill patients are flown to the Alaska Native medical center in Anchorage and if capacity there is filled the spillover goes to Anchorage-area hospitals.
State officials have always worried about serious virus outbreaks in rural villages but so far there have been none. However, it is worrisome that a number of small villages still do not have water or sewer systems, so the ability for frequent handwashing in limited. Studies have shown that infectious diseases spread more rapidly in homes without water and sewer, Dr. Hodges said.
What complicates things more is crowded housing and multi-generation families in one house, with the elderly more vulnerable, she said.
“The models that are used to predict the increase in cases mostly point to an increase in community spread followed by hospital admissions and then ICU admissions and then deaths. I don’t think we can bank on Alaska having a different trajectory than the rest of the country. It is clear that something must be done to interrupt our current trajectory,” Dr. Hodges said.
Kosin cautioned that another shutdown of nonessential care was not a solution. “Delaying medical care (for non-COVID issues) creates a whole set of other issues and problems,” he said.
The steps needed to slow the virus spread are really simple if people would take them. Until a vaccine is available, which may be next year, “it is doing our part as individuals in wearing a mask, washing our hands and practicing physical distancing,” Kosin said.