As the United States enters a new stage of the pandemic wave, hospital systems are being reconfigured in radical ways to handle the growing number of sick, and over the next few weeks, hospitals appear likely to look and operate very differently than today. With the need for social distancing even among the sick, securing and configuring physical spaces large enough to handle the load has become one of the biggest challenges facing state officials and hospital administrators.
“What we’ve done is shift from all daily operations to preparing for mass numbers of people with covid-19," Omar Lateef, chief executive of Rush University Medical Center in Chicago, said.
The mounting costs of the hospital build-out are being borne mostly by individual state treasuries and private medical centers, with some help from the Federal Emergency Management Agency and Army Corps of Engineers. But there is an expectation the federal government will provide some relief. The $2 trillion aid bill Congress rushed to pass contains $100 billion for hospitals to offset expenses related to the coronavirus surge.
Part of the reason for the need for auxiliary, emergency measures is that many hospitals have closed in recent years because of financial trouble. The United States has fewer beds per capita — just 2.7 per 1,000 people — than many other countries. That compares with 6.5 per 1,000 for South Korea and France, for example, and 4.3 for China.
The U.S. has 924,100 hospital beds, most of which are occupied on a typical day, according to a 2018 survey from the American Hospital Association. But in a severe pandemic situation, such as the one the country faced during the 1918 flu pandemic, experts have estimated that 38 million people would need medical care, resulting in 9.6 million hospitalizations and 2.9 million intensive care stays.
The ongoing transformation of the American hospital system mirrors what was done in other countries that faced the pandemic first.
There was the Chinese megalopolis Wuhan, where patients were sorted by severity of disease into different hospitals — 10 temporary ones for the mildly sick or contagious in sports stadiums and similar facilities, 39 for those with critical illness or who were 65 and older and six for critical care. In Italy’s Lombardy region, the hospital system was essentially cleaved into two: one for coronavirus patients with 55 hospitals, and the remaining few hospitals reserved for those experiencing more ordinary emergencies such as strokes, accidents or childbirth.
With public health officials estimating millions of Americans — up to a fifth of the population — may need to be hospitalized, states and hospitals are taking creative approaches to housing the ill while containing the contagion.
Plans remain in flux in many areas, but health officials describe four general tiers of treatment.
The first is triage, which includes drive-through test sites and tents in parking lots. This is where most patients would have initial contact with the hospital system. They would be swabbed, and their temperatures taken. At Mount Sinai Hospital in New York, staff stop those who enter the emergency room and direct anyone with flu-like symptoms to a separate area.
“We took over a clinic space right next to the emergency department, and we made it a zone for patients with respiratory illness,” Jolion McGreevy, the hospital’s emergency department medical director, said. A dedicated team in protective gear treats patients escorted to that area.
The second tier is for the mildly ill or those awaiting test results. Chicago is renting thousands of hotel rooms. San Francisco is setting up RVs in the Presidio, a park in the northern part of the city.
As shown in a photo that went viral last week , Yale University in New Haven, Conn., is setting up rows of beds in its gymnasium. Yale University spokeswoman Karen N. Peart said the space would be activated if the school’s health center fills up. She said it would offer only general care such as the monitoring of vital signs and provision of food and water.
“We hope we never have to use it. But it could support those who are unable to care for themselves at home, yet are not sick enough for hospital admission,” Peart said.
In Louisiana, Lt. Gov. Billy Nungesser (R) said cabins in state parks will temporarily shelter the homeless or people who cannot return to their homes while awaiting coronavirus test results. A park ranger will stand watch to make sure “nobody goes in and out unassisted.” State police will also guard the cabins, he said. A caterer will provide meals to be delivered to each cabin.
“By putting one person in each cabin, if it comes back negative, then they can just reuse the cabin. If it’s positive, then they’ve got to clean that cabin good, but they can then just reuse that cabin,” Nungesser said in an interview.
The third level of care consists of the existing hospital system, and administrators interviewed in recent weeks said they anticipate handling mostly severe to critical cases. Many major medical centers in several large cities said they would continue accepting patients with ordinary emergencies ranging from heart attacks to births, but they confined coronavirus patients to separate areas so they cannot transmit the virus to other patients.
Of particular concern is finding enough room for the large number of patients expected to need mechanical ventilators to breathe.
At Northwestern Memorial Hospital in Chicago, doctors are working to increase the 97 intensive care beds to 240. Richard Wunderink, medical director for one of the ICUs, said rooms have been shifted to create a dedicated covid-19 unit that has negative airflow to prevent infectious material from contaminating other areas.
In some parts of the country, existing facilities such as M Health Fairview Bethesda Hospital, a long-term care center in St. Paul, Minn., are being remade as covid centers. Bethesda has 90 beds including 35 intensive care beds. M Health Fairview, which owns the property, said current patients were being transferred to other facilities in preparation.
In New York, the epicenter of the virus in the United States and where the ill are mounting, construction of the four temporary hospitals inside the Javits convention center began this week. Each will have 250 beds and occupy 40,000 square feet. New York Gov. Andrew M. Cuomo (D) has said another 1,000 beds could be added for those who are less ill if needed.
Some states are preparing for patients who have received significantly less attention than the sick: the recovering.
Taking lessons from a surge in coronavirus patients that overwhelmed hospitals in Washington state, Colorado hospitals are setting up a system that would allow patients recovering from the illness to transfer out of hospitals to make room for the critically ill, said Julie Lonborg, spokeswoman for the Colorado Hospital Association.
Lonborg said the state had talked to states that were seven or 10 days ahead of Colorado in the outbreak and asked what they wish they had done differently: “They said part of what was stressing the system was that once patients were no longer critically ill, but still needed to be cared for, they were taking up space in the hospital that could be used by critically ill patients," she said.
With nursing homes refusing to accept patients without a negative covid-19 test, recently vacated college dorm rooms and hotels in Denver may be pressed into service, she said.
“It’s a pressure relief valve on the back end,” she said.
Ben Guarino in New York, Juliet Eilperin in Washington, Jennifer Oldham in Denver, Steve Burkholder in Connecticut and Shirley Wang in Iowa City contributed to this report. Martin reported from Houston.