US hospitals are filling up. They are filling up with patients who have heart attacks. They are filling up with patients who need chemotherapy and then are immune-compromised for weeks after each round. They are filling up with patients who just had a stroke. They are filling up with new mothers holding their chubby cheeked babies for the first time. They are filling up with people mangled after their car slid on some black ice. These are all normal demand drivers. These are the situations that we have built out both the physical space and the workforce to accommodate. They are filling up with COVID patients who were infected in mid-November. Our hospital systems are not built for this type of demand surge.
Let’s start with hospitalizations: 100,226 total on 12/2/20.
On the average day in 2018, there were 612,000 hospitalized patients. Assume this is 620,000 in 2020 without Covid
So roughly **16%** or ONE in SIX hospitalized patients in the US has Covid.https://t.co/uDLoQ4Lp3v pic.twitter.com/VYlMfYIXjG
— Michael L. Barnett (@ml_barnett) December 3, 2020
The marginal patient is the person who is a coin-flip at that point in time to admit or not admit, to keep or to discharge from a hospital bed.
The marginal patient will be responsive to supply. A doctor could look at a patient who probably will do well enough if they are sent home with a follow-up visit in a few days scheduled, but could do better or at least have less risk if they are admitted to the hospital and monitored for a day. That person is far more likely to be admitted when the doctor looks up and down the hospital hallways and sees half a dozen open rooms on just that floor then if there is one bed that might be open in a an hour or two.
As COVID case counts top 200,000 per day, hospitalizations will follow. Many hospital systems are already at or near capacity. More hospital systems will be at or over regular capacity in the next few weeks. This means the marginal patient will be very different in December 2020 than the marginal patient in 2019. Patients who were easy admits or easy keep for an extra day in 2019 will either never see a hospital bed or will be in and out very quickly. We, as a society, will be taking tremendous number of risks and gambles that we normally never would have taken.
We’re likely to see at least several days of 200,000 or more new, diagnosed infections as Thanksgiving Day infections are just starting to work their way into our data. Anything that we do today to minimize infection spread will not show up on hospitalizations until the middle of the month or later. Until we get infections down and then wait several weeks, the marginal patient who gets a hospital bed will be far sicker and in far more need than typical.
Cheryl Rofer
I had a twinge in the right side of my abdomen last night, and all I could think was how much I don’t want to go to any hospital right now. Fortunately, it was a twinge, not appendicitis.
I am not looking forward to the stories of patients on ventilators in the hospital halls and triage measures, but they’re coming.
I’ve been saying a half-million dead by Inauguration, and yesterday Joe agreed with that number.
Brachiator
We saw that there was a lot of travel and visiting during Thanksgiving. And here in California and elsewhere we have seen stories about government officials asking people to stay home, who then traveled or had dinner with groups of family and friends.
I hope people do better, but we have Christmas and other holidays coming up, as well as colder weather leading people to be indoors more.
gvg
@Brachiator: We had a very short Thanksgiving distantly out doors in Florida. I cooked my offering in multiple small glass containers so no need to divide at the “dinner” & leftovers went home. I didn’t even get within 6 feet of my parents. and it was just us.
It has gotten colder though, I am not sure what we will do for Christmas. Colder areas of the country can’t even do this. We’ll be OK if we can’t do anything though.
Dupe1970
This is what scares me. That despite my best efforts, I do get sick and have to deal with rationed care because so many of my fellow Americans said “eff it!”
Fair Economist
“Several days of 200,000 or more” is a really tame prediction given that we’ve already had over 200,000 for the last two days. With winter intensifying and the holidays continuing over 300,000 for an extended period is very likely and it could get even worse than that.
satby
Hi David, want to share on FB because people read these posts when I do. Can you switch the image again?
A big white cat doesn’t have the same credibility, although we all think he should.
Steeplejack
@Dupe1970:
Yes, it is unsettling to think of a hospital bed not being available for anything.
Cervantes
It’s an empirical question whether the normal situation is that too many people are admitted, rather than just the right ones. I would venture to say it’s the former. Hospitals are dangerous places — they’re full of pathogens, and people with holes in them. Just lying in bed for a couple of days is not actually good for people in most circumstances, and for old people with even moderate dementia there’s a risk of delirium. Obviously there’s a point at which full hospitals mean people are not admitted who should be, but it’s not a valid assumption that moving the bar a little higher is necessarily bad.
Wag
@Cervantes: An interesting point, and one that has been debated for years, and won by those who want to shorten hospital stays as much as possible. The bar has already been moved. To that end, procedures that would have normally triggered a several day hospital stay, for example a knee replacement surgery, are now being done as outpatient surgeries. Need your gallbladder taken out? Sleep well in you own bed that same night!
This change has been appropriate, but has also distilled the patient population who remain in the hospital to a much more care intensive population, sicker than before. Now couple that slow distillation of a generally sicker inpatient population with a pandemic with 200-300,000 new cases of COVID per day, with multiple admissions to the ICU, and we are headed for disaster.
topclimber
Dave, have you seen any studies about what the impact on everyday physical conditioning of so many people being out of work or staying close to home for long stretches? BJ has been replete with anecdotes of housebound folks eating and drinking more than usual, often much more, perhaps in reaction to the stress a pandemic causes.
Those who continue exercise programs are probably a declining proportion of what used to be–but that is just my guess. Just not being at work, walking around, getting up and down from a desk to attend to duties, eliminates another source of metabolic demand.
At what point, if any, do you think this all shows up in a worsening at-risk profile for the population at large?
jonas
Here in my rural upstate NY county, the local hospital executives are assuring everyone that we have plenty of beds, no need for panic, etc. Meanwhile, the local nurses’ union is painting a far more dire picture about PPE and staffing shortages. Now hospitals are always critically understaffed according to the nurses’ union, but unfortunately, the local paper just kind of gets statements from both sides and goes ¯\_(ツ)_/¯, so who knows what the real situation is.
I wonder how much of this “Covid is all overblown” attitude you see in rural America is due to the fact that most small towns and even smaller cities lack papers and other local media outlets with dedicated beat reporters who could actually report on something like this using multiple sources and fact-checking. Instead the front page headlines are a couple of AP wire stories and then some fluff about a local high school athlete winning a scholarship and how some firemen got together to raise money to buy a kid a new wheelchair or something. Out of sight, out of mind!
Kathleen
A friend who works in IT at a local hospital said analytics show hospitalizations will increase 3 fold in 3 weeks (Cincinnati).
Barbara
Our health system operates with such an aura of excess that many people, apparently, have no conception that availability of health care faces actual supply constraints. Even if you can feel somewhat assured that you are less likely to die from COVID than average, there is much less assurance that your outcome (death or not) will not be affected greatly by the availability of hospital beds and staff with certain kinds of expertise.
Alex
@Wag: There’s also the problem that as patient acuity has increased, staffing ratios have not. Leading to poorer patient outcomes and staff injuries.
Even in normal times, a lot of the marginal hospital patients don’t have someone to care for them at home. Many of them will end up in nursing homes/rehab facilities at least temporarily. And those facilities are deathtraps right now, though we don’t even know how many home care patients have been infected by those caring for them.
Alex
@topclimber: Counterpoint– I see a lot more people taking walks in my neighborhood. I have 3 extra hours a day I would normally spend in the extremely sedentary activity of driving.
Barbara
@topclimber: @Alex:
To this point, I am taking two online fitness classes a day through the studio I have been a member of for more than five years. There are only minimal equipment requirements, and I like having some contact with the instructors and other members of the class. I figure that it’s a reasonable displacement of the approximate amount of time I used to spend commuting to work.
David Anderson
@Satby Updated
David Anderson
@Cervantes: The health economists will be fighting over this question for years.
We have done a very aggressive job of pushing patients out of hospital beds. The marginal patient in 2019 is probably significantly sicker than the marginal patient in 1999 or 1989.
David Anderson
@topclimber: good question and I don’t know.
LongHairedWeirdo
That actually bumps up the scariness a bit more… as marginal, “check ’em at shift change, and respond to their call button” patients are discharged, and replaced with higher need patients, that means that normally adequate staffing is no longer adequate; and I’ve seen reports that Covid-19 in the ICU keeps nursing staff busy (each takes more time and effort than the average ICU patient).
And add to that, if you kept *me* busy, 16 hours a day, solving database woes, sure, I’d start to slip a bit, here and there, and after a few days, those 16 hours would only get as much work out of me as 12 hours does when I’m fresh… but I’m not watching people suffer and die. I never have to ask “did I make a choice that, made differently, would have saved that patient?”
If the world had true justice in it, it would take a generation for any medical practitioner to ever trust a Republican again.
Chicagopat
@jonas: Hi! Long time lurker here, seldom comment. I’m an ER doc in rural Illinois. The front page of the local paper at my hospital was a graph of icu bed availability in the county. Not good (18%, which seemed inflated to me based on personal experience, but I imagine the hospital suits give best case numbers to the media). We had 7 deaths in our icu (which normally doesn’t take vented patients) in one week last week, which is about twice as many as we usually have in a month. I’m starting to see folks that have recovered from COVID coming in with pulmonary emboli, asthma without any prior history of asthma, etc. Essentially the “long covid” cases that you hear discussed, although i fear it may not prove to be very long for some of them. This site is a nice oasis of sanity I go to every shift. I appreciate all the front pagers for all their hard work.
Lobo
The secondary effects have always worried me. While you may not be hospitalized for COVID, the beds, supplies, or staff might not be available for anything else. While personal responsibility might be a shield against COVID(sarcastic), other negative events will occur and when that happens will rationed care be there to treat it or treat it sufficiently. Are we in a triage situation?
Wag
@Chicagopat: I’m primary care in urban Colorado. We are seeing huge upticks in COVID diagnoses as well. In the past 2 weeks 4 patients of mine were in the ICU, one on a vent. One of the ICU patients is a 45 year old healthy ED physician. All are out of the Unit now, but are in for a long haul. The weeks to come are going to be intense.
Bob Hertz
Caring for severe Covid patients is extremely labor-intensive. It may require six doctors and nurses to turn over a patient, what with all the tubes and IV lines. It may require the equivalent of one patient per nurse in terms of staffing.
And that is just to keep the Covid patient alive. Many Covid patients may need to stay in the ICU for three weeks.