Coronavirus pandemic would swamp Washington hospitals. Are there enough ventilators, masks?

Emergency rooms would likely be swamped, overflowing into “surge tents” outside. Intensive care units might fill to capacity. Test kits and masks could run low. And medical personnel would almost certainly get overwhelmed.

A coronavirus pandemic would strain Washington’s ability to quickly and effectively contain the disease. The state already has confirmed 162 cases and 22 deaths from COVID-19, and experts are worried the state’s health care system won’t be able to keep up if those numbers skyrocket to pandemic levels in the weeks ahead.

State officials in Washington and elsewhere have already complained about the availability of test kits. Masks are in such short supply, Washington has had to request more protective masks for healthcare workers from a federal national stockpile.

Now another potential problem looms: The state’s hospitals could run dangerously low on a vital piece of medical equipment: ventilating machines that could enable the sickest COVID-19 patients to continue breathing. Yet the state’s public health department can’t say how many of the machines there are.

“We do not know how many ventilators are in the state,” Danielle Koenig, a spokeswoman for the Washington State Department of Health, said in an email.

The need for those machines could be dire. In 2013, King County officials estimated in a pandemic influenza response plan that in a moderate pandemic as many as 64,875 patients in that county would get sick, and 389 would require a ventilator. In a worst-case pandemic, similar to the 1918 Spanish flu, as many as 742,500 could fall ill; and as many as 4,455 King County patients would need them.

Washington’s hospital association estimates there are fewer than 3,300 ventilators currently in the state, based on the numbers of intensive care unit beds in the state’s hospitals, which generally have a ventilation machine available.

At a Feb. 25 hearing on Capitol Hill, U.S. Sen. Patty Murray, D-Wash., pressed Health and Human Services Secretary Alex Azar about whether the nation has enough ventilators, masks and other equipment.

“Well of course not, or we wouldn’t be asking for a supplemental (appropriation) to seek more money to procure more of that,” Azar replied, according to a transcript released by Murray’s office. Congress passed an $8.3 billion appropriation to fight the coronavirus outbreak.

Hospitals already at capacity

As it is, the coronavirus scare comes at a difficult time for Washington’s 117 hospitals.

Washington’s emergency rooms are already overcrowded. The median ER wait time for patients before being admitted to Washington hospitals was 274 minutes in 2018, or more than four hours, according to the federal Centers for Medicare & Medicaid Services.

The median time spent in the ER for those discharged without admission was 140 minutes.

Hospitals, nationwide, also “routinely operate at or near full capacity and have limited ability to rapidly increase services,” according to a report on COVID-19 last month by doctors at Johns Hopkins University’s Center for Health Security. “There are currently shortages of healthcare workers of all kinds. Emergency departments are overcrowded and often have to divert patients to other hospitals.”

The 2018 flu epidemic in the U.S. forced some hospitals to erect surge tents — “an inflatable, military-style hospital ward” — to care for the extra patients who flooded emergency rooms.

If the outbreak worsens significantly, hospitals would have to make 30 percent of their beds available for COVID-19 patients in one week’s notice, the report said. That might involve discharging other patients sooner than expected, converting single rooms to doubles, and taking other steps like placing patients in classrooms.

Health experts have long been aware of the potentially dire consequences of a shortage of ventilators during a severe respiratory disease outbreak.

“In a severe influenza pandemic, hospitals will likely experience serious and widespread shortages of patient pulmonary ventilators and of staff qualified to operate them,” according to a 2011 report in the journal Health Care Analysis. “Deciding who will receive access to mechanical ventilation will often determine who lives and who dies.”

How bad could it get?

A 2005 study by the U.S. Department of Health and Human Services said nearly 65,000 Americans would need to go on ventilators in case of a moderate influenza pandemic. The number would shoot up to 742,000 if a severe pandemic struck, comparable to the 1918 flu that killed millions around the world.

Yet a 2010 federal study calculated there are only 160,000 ventilators available at America’s hospitals, plus another 10,000 in a “strategic national stockpile” run by the U.S. Centers for Disease Control and Prevention.

What’s more, a Johns Hopkins University study calculated that America has only 135,000 respiratory therapists capable of operating the machines.

But Dr. Art Reingold, an epidemiology expert at the University of California, Berkeley, School of Public Health, cautioned, however, that the numbers of available ventilators may be misleading. After all, not everyone who needs one will fall ill at the same time, and each person who gets sick won’t need to be on them for the same amount of time, he said.

“That makes it a complicated calculation,” he said.

Washington hospitals bracing

Washington’s hospitals don’t have extra capacity and are not holding beds open for possible COVID-19 patients, said Beth Zborowski, a spokeswoman for the Washington State Hospital Association.

“However, hospital space can and will be made quickly available in an emergency or with a surge of critically ill patients,” Zborowski said in an email. “Many hospitals have activated their emergency response plans to prepare to respond to community need, though most hospital operations are continuing as normal.”

Washington hospital officials say they’re ready for whatever the coronavirus brings.

“We manage infectious disease on a regular basis and adhere to policies in place for this purpose,” said Cary Evans, a spokesman for CHI Franciscan, which operates 11 acute care hospitals and more than 200 primary and specialty care clinics throughout the greater Puget Sound. “We have the necessary supplies and equipment and are prepared to identify, isolate and treat any potential patient who seeks care in our facilities.”

Zborowski said Washington hospitals also have experience in dealing with unprecedented strains on resources. She cited the 2017 I-5 train derailment in DuPont that injured more than 65 people and killed three.

“Area hospitals canceled elective surgeries and procedures and were ready to accept injured patients, Zborowski said. “The capacity they created far exceeded the demand. Hospitals also work with each other and through public health and regional emergency response coalitions to help get supplies where there is the greatest need.”

None of the Washington hospitals contacted by McClatchy provided their numbers of ventilators.

Ventilator lotteries?

The issue of ventilator shortages has worried scientists, emergency-preparedness officials and others for years.

A white paper by the U.S. Centers for Disease Control and Prevention three years ago acknowledged that the agency’s Strategic National Stockpile of about 10,000 ventilators “might not suffice to meet demand during a severe public health emergency.”

In 2015, the New York State Health Department, anticipating a dramatic shortage of ventilators, released a 272-page guide on how the machines would be “ethically allocated” during a flu pandemic.

That might mean using a lottery to decide who gets a ventilator.

The guidelines say that if a number of similarly sickened patients with equal likelihoods of survival come into a facility without enough ventilators to serve them, “a randomization process, such as a lottery, is used each time a ventilator becomes available because there are no other evidence-based clinical factors available to consider.”

That sort of strategy would be difficult to carry out, said Art Caplan, director of the medical ethics program at New York University’s Langone Medical Center. There would be resistance from doctors, who’d be reluctant to take patients off machines unless it was clear their odds of survival were low, he said.

Meanwhile, such policies would prove difficult to enforce.

“If you have guidelines, you have to enforce them,” Caplan said, “and it’s never clear who is enforcing them.”

Caplan said an added worry as the outbreak spreads is that America’s healthcare system is notoriously bad at sharing resources, and it lacks enforceable plans for scenarios that require moving patients to new facilities that have the equipment they need, Caplan said.

“That’s crucial,” Caplan said. “If you have to move (patients), who’s going to coordinate it? Who are the ambulances? Who’s paying? You’ve got to make them all play ball and, generally speaking, that’s not a virtue of the current health system.”

Avoiding a dire scenario where there aren’t enough ventilation machines and other life-saving treatments to go around is precisely why public health officials have been giving a consistent message: Aggressively wash your hands, get your flu shots, and stay home when you’re sick.

If everyone takes steps to avoid getting others sick, it prevents overwhelming an already overworked public health and hospital situation, experts say.

“We are doing all the right things to keep that from happening,” said Darcy Jaffe, the Washington hospital association’s vice president for safety and quality. “The (advice of) wash your hands, stay home, don’t cough on people -- the basics of prevention -- is really what’s going to keep us out of this… (scenario) that we won’t have what we need to take care of people when they get really sick.”

This story was originally published March 10, 2020 at 5:00 AM.