The city of Tulsa, Oklahoma, briefly ran out of intensive care beds earlier this month. For a time, just 11 ICU beds were free across all of North Dakota. And last week, availability in some parts of Minnesota was down to single digits.
In Illinois, the state health director warned last week that some hospitals have already reported running low on beds amid the state’s second massive COVID-19 surge.
“We are not at the point where we are going to have anybody just flailing in the hallway because we can’t get them a bed … (but) that is a real possibility,” Dr. Ngozi Ezike told reporters Friday. “That has happened in other parts of this country, in other parts of this world. We’re not going to let that happen in Illinois, but it takes all of us to make sure that that doesn’t happen.”
As COVID-19 hospitalizations have risen to unprecedented levels in Illinois and other states, the same questions from the spring surge are reemerging: Will Illinois hospitals run out of beds? And if they do, where and when?
Last week, the Pritzker administration released projections from two sets of researchers that estimated the future number of hospitalized COVID-19 patients, including those in intensive care units. These models don’t directly address when beds might run out, but a Tribune analysis of the more pessimistic projections suggests that, if trends don’t improve, all of the state’s currently available ICU beds could be in use by early December.
One caveat is that both models assume no changes in people’s behavior, and the researchers expect the state’s new “Tier 3? restrictions will have a positive effect.
In fact, the latest state data on hospitalizations offers hints of improvement — a possible bending of the curve. But those following the data say it’s too early to tell if the changes are significant or just statistical fluctuations. Any improvements also could be undone by infection surges related to holiday gatherings.
Doctors say their biggest concerns for overcrowding are in the ICUs, the specialized units in hospitals that handle the sickest of the sick. In one of the state’s 11 regions — encompassing Will and Kankakee counties, with more than 800,000 residents — there were just 22 open ICU beds on Thursday night, a situation Ezike described the next day as “dire.”
Which hospitals had available beds? It’s impossible to tell from the state data. The state gathers information on specific hospitals but has declined to make it public.
Amid a surge of patients, hospitals do have some flexibility to free up beds, such as by delaying procedures for patients who do not have COVID-19. They did that this spring, and some are doing it now.
An advocacy group of health care workers that has been sounding the alarm about hospital capacity, the Illinois Medical Professionals Action Collaborative Team, noted that any adjustments hospitals make to handle more patients can cause collateral damage.
“Hospitals have levers that they can pull to increase bed capacity when faced with these surges, but none of these levers are without harm,” said the group’s CEO, Dr. Vineet Arora, a University of Chicago professor of medicine.
“When people say, ‘Well when is COVID going to overwhelm your hospital?’ — by the time you’re having that conversation, you’re already harming somebody,” she said. “If you’re somebody who requires that elective surgery to diagnose and treat your cancer, you’re not getting that care.”
The better news is that doctors and nurses have figured out better ways to treat people since the springtime surge, making it less likely that people hospitalized with the virus end up dying from it.
However, the current surge is striking all parts of Illinois, not just the Chicago area, which adds to the challenges. The sheer volume of cases now also is leading to more deaths, and health advocates say the heavy caseload threatens to again raise a patient’s odds of dying if doctors and nurses do not have time to provide the best care.
Already, many health care workers feel stretched to the limit, said Dr. Kamaljit Singh, director of infectious disease research at NorthShore University HealthSystem.
“Our hospitals and staff — including hospitals around the state and country — are close to a breaking point,” Singh said at a news briefing Thursday.
A flood of patients
Here’s what is clear: The number of COVID-19 patients has risen dramatically in less than two months.
The figures have surpassed the highest daily bed usage from the spring, with the figure now topping 6,100. That’s a significant rise from less than 1,700 on Oct. 1, when Illinois began seeing sharp rises across the state, although recent days show signs that the surge may be slowing.
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Intensive care units, while not yet breaking the statewide spring surge record, have also seen dramatic climbs, from fewer than 400 COVID-19 patients on Oct. 1 to more than 1,200, though here also there are hints that the curve may be bending.
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The Pritzker administration has not released specific projections on when beds could run out, although the governor and Ezike have repeatedly warned it will happen if trends don’t change. On Friday, Pritzker said residents shouldn’t be fooled into complacency because they hear hospitals still have open beds.
“People have been pushing this online, this idea that ‘Oh, there’s plenty of space in the hospitals.’ They’re not looking forward,” Pritzker told reporters, later adding: “What you’re looking at is directionally and the speed at which COVID patients are filling up these beds. So we’re trying to look forward weeks, right, so that we don’t end up at Christmastime in the situation where they’re at 105% (capacity).”
The state regularly asks researchers at the University of Illinois and Northwestern University to forecast whether hospitals will overflow. But the last set of projections the state was willing to release was from nearly two weeks ago, and only predicted trends up to Dec. 11. Both models assumed people’s behavior wouldn’t change. The U. of I. forecast anticipated the state would have enough ICU beds available, at least through that date, but Northwestern’s version suggested the state was more likely to run out of beds by then.
Pritzker at a briefing last week highlighted a more detailed set of projections that were specific to COVID-19 patients and predicted, among other things, that many more COVID-19 patients could fill ICU beds in the spring of 2021 than was the case this year.
Both universities noted that these projections were again based on the worst-case scenario — that state residents wouldn’t change their behavior. Still, updated projections provided to the Tribune on Thursday offer a stark assessment of how quickly ICUs could fill up with COVID-19 patients if the worst trends of the fall were to continue.
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Under the University of Illinois projection, the number of COVID-19 patients in ICU beds is expected to reach 2,300 to 4,300 by New Year’s Day, with a median prediction topping 3,400. And the state has only 3,300 ICU beds, by last count.
In addition, ICUs are currently caring for roughly 1,400 patients who don’t have COVID-19. Do the math, and the state wouldn’t have enough ICU beds even under the model’s rosiest scenario.
Again, it’s possible for hospitals to add more ICU beds, and the state could also open up more space, such as the field hospital at McCormick Place that went largely unused earlier in the year. This time, Pritzker said, the state would first tap a closed Blue Island hospital that had 28 ICU beds when it was last operating.
But public health experts say the real challenge isn’t space but staffing. Hospital workers are getting sick, too, and those skilled enough to do critical care work are now heavily recruited around the country by hospitals desperate to staff their own crowded buildings. In one sign of the challenge, the number of ICU beds that hospitals said they could operate suddenly dropped by about 500 last week. According to the state, officials had pushed hospitals to submit a count of the number of beds that could be staffed within four hours, if needed.
Hospitals can help ease the pressure by reducing the number of ICU patients who don’t have COVID-19. In the spring, hospitals statewide saw a 70% drop of the number of non-COVID-19 ICU patients in a matter of weeks — both by cutting nonemergency surgeries and because fearful sick people stayed away.
If hospitals collectively had the same drop this fall, they’d end up with just over 600 patients a day in the ICUs who did not have COVID-19, down from a peak of roughly 2,000.
To analyze when the state might run out of ICU beds, the Tribune took the U. of I.’s median projection for the number of COVID-19 patients in ICUs, then added in the number of patients who could be there for other reasons. Even if that second number fell to around 600, the number of ICU patients overall could fill all available beds by Dec. 11, according to the Tribune’s analysis.
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Advocate Aurora Health said it has already started trying to free up more beds by delaying some inpatient elective surgeries. The system, which has 10 hospitals in Illinois and hospitals in Wisconsin, now has hundreds more patients than it had in the spring. Edward-Elmhurst Health hospitals in Elmhurst and Naperville reported they have had to add beds because of rising patient counts.
Other hospitals, such as Silver Cross Hospital in New Lenox, had not yet had to delay elective surgeries as of Thursday, though it added an additional unit with negative pressure to handle more COVID-19 patients. Amita Health St. Alexius Medical Center Hoffman Estates, though “very, very busy,” had not added beds as of earlier last week, said Dr. Michael Handler, chief medical officer of Amita’s northwest region.
Hospitals are also trying to be creative about how to accommodate more patients, such as by using nontraditional spaces. Rush University Medical Center, last week, converted its main lobby into a triage center for less seriously ill patients with COVID-19-like symptoms.
‘Beyond tragedy’
The U. of I.’s model predicted what could happen with COVID-19 patients needing ICU beds if Illinoisans didn’t collectively change their behavior to slow the spread of the virus. Northwestern offered two models: one that assumed similar conditions, plus one that predicted what could happen if the curve of the fall surge is bent as well as the spring’s.
Those Northwestern models show just how drastically different the scene at hospitals could be.
On one extreme, with no change in people’s behavior, Northwestern’s model projected an even worse hospital scenario than the U. of I.’s.
Assuming, again, that the number of non-COVID-19 patients falls to around 600, the Tribune found that ICU beds statewide could be full by Dec. 10 under the first Northwestern model’s median projection. That Northwestern model also suggests that the overflow conditions could last into March — although researchers caution that predictions get less reliable as they extend further into the future.
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Another big caveat: Both the U. of I. and Northwestern forecasts were based on trends through the middle of last week and don’t account for the slower growth of recent days, which could alter trend lines.
Researchers said last week that they expect that Illinoisans, as a whole, will do more to limit the virus’s spread. People did so in the spring — bending the curve without overwhelming hospitals. If Illinoisans succeed again, the state would, collectively, likely have enough ICU beds, according to the Tribune’s analysis of Northwestern’s more optimistic model.
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Will the state bend the curve again? That’s the big question, and not just in Illinois. Across the country, a pandemic-weary public is navigating a politically charged atmosphere in which social media can amplify critics’ complaints that restrictions are overkill.
“Doctors and nurses tell me that some people who come into emergency rooms with COVID — sometimes struggling to breathe — are screaming at hospital workers about how the disease is a political hoax or some sort of hospital profit scheme,” Pritzker told reporters Wednesday. “It’s beyond tragedy for all involved.”
With the fate of jobs and small businesses also a concern — and no federal relief in sight — the restrictions have increased more gradually than in the spring. That may make it harder to see — at least for a few weeks — how well the mitigations limit the spread of the virus.
“There’s just going to be this period of uncertainty for a few weeks, where we can’t even tell whether these mitigations we’re using are bending the curve,” said Jaline Gerardin, a Northwestern University assistant professor of preventive medicine who works with the state on virus modeling.
Nigel Goldenfeld, a University of Illinois physics professor who is working with university colleague Sergei Maslov to develop COVID-19 forecasts, said it’s clear Illinoisans can avoid the worst of the projections.
“The bottom line is that if everyone pitches in and cooperates, we have a good chance of avoiding a health care and economic catastrophe,” Goldenfeld said.
Regional numbers
The predictions Pritzker released are for the state’s overall health system. But each hospital is unique and can experience the pandemic in vastly different ways. Consider Chicago’s Roseland Community Hospital this spring.
When a Tribune reporter visited there in April, state figures showed plenty of available ICU beds in the city overall. But Roseland’s ICU had been at capacity for weeks, with more patients stacked in the emergency room waiting for a bed.
On Friday, when discussing the rise in COVID-19 hospitalizations, Ezike described similar scenarios already occurring across the state, with hospitals asking to go on “bypass” status, meaning they’re too full for ambulances to drop off patients.
More broadly, Ezike on Friday described increasingly precarious scenarios where the state is having to help hospitals figure out how to shift patients to ensure everyone gets treatment.
“We’re playing a little bit of, not to be glib, but a game of checkers trying to move people where there’s an available bed,” she said.
Like many states, the Pritzker administration collects basic figures on the numbers of COVID-19 patients, other patients and open beds each day for each hospital. Just recently in Ohio, a judge ruled that state should release each hospital’s daily counts after a media organization argued it was important for the public to know how individual local hospitals were faring.
In Illinois, the Pritzker administration has chosen so far not to release the data. The Tribune asked for it Nov. 11, but the administration said it will take the maximum time to respond under Illinois law, which the state said is Nov. 30.
The state does release some metrics by region, including the percentage of ICU beds available. Anything below 20% concerns the state. As of late Sunday night, the regions encompassing DuPage, Kane, Kankakee, Will and suburban Cook counties were under that level, as was the region for west central Illinois.
IMPACT, the health care workers group, argues that the critical threshold is 10%, which is its rough estimate of when the average hospital would stop accepting transfers to preserve remaining ICU space for its own worsening patients or to account for time to move people in and out.
The state’s modelers also project COVID-19 hospitalization increases by region, and Northwestern was willing to release its regional projections to the Tribune. The Tribune then compared the median projections with the total number of known ICU beds in each region.
Those worst-case projections — assuming no behavior change by Illinois residents — suggest that every region except for one would run out of ICU beds just based on COVID-19 patients alone, not counting any non-COVID-19 patients taking up beds.
If the curve can be bent like it was in the spring, all of the regions would have enough beds, the projections suggest.
Isn’t COVID-19 less deadly anyway?
The good news of the pandemic is that doctors across the country have learned more and gotten better at treating patients.
One New York study found that the death rate for COVID-19 patients in one hospital system had dropped from nearly 26% in March to less than 8% in August. They found the drop was significant, even after adjusting the figures to account for differences in people’s age and level of sickness.
“In March and April, we had no idea how to manage these patients,” said the study’s lead author, Dr. Leora Horwitz. “We’d never seen this disease before.”
But Horwitz cautioned that another reason for better outcomes this summer could have been the fact that the system was less crowded. Just how much the odds worsen in overwhelmed hospitals is “the million-dollar question.” After all, frantic doctors and nurses — or those moved into new roles in newly opened ICU wings — may struggle to do as well as peers with more time and experience.
“It is really important to understand, these (improving) numbers are not written in stone,” she said.
Public health advocates also say that the overall chances of death from COVID-19 are worsening across the state because so many people are getting infected. So even if COVID-19 may be less likely to claim a single infected person, the rapid spread of the disease means that it can play those lower odds over a far larger group.
That’s one reason the number of COVID-19 deaths has been rising.
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And that number doesn’t count the additional deaths that could result when people postpone necessary surgeries unrelated to COVID-19, such as for cancer and heart conditions, or avoid going to the hospital when they are sick.
“People stop coming (to the hospital),” Arora said. “They’re seeing stay-at-home advisories. And they’re seeing an increase in cases. And they start to think, ‘Oh, I should just stay at home.’ And that’s actually dangerous because, by the time that happens, you’re actually making trade-offs.”
jmahr@chicagotribune.com
lschencker@chicagotribune.com
