TALLAHASSEE — For the last three weeks, hospitals throughout Florida have been rearranging beds, converting office space and conference rooms, and retrofitting free-standing emergency rooms to wage war on an enemy they never before contemplated: COVID-19.
They’ve gotten regulatory waivers to overcome the bureaucratic hurdles. Some have accelerated construction on planned spaces and wired empty buildings to get them open. They have created surge schedules, cross-training staff to handle the respiratory disease, and they have turned off the spigot of revenue that comes from a steady stream of elective surgeries.
As Florida prepares for a surge in seriously ill COVID-19 patients in the next two weeks, healthcare officials across the state say hospitals have plenty of room to handle more patients.
“Hospitals are tracking capacity pretty closely and some are using their own software and resources to come up with their own estimates,’’ said Crystal Stickle, interim president of the Florida Hospital Association. “Everybody feels pretty good [that] they have the capacity right now.”
Questions remain, they say, about the availability of ventilators, masks and other supplies needed to accommodate both patients and front-line workers as Florida braces for the worst days of the pandemic.
But underpinning their confidence is the state’s inventory of bed space and a national model built on assumptions based on positive test results that, healthcare experts admit, is fraught with uncertainty because only a small fraction of Floridians have been tested for the virus, and the universe of potential cases remains unknown.
By Friday morning, 57% of the hospital beds in Florida were occupied, and 62% of the intensive care unit (ICU) beds were filled, according to data collected by the Agency for Health Care Administration.
But the estimates being used by Florida public health officials, developed by the Institute for Health Metrics and Evaluation at the University of Washington, have already changed significantly in the last week — moving the expected peak date from May 4 to April 21 when Florida hospitals will face the greatest demand from COVID-19 patients and as many as 242 people could die a day. That gave Florida officials less time to prepare.
“It just goes to show you how unpredictable this situation is,’’ said Jared Moskowitz, director of the Florida Division of Emergency Management at a roundtable discussion with the Miami Chamber of Commerce on Thursday. “We could wake up tomorrow and it could change again.”
That’s what happened. On Friday, the Florida projection moved to April 26.
He compared the models to the spaghetti graphs as a hurricane approaches, warning that “people just need to be vigilant” maintain social distancing, and realize “we’re not at the peak yet.”
Hospital officials have been learning from the experience of hospitals primarily in Italy and New York, said Stickle, who represents more than 200 health systems in the state.
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But as the disease often takes days and sometimes weeks before a patient becomes critically ill, the lull at many hospitals now is expected to become a flurry of activity — as has happened in New York, New Orleans and Detroit.
Paul Biddinger, director of the Emergency Preparedness Research, Evaluation & Practice program at Harvard T.H. Chan School of Public Health, said that the peak in hospitalization is expected to plateau for a week or two in most places.
But it will be followed with another, more critical peak, the need for ICU beds “because patients typically take a couple of days to get to the critical period.”
The University of Washington model suggests Florida will need 1,547 ICU beds by April 24 and will have 1,695 available.
Bay and Lee counties had the lowest supply of ICU beds on Friday, according to the AHCA data, with only 12% and 9% of the bed space available.
Although information about treating critically ill patients is moving quickly based on observations from Italy and China, Biddinger said, “COVID causes a lot of unusual complications that we haven’t really seen before in different infectious diseases.”
For example, patients develop blood clots more easily, and they are seeing patients with kidney damage, which “may be related to fluid management and sometimes the disease,’’ he said.
Although AHCA has released data on the number of ICU beds and has been tracking the state’s ventilator capacity, it has refused to release its data and any projected shortage.
If there is a shortage of ventilators, Florida hospitals are preparing to convert anesthesia machines to ventilators, which will require anesthesiologists to manage, Stickle said.
“We’re still trying to get additional ventilators to be prepared for a worst-case scenario,’’ she said.
No hospital has said that it doesn’t have the ventilators to mean its current patient count but, she said, “ we haven’t gotten to the surge, and that’s where the state’s procured resources will come into play.”
Hospital officials in Miami-Dade, Broward and Palm Beach counties have a daily call to ensure they are sharing data and trends “to prepare for whatever the surge may look like,’’ Stickle said.
The “unprecedented coordination” is happening between for-profit and not-for-profit hospitals, she said. Hospital systems “that on most days are friendly competitors have put that aside to come up with a game plan to handle this.”
At Jackson Memorial in Miami, which has has 1,460 beds, 37% of its bed space is still available, according to state data.
“Things are under control and we have the capacity to deal with what the community is facing right now,’’ said Matthew Pinzur, vice president and chief marketing officer for Jackson Health System. “We have ample capacity of beds and we have ample capacity in ventilators — only one-third in use right now and 40 percent are used by COVID patients.” [story can end here for print]
Following the examples of other states, Florida ordered hospitals to cancel elective procedures, and that has freed up bed space and lowered patient counts. That has also allowed staff to be cross-trained and paired with others to increase the capacity.
“For example, a hospital may have one ICU nurse and is supporting them with non-ICU nurses,’’ Stickle said.
Also adding strain is the restrictions on who is allowed to be given tests for COVID-19.
“The availability of testing in the community is still extremely, extremely limited,’’ said Pinzur of Jackson Health. “We’ve had to prioritize who is symptomatic and who’s at the highest risk.”
Justin Senior, president of the Safety Net Hospitals of Florida, which represents the state’s not-for-profit health systems, said that delays in testing were an early challenge for hospitals, particularly on the West Coast of Florida, and that tested their capacity.
Anyone who arrived in emergency rooms in respiratory distress would be kept in isolation as hospitals followed enhanced infection control protocols, but many of those patients ultimately tested negative.
Since then, “testing processes have improved and hospitals are gaining experience and sort of getting their sea legs under them,’’ Senior said.
Some hospitals have developed procedures to do the testing on site, but only certain hospitals have the sophisticated equipment to do the tests, which can be labor intensive.
“It takes personnel, and they are having manpower issues,’’ he said. “They can’t work them 24 hours a day. They have had to be judicious about it.”
In Southwest Florida, which has a large and vulnerable elderly population, emergency officials are watching patient counts closely, Senior said. “If resources need to be moved to that part of the state, they can adjust to the need hopefully in time.”
Staffing for the surge is another issue challenging hospitals. State officials have waived regulations to allow out-of-state medical professionals to practice in Florida on an emergency basis but, Stickle said, that option “has been challenging because every other state has the same needs.”
The Florida National Guard medical unit is prepared to assist but hospitals have primarily turned to relying on existing staff, including those who normally work at ambulatory surgical centers and physicians offices that do surgical procedures to supply the backup needed. Some hospitals are also working with staffing companies, Stickle said.
Supplying enough masks and personal protective equipment to staff as hospitals reach peak demand remains a challenge, however. The shortage has forced many hospitals to sterilize and reuse some of their masks and gowns, Stickle said.
“We have ample supplies of personal protective equipment,’’ said Pinzur of Jackson Health, but staff continues to be anxious about it. “There is no clear idea what the right level of PPE is.”
In the areas with the highest numbers of positive cases, Florida emergency operations officials are also setting up five pop-up field hospitals in the hardest hit areas.
The state is working with private contractors to set up and staff 250-bed field hospitals. One in Miami-Dade County is being built at the county fairgrounds in Tamiami Park. Others underway are planned for Fort Lauderdale, Lee County, Jacksonville and West Palm Beach.
Palm Beach County lags in testing but leads the state in the number of fatalities. The Medical Examiner’s Office is so inundated with a backlog of cases, it has leased two 40-foot refrigerated containers to store bodies.
In Miami Beach, the convention center is being transformed into an emergency hospital with 400 general beds and 50 intensive-care beds for COVID-19 patients.
In less than two weeks, it will be staffed by 184 members of the Florida National Guard’s medical team, including 10 physicians, 19 physician assistants, five case managers, five social workers, 25 medical clerks, 25 housekeepers, a patient transporter, 25 EMT technicians, two medical assistants, 50 paramedics, 16 registered nurses and one licensed infection preventionist.
Gov. Ron DeSantis said at a news conference in Jacksonville Friday that he hopes none of the overflow facilities ever need to be used.
Meanwhile, everyone is watching the models and the daily infection rates posted by the state on the Department of Health dashboard. As of Friday morning, there were 17,531 positive cases and 2,360 people hospitalized with COVID-19.
“If we can maintain that for 20-25 days, and the new infections start to drop, that’s when we know we’re at the peak,’’ Senior said. “Hopefully we’ll start to turn those numbers.”
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