LEBANON — Images of hospitals and caregivers inundated by a wave of seriously ill patients in New York City and other COVID-19 hot spots raise important questions about the capacity and preparedness of health care facilities in rural areas like the Upper Valley.
“I’m very worried about what’s going to happen to the critically ill people in rural areas when the infection becomes more widespread there,” Ashish Jha, director of the Harvard Global Health Institute, said in a webcast Thursday.
Twin State officials have voiced similar concerns.
“The whole fear is that the health care system will be overwhelmed,” said Jake Leon, spokesman for the New Hampshire Department of Health and Human Services.
Local health care providers say they’re ready.
“We are prepared to take care of anyone who has a more complicated disease or needs a more thorough evaluation,” Dartmouth-Hitchcock Health’s Chief Clinical Officer Ed Merrens said in a video made March 24 and posted on the D-H website. D-H officials did not respond to requests for additional comments.
“New Hampshire hospitals are ready to meet the needs of all patients in the state including situations involving high-threat infectious diseases such as COVID-19 and influenza,” said Vanessa Stafford, vice president for communications for the New Hampshire Hospital Association.
So far, northern New England has not seen the surge in COVID-19 cases that some not-so-distant cities have experienced, though New Hampshire and Vermont together had tallied 15 deaths as of Monday. And experts remain concerned about a likely sharp increase in the need for intensive care beds and the ventilators that keep alive the sickest and most vulnerable COVID-19 patients.
“The capacity of ICU care in rural areas in America is really quite limited,” Jha said. “And when people get very sick and need ICU care, it’s going to be very, very hard to provide all the ICU care they need.”
“Based on what we are hearing from Seattle and New York City, we are getting ready for anything from incredibly busy to more extreme scenarios in which we have to ration mechanical ventilators,” said Tim Lahey, an infectious disease physician and professor at the University of Vermont’s Larner School of Medicine.
Mechanical ventilators that supply oxygen to patients otherwise unable to breathe make up the last line of defense for the sickest and most vulnerable COVID patients.
“If you have respiratory failure and you don’t get a ventilator, you die,” Jha said.
But ventilators are in short supply. Need could exceed supply by factors ranging from 1.4 to 31, according to an article published March 23 by the New England Journal of Medicine. The authors cited a February report by the Johns Hopkins Center for Health Security that estimated a nationwide inventory of 62,000 advanced ventilators usable to treat the sickest patients as well as another 98,000 basic ventilators. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said March 15 that an additional 12,700 ventilators were available in the Centers for Disease Control Strategic National Stockpile.
A coalition of hospitals, including D-H, that serve Vermont has 170 critical care ventilators, of which 99 were available Tuesday, according to Stephanie Brackin, an information manager at the Vermont COVID-19 Joint Information Center. New Hampshire officials said hospitals in the state have 1,000 ventilators and other machines that could be used as ventilators and have requested at least 45 more from federal agencies.
“Based on what hospitals anticipate they will need in a health care surge, we have requested ventilators from the Strategic National Stockpile and continue to work in the open market to procure additional supplies,” said Leon, the DHHS spokesman. “We continue to look at the most up-to-date models and work with hospitals week to week to reevaluate what they expect they will need to address a potential surge.”
Both states’ tallies appear to include units at Dartmouth-Hitchcock Medical Center. D-H officials did not provide data on ventilator availability.
Jha warned that if the number of critically ill COVID patients exceeds ventilator availability “we’re going to ration care so that some people will live and some people will die and so we should have some systematic approach for doing that.”
Such triage decisions seem inevitable, he added: “We’ve got to do absolutely everything in our power to make sure that doesn’t come up.”
DHMC, which serves as the main hospital providing specialized care in a region that includes 233 ZIP codes in New Hampshire and Vermont, is likely to face other capacity concerns, according to the Harvard Global Health Institute. The Lebanon “hospital referral region” served by D-H is home to 320,000 adults including 78,000 age 65 or older and has 105 beds in intensive care units at D-H and smaller hospitals and a total of 939 hospital beds, according to the HGHI tally.
HGHI plugged those numbers into a model that showed a “best case” scenario in which about 20% of adults in the region, or 64,000 individuals, would be infected by the novel coronavirus and nearly 14,000 would require hospitalization, while the spread of COVID-19 would be slowed — by “flattening the curve,” as public health experts say — to extend over an 18-month period.
Even under this relatively “optimistic” forecast, which accounts for additional hospital and ICU beds freed up by postponing elective surgery and otherwise reducing usage by non-COVID patients (measures already undertaken by D-H and other hospitals), peak demand for intensive care beds would exceed the available supply by 18%.
And failing to flatten the curve could have dire consequences.
In its worst-case scenario, HGHI estimates that more than 190,000 adults in the D-H service region could be infected with COVID-19, that more than 40,000 could require hospitalization and that the virus would spread rapidly to peak in about six months.
Under these pessimistic assumptions, regional demand for hospital beds for COVID patients would reach four times the available supply — even after measures to reduce non-COVID usage. Worse still, at the peak of the pandemic more than seven sick patients would stand in line for each of the 80 available intensive care beds in local hospitals.
Public health experts acknowledge that modeling for a previously unknown virus will be inexact, often wrong, and will need to be revised, but that it nonetheless sounds an important warning that action needs to be taken. Tara Kirk Sell, a senior scholar at the Johns Hopkins Center for Health Security, said, “When a model tells us something that’s very alarming, it tells us that there’s probably some actions that we need to take now.”
Jha said it is too late to build or buy enough ventilators or new intensive care capacity to cover a rapidly surging virus.
New Hampshire officials are rushing to make other preparations.
“We’re not at the apex of the crisis here,” Leon said. “We’re going to continue to see more cases.”
Leon said the state aims to have ready this week eight flex sites with a total capacity of 1,700 to 1,900 beds that could be activated to provide more inpatient or outpatient care. That capacity could be used by less severely ill COVID patients or to reduce exposure to the virus for non-COVID patients. Sites have lined up at Southern New Hampshire University in Manchester and NHTI in Concord, and Upper Valley officials are working to include one near DHMC, likely in a Dartmouth College athletic facility.
Jha stressed the importance of ongoing efforts at physical or social distancing: “The closer we are to fewer interactions, the more the virus slows down.”
Stafford, the New Hampshire Hospital Association spokeswoman, agreed: “By practicing social distancing, diligently hand-washing and not utilizing the Emergency Department unless there is a true emergency, such as significant difficulty breathing, residents can help preserve precious hospital resources for those that truly need them.”
“We want to give our hospitals a shot,” Jha added. “The more we spread it out, the more time we have for testing therapies, the more time we have to have a vaccine.”
Rick Jurgens can be reached at rickndiane2@gmail.com or 802-281-6641.
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