POST 99. December 29, 2020. CORONAVIRUS. “ICUs are being overwhelmed across many parts of California. Statewide aggregate ICU availability has been at 0% since Christmas Eve…. a surge on top of a surge on top of a surge.”… “hospitals are getting close to the point where they would begin putting COVID-positive patients under the care of COVID-positive staff who are asymptomatic.”

“This does not mean there are zero ICU beds vacant across California; rather, it means the two regions with 0% capacity — Southern California and the San Joaquin Valley — have reached extremely deep into surge protocols to continue treating severe patients, COVID-19 or otherwise.

Those two regions were placed under the state’s strict stay-at-home order, unveiled by Gov. Gavin Newsom in early December, three weeks ago. The order directs restaurants to cease both indoor and outdoor dining and mandates closures for personal care services like salons and barbershops, on top of the restrictions already in place for purple-tier counties.

State health officials reassess the projected ICU situation in each region after three weeks within the order to determine whether the tight restrictions must continue. Extensions for Southern California and San Joaquin Valley are essentially guaranteed, with an announcement likely coming today from the state as they hit the three-week mark.

For the 13-county Greater Sacramento area, it’s less clear. The region’s three-week window will end this Thursday, on New Year’s Eve. Greater Sacramento has fluctuated around but mostly above the 15% benchmark used as the initial trigger for the stay-at-home order since mid-December. As of Sunday, it had 17.8% ICU availability.

The Bay Area had 11.1% of its ICU beds available through Sunday and must stay under the order through at least Jan. 8. Only the 11-county Northern California region, north of Greater Sacramento, has not entered the shutdown; it still had 28% availability as of Sunday.

The impact on hospitals goes beyond just COVID-19 patients and overwhelmed intensive care units. Kaiser Permanente confirmed over the weekend that it will postpone “elective and non-urgent surgeries” at its Northern California hospitals for one week, from now through Jan. 4, the San Jose Mercury News reported Saturday.

Health experts are supremely concerned about holiday gatherings last week for Christmas, as well as any New Year’s revelry later this week, and their strong potential to deepen the current crisis.

Officials in ravaged Los Angeles County, as well as Newsom, have referred to the prospect of a “surge on top of a surge on top of a surge.” The initial surge started around early November and grew worse after Thanksgiving, with officials fearing Christmas will present an even bigger jolt to infections, hospitalizations and deaths in the weeks to come.

Ahead of Christmas, many in California and across the U.S. pleaded for people to either cancel or scale back their holiday gathering and travel plans. Many Americans appear not to have done so: federal data shows nearly 1.2 million passengers passed through security checkpoints last Wednesday and almost 1.3 million on Sunday, making those the two busiest air travel days since the start of the pandemic in mid-March.

It remains a bit too early to draw many conclusions, but there have been some modest signs of potential slowdown in California’s current surge in data from the past week…

The metrics are all still on upward trajectories — especially deaths, which lag weeks behind the other indicators — but the first step toward plateau or decline is a slower acceleration of increases. But, as health officials warn, it’ll take a couple of weeks to see whether Christmas and/or New Year’s celebrations undo this apparent progress, and if so, to what extent.

Given the holiday impact, Newsom said in a recent video message that the state projects its hospital number will double in the next month, up to more than 36,000 hospitalized patients.” (A)

“With ICUs filled, hospitals will step up measures to ensure the sickest patients still get the highest levels of care possible. That often means moving some patients who would typically be in the intensive care unit to other areas of the hospital, such as a recovery area, or keeping them in the emergency room for longer than normal.

The patients are still getting intensive care, and that strategy can work to a point. But eventually, there may be too many critically ill patients for the limited numbers of ICU doctors and nurses available, leading to greater chances of patients not getting the specialized care they need. And that can lead to increases in mortality.

Once ICU beds are full, hospitals go into surge mode, which can accommodate 20% over usual capacity. Officials have also been training medical personnel who work elsewhere in hospitals to allow them to work in ICUs, and seeking nurses from outside the United States.

But the forecasted size of the surge of severely ill COVID-19 patients needing hospitalization in the coming weeks is now so large, it blew past projections issued just a few weeks ago. Officials were forced to redraw their charts to accommodate the enormous surges in projected ICU bed demand.

There are now more than 1,000 people with COVID-19 in L.A. County’s intensive care units, quadruple the number from Nov. 1. Forecasts say that by early January, there could be 1,600 to 3,600 COVID-19 patients in need of ICU beds if virus transmission trends remain the same.

There are only 2,500 licensed ICU beds in L.A. County.

“There are simply not enough trained staff to care Coronavirus updates: California now for the volume of patients that are projected to come and need care,” Dr. Christina Ghaly, the county’s director of health services, said. “Our hospitals are under siege, and our model shows no end in sight.”

About 600 new patients with COVID-19 are now being admitted to hospitals daily in L.A. County, and officials say that could rise to 750 to 1,350 a day by New Year’s Eve.

“If the numbers continue to increase the way they have, I am afraid that we may run out of capacity within our hospitals,” said Dr. Denise Whitfield, associate medical director with the L.A. County emergency medical services agency and an emergency room physician at Harbor-UCLA Medical Center. “And the level of care that every resident in Los Angeles County deserves may be threatened just by the fact that we are overwhelmed.”

Though officials have noted that the number of available ICU beds changes constantly as new patients are admitted, stabilized or die, the number of unoccupied beds in California’s most populous region has steadily eroded as hospitals have been flooded by unprecedented numbers of COVID-19 patients…

“Many hospitals have already broken nurse staffing ratios, and their staff are not necessarily getting either the breaks or rest that they’re supposed to be getting,” Ghaly said.

Last weekend, Whitfield said, Harbor-UCLA was able to manage its COVID patients, but crowding meant that some patients needed to stay in the emergency department when they should have been transferred elsewhere in the hospital.

“What that means is that when a patient needs to be admitted to the hospital, requiring either an ICU or an inpatient bed, that we just don’t have the staffing or the actual bed space to care for them,” Whitfield said.

A backed-up emergency room then makes it harder for emergency physicians and nurses to take care of patients with other emergencies, including strokes, heart attacks and trauma.

Whitfield said she’s been an emergency room doctor for a decade, but the past weekend was the first time she felt the overcrowding situation “has actually threatened the level of care that we can provide for our patients.”

“And so looking at … how these numbers are increasing throughout the county, it’s really, really quite frightening to me,” Whitfield said.”” (B)

“Hospitals are now postponing elective surgeries in order to help alleviate the growing pressure on our healthcare system.

Emergent surgeries, meaning immediately life or limb threatening, are not being impacted. Any elective surgery that would require admission to a hospital is being looked at as something to potentially postpone.

But what will the delay or avoidance of medical care mean for overall patient health?

A report published by the U.S. Department of health and human services estimated 41% of adults nationwide avoided medical care before June 30th of 2020 because of concerns about the coronavirus, and 12% of adults put off urgent or emergency care.

In a press conference earlier this week, Fresno county’s interim public health officer Dr. Rais Vohra, explained the meaning of an elective procedure.

“You have to understand that, you know, just because something is elective, like for example a tumor operation, you know, that can’t go forever or else the patient is going to have a really bad outcome,” said Dr. Vohra, “So there’s some gray areas there and we’re asking all the hospitals to take really hard looks at exactly how they can conserve their operating room resources and convert those over to help with the acute management issues.”

The department of defense is sending a team of 10 to 12 people, which should help out a bit. Those air force doctors were supposed to get here Monday, but that’s been pushed back to December 31st.

And while Dr. Vohra says coronavirus fatalities are happening in every age group, the group with the highest numbers might surprise you.

“Every age group actually also has very tragic fatalities from the very young to the very old,” said Dr. Vohra, “It turns out one surprising trend is that the 45 to 65 age group is actually having more fatalities than the 65 to 75 age group.”

Another interesting topic brought up by Dr. Vohra was this idea he called “contingency staffing mode”. He said valley hospitals are getting close to the point where they would begin putting COVID-positive patients under the care of COVID-positive staff who are asymptomatic. Dr. Vohra said this has been done in other hospitals across the country.

The county’s system for processing deaths is backed up due to the coronavirus. According to Dr. Vohra, there are still dozens of death certificates that have not been reported out.” (C)

“California’s health care system is in the throes of a coronavirus crisis stemming from ill-advised Thanksgiving gatherings, top executives from the state’s largest hospital systems said Tuesday as they put out a “desperate call” for residents to avoid a Christmas repeat they said would overwhelm the state’s medical system.

Increasingly exhausted staff, many pressed into service outside their normal duties, are now attending to virus patients stacked up in hallways and conference rooms, said officials from Kaiser Permanente, Dignity Health and Sutter Health, which together cover 15 million Californians.

The CEO of the Martin Luther King, Jr. Community Hospital in Los Angeles, Dr. Elaine Batchlor, separately said patients there have spilled over into the gift shop and five tents outside the emergency department.

The officials offered what they called a “prescription” for Californians to slow the virus spread, a marketing effort dubbed “Don’t share your air.” The underlying message is to stay away from people from other households, which is what many failed to do at Thanksgiving.

“We simply will not be able to keep up if the COVID surge continues to increase,” Kaiser Permanente chairman and CEO Greg Adams said. “We’re at or near capacity everywhere.”

The state reported 32,659 newly confirmed cases Tuesday and another 653 patients were admitted to hospitals, one of the biggest one-day hospitalization jumps. A state data models predict nearly 106,000 hospitalizations in a month if nothing changes. The current level is 17,843.

The officials blamed Thanksgiving transmissions they fear will be repeated if people gather for Christmas and New Year’s and don’t take precautions like wearing masks, socially distancing, staying home as much as possible and not socializing with others….

“We don’t have space for anybody. We’ve been holding patients for days because we can’t get them transferred, can’t get beds for them,” said Dr. Alexis Lenz, an emergency room physician at El Centro Regional Medical Center in Imperial County, in the southeast corner of the state. The facility has erected a 50-bed tent in its parking lot and was converting three operating rooms to virus care.

Imperial County now is seeing 20% of people tested come back positive, compared with the state average of about 13%.

Officials in hard-hit Fresno County in the San Joaquin Valley meanwhile said temperature trackers on their 14,800 Moderna vaccine doses show that some will need replacing, though the vaccine doesn’t need the same ultra-cold care as the Pfizer vaccine.

Vaccine shipments aren’t used if there are “temperature irregularities” as occurred Monday with a shipment to Fresno, said California Department of Public Health spokeswoman Ali Bay. A replacement shipment should arrive Wednesday, she said.

“Temperature irregularities are rare, but they do occur,” she said in an email. “The federal government, manufacturers, distributors, the state, and local government have all planned for this possible scenario and have a system in place to ensure it is immediately addressed.” “ (D)

“As Americans celebrate the rollout of a coronavirus vaccine, many of the doctors and nurses first in line for inoculation say a victory lap is premature. They fear that the optimism stirred by the vaccine will overshadow a crisis that has drawn scant public attention in recent months: the alarming shortage of personal protective equipment, or P.P.E., that has led frontline medical workers to ration their use of the disposable gloves, gowns and N95 respirator masks that reduce the spread of infection.

At St. Mary’s Medical Center in Duluth, Minn., health care workers who treat Covid-19 patients are required to reuse their tightfitting respirator masks up to six times before throwing them away. Although soiled N95s are sterilized each day with ultraviolet light, Chris Rubesch, 32, a cardiac nurse, says the masks invariably sag after two or three shifts, leaving gaps that can allow the virus to seep through. “Our days are filled with fear and doubt,” Mr. Rubesch said. “It’s like driving a car without seatbelts.”

Many of the shortages are the result of skyrocketing global demand, but supply chain experts and health care providers say the Trump administration’s largely hands-off approach to the production and distribution of protective gear over the past nine months has worsened the problem. That has left states and hospitals to compete for limited supplies. Price gouging has become the norm, and scores of desperate institutions have been duped into buying counterfeit products…

With the White House largely disengaged from the crisis, medical workers, supply chain specialists and public health experts are urging President-elect Biden to make good on his campaign promises to use the Defense Production Act to boost domestic manufacturing of personal protective equipment, test kits, vaccines and the medical supplies needed to immunize hundreds of millions of Americans. They are also hoping the incoming administration will take over the distribution of scarce goods and put an end to profiteering and the mad scramble for P.P.E. that has pitted states and deep-pocketed hospital chains against nursing homes and small rural hospitals…

Hospital purchasing agents say they are facing an unparalleled shortage of single-use nitrile gloves — one of the most important items for reducing the spread of infectious pathogens — with prices soaring to $300 a case from $30 before the pandemic. Get Us PPE, a volunteer organization that connects health care facilities to available protective gear, says requests for help have more than tripled in the first half of December compared with the same period last month. Nearly 90 percent of the frontline workers the group surveyed across the country say they are repeatedly reusing masks designed for single use.

The pandemic has exposed flaws in freewheeling distribution system that enables hoarding by wealthy hospital chains and a global supply network overly reliant on overseas manufacturers. This was evident in the early months of the pandemic, when transcontinental flights that ferry Asian-made medical gear to the United States were largely frozen. And the crisis grew worse as China turned off the export spigot and commandeered its mask factories for domestic use.” (E)

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• A.California now the COVID epicenter of the US; ICU space at 0%, by Michael McGough, https://www.msn.com/en-us/health/medical/coronavirus-updates-california-now-the-covid-epicenter-of-the-us-icu-space-at-0-25/ar-BB1cin7h?ocid=uxbndlbing
• B.ICU availability in Southern California at 0%, and it’s going to get worse, officials warn, By LUKE MONEY, RONG-GONG LIN II, SOUMYA KARLAMANGLA, https://www.latimes.com/california/story/2020-12-17/southern-california-out-of-icu-beds-amid-covid-19-surge
• C.Hospitals to delay elective surgeries as coronavirus cases surge, by Shelby Bracho, https://kmph.com/news/local/hospitals-to-delay-elective-surgeries-as-coronavirus-cases-surge
• D.California’s new virus message: ‘Don’t share your air’, By DON THOMPSON, https://abcnews.go.com/Health/wireStory/california-100000-hospitalizations-month-74855543
• E.Health Care Workers Still Face Daunting Shortages of Masks and Other P.P.E., by Andrew Jacobs, https://www.nytimes.com/2020/12/20/health/covid-ppe-shortages.html?referringSource=articleShare
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