March 12, 2020

Amid coronavirus, will hospitals run out of face masks? (Or ventilators? Or beds?)

Daily Briefing

    Hospitals across the country are running short on protective gear—and some estimates indicate the United States may not have enough beds and ventilators—needed to fight the new coronavirus.

    Our analysis: The 'recurring themes' of disease outbreaks

    U.S. hospitals are expecting an influx of patients with COVID-19, the disease caused by the new coronavirus. State and federal officials as of Thursday morning reported 1,289 confirmed or presumed positive cases of COVID-19, up from 231 on Friday. So far, 37 U.S. deaths have been linked to the new coronavirus. CDC as of Wednesday said at least 75 of the country's COVID-19 cases stemmed from human-to-human transmission of the new coronavirus in the United States.

    Could hospitals run out of beds, ventilators?

    In the New York Times' "The Upshot," Aaron Carroll, a professor of pediatrics at Indiana University School of Medicine, writes, "A crucial thing to understand about the coronavirus threat … is the difference between the total number of people who might get sick and the number who might get sick at the same time."

    While the United States is able to handle large numbers of flu cases each year, Carroll notes that those cases occur "over eight months or more." He explains, "They don't increase exponentially over the course of weeks, as the cases of COVID-19 are doing right now."

    If the number of COVID-19 cases rises dramatically in a small period of time, U.S. hospitals will likely feel the strain, Carroll warns. He notes that the United States currently has 2.8 hospital beds per 1,000 people, which is fewer than those in China and Italy—two countries that have struggled to treat their large influxes of patients. What's more, Carroll writes, the United States has an estimated 45,000 ICU beds, some of which are already in use for patients without COVID-19. According to Carroll, that figure would not be enough to treat the estimated 200,000 Americans who would need an ICU bed in a moderate outbreak, if all of those patients are sick at once.

    Carroll also points to a recent Johns Hopkins' report, which estimated the United States has about 160,000 ventilators. While Carroll acknowledges that the number is "a lot" under normal circumstances, shortages could occur in the event of a pandemic, such as the new coronavirus. "It's very possible that many of the ventilators are being used right now for patients with other illnesses," Carroll writes. "They're also not mobile, and local outbreaks will quickly surpass the numbers of ventilators and respiratory therapists."

    Hospitals are running out of N95 masks

    Meanwhile, hospitals are facing a more immediate shortage of critical gear intended to protect providers from the virus, particularly N95 respirator masks.  

    As the Washington Post reports, N95 masks are tighter and thicker than surgical masks and can filter out 95% of airborne particles. The masks are critical for reducing the spread of the new coronavirus between health care workers and infected patients, the Post notes.

    However, increased demand for the masks at health care facilities, as well as panic-buying by consumers, has depleted the global supply of N95 masks—leaving many U.S. hospitals unable to get new shipments.

    Executives at Grady Memorial Hospital in Atlanta on Monday reported the hospital had about a month's supply of N95 masks left, even though the officials buy the "maximum amount allowed to [them] each week," according to Lindsay Caulfield, SVP at the hospital.

    Marc Habert, a pediatrician in New York, said a group he works for that operates eight offices across three counties had practically no N95 masks or protective equipment. "We can't get any. Everything's back-ordered," he said.

    According to the Post, an HHS spokesperson has said providers should look to their local or state health department for masks, but those efforts have been futile for some facilities.

    "I was on a phone call earlier with the local department of health and they basically said the state has supplies, but we need to show we tried to order from three separate places first," Habert said.

    As a result, a lot of hospitals are beginning to ration their products by reducing the number of masks health care workers and patients can access and use each day.

    Susan Ray, an infectious disease specialist at Grady Memorial Hospital, said, "Right now we are just anticipating that we are going to have a lot of patients," she said, "[A]nd we aren't going to have enough supplies if we don't figure out how to use less."

    Experts worry US' emergency stockpile can't meet increased demand

    Making matters worse, some experts worry the United States' Strategic National Stockpile (SNS) of medical equipment isn't robust enough to meet increased demand tied to the COVID-19 outbreak.

    The U.S. government has used the SNS to respond to the Sept. 11, 2001, terror attacks, the 2001 anthrax attacks, and the 2015 Zika virus outbreak. The largest SNS deployment so far occurred during the H1N1 pandemic of 2009, when the federal government distributed 85 million N95 respirators, along with millions of gloves and gowns. However, according to the Post, the stockpile has not been replenished since the 2009 H1N1 pandemic.

    HHS last week said the stockpile has about 12 million N95 respirators and 30 million surgical masks, but HHS Secretary Alex Azar said up to five million of the N95 masks could be expired. In addition, the federal government currently is using the SNS to provide protective gear to medical staff on the front lines of efforts to repatriate and quarantine Americans who were evacuated from China and Japan after potentially being exposed to the new coronavirus.

    How the government is working to address supply shortages

    President Trump on Wednesday issued an executive order giving the HHS secretary the authority to increase the availability of N95 masks. The order states,"The Secretary of Health and Human Services shall take all appropriate and necessary steps with respect to general use respirators to facilitate their emergency use by healthcare personnel in health care facilities and elsewhere."

    Steven Adams, acting director of the SNS, separately said a lot of the older respirator masks are still usable under recently updated guidelines, and the federal government has promised to purchase 500 million more masks—though those masks will be manufactured and provided to the SNS over the next 18 months

    At the same time, CDC is working to build a system that would track hospital inventory of masks, gloves, and other critical equipment. However, according to NPR's "Shots," hospitals typically have considered their inventories to be confidential.

    The move comes after CDC relaxed its guidelines on the types of face masks providers should use while treating patients with suspected or confirmed cases of COVID-19 to match guidelines from the World Health Organization (WHO). WHO recommends health care workers use N95 respirators only during procedures that cause the patient to send virus particles into the air, such as intubation. CDC in a statement said surgical masks, which protect against larger droplets but do not form a seal around the face, are "an acceptable alternative when the supply chain of respirators cannot meet the demand."

    CDC also has said that health care workers can use N95 masks beyond their expiration dates and for "repeated close contact encounters with several patients" instead of discarding them after one use.

    Health care workers who have conditions that place them at a greater risk of contracting COVID-19 but have no access to N95 masks, should avoid treating patients with suspected or confirmed cases of the disease, CDC said. CDC added that workers who have had the disease "may have some protective immunity," and therefore should be the first on the front lines.

    However, CDC said, "When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19."

    FDA last week also announced that health care workers can use respirator masks approved by the National Institute for Occupational Safety and Health (NIOSH), which is not regulated by FDA, during the outbreak. NIOSH-approved masks are typically used in the construction and manufacturing industries (Goodnough, New York Times, 3/9; Facher, STAT News, 3/10; Reinhard/Brown, Washington Post, 3/10; Sun, Washington Post, 3/10; Smith et al., New York Times, 3/11; CDC website, 3/10; HHS release, 3/4; Carroll, "The Upshot," New York Times, 3/12; Brady, Modern Healthcare, 3/11; Farmer, “Shots,” NPR, 3/12).

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