'Dangerous trajectory' for Pittsburgh area hospitals as covid cases surge

A region known for its expansive hospital networks is beginning to see alarming trends in covid-19 hospitalizations and facility capacity.

“We’re on a very, very, very dangerous trajectory right now,” said Dr. Tom Walsh, an infectious disease specialist at Allegheny Health Network. “We’re seeing rapid, exponential increases and if we continue down this path … and people are still congregating and getting together with people outside the home and traveling, it could be a disaster.”

In recent weeks, health professionals in the region have assured the public that with their shared resources and expansive networks, Western Pennsylvania could be spared the worst of bed and staffing shortages that have ravaged other parts of the country. But in just the last week, amid record high case counts and renewed public restrictions, most health leaders have taken a more urgent tone.

On Wednesday, Pennsylvania Health Secretary Dr. Rachel Levine cited a University of Washington model that predicts the state could run out of ICU beds in December. Allegheny County Health Director Dr. Debra Bogen said the increase in cases, if sustained, will threaten the area’s health systems.

“After a few weeks at these levels, we could stress our hospital system, including not having enough health care workers,” Bogen said at a briefing Wednesday.

County-level data from the Pennsylvania Department of Health indicates Allegheny County’s ICU capacity is dwindling, with only 108 beds available as of Friday. That’s about 13% of the total ICU capacity countywide. Earlier in the week, that percentage had dipped below 10%.

Only 17% of medical or surgical beds in the county are available as of Friday, along with 17% of airborne isolation beds.

“It’s not good or bad, it’s just informative,” said Dr. Don Yealy, chair of emergency medicine at UPMC, who said the low ICU percentage isn’t necessarily any different from non-pandemic years. UPMC has stated it can bring additional ICU and inpatient beds online depending on the need.

“I’m convinced that even if these numbers grow dramatically higher that we will be able to respond,” Yealy said.

But other health experts in the region noted that such a low percentage is reason for pause. It’s hard to assess the entire county’s capacity without comparing data from individual health systems for this time in previous years, said Dr. Amesh Adalja, a Pittsburgh-based infectious disease expert with the Johns Hopkins Center for Health Security. Given the number and size of Allegheny County’s hospitals, that number should be higher, he said.

“Ten percent doesn’t give you a lot of margin to work with,” said Adalja, “especially when you think it’s not just covid patients. It’s patients with other needs from the ICU.”

Concern from hospital leaders isn’t just about beds and ventilators, but also staff. As community transmission increases, so do the number of health care workers who become infected and need to quarantine.

Walsh noted that hospitalizations tend to lag one to two weeks behind new cases, and deaths follow hospitalizations. Right now, hospitalizations are surging and case counts are still climbing. That means that come a few weeks from now – barring some significant change – hospitalizations, intensive care and ventilator use will jump even higher.

Projecting the potential deaths three to four weeks from now is even grimmer, Walsh said. Nationally, if the U.S. continues adding cases at its current rate, there could be more than 3,000 deaths a day from covid-19.

“That’s going to be like 9/11 happening every single day,” he said. “That’s the trajectory that we’re on.”

Compared to past peaks

This surge is not like the others. The number of covid-19 patients hospitalized in Allegheny County alone is nearly double what it was in late July, the last time the virus peaked in the region. Over the summer, hospitalizations hit a peak on July 23, at 184 patients. On Nov. 20, there were 385.

About 35% of them are receiving ICU care. Fifty-four of them are on ventilators — about 7% of the county’s ventilator capacity.

Similar patterns exist in Westmoreland, Washington and other neighboring counties. In each place, state data shows, more patients are filling hospitals than they did through other spikes. For instance, in Washington County, where 77 covid-19 patients are hospitalized, 13.5% of ICU beds are still available. In Westmoreland County, where there are 76 covid-19 patients, 40% of ICU beds are available, but only 12% of medical/surgical beds.

“It’s much different now than anything we’ve experienced throughout all of our time,” Walsh said. “We have many more patients hospitalized than we’ve ever had before at Allegheny Health Network. … At any given day right now, we’re more than double anything we’ve ever had before and we’re rising exponentially.

“While we still have the staff and the bed availability and the ventilator availability,” he added, “if you’re doubling every two weeks, eventually you won’t have that availability.”

Physicians from both systems have said that while hospitalizations increase, patient outcomes for those with covid-19 have markedly improved since the spring. Fewer patients are entering the ICU, requiring ventilation or dying, officials from both UPMC and Allegheny Health Network have said.

But in Allegheny County, more covid-19 patients were on ventilators on Nov. 18 than at any other point in the pandemic — amounting to 55 patients. This is still less than 7% of the county’s total ventilator capacity of 812, according to the data, but it had grown by 11 patients in just 24 hours.

The same date marked an all-time high for the number of covid patients in intensive care for the county, with 127 adult patients across the county’s various hospitals (more than 35% of total covid hospitalizations).

Walsh said that while the proportion of hospitalizations, intensive care, ventilator use and deaths has gone down, the sheer number is still so high that it’s cause for concern. AHN hospitals have dedicated units to care for covid-19 patients, Walsh said, sometimes entire intensive care units. When those fill, then more beds must be added or converted.

The rising hospital population is “really dangerous,” Walsh said – not just for covid-19 patients, but for everyone. Resources diverted to care for growing covid-19 patients mean less for those entering the hospital for routine reasons or other emergency needs – car crashes, surgeries, illnesses like influenza.

“Covid fatigue seems to be really contributing,” he said. “And we’re not seeing appropriate levels of fear.”

The full picture

Western Pennsylvania is in a unique position in that it has multiple health systems, Adalja said, that are able to share resources and help each other.

“In this area, it’s a little bit different from other parts (of the country), because we do have two major systems that have major hospitals and they can work kind of in tandem,” he said. “They can move patients among them fairly seamlessly and they do that all the time.”

UPMC, Allegheny Health Network and Excela Health each provide systemwide statistics for hospitalizations, ICU beds, ventilator use and other factors.

UPMC officials last week said facilities in Western Maryland and Altoona are experiencing higher rates of covid hospitalization than before, but qualified the statement by saying UPMC resources can be shared across the network. Patients can be transferred; equipment and supplies can be shared.

Yealy noted an internal data dashboard that he said is updated every hour, tracking hospitalizations, capacity and materials. That information is used to track where resources are headed within the system.

“Not every community or individual site has the same exact experience,” Yealy acknowledged. “Some may have more or less in absolute numbers.”

AHN operates the same way. Walsh said chief medical officers for each hospital collaborate regularly to shuffle resources. Critical care physicians travel among the hospitals when needed to provide extra attention to regional hospitals like Allegheny Valley, Forbes and Jefferson in addition to those located within minutes of each other. So far, he said, no hospital has needed significant resources brought in from another, “to any large degree.”

But it’s also hard to tell at this point if individual hospitals are struggling more than others — and if they are, how badly. None of the systems have public-facing data dashboards to show what’s going on at individual facilities.

Adalja said that for the most part, metrics tracking systemwide progress will suffice, considering many hospitals are in close proximity. A hypothetical resource shortage at one hospital in Pittsburgh is not really an issue when there is another hospital a few blocks away, he said. For that reason, having systemwide numbers is probably more “operationally useful,” he said.

But that ease doesn’t necessarily apply for system hospitals that are more remote from others.

“Obviously, if you live in Bedford County, you want to know what UPMC Bedford’s ICU capacity is, or if you live in Mercer County, you want to know what AHN Grove City’s capacity is,” Adalja said.

Amid the pandemic’s greatest surge this year, that data is all the more important to see. Without seeing hospital-level data, it’s difficult for the public to tell which parts of the region are struggling the most with hospital capacity, and to what extent.

“Part of science is learning and growing and putting that knowledge we’ve gained into place,” said Raeven Faye Chandler, director of the Pennsylvania Population Network, a research center housed at Penn State University. “If there are certain facilities (that) may have been less prepared and may have been put under more stress, I think it’s important that we can learn why that is and make changes for the future.”

Chandler reflected on her daily use of the Department of Health’s covid-19 data dashboard. While it shows the total number of hospitalizations, ventilators in use and other figures, there is still a lot that can’t be seen. Are those hospitalizations spread out evenly? Are certain facilities under greater duress from their number of patients? There’s really no way to tell.

There is also some inconsistency among individual hospitals, she said, about how certain beds are defined — some facilities have converted entire units to covid-19 care, for example, but there is no clarity on the dashboard as to whether those beds are considered ICU or airborne isolation beds. Inconsistent definitions among individual hospitals could potentially change the way researchers and data scientists interpret data from the state.

“The greater the amount of data, the greater amount of knowledge,” she said.