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In Seattle, hospital workers tied bandanas around their faces to protect themselves from the coronavirus because they didn’t have enough masks.
In Italy, doctors were ordered to take ventilators away from patients who were fighting to breathe and give them to other patients who were more likely to survive.
In New York City, patients have been sharing ventilators as beds are crammed into emergency rooms.
But despite bleak forecasts from national models, it’s unclear whether Utah hospitals are likely to become similarly overwhelmed by seriously ill people as coronavirus infections spread throughout the state.
“We have some surge capacity ability, but whether that remains sufficient to handle what we could experience here in Utah remains to be seen,” said David Sundwall, a former director of the U.S. Health Resources and Services Administration.
Sundwall was the director of the Utah Department of Health when the state developed a flu pandemic plan released in 2007; it anticipated an outbreak consuming state supplies of hospital beds and caches of ventilators and medical gowns.
Although Utah health officials for weeks have said the state is taking inventory of critical hospital resources in preparation for a major outbreak, there still are no exact and up-to-date counts of mechanical ventilators or beds in the intensive care units of Utah’s hospitals, said Tom Hudachko, spokesman for the state Health Department.
Meanwhile, inadequate testing nationwide has left Utah and other states in the dark as to how many people are actually infected at this point. In places like New York, most testing has been abandoned altogether in an attempt to save medical supplies so hospital staff can care for people who are already sick.
But the information Utah does have hints at an outbreak that could be slower moving and less deadly than researchers have predicted in some other states. The state may still have a chance to avoid the catastrophic patient surges seen in New York and elsewhere, said state epidemiologist Angela Dunn.
“If our curve continues the way it is, we will likely have a strain on our health care system. We are preparing for that and we are really working hard to stay below our capacity,” Dunn said.
The good news
As health experts scramble to develop models to predict infection rates and hospital needs in the coming months, projections have been poor for Utah, as everywhere.
In a recent report, the Harvard Global Health Institute found that even in its best case scenario, Utah likely would not have enough ICU beds for all of the patients who would need them.
If only 1-in-5 Utahns were to become infected over a slow course of 18 months — the least severe outbreak that the report calculates — all 700 or so of the ICU beds that researchers identified in Utah would likely be full.
On the other hand, if it takes just six months for 20% of Utahns to be infected, patients would overwhelm not only Utah’s ICU beds, but also its regular hospital beds, the report states.
And if coronavirus in Utah is more infectious than that — 40% is the “moderate” expected rate, according to the study — all hospital beds, both in and out of ICUs, would likely be full, even if the spread is slowed to 18 months, the model predicts.
While the forecast is dire, Utah has some advantages on its side.
First, the number of hospital beds calculated by the Utah Department of Health based on state licensure records — 5,849 beds — is substantially higher than the 4,869 hospital beds reported by the American Hospital Association in 2018, which the Harvard model used in its forecasts.
Second, the model anticipates about 20% of infected Utahns will require hospital care. But that’s about double the hospitalization rate of 10% seen in confirmed Utah cases so far, state health officials have said — a number that’s generally been consistent from day to day since Utah’s first confirmed case on March 6, Hudachko said.
And that low rate of 10% held even when Utah was focusing its limited tests on patients requiring hospital care. Until Monday, people with mild symptoms were generally denied tests unless they had contact with a confirmed patient or had recently traveled to an area with widespread infection. And people with no symptoms still are not being tested.
Utahns, on average, may be less likely to need hospital care because the population skews young, Dunn said — though the model does factor in the number of senior residents, who are more susceptible to serious illness from COVID-19.
Serious illness also is more likely to befall smokers and patients with underlying health conditions, including obesity and heart conditions — all of which are less prevalent in Utah than in most other states.
Third, the number of confirmed cases in Utah — 602 as of Saturday — also is not particularly high, compared to states with the biggest outbreaks, like New York (44,635 cases), New Jersey (8,825 cases), California (3,777) and Michigan (3,657).
The number of confirmed cases itself may not be meaningful. Throughout the U.S., as in Utah, many patients with symptoms of COVID-19 have been denied tests due to supply shortages, so no one knows how many people actually are infected, health officials have said.
But what is promising about Utah's numbers is one, how slowly they have changed so far, and two, how many people are testing negative.
Since Monday, when testing was expanded to many more patients, the number of confirmed cases each day has generally not risen any faster than it did when testing was far more restricted. After cases spiked by 42% on Monday, increases stayed under 20% each day until Saturday, when the case total rose by 25%.
“We were at about 30% increase day to day," Dunn said last week in a briefing. “That is with increased numbers being tested as well. ... It is a good sign that we are not [seeing] an exponential increase.”
Meanwhile, the increases in cases are not outpacing increases in the total number of people tested — which also suggests the virus is not spreading explosively. About 5% of people tested in Utah have tested positive, which is less than in places where infection is widespread, Dunn has said.
And perhaps most crucially, Utah implemented some broad social-distancing earlier in the outbreak, in terms of known cases, than some other states have. There were only six reported cases in Utah when Gov. Gary Herbert ordered a halt to mass gatherings on March 12 ; eight reported cases when statewide school closures were announced on March 13; and 51 reported cases when in-house service stopped in all bars and restaurants.
By contrast, Colorado announced statewide school closures a week after Utah did, when there were more than 200 confirmed cases there. Michigan had more than 1,000 confirmed cases as officials there exempted churches from the state’s mass gathering rules last week.
“We are doing excellent social distancing in Utah,” Dunn said. “The fact that we have a low hospitalization rate is a good sign that people are adhering to those recommendations.”
Scientists at Columbia modeled the likely impact of social distancing controls in each U.S. county over time, The New York Times reported. With no social distancing orders, Utah would have seen at least 40% infection rates in every county by mid-June. With some controls — partial adherence to social distancing guidelines and a patchwork of orders on work and dining, for example — all Utah counties would reach 40% by the end of July.
Under strict lockdown conditions, no Utah counties would be expected to reach 20% infection by August — though the state was expected to reach peak infection rates sometime after that, researchers predicted.
The bad news
But other factors should caution against optimism, health experts say.
First, the lack of testing prevented Utah and the rest of the United States from tracking and isolating infected patients early on — and that’s not something previous epidemic plans accounted for.
Sundwall said the task force he led took testing for granted, but he hopes that Utah will be able to extrapolate how many are sick and who will need care based on what’s happened elsewhere.
“This virus is a rascal,” said Sundwall, who still works as a primary care physician in Midvale and Salt Lake City four days a week. “It just doesn’t seem to behave at all. It spreads too quickly.”
Second, the 14-day incubation period means the little testing data Utah does have speaks more to the spread of the virus a week or so ago, rather than now.
Low numbers, Dunn said, are “certainly a great sign but we still need to wait those 14 days to determine how the trend is really looking, because we’re just now finding out about cases that could have been infected two weeks ago."
New York state, for example, two weeks ago had the same number of confirmed cases that Utah has now. By Saturday, there were more than 50,000 confirmed cases and more than 700 deaths.
Third, Utah’s hospital resources aren’t evenly distributed among every resident.
Salt Lake City hospitals provide acute care not just to Utahns but to many in Idaho, Wyoming and Colorado as well, according to referral estimates in the Harvard study. Meanwhile, rural Utahns live hours from the nearest ICU, and health care workers and public health officials have warned that a rapid outbreak in one of Utah’s tourist towns could leave many patients without adequate care.
In Moab, for example, there are no ICU beds, and only three ventilators that are mostly used to transport patients to other hospitals. Castleview Hospital in Price has just six ICU beds and four ventilators, said Braden Bradford, director of the Southeast Utah Health District.
“Typically, it hasn’t been an issue; they feel prepared for what they normally deal with,” Bradford said. But Moab and the rest of Grand County “are very worrisome to us,” he said.
Canyonlands and Arches national parks closed last week amid pleas from local officials that health resources were not adequate for the tourists the parks were attracting.
“The availability of ventilators and ICU beds is most likely just not at the capacity to where we’re going to need it to be,” agreed Alison Smith, the incoming president of Utah Chapter of the American College of Emergency Physicians and a doctor in Pleasant View.
While big hospitals such as Intermountain Medical Center in Murray and the University of Utah’s hospital can erect special units to receive COVID-19 cases, smaller hospitals don’t necessarily have that space or the extra staff, Smith said.
At the emergency department where she works, Smith, who is due to give birth in eight weeks, sees every sick patient who walks into the emergency room.
“We don’t have enough staff to [separate patients] at a smaller facility,” Smith said, “and I think that’s going to be a problem for rural facilities in general. It’s not for lack of motivation. I think everyone’s doing the best with what we have to work with. This is just unprecedented."
Meanwhile, state officials still need to tally the resources they have. A 2018 report on crisis preparedness estimates there are about 600 ventilators in the state — a fraction of what would be needed for the anticipated 6,400 patients who would need them in a pandemic “of similar severity to the 1918 flu.”
But that ventilator count is years old and several hospitals have been built since then, said Jill Vicory, director of the Utah Hospital Association.
“We’re trying to get a handle on that,” Vicory said. "The system hasn’t been birddogged as closely as it should be. ... We are certainly aware we need to get a good number on that.”