Why is county facing COVID-19 shutdown if hospitalizations remain low? - The San Diego Union-Tribune

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More than six months after the federal government set them up, 202 cots continue to fill a vacant floor of Palomar Medical Center Escondido.

Installed in late April to provide overflow capacity should COVID-19 patients swamp available capacity in permanent hospital units, the thin mattresses on light metal frames have never been needed.

While individual medical facilities in the South Bay came close to filling up in June and July as infected U.S. citizens living in northern Baja California surged across the border for care, transfers to less-impacted facilities throughout the region spread out the load enough to avoid filling a single cot.

More recently, COVID-19 patients have made up a small minority of those being treated at local hospitals. Though a recent surge in cases is now causing the number to trend upward a bit, those with coronavirus infections have recently represented only about 6 percent of all local hospitalizations.

And yet San Diego County teeters on the brink of falling to the most-restrictive level of the state’s reopening system due to a case rate per 100,000 residents that exceeded the allowable 7 last week. If a similar result arrives in Tuesday’s state tier report, many local businesses, including restaurants and movie theaters, would have to stop serving customers indoors and nursing homes would cease allowing visitors.

It’s quite a stark situation given that, while there has been a recent increase in cases and hospitalizations, the numbers have not created a crisis situation. Friday’s county COVID-19 report indicated that 74 percent of the 6,030 hospital beds available throughout the county were occupied. Out of 4,484 occupied beds, just 332 were confirmed or suspected to be fighting the disease. There were 1,546 unoccupied beds across the region.

San Diego County, and many places in California, has seen relatively-steady hospitalization rates even as reports of inundated medical facilities surface in communities across the nation.

It is a situation that layer after layer of public health orders have been designed to create and preserve. The region has sacrificed greatly to preserve capacity in the health care community even though doing so has ruined livelihoods, strained family relationships and kept kids out of schools.

As the dreaded purple tier has loomed again and again in recent weeks, the local hospitalization situation has become ever more polarizing.

The idea of moving backwards at a time when hospitals do not appear to be close to being overwhelmed chafes, especially since the state has so far refused to include collective medical facility capacity in the metrics that decide which counties are able to reopen and how much.

It is possible to lose operating capacity based on relatively-small increases in a community’s per-capita case rate or in the percentage of coronavirus tests coming back positive even if those trends don’t appear to be an immediate threat to the shared resource — health care capacity — that the tiered system is ultimately built to protect.

For months, many have publicly complained at the idea that local hospitalization rates aren’t given more consideration in the state’s four-tiered reopening structure.

Asked to address the situation during his regular COVID-19 news conference Tuesday, Dr. Mark Ghaly, California’s health and human services secretary, noted that hospitalizations are a lagging indicator. It can take days or weeks after infection for a coronavirus infection to become severe enough to require a hospital stay.

“As cases rise, I can almost predict, three, three and a half weeks later, that there will be some increase in hospitalizations,” Ghaly said.

He added that the focus on new cases provides a more-immediate indication of when the virus is starting to spread in a community at a faster rate.

“We feel confident, especially as we see other states quickly and, sort of dramatically, get overwhelmed in their own health care delivery systems, that we’ve made the right choice and that this is where we’ll be for the foreseeable future,” Ghaly said.

The disagreement over how to handle the situation has shown itself over and over again among members of the San Diego County Board of Supervisors, with the majority supporting the state’s tier system even as a vocal minority has demanded more local control.

During the health department’s weekly COVID-19 update this week, county Supervisor Nathan Fletcher pointed out the obvious difference between California and many other places that have seen sharp upticks in their hospitalization rates.

“Right now, Missouri, Oklahoma, Iowa, Indiana, Nebraska, New Mexico are all reporting record-high hospitalizations and significant strains on their health care systems because they did not act soon enough to slow the spread ... that is what the tiered system, and that is what our actions, strive to avoid,” Fletcher said.

He left out Texas which saw its governor, Greg Abbott, peg that state’s reopening pace to local hospitalization rates in September, allowing a large range of businesses to operate at 75 percent capacity as long as COVID-19 patients did not exceed 15 percent of total heads in hospital beds.

The strategy of waiting until hospital capacity increases beyond a certain threshold has clearly not worked. According to data posted daily on the COVID-19 dashboard of the Texas Department of State Health Services, the Lone Star State averaged a collective daily hospital census of 3,440 in September which increased to 4,314 in October and 5,882 so far in November.

With more than 6,000 COVID-19 patients in Texas hospital beds as of Friday, there remained more than 11,000 beds available statewide; however, hospitals in some cities, such as El Paso, have recently reported such growth in hospitalizations that extreme measures have been required. In addition to instituting a local curfew, El Paso officials also recently announced an “alternate care site” opened at the El Paso Convention and Performing Arts Center.

But some feel there is room for more local wisdom between the reopening philosophies typified by the approaches that currently hold sway in California and Texas.

County Supervisor Jim Desmond has asked his colleagues for months to pursue a path that seeks more “local control” over which businesses and other organizations can be open and at what levels.

Remaining hospital capacity in individual areas should be taken into account in local reopening decisions.

“We have to protect the most vulnerable, we have to be concerned about the spread, but, unfortunately, we’ve become, I think, overly-focused on the number of cases and not on the number of illnesses or hospitalizations,” Desmond said. “They have not been, in my opinion, correctly weighed into the decision making.”

But, many will ask, what about hospitalization increases observed recently in states that have been more liberal with their reopening strategies?

Here, Desmond said, San Diego County has proven its ability to manage the spread locally. He pointed to a large outbreak shortly after the reopening of San Diego State University that has grown to more than 1,000 cases. Intense public health outreach, contact tracing and enforcement of health orders, he noted, managed to stop the outbreak on campus from exploding into the kind of community-wide conflagration of cases that would be necessary to push the local health care system to the brink of collapse. UC San Diego, he noted, was able to learn from what unfolded at SDSU and, thus far, has not experienced a similar outbreak as its students return to campus.

“If you open up more, you’re going to have more spread. But the question is, do we have the capacity to manage that increase?” Desmond said. “After an increase, does it stabilize out, does it attenuate down? If it does, good, we can open up some more. But we’re at the point now of moving backwards, instead of forwards.”

While that line of thinking has gotten plenty of applause from many local business owners, especially the mom-and-pop establishments who have suffered the most due to outbreak operating restrictions, the health care community has not joined in.

In an email, Chris Van Gorder, chief executive officer of Scripps Health, said looking at bed capacity alone to gauge the severity of the virus’s impact on the health care system is too narrow a lens to see the whole picture.

“It’s never about the total number of hospital beds,” Van Gorder said. “I think that is where the public and some elected officials get it very wrong. It’s about ICU beds, specialized equipment like ECMO or dialysis for the sickest of COVID patients, staff and supplies.

“We can surge to some degree, but once you run out of critical care capability, staff, certain drugs and supplies and the specialized equipment necessary to care for COVID patients, you are in a crisis.”

The view on the front lines is similar. Dr. Lisa Lowe, an emergency medicine specialist who works at VA San Diego and Sharp Memorial Hospital, said she favors the current efforts to prevent as many infections as possible. This stance, she said, is in part because of the need to preserve capacity in the health care system to treat those without COVID-19 and also because it is still too soon for medical science to fully understand the long-term consequences of becoming infected, even for those who are young and healthy.

There are many viral infections known to increase the long-term risk of serious illnesses. Human papillomavirus infection, for example, is known to significantly increase the chances of developing cervical cancer. Hepatitis B and C viruses can cause deadly liver cancer. A Varicella infection, which causes chickenpox, can cause a person to develop a painful case of the shingles much later in life.

“At this point in time we don’t know what the disease holds next year or in 10 or 20 years from now if you get it today,” Lowe said. “But we do know there is a contingent of young, healthy, athletic people who are getting cardiomyopathy — bad heart disease that can lead to heart failure and death.”

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Why is county facing COVID-19 shutdown if hospitalizations remain low? - The San Diego Union-Tribune
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