COVID-19 hospitalizations increase, bring grim projections

The pace of new COVID-19 hospitalizations is increasing so rapidly in Los Angeles County that it is now literally out of the ordinary, forcing officials to redraw the graphics used to illustrate grim projections of what lies ahead.

In October, fewer than 150 patients infected with the coronavirus were admitted to hospitals daily.

By the end of November, that number had doubled to around 300 patients per day – as high as it has ever been in the entire pandemic.

And now it has more than doubled yet again, to around 700 new hospital patients a day, days before Christmas. This rate is causing a crisis in LA County.

If disease transmission behavior does not change, a projection released by the county’s Department of Health Services indicates LA County could be referred to between 700 and 1,400 new hospital patients per day by New Year’s Eve. New Year.

Daily COVID-19 hospitalizations could increase tenfold from October

“The model suggests we could easily see 10 or more times admissions per day than what we saw in October,” said Dr. Roger Lewis, director of COVID-19 hospital demand modeling for the LA County Department of Health Services and Professor of Emergency Medicine at Harbor-UCLA Medical Center in West Carson.

Already, the number of people in LA County hospitals with COVID-19 was nearly 5,900 on Sunday – more than double the summer peak of the second wave of the pandemic, in which no more than 2,232 people were in hospital with illness on any particular day.

This means that by the end of the year, we could see as many as 9,000 people with COVID-19 occupying LA County hospital beds.

And by mid-January, there could be 14,000 if there is no change in transmission behavior.

Particularly alarming is the graph showing the forecast of intensive care unit demand.

“We do not have intensive care beds available”

Last week, LA County effectively ran out of ICU bed capacity available for COVID-19 patients – the first time this has happened in this pandemic.

“We don’t have intensive care beds for additional patients at the moment,” Lewis said.

More than 1,200 COVID-19 patients in LA County were in intensive care on Sunday, more than triple the number at the end of November.

“Now, that doesn’t mean that hospitals don’t continue to do all they can to increase capacity. But there is a limit to what can be done, ”Lewis said on Friday. “I think the biggest challenge hospitals will face in the next week or two will be the staff needed to take care of patients with COVID-19, who require higher level care.”

On Monday, Director of Public Health Barbara Ferrer said LA County was on track to register 110 COVID-19 deaths per day in a matter of weeks. The county currently records an average of 84 deaths per day.

So what do hospitals do when there are no more beds available in the ICU?

Lots of options for dealing with an ICU shortage – none are ideal

Some of the options for finding ways to treat critically ill patients when the ICU is full:

• Ask nurses to take on more intensive care patients than usual. Normally, an intensive care nurse looks after one or two patients at a time. Nurses may be asked to treat three or four simultaneously.
• Place critically ill patients in physical locations outside of the ICU, such as keeping them longer in the emergency room. But “it’s not ideal to be in a physical place that’s been built to provide this level of care,” Lewis said.

“Just having the system meet this growing demand and do the best it can with what we have is not going to produce the best patient outcomes that we might get if we had a lower demand for care,” Lewis said. “Everyone does things differently from what we would ideally like to do because there are more patients than we can handle.

And that means patients are at risk of worse outcomes. “This includes longer lengths of hospital stay, longer periods of time on the ventilator and ultimately mortality,” Lewis said.

When there are too many patients for the available medical staff, “there just won’t be the same quality of surveillance,” said Dr. Robert Kim-Farley, epidemiologist and infectious disease expert at UCLA Fielding School. of Public Health.

Other temporary measures are not ideal. Keeping critically ill patients who need to be in intensive care on hold in the emergency room not only degrades the quality of care, Kim-Farley said, but also creates a ripple effect that causes patients to wait in emergency rooms. ambulances for hours just outside the hospital. This leaves fewer ambulances available to answer calls.

Concerns about burnout

Burnout is another major point of concern. Nurses are the ones who are at the bedside of intensive care patients, and they are now being asked to work in more intensive care settings than normal, taking care of more patients, “and they will be asked to do so for periods of time. weeks. Lewis said.

So far, newly diagnosed coronavirus cases continue to rise in LA County and statewide, to near-daily record levels. This means that the rate of infections that have occurred during the Thanksgiving holidays and in people who have been infected by these people is still increasing.

Ultimately, a fraction of those who test positive this week will need hospital care – the state estimates that about 12% of people test positive statewide and 10% in LA County – and the average length of stay at the hospital is six days before recovery or death.

“So we’re going to be asking the system to take on even more patients than it is today for the next two weeks at least,” Lewis said.

Two to three weeks to notice a change in behavior

“If everyone started to be extremely careful today and the transmission was significantly reduced, then the benefits of this – which would be huge – would start to show in about three weeks,” Lewis said on Friday. “So, for the remainder of December, we expect to see … an increase in the number of hospitalizations and growing challenges for the health care system to provide the best possible care to as many people as possible.”

It can usually take around two to three weeks from the time a person is exposed to the virus for them to get so sick that they need to be hospitalized.

“What we have under our control is what is happening in January,” Lewis said. “If we do the right things now, January can be ‘no worse’ than December. But if we continue to see the transmission as it was last month, then January will be even worse. “

When might we see evidence that the stay-at-home order is working?

A big question is whether the regional stay-at-home order that went into effect for most Californians on December 7 works.

Dr George Rutherford, epidemiologist and infectious disease expert at UC San Francisco, said that when COVID-19 lockdown orders went into effect in France, UK and Spain, “it took about two to three weeks for the effects of the lockdown to kick in. “

So this week, Rutherford will start looking at daily case rates to see if cases are starting to flatten out or maybe go down.

Ferrer said she would start looking at trends around Christmas to see if daily cases start to decline.

It will be around New Years’ time for the stay-at-home order’s effect to begin to be reflected in hospital admissions, Lewis said.

Kim-Farley said it would be essential for people to say no to social gatherings during the winter break. “Are you invited to a party?” Just say no. Are you invited to friends’ homes for dinner? Just say no. That way, when you need an intensive care bed, the hospital won’t say ‘no’ to you.

Times editor Maura Dolan contributed to this report.