Bed Capacity, Capacity Management, CDC, Covid-19, HealthData.gov, Herd Immunity, Hospital Utilization, ICU Capacity, ICU Utilization, Influenza, Justin Hart, Lockdown Illnesses, Missouri, PCR Tests, Prevalence, Seasonality, St. Louis MO, Staffed Beds, Staffed Utilization, Statista
The fall wave of the coronavirus has brought with it an increase in COVID hospitalizations. It’s a serious situation for the infected and for those who care for them. But while hospital utilization is rising and is reaching tight conditions in some areas, claims that it is already a widespread national problem are without merit.
National and State Hospital Utilization
The table below shows national and state statistics comparing beds used during November 1-9 to the three-year average from 2017 – 19, from Justin Hart. There are some real flaws in the comparison: one is that full-year averages are not readily comparable to particular times of the year, with or without COVID. Nevertheless, the comparison does serve to show that current overall bed usage is not “crazy high” in most states, as it were. The increase in utilization shown in the table is highest in IA, MT, NV, PA, VT, and WI, and there are a few other states with sizable increases.
Another limitation is that the utilization rates in the far right column do not appear to be calculated on the basis of “staffed” beds, but total beds. The U.S. bed utilization rate would be 74% in terms of staffed beds.
Average historical hospital occupancy rates from Statista look like this:
Again, these don’t seem to be calculated on the basis of staffed beds, but current occupancies are probably higher now based on either staffed beds or total beds.
As of November 11th, a table available at HealthData.gov indicates that staffed bed utilization in the U.S. is at nearly 74%, with ICU utilization also at 74%. As the table above shows, states vary tremendously in their hospital bed utilization, a point to which I’ll return below.
COVID patients were using just over 9% of of all staffed beds and just over 19% of ICU beds as of November 11th. One caveat on the reported COVID shares you’ll see for dates going forward: the CDC changed its guidelines on counting COVID hospitalizations as of November 12th. It is now a COVID patient’s entire hospital stay, rather than only when a patient is in isolation with COVID. That might be a better metric if we can trust the accuracy of COVID tests (and I don’t), but either way, the change will cause a jump in the COVID share of occupied beds.
Interpreting Hospital Utilization
Many issues impinge on the interpretation of hospital utilization rates:
First, cases and utilization rates are increasing, which is worrisome, but the question is whether they have already reached crisis levels or will very soon. The data doesn’t suggest that is the case in the aggregate, but there certainly there are hospitals bumping up against capacity constraints in some parts of the country.
Second, occupancies are increasing due to COVID patients as well as patients suffering from lockdown-related problems such as self-harm, psychiatric problems, drug abuse, and conditions worsened by earlier deferrals of care. We can expect more of that in coming weeks.
Third, lockdowns create other hospital capacity issues related to staffing. Health care workers with school-aged children face the daunting task of caring for their kids and maintaining hours on jobs for which they are critically needed.
Fourth, there are capacity issues related to PPE and medical equipment that are not addressed by the statistics above. Different uses must compete for these resources within any hospital, so the share of COVID admissions has a strong bearing on how the care of other kinds of patients must be managed.
Fifth, some of the alarm is purely case-driven: all admissions are tested for COVID, and non-COVID admissions often become COVID admissions after false-positive PCR tests, or simply due to the presence of mild COVID with a more serious condition or injury. However, severe COVID cases have an outsized impact on utilization of staff because their care is relatively labor-intensive.
Sixth, there are reports that the average length of COVID patient stays has decreased markedly since the spring (it is hard to find nationwide figures), but it is also increasingly difficult to find facilities for post-acute care required for some patients on discharge. Nevertheless, if improved treatment reduces average length of stay, it helps hospitals deal with the surge.
Finally, thus far, the influenza season has been remarkably light, as the following chart from the CDC shows. It is still early in the season, but the near-complete absence of flu patients is helping hospitals manage their resources.
St. Louis Hotspot
The St. Louis metro area has been proclaimed a COVID “hotspot” by the local media and government officials, which certainly doesn’t make St. Louis unique in terms of conditions or alarmism. I’m curious about the data there, however, since it’s my hometown. Here is hospital occupancy on the Missouri side of the St. Louis region:
It seems this chart is based on total beds, not staffed beds, However, one of the interesting aspects of this chart is the variation in capacity over time, with several significant jumps in the series. This has to do with data coverage and some variation in daily reporting. Almost all of these data dashboards are relatively new, so their coverage has been increasing, but generally in fits and starts. Reporting is spotty on a day-to-day basis, so there are jagged patterns. And of course, capacity can vary from day-to-day and week-to-week — there is some flexibility in the number of beds that can be made available.
The share of St. Louis area beds in use was 61% as of November 11th (preliminary). COVID patients accounted for 12% of hospital beds. ICU utilization in the St. Louis region was a preliminary 67% as of Nov. 11, with COVID patients using 29% of ICU capacity (which is quite high). Again, these figures probably aren’t calculated on the basis of “staffed” beds, so actual hospital-bed and ICU-bed utilization rates could be several percentage points higher. More importantly, it does not appear that utilization in the St. Louis area has trended up over the past month.
At the moment, the St. Louis region appears to have more spare hospital capacity than the nation, but COVID patients are using a larger share of all beds and ICU beds in St. Louis than nationwide. So this is a mixed bag. And again, capacity is not spread evenly across hospitals, and it’s clear that hospitals are under pressure to manage capacity more actively. In fact, hospitals only have so many options as the share of COVID admissions increases: divert or discharge COVID and non-COVID patients, defer elective procedures, discharge COVID and non-COVID patients earlier, allow beds to be more thinly staffed and/or add temporary beds wherever possible.
Anyone with severe symptoms of COVID-19 probably should be hospitalized. The beds must be available, or else at-home care will become more commonplace, as it was for non-COVID maladies earlier in the pandemic. A continued escalation in severe COVID cases would require more drastic steps to make hospital resources available. That said, we do not yet have a widespread capacity crisis, although that’s small consolation to areas now under stress. And a few of the states with the highest utilization rates now have been rather stable in terms of hospitalizations — they already had high average utilization rates, which is potentially dangerous.
COVID is a seasonal disease, and it’s no surprise that it’s raging now in areas that did not experience large outbreaks in the spring and summer. And those areas that had earlier outbreaks have not had a serious surge this fall, at least not yet. My expectation and hope is that the midwestern and northern states now seeing high case counts will soon reach a level of prevalence at which new infections will begin to subside. And we’re likely to see a far lower infection fatality rate than experienced in the Northeast last spring.