What’s in it for Me?
“Just over 6,000 Positive Tests for Covid-19 in the coming weeks may be enough to cripple our hospital system in San Diego County”
If I have your attention, then come along for the ride below, as it may take a few minutes.
What’s in it for me (WIFM) is a classic driving force for how humans react to any project, program, or change. Within the context of the Covid-19 pandemic and the social distancing guidelines, it’s clear we’re trying to avoid death but are we focused on our own death, the deaths of our loved ones or the fatalities in the community at large? Identifying our objective is critical to getting people to buy in and stay focused on the goal, for the duration it takes. If we don’t make this clear consistently, and show progress against it, we are going to lose stamina and conviction.
Each time I see a new article, post, or information about how this drug is going to help or that only one portion of the population will be affected, I admit, I’m distracted. It takes my mind and focus away from the plan. Its great that Ford & GE are working on ventilators, or that MIT has released an open source plan. It’s exciting that we have over 40 companies working on a vaccine. Its amazing the number of people working on new tests. So we’re good right?
Here are some of the common reactions
“Only old people are dying and affected”
“Only immunocompromised are at risk”
“Only obese people are at risk”
“We'll have plenty of ventilators in a few weeks after all the new production”
“We have millions of tests out there”
This is driving a frustration that we are all doing this to save a very small percentage of the population. Quite frankly its probably not most of us that are going to have a complication from Covid-19. What a waste of time. And we hear people say this is no different from the flu (not true yet).
The crisis that we’re facing is a local one. It’s one of the capacity of our hospitals to service demand when people are critically ill and need their services. As a general population, we don’t visit the hospital very often, and we visit the ICUs even less, but when we do, we know that it potentially saved our life.
The fact is, we’re losing focus on WHY we’re social distancing and sheltering in place. The healthcare system is fragile and it doesn’t take much to make it collapse. I want to start by diving in San Diego County, where I live. I’m using my community, but if you live elsewhere, the logic and numbers are unlikely to be far off. I’m using our county to illustrate local context.
San Diego County Healthcare System Facts
First, some facts about our healthcare system in San Diego County
3.3 million people
~8,400 hospital beds
~884 ICU beds (Intensive Care Unit, approx 24 per 100,000 people)
~824 Ventilators (Needed to take over breathing functions in the most critically ill patients)
At any given moment
Hospital beds have an occupancy rate of 60%
National average for ICU bed occupancy is 60% (I did not find local statistics)
San Diego County Covid-19 Numbers
It is amazing how quickly we’re publicly reporting data from so many sources. It’s almost too much at times and overwhelming. What’s useful and what’ not? Let’s take a look.
Coronavirus Statistics for San Diego County, March 31st, 2020
San Diego communicates these figures daily. I struggle to draw conclusions from this data.
Is our situation getting better?
Is social distancing working?
Is shelter in place still necessary?
What number is bad?
When do we know we were successful and we can stop?
Since the context isn’t given, let’s create some of our own. We have 3.3 Million people in San Diego County, have tested ~10,000 people and have 734 positive tests resulting in 136 hospitalizations.
When do we hit critical stress points in our health system? That’s not clear in the data the county is publishing. Another observation, though I won’t consider this again in this post, is that when we are presented with cumulative statistics, we can’t see the number of patients that are in the system right now. We need to look at working inventory instead of these cumulative totals. Each day new patients arrive, and some leave (they get better or die). However, since we’re in early days in our county, for now we can assume they all patients who are admitted are staying in the hospital (an average stay for Covid-19 is 2-4 weeks)
Another thing we can lose sight of is that people get in car accidents, have heart attacks or strokes, renal failure, workplace injuries, alcohol poisoning, and a whole host of other events that require a hospital visit and potentially a progression to the ICU. The ICU is primarily filled with patients that need close monitoring, have cardiac issues, lung issues, or serious diseases. Covid-19 is not the only thing out there that is currently consuming ICU space.
I’ve tried to estimate what the critical stages would be for filling our county’s ICUs and thereby creating a healthcare crisis right in my backyard. I’ll show you the visual first and then describe how I did the math.
It Won’t Take Much to Cripple our ICUs
San Diego County Covid-19 patients added to normal ICU admits &their impact on ICU utilization**
On the top is a Low (25%), Avg (50%) and High (75%) utilization of our ICUs w/out Covid-19
On the left are the number of patients who test positive for Covid-19
In the middle are projected ICU utilization numbers when a row meets a column.
Our ICUs can get filled up pretty quickly. It doesn’t take a huge influx to usurp their capacity.
Normal ICU Utilization
If we do a very simple calculation to look at the number of ICU beds we have right now in the county, it can help us to model ICU capacity during a lighter period, a normal period and a critical time.
25% - which is less then typically occupied
50%, - which is about average ICU occupancy
75% - which would be abnormally high ICU occupancy, but happens from time to time through the course of the year.
Imagine if we had an earthquake, or a hurricane, perhaps a tornado, or a severe car crash or mass shooting. You can imagine in those scenarios, the ICUs might be above normal capacity. ICU averages may be lower when you look over the course of the year, but on any given day, they could range between the 25% and 75% range.
Infected Population & Impact on Hospitalization
Now let’s look at how many people test positive for Covid-19 and use the rates we have established. So far 20% of patients who test positive* need to be hospitalized and 41% of them are ending up in the ICU. I used three possible scenarios. 1,000, 5,000, and 10,000 people testing positive.
*Note, it seems like we have about a 7% positive test rate for Covid-19 in San DIego County. That means for every 10K tested, there are 700 people testing positive and 9,300 testing negative. If you extrapolate using that rate, in the above example:
1,000 positive tests means ~14,000 tested & 200 in the hospital, 82 in the ICU (approximately today)
5,000 positive tests means ~71,000 tested, 1000 in the hospital, 410 in the ICU.
10,000 positive tests means ~140,000 tested, 2000 in the hospital, 820 i the ICU.
Experts suggest that 20-50% of us will get the virus this year.
10,000 Positive Cases Represents Only 0.3% of our Population.
It is eye opening to realize that we’ve always lived with level of fragility. It’s not right or wrong, its just never been stressed or had the potential to be stressed so acutely on a global scale like this. I’d suspect in the Yellow to Red ranges, you begin to see very high death rates (for both Covid and non-Covid patients) as we won’t have the equipment, labor, or energy to support that level of demand. Its also important to know that without widespread testing, we don’t know if these numbers are overestimated or underestimated. You can see that if we are too quick to get back to business as usual, how quickly we can hurt our hospital system. Hospital and ICU utilization in particular are going to be very telling stats in the days and weeks going forward.
I think it’s less useful to look statewide, but you can find a similar view for the State. You can extrapolate nationwide as well. The link below will allow you to put in your own state and see where your projections are.
California : ICU, Bed & Ventilator Capacity
The Green Line is our ICU capacity in California.
Dotted line is WITH our current stay at home restrictions.
The Shaded Green is the “do nothing” scenario.
Expected PEAK is April 27th
NYC ICU Utilization Likely Exceeding 100%
New York City ICU utilization March 26
There were only 307 ICU beds left in New York City on March 26th. They were at 85% occupancy. There’s more to the story as you drill into the data hospital by hospital. You may find that one hospital is at 100% and another at < 85%. The crisis is a local one. Take a look at the map below which shows all the hospitals and where they are building new capacity in New York.
This was as of March 26th. Since then, if you track their increase in cases, and hospitalizations, you can gauge how many are in the ICU as of today (after subtracting deaths & recoveries) and project that they must be approaching 100% utilization .
New York City Hospital Locations
Breakdown of all the hospital locations in NYC. The red circles are where new bed capacity is being added including the Javitz center, formerly a convention center in mid-town Manhattan
One final visual. If you’re in sales or marketing, you know the visualization tool called the funnel. You need a lot of volume at the top of the funnel to close a sale. That is, you have to make a lot of phone calls before you close one sale. Similarly, as more people are infected, then tested, we’ll see more people trickling their way into the ICU. Several tactics exist that reduce the impact within that funnel. The number one thing we can do in this case, is to have fewer people infected an entering the funnel.
San Diego County Infection Funnel as of March 31st
These rates might ultimately be wrong, we won’t know until there’s wide spread testing. That’s really the most important priority and the one thing we should be laser focused on. If the rates are wrong, we can adjust the model, adjust the curve and maybe get back to normal. If the rates are worse, then we may be in this situation for longer than we’re expecting. Its too late for New York. Its not too late for the rest of us.
No matter how you look at it, we need to stay focused. Our ICUs don’t have the capacity to support severe cases and hospitalizations as the infection rate grows. The three sets of actions we hear in the media and elsewhere, each impact different stages of the funnel. We’ll keep hearing about improvements in ventilators, pharmaceuticals and testing which is exciting and a testament to our innovative spirit. The problem is that having more ventilators may create some capacity at the bottom of the funnel, they may not have enough effect if we don’t have enough ICU beds and staff to manage them. Pharmaceuticals could make a big difference if we have any proof that they work. Its hard to know that right now as patients taking things like hydroxychloraquine might have gotten better without it, we jut don’t know. With what we know right now, and knowing how close a collapse of our healthcare system could be, capacity is our biggest concern. We simply need to keep people out of the hospital.
Of all the metrics to keep track of, keep track of your local hospital systems utilization
So back to the initial question, what’s in it for me or you? If we stay home, practice social distancing, we slow the spread of this virus and impact the very top part of this funnel, thereby effecting all stages. In this scenario, the people we spend our days with are less likely to get sick and with fewer people being infected, fewer people will be hospitalized. Since fewer people are being hospitalized, fewer ICU beds will be needed and there will be fewer casualties of any kind. While the disease may not be fatal to most of us there are still 100s of other things that could send any of us to the hospital. Would you be ok living in a place that had ZERO hospital access and ZERO ICU care?
Stay Focused on What Matters
Keep Hospitals Working.
This is the Way
** Footnote from the above ICU calculation, a few caveats to my analysis of infection & utilization numbers.
I recognize that if I had my hands on all of the actual data, that there are 100 ways to sharpen the knife so to speak on my calculations. I realize that not all populations segments have the same probabilities and flow throws on my funnel. However, with so few people required to be sick to jam up the ICUs, I don’t think it makes a material difference.
10K positive patients happening over 1 year is very different from over 1 month. Staying at home keeps the infections hopefully in serial vs. in parallel so to speak.
If we tested more people we might adjust all of these figures as they may prove to be wrong. We’ll only get that knowledge with time unfortunately.
Sources
https://www.chcf.org/wp-content/uploads/2017/12/PDF-RethinkingUseOfICUCareBedsInCA.pdf
Hospitals lose money on ICU patients
https://accessmedicine.mhmedical.com/content.aspx?bookid=1944§ionid=143521546#1136418502
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840149/
https://www.bloomberg.com/graphics/2020-new-york-coronavirus-outbreak-how-many-hospital-beds/
https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/2019-nCoV/status.html
https://www.kpbs.org/news/2020/mar/25/icu-bed-capacity-varies-widely-nationwide-see-how/
https://thecity.nyc/2020/03/new-york-hospital-icus-nearing-limit-as-covid-19-surges.html
https://www.nbcsandiego.com/news/local/major-gaps-in-coronavirus-testing-in-counties-across-california/2297121/
http://covid19.healthdata.org/
https://www.regencymedicalcentre.com/patients-in-the-intensive-care-unit/