Houston’s @TXMedCenter has apparently reached baseline ICU bed capacity, and has stopped public reporting of these figures.

A few thoughts from our experience in New York City #COVID19 1/16 https://www.washingtonpost.com/nation/2020/06/28/coronavirus-live-updates-us/?tid=a_classic-iphone&p9w22b2p=b2p22p9w00098&no_nav=true#link-2JA4NGLQFFHM7K34BA2K2PTIRY

1) This is worrisome, especially as Texas cases still seem to be rising. Equilibrium is reached when new cases per day equal number recovered per day. Doesn’t seem like the state is anywhere close to that. 2/

Graphic from https://www.nytimes.com/interactive/2020/us/texas-coronavirus-cases.html

Because of the #COVID19 disease course in which clinical decompensation may occur a week or so after presentation to the emergency department, ICU admissions could continue to swell even after new cases slow. 3/

2) Widespread testing in Texas could be a significant factor compared to NYC in March and April. Case numbers could reflect better detection, and this would be a positive signal about what to expect for the ICU. 4/

3) @TXMedCenter has had at least three more months than we had to plan for this scenario. Expanding ICU capacity is not just about figuring out where to put ICU-level patients. 5/

It’s also about ensuring adequate equipment availability, from the beds themselves, medical gas supply, infusion pumps, pharmacy, staff PPE.

For additional capacity, supply chains, support services, and new ways to organize and new processes have to be implemented. 6/

Simple things like, “Who will empty the sharps container?” and “Where will we dispose of urine?” may require some thinking for ICUs in nontraditional spaces. 7/

4) The most difficult part is staffing. Who are the doctors, nurses, and therapists who will take care of the new ICU patients? If they are not used to working in an ICU, how will they be educated and overseen? 8/

What will their staffing model and shifts look like? How will the IT infrastructure support them? How will they be fed? Where will they rest? 9/

And what about nutrition support, physical therapy, chaplain services, and social work in addition to regular specialist consults like ID, pulmonology and nephrology? 10/

These efforts need layers of leaders to oversee the structure of this organization: to deal with problems, issues, and conflicts as they arise.

These leaders will need to manage change like they never have before. 11/

5) In the end, expanding capacity is not an endeavor that feels like additive effort, but rather exponential complexity.

As a native Texan, I was disheartened to see lack of attention to mask-wearing and social distancing over the last several weeks. 12/

But I trust that the medical community has used the last few months to plan for this scenario, which seems to be headed toward something at least as bad as what we experienced. 13/

Planning and capacity are key. If patient numbers were to overwhelm capacity, then mortality rates would be expected to increase drastically. 14/

And lastly, at the hospital level, attention should be paid to disparities in care within. Are patients getting “better” care if they land in a native ICU than if they are admitted to a non-traditional ICU? How can resources be managed with an eye toward equity and fairness? 15/

Healthcare workers will always be committed to their patients out of professional duty. But equity and justice are essential for healthcare workers to remain committed to their institutions. 16/16