Coronavirus surge filling ICU beds across Marin and Bay Area
As coronavirus cases surge and new federal hospital-tracking data show infected patients are beginning to max out intensive-care units across the country, hospitals in Marin and the greater Bay Area are reportedly close behind.
At The Ark’s press deadline Dec. 14, Marin and state officials reported 17.8-percent staffed ICU-bed-availability for the Bay Area, while Marin officials reported just 3 percent availability.
“So far, we have not run out of our ICU capacity,” Marin Public Health Officer Matt Willis said in an interview last week. “That’s what we are trying to avoid, because that’s when we have to start making tough decisions.”
However, varying methods of calculation, and little transparency from the county and the state, make true capacity difficult to discern.
According to Willis, the county has 39 physical adult ICU beds “on paper,” but it regards only 29 of them as staffed or able to be staffed quickly under normal hospital routine. Based on the reported percent available, which appears in Marin’s emailed daily coronavirus status updates and on its virus-tracking dashboard, that would leave just one available staffed adult ICU bed for both COVID-19 and non-COVID patients.
Coronavirus surge hits state, Bay Area, Marin
Gov. Gavin Newsom Dec. 3 announced the state would begin using available ICU capacity as its new metric for regional lockdowns. Once a region —Northern California, Greater Sacramento, Bay Area, San Joaquin Valley and Southern California — drops below 15 percent available staffed adult ICU beds, each county in the region must impose a strict stay-at-home order reminiscent of the early days of the pandemic. Three regions were quickly shut down, with the San Joaquin Valley with zero ICU bed availability and Southern California at 2.7 percent availability at The Ark’s press time Dec. 14, while Greater Sacramento had 14.8 percent.
When Newsom announced the new protocol, California had just set a single-day record of more than 30,000 new cases and, within days, the U.S. saw a 24-hour record of 3,411 new deaths on Dec. 10 — more than the single-day toll of the Sept. 11 terror attacks or the bombing of Pearl Harbor — and 244,011 new cases on Dec. 12, according to the U.S. Centers for Disease Control and Prevention.
The day after Newsom’s announcement, Marin, in coordination with Alameda, Contra Costa, San Francisco and Santa Clara counties and the city of Berkeley, said it would pre-emptively close down through at least Jan. 4 to prevent local hospitals from being overwhelmed by the surge in COVID-19 patients.
Marin’s pre-emptive stay-at-home order went into effect at noon Dec. 8 — the same day it was rolled back to the state’s most-restrictive purple-tier, for widespread transmission of the virus, under the state’s blueprint for reopening the economy. The county saw 84 new cases Dec. 7, the highest since the single-day record of 90 in mid-July and up from about 10 new daily cases a month ago. For the state’s seven-day tier-evaluation period ending Nov. 28, Marin’s adjusted daily new-case rate nearly doubled to 8.1 per 100,000 residents, while test positivity edged up to 2.2 percent from 1.8 percent.
“We know that ICU data is directly linked to (coronavirus) case rates,” Willis said at a Dec. 9 online question-and-answer session. “Between 5 and 10 percent of those diagnosed with COVID-19 will require hospitalization, and some set of those will require an ICU stay.
“ICU capacity is really a lagging indicator following case rates,” Willis said. “When we see surges in cases, we are bracing ourselves essentially for influxes into the hospitals, and that’s what we’re seeing now. We know that mortality increases when capacity is exceeded.”
The new tier assignment had little direct impact on economic and personal activity, as the stay-at-home order shut down indoor and outdoor dining, hotels, campgrounds, museums, zoos, hair salons and other personal-care services. Retail stores are allowed to stay open at 20 percent capacity, grocery stores at 35 percent and essential businesses can continue operations.
Willis said the metrics used for tier-based restrictions, which include per-capita new-case rates, test positivity and equity measurements, are no longer sufficient, as more than 99 percent of California residents are in the purple tier, the state’s most restrictive.
However, the decision to move the lockdown trigger to a single metric of percent ICU bed availability has raised questions about how capacity is measured by state and local health officials — and about the transparency of the data itself.
Marin, California using different measurements
The Ark has found that state and county health officials are using different methods to tally bed counts in Marin, leading the state to report the county has more available beds than the county uses in its own percent calculation.
According to Willis, the county’s tally of 29 total ICU beds is representative of the “real-life scenario” in Marin. He said his office calls the three county hospitals that have ICU facilities — MarinHealth Medical Center in Greenbrae, Kaiser Permanente Medical Center in Terra Linda and Novato Community Hospital — to determine their “functional capacity” each day. That’s determined by how many ICU beds could be staffed by available doctors and nurses within four hours, he said.
The county’s tally does not include physical beds that are open if they cannot be quickly staffed, and it does not include ICU surge beds. Willis said that’s because, so far, Marin has not needed to tap into any additional beds that could be made available at local hospitals if the surge in severely ill COVID-19 patients surpassed current capacity.
He said there’s a series of steps a hospital will take to increase ICU capacity, including calling in travel nurses, up-training or cross-training staff and canceling elective procedures and surgeries.
“That could double capacity, but that is at the expense of a lot of other health-care procedures that need to be happening,” Willis said.
However, on Dec. 7, the U.S. Department of Health and Human Services debuted a new weekly report of patient impact and hospital capacity by facility for nearly 5,000 medical centers in the U.S. Its data, as of Nov. 27, showed Marin’s three hospitals self-reported a seven-day average of 39.7 existing adult ICU beds, 32.7 of those staffed. The seven-day-average as of Dec. 7, released at The Ark’s press deadline Dec. 14, was 38.9 total adult ICU beds, 31.9 staffed.
Both reports show Marin hospitals are self-reporting to the state they have roughly three to four more staffed beds than the 29 used for Marin’s own count. The difference can be significant when using 15-percent availability as the sole metric to order a tight economic shutdown. On Dec. 9, Marin reported 11 percent availability among its 29 beds, suggesting three available ICU beds — a figure Willis confirmed with The Ark. If Marin in fact had 32 staffed beds, six would have been available, or nearly 19 percent.
Further, the state on Dec. 9 reported Marin had 13 available beds.
Willis said the state is using hospital census data and the number of state-licensed beds, which he said has made the state’s tally of available beds in Marin “artificially high.” That suggests California is counting Marin’s 10 open, unstaffed beds and deeming them available in its own count — though California’s own definition states otherwise.
According to California’s COVID-19 dashboard, hospitals are required to self-report “the total number of available staffed ICU beds daily. This includes both existing staffed ICU beds and staffed ICU surge beds.”
Willis and other Marin public-health officials did not respond to a follow-up seeking clarification on the discrepancy.
Meanwhile, the state indicates its availability calculation is based on the total number of physical beds — a reflection of total ICU capacity, even if the beds are unstaffed — rather than Marin’s calculation that limits the total only to beds that are staffed or could be within four hours.
The differences create multiple possible calculations for capacity on Dec. 9, for example: three available beds of 29 staffable beds, or six of 32, or 13 of 39 total existing physical beds — or even 13 of a third, as-yet-unknown number that combines both existing physical beds and potential surge beds.
One local physician contacted The Ark to say his own survey of colleagues found the three hospitals had about 70 staffed and unstaffed existing and surge ICU beds, or about 30 more than Marin is using in its own availability calculation. The figure roughly aligns with an estimate by third-party tracker CovidActNow, a nonprofit that works with Stanford, Harvard and Georgetown universities and provides other coronavirus-tracking data to the state.
The California Department of Public Health and Newsom’s office didn’t provide further clarity.
When The Ark first contacted the state health department on Dec. 3, it provided a link to county-by-county hospital data from early April, less than a month into the pandemic. The office stopped responding when The Ark requested updated hospital data and comment on the figures and methods used to measure ICU capacity.
Those answering phone calls to the offices instructed The Ark to submit questions by email.
The U.S. health department publicly released its by-hospital data the following week.
Willis said he hopes the state’s way of tallying ICU capacity will soon align with what local jurisdictions are doing.
“It’s confusing … when the data tools themselves are evolving. The state is still trying to determine what is the best way to come up with this concept,” Willis said.
However, it’s also unclear why Marin declines to publish the two figures — its count of daily staffed ICU bed availability and total number of beds — used for the availability percentage that it publishes and updates daily on its dashboard.
“We’re talking internally how we can provide more clarity on daily functional capacity census,” said Laine Hendricks, Marin’s public information officer.
Marin typically at 75 percent capacity in winter
Willis said Marin has enough ventilators and personal-protective equipment for health-care workers to handle a surge in hospitalizations. However, he said the strain comes from too few ICU-trained doctors and nurses available to staff the surge beds, due to the constraints felt by hospitals across the state and country.
He pointed out that it’s not uncommon, even in non-pandemic times, for ICUs to have only a few open beds. In Marin, ICUs are typically about 75 percent full because of illnesses like stroke, heart attacks and pneumonia. But with the pandemic, the pressure on hospitals nationwide is much more than it normally would be and is expected to increase based on surging cases of COVID-19 and seasonal influenza this winter.
Marin hospitals operate in a regional system, he said, so when there isn’t capacity at one hospital, a patient can be transferred to another regional hospital that has an opening. But that process has gotten complicated as hospitals across the region fill up.
“What had worked out in the past doesn’t work now,” Willis said. “Certain areas or hospitals might have experienced a constraint, but now they are all feeling that constraint. If no one can accept the patient, that’s when we see increased mortality.”
Willis said Marin hospitals have fielded an increasing number of requests from other counties asking to send over patients they don’t have the capacity for, but those requests are being categorically denied due to the county’s own limitations.
Executive Editor Kevin Hessel contributed to this report. Reporter Hannah Weikel covers the city of Belvedere, as well as crime, courts and public safety issues on the Tiburon Peninsula. Reach her at 415-944-4627.