vox--2020-07-16--Just 4 states meet these basic criteria to reopen and stay safe

All 50 states have moved to reopen their economies , at least partially , after shutting down businesses and gatherings in response to the coronavirus pandemic .
But a Vox analysis suggests that most states haven ’ t made the preparations needed to contain future waves of the pandemic — putting themselves at risk for a rise in Covid-19 cases and deaths should they continue to reopen , as some states have already seen .
Experts told me states need three things to be safe to open .
State leaders , from the governor to the legislature to health departments @ @ @ @ @ @ @ is no longer spreading unabated .
They need the testing capacity to track and isolate the sick and their contacts .
And they need the hospital capacity to handle a potential surge in Covid-19 cases .
More specifically , states should meet at least five basic criteria .
They should see a two-week drop in coronavirus cases , indicating that the virus is actually abating .
They should have fewer than four daily new cases per 100,000 people per day — to show that cases aren ’ t just dropping but are also @ @ @ @ @ @ @ least 150 new tests per 100,000 people per day , letting them quickly track and contain outbreaks .
They need an overall positive rate for tests below 5 percent — another critical indicator for testing capacity .
And states should have at least 40 percent of their ICU beds free to actually treat an influx of people stricken with Covid-19 should it be necessary .
These metrics line up with a range of expert recommendations , as well as the various policy plans put out by both independent groups and government officials to @ @ @ @ @ @ @ metrics doesn ’ t mean that a state is ready to safely reopen its economy — a process that describes a wide range of local and state actions .
And failing them doesn ’ t mean a state is in immediate danger of a coronavirus outbreak if it starts to reopen ; with Covid-19 , there ’ s always an element of luck and other factors .
But with these metrics , states can gauge if they have repressed the coronavirus while building the capacity to contain future outbreaks should they come .
@ @ @ @ @ @ @ how ready states are for the next phase of the fight .
So far , most states are not there .
As of July 16 , just four states — Maine , Massachusetts , New Jersey , and Vermont — met four or five of the goals , which demonstrates strong progress .
Twenty-two states and Washington , DC , hit two or three of the benchmarks .
The other 24 achieved zero or one .
Even the states that have made the most progress aren ’ t safe to fully reopen .
@ @ @ @ @ @ @ the threat of the coronavirus is still out there .
Especially in states that suffered big outbreaks , such as New York , even a lot of progress doesn ’ t mean all the underlying problems that led to an epidemic are gone .
Nor do the metrics cover everything that states should do before they can safely reopen .
They don ’ t show , for example , if states have the capacity to do contact tracing , in which people who came into contact with someone who ’ s sick with @ @ @ @ @ @ @ detectives ” and quarantined .
Contact tracing is key to containing an epidemic , but states don ’ t track how many contact tracers they ’ ve hired in a standardized , readily available way .
States also don ’ t have ready data for health care workers ’ access to personal protective equipment , such as masks and gloves — a critical measure of the health care system ’ s readiness that ’ s difficult to track .
But the map gives an idea of how much progress states have made toward @ @ @ @ @ @ @ .
States will have to follow these kinds of metrics as they reopen .
If the numbers — especially coronavirus cases — go in the wrong direction again , experts said governments should be ready to bring back restrictions .
If states move too quickly to reopen or respond too slowly to a turn for the worse , they could see a renewed surge in Covid-19 cases .
“ Planning for reclosing is part of planning for reopening , ” Mark McClellan , a health policy expert at Duke , told me .
@ @ @ @ @ @ @ there will be needs for pauses and going back — hopefully not too much if we do this carefully.
” So this will be a work in progress , at least until we get a Covid-19 vaccine or the pandemic otherwise ends , whether by natural or human means .
But the metrics can at least help give states an idea of how far along they are in the fight against the coronavirus .
What ’ s the goal ?
A 10 percent drop in daily new coronavirus cases compared to two weeks @ @ @ @ @ @ @ cases compared to one week ago , based on data from the New York Times .
Which states meet the goal ?
Maine — just one state .
Why is this important ?
Guidance from the White House and several independent groups emphasize that states need to see coronavirus cases drop consistently over two weeks before they can say they ’ re ready to begin reopening .
After all , nothing shows you ’ re out of an outbreak like a sustained reduction in infections .
“ The first and foremost [ metric @ @ @ @ @ @ @ continued decrease in cases , ” Saskia Popescu , an infectious disease epidemiologist , told me .
“ It ’ s a huge piece.
” A simple reduction in cases compared to two weeks prior isn ’ t enough ; it has to be a significant drop , and it has to be sustained over the two weeks .
So for Vox ’ s map , states need at least a 10 percent drop in daily new cases compared to two weeks prior and at least a 5 percent drop compared to one @ @ @ @ @ @ @ a reflection of testing capacity : More testing will pick up more cases , and less testing will pick up fewer .
So it ’ s important that the decrease occur while testing is either growing or already sufficient .
And since states have recently boosted their testing abilities , increases in Covid-19 cases can also reflect improvements in testing .
Even after meeting this benchmark , continued caution is warranted .
If a state meets the goal of a reduction in cases compared to one and two weeks ago but cases seemed @ @ @ @ @ @ @ then perhaps it ’ s not time to reopen just yet .
And if cases have dropped but only from a very high baseline of cases , then that ’ s less comforting than a drop from a lower baseline .
“ You have to use common sense , ” Cyrus Shahpar , a director at the public health policy group Resolve to Save Lives , told me .
What ’ s the goal ?
Fewer than four daily new coronavirus cases per 100,000 people per day , based on data from the @ @ @ @ @ @ @ .
Which states meet the goal ?
Connecticut , Hawaii , Maine , Massachusetts , New Hampshire , New Jersey , New York , and Vermont — eight states .
Why is this important ?
One of the best ways to know you ’ re getting away from a disease outbreak is to no longer see a high number of daily new infections .
While there ’ s no universally accepted number , experts said that four daily new coronavirus cases per 100,000 people is a decent ceiling .
“ If I go @ @ @ @ @ @ @ coronavirus cases a day ] , it ’ s different than going from 1,000 to 2,000 to 3,000 , even though the percent difference is the same , ” Shahpar said .
“ That ’ s why you have to take into account the overall level , too.
” To put it another way , it ’ s not enough for daily new Covid-19 cases to drop , even for weeks .
Cases also should fall below a certain level before a state can be deemed truly safe .
At the same time @ @ @ @ @ @ @ four daily new cases per 100,000 but it ’ s seen a recent uptick in cases , that ’ s a reason for caution .
Even the worst-hit states , after all , began with a handful of cases before they saw an exponential surge .
But if your state is below the threshold , it ’ s in a pretty solid place relative to most other states .
What ’ s the goal ?
At least 150 tests per 100,000 people per day , based on data from the Covid Tracking Project @ @ @ @ @ @ @ meet the goal ?
Alabama , Alaska , Arizona , Arkansas , California , Connecticut , Delaware , Florida , Georgia , Idaho , Illinois , Iowa , Kansas , Louisiana , Maine , Maryland , Massachusetts , Michigan , Minnesota , Mississippi , Missouri , Montana , Nebraska , Nevada , New Jersey , New Mexico , New York , North Carolina , North Dakota , Ohio , Oklahoma , Rhode Island , South Carolina , Tennessee , Texas , Utah , Vermont , Virginia , Washington , West Virginia , and @ @ @ @ @ @ @ states .
Washington , DC , did as well .
Why is this important ?
Since the beginning of the coronavirus pandemic , experts have argued that the US needs the capacity for at least 500,000 Covid-19 tests a day .
Controlling for population , that adds up to about 150 new tests per 100,000 people per day .
Testing is crucial to getting the coronavirus outbreak under control .
When paired with contact tracing , testing lets officials track the scale of the outbreak , isolate the sick , quarantine those the @ @ @ @ @ @ @ deploy community-wide efforts as necessary .
Testing and tracing are how other countries , like South Korea and Germany , have managed to control their outbreaks and started to reopen their economies .
The idea , experts said , is to have enough surveillance to detect embers before they turn into full wildfires .
“ States should be shoring up their testing capacity not just for what it looks like right now while everyone ’ s in their homes , but as people start to move more , ” Jen Kates , the @ @ @ @ @ @ @ at the Kaiser Family Foundation , told me .
“ As people start doing more movement , you ’ ll have to test more , because people are going to come into contact with each other more.
” The 500,000-a-day goal is the minimum .
Some experts have recommended as many as millions of tests nationwide each day .
But 500,000 is the most often-cited goal , and it ’ s , at the very least , a good start .
It ’ s preferable if states report this number by how many @ @ @ @ @ @ @ just the total number of tests .
For containing an outbreak , it ’ s generally more useful to test 500,000 people one time than to test one person 500,000 times .
But some states report the figures for total tests , not the number of tested individuals — counting tests for a single person multiple times .
That could skew the numbers .
This goal is also supposed to be for diagnostic tests , not antibody tests .
Diagnostic tests gauge whether a person has the virus in their system and is @ @ @ @ @ @ @ moment of the test .
Antibody tests check if someone ever developed antibodies to the virus to see if they had ever been sick in the past .
Since diagnostic tests give a more recent gauge of the level of infection , they ’ re seen as much more reliable for evaluating the current state of the Covid-19 outbreak in a state .
But some states have mixed up numbers for diagnostic and antibody tests , which could skew the data collected by the Covid Tracking Project .
“ The virus isn ’ @ @ @ @ @ @ @ manipulating the numbers or not in order to look more favorable ; it ’ s going to continue to spread , ” Crystal Watson , a senior scholar at the Johns Hopkins Center for Health Security , told me .
“ It ’ s better to really understand what ’ s going on and report that accurately.
” For states honestly reporting these numbers , though , they ’ re a critical measure of their ability to detect , control , and contain coronavirus outbreaks .
What ’ s the goal ?
Below @ @ @ @ @ @ @ positive over the past week , based on data from the Covid Tracking Project .
Which states meet the goal ?
Alaska , Connecticut , Delaware , Hawaii , Illinois , Maine , Massachusetts , Michigan , Minnesota , Montana , New Hampshire , New Jersey , New Mexico , New York , Rhode Island , Vermont , West Virginia , and Wyoming — for a total of 18 states .
Washington , DC , did as well .
Why is this important ?
The positive or positivity rate , which tracks how @ @ @ @ @ @ @ , is another way to measure testing capacity .
Generally , a higher positive rate suggests there ’ s not enough testing happening .
An area with adequate testing should be testing lots and lots of people , many of whom don ’ t have the disease or don ’ t show severe symptoms .
The positive testing rate in South Korea , for example , is below 2 percent .
High positive rates indicate only people with obvious symptoms are getting tested , so there ’ s not quite enough testing to @ @ @ @ @ @ @ Previously , the World Health Organization ( WHO ) recommended a maximum positive rate of 10 percent .
But the WHO more recently recommended 5 percent , which is in line with the rate for countries that have managed to better control their outbreaks , like Germany , New Zealand , and South Korea .
“ Even lower is better , ” Shahpar said .
The positive rate data is subject to the same limitations as the overall testing data from the Covid Tracking Project .
So if a state includes antibody tests @ @ @ @ @ @ @ skew the positive rate to look better than it is .
States only risk hurting themselves if they do this .
What ’ s the goal ?
Below 60 percent occupancy of ICU beds in hospitals , based on data from CovidCareMap .
Which states meet the goal ?
Alaska , California , Idaho , Illinois , Iowa , Louisiana , Massachusetts , Minnesota , Missouri , Nebraska , New Hampshire , New Jersey , New Mexico , South Dakota , Utah , Vermont , Wisconsin , and Wyoming — for a total @ @ @ @ @ @ @ important ?
If a pandemic hits , the health care system needs to be ready to treat the most severe cases and potentially save lives .
That ’ s the key goal of “ flattening the curve ” and “ raising the line , ” in which social distancing helps reduce the spread of the disease so the health care system can maintain and grow its capacity to treat an influx of Covid-19 patients .
“ There ’ s this idea that in six weeks we can open more things , ” Amesh @ @ @ @ @ @ @ Johns Hopkins Center for Health Security , told me .
“ But the virus is still there .
It ’ s all about making sure that the case count isn ’ t too immense for our hospital system to deal with.
” The aim is to avoid the nightmare scenario that Italy went through when it had more Covid-19 cases than its health care system could handle , leading to hospitals turning away even dangerously ill patients .
To gauge this , experts recommended looking at ICU capacity , with states aiming to @ @ @ @ @ @ @ their ICUs .
Hitting the benchmarks is the beginning , not the end Vox ’ s map is just one way of tracking success against the coronavirus .
Other groups have come up with their own measures , including Covid Act Now , Covid Exit Strategy , and Test and Trace .
Vox ’ s model uses more up-to-date data than some of these other examples , while focusing not just on the state of the pandemic but also on states ’ readiness to contain Covid-19 outbreaks in the future .
Very few @ @ @ @ @ @ @ experts .
But even those that do shouldn ’ t consider the pandemic over .
They should continue to improve — for example , getting the positive rate below 1 percent , as in New Zealand — and look at even more granular metrics , such as at the city or county level .
Meeting the benchmarks , however , indicates a state is better equipped to contain future coronavirus outbreaks as it eases previous restrictions .
Experts emphasized that states have to keep hitting all these goals week after week and day @ @ @ @ @ @ @ low , testing ability needs to stay high , and hospital capacity should be good enough for an influx of patients — until the pandemic is truly over , whether thanks to a vaccine or other means .
Otherwise , a future wave of coronavirus cases , as seen in past pandemics , could kill many more people .
“ You need to have all the metrics met , ” Popescu said .
“ This needs to be a very incremental , slow process to ensure success.
” And if the numbers do @ @ @ @ @ @ @ states should be ready to shut down at least some parts of the economy again .
Maybe not as much as before , as we learn which places are truly at risk of increasing spread .
But experts caution that future shutdowns will likely be necessary to some extent .
“ I do worry we ’ re going to see surges of cases and hot spots , ” Watson said .
“ We do need to keep pushing on building those capacities .
… Otherwise , we ’ re just rolling the dice @ @ @ @ @ @ @ It ’ s better if we have more control of the spread.
” That ’ s another reason these metrics , along with broader coronavirus surveillance , are so important : They not only help show how far along states are in dealing with their current Covid-19 outbreaks , but will help track progress to stop and prevent future crises as well .
Every day at Vox , we aim to answer your most important questions and provide you , and our audience around the world , with information that has the power @ @ @ @ @ @ @ never been more vital than it is in this moment : to empower you through understanding .
Vox ’ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an economic downturn .
Your financial contribution will not constitute a donation , but it will enable our staff to continue to offer free articles , videos , and podcasts at the quality and volume that this moment requires .
Please consider making a contribution to Vox today .

All 50 states have moved to reopen their economies, at least partially, after shutting down businesses and gatherings in response to the coronavirus pandemic.
But a Vox analysis suggests that most states haven’t made the preparations needed to contain outbreaks — putting themselves at risk for a rise in Covid-19 cases and deaths should they continue to reopen. Some states have already had to backtrack on reopening measures.
Experts told me states need three things to be safe to open. State leaders, from the governor to the legislature to health departments, need to ensure the SARS-CoV-2 virus is no longer spreading unabated. They need the testing capacity to track and isolate the sick and their contacts. And they need the hospital capacity to handle a potential surge in Covid-19 cases.
More specifically, states should meet at least five basic criteria. They should see a two-week drop in coronavirus cases, indicating that the virus is actually abating. They should have fewer than four daily new cases per 100,000 people per day — to show that cases aren’t just dropping but are also below dangerous levels. They need at least 150 new tests per 100,000 people per day, letting them quickly track and contain outbreaks. They need an overall positive rate for tests below 5 percent — another critical indicator for testing capacity. And states should have at least 40 percent of their ICU beds free to actually treat an influx of people stricken with Covid-19 should it be necessary.
These metrics line up with a range of expert recommendations, as well as the various policy plans put out by both independent groups and government officials to deal with the coronavirus.
Meeting these metrics doesn’t mean that a state is ready to safely reopen its economy — a process that describes a wide range of local and state actions. And failing them doesn’t mean a state is in immediate danger of a coronavirus outbreak if it starts to reopen; with Covid-19, there’s always an element of luck and other factors.
But with these metrics, states can gauge if they have repressed the coronavirus while building the capacity to contain future outbreaks should they come. In other words, the benchmarks show how ready states are for the next phase of the fight.
So far, most states are not there. Just four states — Colorado, Connecticut, New Jersey, and New York — met four or five of the goals, which demonstrates strong progress. Twenty-five states and Washington, DC, hit two or three of the benchmarks. The remaining 19 achieved zero or one. (Alabama and Florida are excluded due to recent issues with test reporting.)
Even the states that have made the most progress aren’t safe to fully reopen. Without a vaccine or similar treatment, the threat of the coronavirus is still out there. Especially in states that suffered big outbreaks, such as Arizona and New York, even a lot of progress or some progress doesn’t mean all the underlying problems that led to an epidemic are gone.
Nor do the metrics cover everything that states should do before they can safely reopen. They don’t show, for example, if states have the capacity to do contact tracing, in which people who came into contact with someone who’s sick with Covid-19 are tracked down by “disease detectives” and quarantined. Contact tracing is key to containing an epidemic, but states don’t track how many contact tracers they’ve hired in a standardized, readily available way.
States also don’t have ready data for health care workers’ access to personal protective equipment, such as masks and gloves — a critical measure of the health care system’s readiness that’s difficult to track.
But the map gives an idea of how much progress states have made toward containing the coronavirus and keeping it contained.
States will have to follow these kinds of metrics as they reopen. If the numbers — especially coronavirus cases — go in the wrong direction again, experts said governments should be ready to bring back restrictions. If states move too quickly to reopen or respond too slowly to a turn for the worse, they could see a renewed surge in Covid-19 cases.
“Planning for reclosing is part of planning for reopening,” Mark McClellan, a health policy expert at Duke, told me. “There will be outbreaks, and there will be needs for pauses and going back — hopefully not too much if we do this carefully.”
So this will be a work in progress, at least until we get a Covid-19 vaccine or the pandemic otherwise ends, whether by natural or human means. But the metrics can at least help give states an idea of how far along they are in the fight against the coronavirus.
Goal 1: A sustained two-week drop in coronavirus cases
What’s the goal? A 10 percent drop in daily new coronavirus cases compared to two weeks ago and a 5 percent drop in cases compared to one week ago, based on data from the New York Times.
Which states meet the goal? Arizona, California, Colorado, Georgia, Mississippi, Nevada, Oregon, Texas, and Wyoming — a total of nine states.
Why is this important? Guidance from the White House and several independent groups emphasize that states need to see coronavirus cases drop consistently over two weeks before they can say they’re ready to begin reopening. After all, nothing shows you’re out of an outbreak like a sustained reduction in infections.
“The first and foremost [metric] is you want to have a continued decrease in cases,” Saskia Popescu, an infectious disease epidemiologist, told me. “It’s a huge piece.”
A simple reduction in cases compared to two weeks prior isn’t enough; it has to be a significant drop, and it has to be sustained over the two weeks. So for Vox’s map, states need at least a 10 percent drop in daily new cases compared to two weeks prior and at least a 5 percent drop compared to one week prior.
Reported cases can be a reflection of testing capacity: More testing will pick up more cases, and less testing will pick up fewer. So it’s important that the decrease occur while testing is either growing or already sufficient. And since states have recently boosted their testing abilities, increases in Covid-19 cases can also reflect improvements in testing.
Even after meeting this benchmark, continued caution is warranted. If a state meets the goal of a reduction in cases compared to one and two weeks ago but cases seemed to go up in recent days, then perhaps it’s not time to reopen just yet. And if cases have dropped but only from a very high baseline of cases, then that’s less comforting than a drop from a lower baseline.
“You have to use common sense,” Cyrus Shahpar, a director at the public health policy group Resolve to Save Lives, told me.
Goal 2: A low number of daily new Covid-19 cases
What’s the goal? Fewer than four daily new coronavirus cases per 100,000 people per day, based on data from the New York Times and the Census Bureau.
Which states meet the goal? Connecticut, Maine, New Hampshire, New Jersey, New York, and Vermont — just six states.
Why is this important? One of the best ways to know you’re getting away from a disease outbreak is to no longer see a high number of daily new infections. While there’s no universally accepted number, experts said that four daily new coronavirus cases per 100,000 people is a reasonable ceiling.
“If I go from one to two to three [coronavirus cases a day], it’s different than going from 1,000 to 2,000 to 3,000, even though the percent difference is the same,” Shahpar said. “That’s why you have to take into account the overall level, too.”
To put it another way, it’s not enough for daily new Covid-19 cases to drop, even for weeks. Cases also should fall below a certain level before a state can be deemed truly safe.
For example, Arizona has seen its daily new cases drop over the past two weeks. But its daily new cases are still, after controlling for population, the third-highest in the country. That indicates an epidemic that remains out of control.
At the same time, if your state is now below four daily new cases per 100,000 but it’s seen a recent uptick in cases, that’s a reason for caution. Even the worst-hit states, after all, began with a handful of cases before they saw an exponential surge.
But if your state is below the threshold, it’s in a pretty solid place relative to most states.
Goal 3: High coronavirus testing capacity
What’s the goal? At least 150 tests per 100,000 people per day, based on data from the Covid Tracking Project and the Census Bureau.
Which states meet the goal? Alaska, Arkansas, California, Colorado, Connecticut, Delaware, Georgia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Rhode Island, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, and West Virginia — 37 states. Washington, DC, did as well. (Alabama and Florida are excluded due to recent issues with test reporting.)
Why is this important? Since the beginning of the coronavirus pandemic, experts have argued that the US needs the capacity for at least 500,000 Covid-19 tests a day. Controlling for population, that adds up to about 150 new tests per 100,000 people per day.
Testing is crucial to getting the coronavirus outbreak under control. When paired with contact tracing, testing lets officials track the scale of the outbreak, isolate the sick, quarantine those the sick came into contact with, and deploy community-wide efforts as necessary. Testing and tracing are how other countries, like South Korea and Germany, have managed to control their outbreaks and started to reopen their economies.
The idea, experts said, is to have enough surveillance to detect embers before they turn into full wildfires.
“States should be shoring up their testing capacity not just for what it looks like right now while everyone’s in their homes, but as people start to move more,” Jen Kates, the director of global health and HIV policy at the Kaiser Family Foundation, told me. “As people start doing more movement, you’ll have to test more, because people are going to come into contact with each other more.”
The 500,000-a-day goal is the minimum. Some experts have recommended as many as millions of tests nationwide each day. But 500,000 is the most often-cited goal, and it’s, at the very least, a good start.
It’s preferable if states report this number by how many people they’ve tested, not just the total number of tests. For containing an outbreak, it’s generally more useful to test 500,000 people one time than to test one person 500,000 times. But some states report the figures for total tests, not the number of tested individuals — counting tests for a single person multiple times. That could skew the numbers.
This goal is also supposed to be for diagnostic tests, not antibody tests. Diagnostic tests gauge whether a person has the virus in their system and is, therefore, sick right at the moment of the test. Antibody tests check if someone ever developed antibodies to the virus to see if they had ever been sick in the past. Since diagnostic tests give a more recent gauge of the level of infection, they’re seen as much more reliable for evaluating the current state of the Covid-19 outbreak in a state.
But some states have mixed up numbers for diagnostic and antibody tests, which could skew the data collected by the Covid Tracking Project.
“The virus isn’t going to care whether they were manipulating the numbers or not in order to look more favorable; it’s going to continue to spread,” Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, told me. “It’s better to really understand what’s going on and report that accurately.”
For states honestly reporting these numbers, though, they’re a critical measure of their ability to detect, control, and contain coronavirus outbreaks.
Goal 4: A low test positive rate
What’s the goal? Below 5 percent of coronavirus tests coming back positive over the past week, based on data from the Covid Tracking Project.
Which states meet the goal? Alaska, California, Colorado, Connecticut, Delaware, Illinois, Louisiana, Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey, New Mexico, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Washington, West Virginia, and Wyoming — 23 states. Washington, DC, did as well. (Alabama and Florida are excluded due to recent issues with test reporting.)
Why is this important? The positive or positivity rate, which tracks how many tests come back positive for Covid-19, is another way to measure testing capacity.
Generally, a higher positive rate suggests there’s not enough testing happening. An area with adequate testing should be testing lots and lots of people, many of whom don’t have the disease or don’t show severe symptoms. The positive testing rate in South Korea, for example, is below 1 percent. High positive rates indicate only people with obvious symptoms are getting tested, so there’s not quite enough testing to match the scope of an outbreak.
Previously, the World Health Organization (WHO) recommended a maximum positive rate of 10 percent. But the WHO more recently recommended 5 percent, which is in line with the rate for countries that have managed to better control their outbreaks, like Germany, New Zealand, and South Korea. “Even lower is better,” Shahpar said.
The positive rate data is subject to the same limitations as the overall testing data from the Covid Tracking Project. So if a state includes antibody tests in its test count, it could skew the positive rate to look better than it is. States only risk hurting themselves if they do this.
Goal 5: Availability of ICU beds
What’s the goal? Below 60 percent occupancy of ICU beds in hospitals, based on data from the US Department of Health and Human Services.
Which states meet the goal? Alaska, Colorado, Connecticut, Idaho, Illinois, Iowa, Massachusetts, Nebraska, New Hampshire, New Jersey, New Mexico, New York, North Dakota, South Dakota, Utah, Wisconsin, and Wyoming — 17 states.
Why is this important? If a pandemic hits, the health care system needs to be ready to treat the most severe cases and potentially save lives. That’s the key goal of “flattening the curve” and “raising the line,” in which social distancing helps reduce the spread of the disease so the health care system can maintain and grow its capacity to treat an influx of Covid-19 patients.
“There’s this idea that in six weeks we can open more things,” Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security, told me. “But the virus is still there. It’s all about making sure that the case count isn’t too immense for our hospital system to deal with.”
The aim is to avoid the nightmare scenario that Italy went through when it had more Covid-19 cases than its health care system could handle, leading to hospitals turning away even dangerously ill patients.
To gauge this, experts recommended looking at ICU capacity, with states aiming to have at most 60 percent occupancy in their ICUs.
Hitting the benchmarks is the beginning, not the end
Vox’s map is just one way of tracking success against the coronavirus. Other groups have come up with their own measures, including Covid Act Now, Covid Exit Strategy, and Test and Trace. Vox’s model uses more up-to-date data than some of these other examples, while focusing not just on the state of the pandemic but also on states’ readiness to contain Covid-19 outbreaks in the future.
Very few states hit all the marks recommended by experts. But even those that do shouldn’t consider the pandemic over. They should continue to improve — for example, getting the positive rate below 1 percent, as in New Zealand — and look at even more granular metrics, such as at the city or county level.
Meeting the benchmarks, however, indicates a state is better equipped to contain future coronavirus outbreaks as it eases previous restrictions.
Experts emphasized that states have to keep hitting all these goals week after week and day after day — Covid-19 cases must remain low, testing ability needs to stay high, and hospital capacity should be good enough for an influx of patients — until the pandemic is truly over, whether thanks to a vaccine or other means. Otherwise, a future wave of coronavirus cases, as seen in past pandemics, could kill many more people.
“You need to have all the metrics met,” Popescu said. “This needs to be a very incremental, slow process to ensure success.”
And if the numbers do start trending in the wrong direction, states should be ready to shut down at least some parts of the economy again. Maybe not as much as before, as we learn which places are truly at risk of increasing spread. But experts caution that future shutdowns will likely be necessary to some extent.
“I do worry we’re going to see surges of cases and hot spots,” Watson said. “We do need to keep pushing on building those capacities. … Otherwise, we’re just rolling the dice on the spread of the virus. It’s better if we have more control of the spread.”
That’s another reason these metrics, along with broader coronavirus surveillance, are so important: They not only help show how far along states are in dealing with their current Covid-19 outbreaks, but will help track progress to stop and prevent future crises as well.
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vox--2020-07-16--Hospitals are running out of staff, supplies, and beds for Covid-19 patients — and this time could b

Hospitals are running out of staff , supplies , and beds for Covid-19 patients — and this time could be worse Share All sharing options for : Hospitals are running out of staff , supplies , and beds for Covid-19 patients — and this time could be worse With Covid-19 hospitalizations steadily approaching a record high in the US , states like Arizona have activated emergency plans and requested refrigerated trucks to prepare for overflow at morgues .
Doctors there say packed emergency rooms and ICUs are forcing them to prioritize the sickest patients , leaving other ill patients to @ @ @ @ @ @ @ d ordinarily receive right away .
Hospitals in hot spots across the country are expanding and even maxing out their staff , equipment , and beds , with doctors warning that the worst-case scenario of hospital resources being overwhelmed is on the horizon if their states don ’ t get better control of the coronavirus .
“ With Covid , a lot of times people who aren ’ t sick enough yet get pushed to the back , and then they can become really , really sick unfortunately because we were focusing our @ @ @ @ @ @ @ the brink of death , ” an emergency room doctor at the Banner Health system in the Phoenix metro area , who asked to go unnamed fearing retaliation from his employer , told Vox .
Other doctors in Arizona , where 90 percent of hospital beds statewide were in use Tuesday , say the scarcity of resources means they ’ ll soon be rationing medical care , as doctors in Italy were forced to do .
“ The fear is we are going to have to start sharing ventilators , or we ’ @ @ @ @ @ @ @ , ‘ You get a vent , you don ’ t. ’ I ’ d be really surprised if in a couple weeks we didn ’ t have to do that , ” says Murtaza Akhter , an emergency medicine physician at Valleywise Health Medical Center in Phoenix .
It ’ s not just Arizona .
Doctors and hospital experts in Texas and Southern California say capacity is a major concern for them as well , particularly if new daily cases keep rising .
Several counties in California are facing major outbreaks of @ @ @ @ @ @ @ thin to care for the sickest patients .
States have started to roll back their reopenings in recognition of the intensity of current transmission .
California Gov .
Gavin Newsom announced Monday he would order some businesses to close again .
Texas Gov .
Greg Abbott has finally issued a statewide mask mandate and closed certain establishments .
Arizona Gov .
Doug Ducey also reimposed some restrictions , though has refused to require residents to wear masks in public spaces , instead asking for voluntary compliance with public health experts ’ advice .
@ @ @ @ @ @ @ enough ?
“ If things continue to get worse , ” John Swartzberg , a clinical professor emeritus at UC Berkeley ’ s School of Public Health , says , medical care for Covid-19 patients “ will get much more draconian.
” When New York and New Jersey raced to expand hospital capacity in April to handle the crush of Covid-19 patients , Sunbelt states largely avoided the big spring wave .
But after their governors moved forward with reopening in May even though they didn ’ t meet the public health criteria @ @ @ @ @ @ @ safe , three states in particular — Arizona , Texas , and Florida — saw significant increases in new cases .
Experts say these outbreaks are largely driven by people flocking to newly reopened restaurants , bars , gyms , and other high-risk indoor spaces , as well as weakly enforced or nonexistent face mask mandates .
Now , with new cases and hospitalizations rising in 44 US states and territories , many fear some hot spots may be faced with even bigger surges , with less ability to expand capacity than hospital-dense @ @ @ @ @ @ @ now quickly on their way to exceeding the peak of 59,539 on April 15 , hitting 56,147 on Wednesday , according to the Covid Tracking Project .
Hospital organizations in Florida say facilities there can still expand capacity if needed .
But they , like other hot spot hospitals , are starting to cut back on elective surgeries and procedures — leading them to furlough staff in some cases to compensate for massive losses in revenue — to accommodate the rising tide of Covid-19 patients .
And most worrying for the states now @ @ @ @ @ @ @ in April , when most of the country was in lockdown , there ’ s no clear sense of when the current outbreaks will peak or decline .
With only partial social distancing measures in place and inconsistent mask use , the virus may continue to spread , leading to an unabated wave of severe illness requiring hospitalization , more deaths , and more long-term complications requiring medical care .
Here ’ s a closer look at how some hospitals in Arizona , Florida , Texas , and Southern California are handling the @ @ @ @ @ @ @ patients , and why it may get worse in the coming weeks .
Arizona doctors say the surge is forcing them to make brutal decisions in patient care .
Meanwhile , morale is dangerously low .
As Vox ’ s German Lopez has reported , Arizona ’ s Covid-19 outbreak has lately been the worst in the country , with the highest test positivity rate of all the states : 24.7 percent of tests coming back positive ( nearly five times the recommended maximum of 5 percent ) , compared with 18.7 percent @ @ @ @ @ @ @ , according to Johns Hopkins .
It also , until very recently , had the highest number of daily cases per 100,000 people .
( As of Wednesday , Florida was in the lead , with 54 new cases per day per 100,000 people , compared with Arizona ’ s 48 , according to data compiled by the Washington Post . )
Whichever metric you ’ re looking at , the implication is the same : The virus continues to spread rapidly in the state , despite the governor ’ s ( relatively @ @ @ @ @ @ @ and ensure widespread face mask use since reopening .
Meanwhile , hospitalizations are rising steeply following the upward trend in new cases .
The heat wave underway , which is forcing more people indoors , isn ’ t helping , either .
The unchecked transmission of the virus in the state and resulting pressure on hospitals are particularly infuriating to some emergency room and ICU staff , who say they are losing hope that they will get any relief from the surge of severely ill Covid-19 patients anytime soon .
And they ’ @ @ @ @ @ @ @ fly that they ’ re uncomfortable making .
“ Sending people with Covid home with oxygen tanks because we don ’ t have the resources for them ?
This is something I ’ ve never done in my life before , ” says Akhter of Valleywise Health .
“ This is crazy .
And this is gon na be even worse in a couple of weeks .
So far we ’ re trying to hold steady , but how long will that last ?
” The psychological toll , he says , is @ @ @ @ @ @ @ a shift and be like , ‘ I ’ m losing hope ’ — that ’ s a dangerous place to be in , ” he says .
“ I don ’ t want to feel that way .
And that ’ s because despite the horrible numbers , despite the fact I ’ m still getting the Covid cases [ in the ER ] , despite what we ’ ve been saying to the media from the front line , I drive home from work and I literally see lots of people @ @ @ @ @ @ @ store not wearing masks.
” Another ICU doctor in Phoenix , who spoke on the condition of anonymity because his employer has forbidden staff to speak to the media , described increasingly low morale among health care workers in the state .
“ I think a lot of us feel as if our community has abandoned us almost , because there ’ s a lot of fake news about how masks are not helping the spread , ” he says .
“ I think there ’ s just a sense of abandonment almost @ @ @ @ @ @ @ t have the support of our community ; this individual selfishness that we ’ re seeing in society is really upsetting .
And I think psychologically it ’ s really affecting a lot of my nurses and staff.
” Some of them , he says , are so frustrated and worried about getting sick themselves that they ’ re not coming to work as much , calling in sick , or just cutting their hours .
Akhter thinks there are a lot of people in Arizona who still don ’ t believe Covid-19 @ @ @ @ @ @ @ gets sick , even with non-Covid , with appendicitis , for example , what do they think is going to happen if there are no hospital beds ?
I don ’ t know what else to say other than , like , ‘ What if your loved one gets sick , where do you think she ’ s gon na go ?
’ ” Some of his colleagues in emergency and critical care medicine say they are already running out of ICU beds .
“ We have patients who are admitted to the @ @ @ @ @ @ @ a physical ICU bed for them , ” says the ER doctor at Banner Health who asked not to be named .
“ So they physically stay in the ER .
And they have been staying in the ER for over 24 hours because there is nowhere else for these patients to go .
And then we ’ re using ventilators that have previously been retired , that are more likely to cause lung injury on patients , because , again , there ’ s no other option , no other way.
” @ @ @ @ @ @ @ tight that Tucson Mayor Regina Romero recently told CNN that Pima County might have to send patients to other states for care .
“ Any day , we ’ re going to have to be sending patients to other states because of our lack of capacity , ” she says .
Banner Health system , the largest hospital network in the state , says it has been able to expand capacity so far to keep up with the heightened demand from Covid-19 patients , moving them and resources between hospitals to keep volumes @ @ @ @ @ @ @ , it has also brought in about 400 travel nurses and respiratory therapists from out of state , spokesperson Becky Armendariz told Vox over email .
But she didn ’ t rule out the possibility of exceeding capacity .
“ It is certainly possible for us to reach max capacity if the trend in cases continues.
” The only way to avoid that at this point , the doctors say , is for more people to start wearing face masks and for officials to enforce mandates at the city level .
“ If @ @ @ @ @ @ @ are in big , big trouble , ” says the ICU doctor .
“ That ’ s the ground reality of the situation.
” Florida hospitals are walking a path “ with a precipice on either side ” In terms of sheer numbers of new cases , Florida — the third most populous state in the country — has consistently been in the lead this summer , with a record high of 15,300 new daily cases on Saturday .
( On Tuesday , the number of new daily cases fell to 10,101 .
@ @ @ @ @ @ @ due to the virus , with an average of 81 deaths per day in recent weeks .
According to Justin Senior — CEO of the Safety Net Hospital Alliance of Florida , which advocates on behalf of 14 hospitals in the state that provide care regardless of patients ’ ability to pay — the state ’ s hospital capacity has not been reached yet and there will still be many hospital and ICU beds available if hospitalizations continue to rise rapidly .
Even so , Senior says hospitals are in a precarious place @ @ @ @ @ @ @ side ” as they try to juggle the needs of non-Covid-19 patients with the rising number of Covid-19 patients .
If they postpone elective procedures , like certain surgeries , they lose revenue at a time when they ’ re still reeling from losing , by his estimate , $ 5 billion to $ 6 billion overall from March to May when the state shut down .
If they don ’ t postpone those procedures , it ’ s harder to care for patients in a Covid-19 surge , he says .
“ @ @ @ @ @ @ @ are trying to walk , because you don ’ t want another shutdown completely when there aren ’ t enough patients to avoid layoffs and avoid a really bad financial situation on one side , and of course , overcapacity and overtaxing of resources with too many Covid patients on the other side , ” he says .
In Florida , Senior says , staff is the biggest concern for hospitals at the moment — in particular making sure that they don ’ t burn out and have enough PPE to stay protected @ @ @ @ @ @ @ a really stressful situation , and there ’ s a real recognition of that.
” According to CBS Local in Miami , Florida Gov .
Ron DeSantis has requested that the Federal Emergency Management Agency ( FEMA ) send 1,500 nurses to the state to relieve the pressure on overworked hospital staff .
“ As of Monday morning , FEMA had not approved the request , ” CBS reports .
“ DeSantis , meanwhile , said he is sending 100 nurses under contract with the state to Miami-Dade County.
” Some hospitals , @ @ @ @ @ @ @ dialing back on some elective procedures to lessen the strain on staff and other resources .
“ The next step would be to declare surge capacity — this actually creates additional capacity by allowing a hospital to temporarily deal with an emergency by doubling up patient rooms and relaxing staffing ratios to exceed the hospital ’ s normal bed count , ” he says .
“ You can ’ t keep that up for long .
A final step would be to bring in field hospitals and significant outside resources.
” On Monday @ @ @ @ @ @ @ worried about hospitalizations exceeding 500 per day .
“ If daily hospitalizations shoot up over 500 a day , there will be serious stress ahead , ” he says .
“ 800 or 1,000 and it will be a wild ride.
” Unfortunately , the state is heading in that direction .
On Tuesday , Florida hit 533 hospitalizations : “ If it grows exponentially from here , there ’ s no denying , you know , we ’ re gon na have to relook at everything at the beginning of August , @ @ @ @ @ @ @ they are running out of staff , PPE , drugs , and other supplies Texas hospitals thought they had already seen the worst of Covid-19 in the spring .
This latest surge has surpassed that first surge several times over .
During the first wave , from late February to early May , Houston Methodist Hospital peaked with about 250 coronavirus patients .
Today , they have nearly 700 .
“ There are too many Covid patients , full stop , ” Roberta Schwartz , executive vice president at Houston Methodist , told @ @ @ @ @ @ @ , we ’ re running full-plus now.
” Their experience mirrors the statewide trends : Hospitalizations in Texas had topped out at about 1,800 in early May , but now , after cases began to accelerate dramatically , they ’ ve surpassed 10,000 .
“ Every day , or every other day , we ’ re turning another unit of this hospital into Covid units , ” Schwartz says .
“ It ’ s slowly starving out the other services that we offer.
” She ticked through the list : Half a dozen @ @ @ @ @ @ @ are now being used to house Covid-19 .
An orthopedics unit has been shut down and flipped for patients who require high-oxygen flow .
Cardiology units have also shortened their surgery schedules so that their space can be used for the coronavirus surge .
Schwartz and John Henderson , president and CEO of the Texas Organization of Rural and Community Hospitals , say their hospitals are in better shape now with personal protective equipment than they were in March and April .
But that could change as the crisis gets worse .
Schwartz @ @ @ @ @ @ @ getting gowns and disinfectant wipes .
Henderson says he “ got a couple of SOS calls this week.
” Staffing is a universal problem .
Houston Methodist has already brought in out-of-state nurses and asked its administrative staff with nursing certifications to start doing medical work again .
Nurses are also being asked to work longer and overnight shifts .
Rural hospitals in Texas aren ’ t running out of beds yet , but they are running into a staffing shortage .
These facilities might typically have five patients in a given unit @ @ @ @ @ @ @ accordingly .
But now , there might be as many as 20 patients .
“ You ’ re working every nurse as much as you can work them and still not meeting the need , ” Henderson says .
It ’ s not clear where more staff could come from .
The state has already sent about 2,300 volunteers to the Rio Grande Valley , one of the hardest-hit areas in the state .
“ Other areas are requesting that workforce support , ” Henderson says .
“ But there ’ s not @ @ @ @ @ @ @ be sent.
” Another concern is ventilators .
Rural hospitals in Texas would ordinarily transfer their patients in serious condition , the kind who might be on a ventilator for days , to a larger hospital in the city .
But because urban hospitals are already overrun with Covid-19 patients themselves , there is nowhere for the rural hospitals to send their patients .
Instead , they are forced to keep those patients , causing their beds to fill up even more quickly .
And while the current coronavirus patients are younger than @ @ @ @ @ @ @ says his hospitals don ’ t have enough of the nasal oxygen hookups that are used to help those patients breathe on their own and prevent them from being put on a ventilator .
“ They ’ ve shown to be effective but everybody ’ s trying to get them , ” he says .
Hospitals are putting lessons from the early weeks of the crisis to use .
Remdesivir , an antiviral treatment prescribed to Covid-19 patients with low blood oxygen or who need breathing assistance from a mechanical ventilator , is @ @ @ @ @ @ @ in San Antonio , which got firsthand experience in the initial wave when it was asked to treat some of the first patients from Wuhan and the Diamond Princess cruise ship , has adapted its standard of care to include remdesivir , anti-inflammatory drugs , and putting patients on their stomachs to help them breathe .
They have also reduced their use of ventilators , only using them when absolutely necessary .
But those improvements in treatment require adequate staffing and supplies to implement them .
And as the crisis grows , supples @ @ @ @ @ @ @ We still don ’ t have a steady stream of enough remdesivir , ” Schwartz at Houston Methodist says .
That is the situation on the ground as of early July .
Cases are continuing to climb in Texas , and more people are expected to end up in the hospital as a result .
The emergency plan to set up temporary facilities in convention centers or sports venues is suddenly on the table .
Hospitals like Memorial Hermann in Houston have already activated their surge capacity plans , but that might not @ @ @ @ @ @ @ “ We remain concerned about the current growth rate in new cases and the demand for hospitalization , as we could reach the limit of our surge expansion plans if the current trends do not reverse , ” Drew Munhausen , a spokesperson for the hospital , says in an email .
The hope is that new cases will start to level off soon , now that Gov .
Abbott has reimposed some social distancing restrictions and established a statewide mask mandate .
But for now , Texas hospitals are just waiting and @ @ @ @ @ @ @ ’ re counting hospital admissions and ICU patients on vents , you ’ re weeks behind .
We ’ re chasing it right now , ” Henderson says .
“ There ’ s no optimism today for what the rest of July looks like.
” The worst-case scenario , in these moments , is that people will die who otherwise wouldn ’ t have because the shortage of beds or supplies or staff will lead to suboptimal care .
Even fear itself can be devastating to public health .
As ProPublica and NBC @ @ @ @ @ @ @ dying at home has spiked in recent weeks , suggesting people who either had Covid-19 or another life-threatening condition didn ’ t make it to the hospital in time .
“ When you are unable to take care of patients in the optimal circumstances , you do worry that you are not able to do as good of a job in not-optimal circumstances , ” Schwartz says .
“ And we are about to get into not-optimal circumstances.
” It could be a difficult few weeks ahead .
Youyang Gu ’ s Covid-19 @ @ @ @ @ @ @ peak at the beginning of August and deaths to peak in mid-August .
El Centro Regional Medical Center in Imperial County , one of California ’ s biggest Covid-19 hot spots right now , has already brushed up against its worst-case scenario .
About 60 percent of the patients in the medical center were infected with the coronavirus as of last week , and there aren ’ t enough ventilators , Adolphe Edward , the hospital ’ s CEO , told Vox .
The medical center serves a largely Hispanic community , with @ @ @ @ @ @ @ preexisting conditions that make them more vulnerable to the virus and who require mechanical ventilator support for their breathing when the disease takes a turn for the worse .
The hospital recently saw its available ventilators dwindle to one .
Edward convened an impromptu committee to evaluate the patients currently on ventilators so they could prioritize if another patient who needed one came through their door .
They checked their lung capacity and considered whether they could risk taking one or two of the patients off the ventilator if the need arose .
@ @ @ @ @ @ @ .
He called another nearby hospital and asked if they had any ventilators available .
They had two , which they shipped over to El Centro .
For now , the machines are still there , though Edward says he and the other hospital have stayed in constant contact in case the ventilators need to be transferred again .
Edward sounds exasperated describing that makeshift solution and he wonders why the federal government hasn ’ t started manufacturing “ half a million or a million ” ventilators to meet the need that hospitals @ @ @ @ @ @ @ s got ta figure that out , ” he says .
( The Trump administration signed contracts in April under the Defense Production Act that are supposed to yield a little fewer than 150,000 ventilators by the end of 2020 . )
Statewide , only about 30 percent of all available units are currently in use , according to NPR .
But there have been surges of patients in some regions like Imperial County that have nearly overwhelmed local hospitals .
About 30 percent of ICU beds are still open statewide as well @ @ @ @ @ @ @ as the state outbreak shifts from the younger cohort less prone to serious complications to older people who are more likely to require hospitalization and ventilation .
A California plan to stockpile ventilators never materialized , and the available capacity could be stretched with the hardest-hit areas exporting their patients to facilities in other parts of the state .
El Centro Regional Medical Center is moving patients out of its building at a rate Edward would ordinarily have found unfathomable .
During normal times , the hospital might send out one or two @ @ @ @ @ @ @ Nowadays , they ’ re averaging between six and eight .
“ If you had told me at the beginning we ’ d be transferring that many patients , I would have told you : I don ’ t know what you ’ re drinking , ” Edward says .
For the time being , hospitals elsewhere in the state have the extra space to accommodate them .
But the worry is if the outbreak keeps spreading , that excess capacity will evaporate very quickly .
New Covid-19 cases and deaths in California @ @ @ @ @ @ @ or early September , according to Youyang Gu ’ s Covid-19 Projections , meaning the new surge has not peaked yet .
More hospitals could be faced with the kind of difficult decisions that Edward and his team were nearly forced to make .
Every day at Vox , we aim to answer your most important questions and provide you , and our audience around the world , with information that has the power to save lives .
Our mission has never been more vital than it is in this moment : to @ @ @ @ @ @ @ s work is reaching more people than ever , but our distinctive brand of explanatory journalism takes resources — particularly during a pandemic and an economic downturn .
Your financial contribution will not constitute a donation , but it will enable our staff to continue to offer free articles , videos , and podcasts at the quality and volume that this moment requires .
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Hospitals are running out of staff, supplies, and beds for Covid-19 patients — and this time could be worse
Share All sharing options for: Hospitals are running out of staff, supplies, and beds for Covid-19 patients — and this time could be worse
With Covid-19 hospitalizations steadily approaching a record high in the US, states like Arizona have activated emergency plans and requested refrigerated trucks to prepare for overflow at morgues. Doctors there say packed emergency rooms and ICUs are forcing them to prioritize the sickest patients, leaving other ill patients to deteriorate while waiting for care they’d ordinarily receive right away.
Hospitals in hot spots across the country are expanding and even maxing out their staff, equipment, and beds, with doctors warning that the worst-case scenario of hospital resources being overwhelmed is on the horizon if their states don’t get better control of the coronavirus.
“With Covid, a lot of times people who aren’t sick enough yet get pushed to the back, and then they can become really, really sick unfortunately because we were focusing our efforts on the people who are on the brink of death,” an emergency room doctor at the Banner Health system in the Phoenix metro area, who asked to go unnamed fearing retaliation from his employer, told Vox.
Other doctors in Arizona, where 90 percent of hospital beds statewide were in use Tuesday, say the scarcity of resources means they’ll soon be rationing medical care, as doctors in Italy were forced to do.
“The fear is we are going to have to start sharing ventilators, or we’re gonna have to start saying, ‘You get a vent, you don’t.’ I’d be really surprised if in a couple weeks we didn’t have to do that,” says Murtaza Akhter, an emergency medicine physician at Valleywise Health Medical Center in Phoenix.
It’s not just Arizona. Doctors and hospital experts in Texas and Southern California say capacity is a major concern for them as well, particularly if new daily cases keep rising. Several counties in California are facing major outbreaks of the virus, with hospital resources stretched thin to care for the sickest patients.
States have started to roll back their reopenings in recognition of the intensity of current transmission. California Gov. Gavin Newsom announced Monday he would order some businesses to close again. Texas Gov. Greg Abbott has finally issued a statewide mask mandate and closed certain establishments. Arizona Gov. Doug Ducey also reimposed some restrictions, though has refused to require residents to wear masks in public spaces, instead asking for voluntary compliance with public health experts’ advice.
The question is, will it be enough?
“If things continue to get worse,” John Swartzberg, a clinical professor emeritus at UC Berkeley’s School of Public Health, says, medical care for Covid-19 patients “will get much more draconian.”
When New York and New Jersey raced to expand hospital capacity in April to handle the crush of Covid-19 patients, Sunbelt states largely avoided the big spring wave. But after their governors moved forward with reopening in May even though they didn’t meet the public health criteria set by the federal government to stay safe, three states in particular — Arizona, Texas, and Florida — saw significant increases in new cases.
Experts say these outbreaks are largely driven by people flocking to newly reopened restaurants, bars, gyms, and other high-risk indoor spaces, as well as weakly enforced or nonexistent face mask mandates. Now, with new cases and hospitalizations rising in 44 US states and territories, many fear some hot spots may be faced with even bigger surges, with less ability to expand capacity than hospital-dense New York City.
Hospitalizations nationwide are now quickly on their way to exceeding the peak of 59,539 on April 15, hitting 56,147 on Wednesday, according to the Covid Tracking Project.
Hospital organizations in Florida say facilities there can still expand capacity if needed. But they, like other hot spot hospitals, are starting to cut back on elective surgeries and procedures — leading them to furlough staff in some cases to compensate for massive losses in revenue — to accommodate the rising tide of Covid-19 patients.
And most worrying for the states now battling major outbreaks is that, unlike in April, when most of the country was in lockdown, there’s no clear sense of when the current outbreaks will peak or decline. With only partial social distancing measures in place and inconsistent mask use, the virus may continue to spread, leading to an unabated wave of severe illness requiring hospitalization, more deaths, and more long-term complications requiring medical care.
Here’s a closer look at how some hospitals in Arizona, Florida, Texas, and Southern California are handling the pressures of the latest surge of Covid-19 patients, and why it may get worse in the coming weeks.
Arizona doctors say the surge is forcing them to make brutal decisions in patient care. Meanwhile, morale is dangerously low.
As Vox’s German Lopez has reported, Arizona’s Covid-19 outbreak has lately been the worst in the country, with the highest test positivity rate of all the states: 24.7 percent of tests coming back positive (nearly five times the recommended maximum of 5 percent), compared with 18.7 percent in Florida and 17 percent in Texas, according to Johns Hopkins.
It also, until very recently, had the highest number of daily cases per 100,000 people. (As of Wednesday, Florida was in the lead, with 54 new cases per day per 100,000 people, compared with Arizona’s 48, according to data compiled by the Washington Post.)
Whichever metric you’re looking at, the implication is the same: The virus continues to spread rapidly in the state, despite the governor’s (relatively weak) efforts to discourage indoor gatherings and ensure widespread face mask use since reopening. Meanwhile, hospitalizations are rising steeply following the upward trend in new cases. The heat wave underway, which is forcing more people indoors, isn’t helping, either.
The unchecked transmission of the virus in the state and resulting pressure on hospitals are particularly infuriating to some emergency room and ICU staff, who say they are losing hope that they will get any relief from the surge of severely ill Covid-19 patients anytime soon. And they’re having to make decisions on the fly that they’re uncomfortable making.
“Sending people with Covid home with oxygen tanks because we don’t have the resources for them? This is something I’ve never done in my life before,” says Akhter of Valleywise Health. “This is crazy. And this is gonna be even worse in a couple of weeks. So far we’re trying to hold steady, but how long will that last?”
The psychological toll, he says, is serious too.
“To come off a shift and be like, ‘I’m losing hope’ — that’s a dangerous place to be in,” he says. “I don’t want to feel that way. And that’s because despite the horrible numbers, despite the fact I’m still getting the Covid cases [in the ER], despite what we’ve been saying to the media from the front line, I drive home from work and I literally see lots of people congregating together closely and in the grocery store not wearing masks.”
Another ICU doctor in Phoenix, who spoke on the condition of anonymity because his employer has forbidden staff to speak to the media, described increasingly low morale among health care workers in the state.
“I think a lot of us feel as if our community has abandoned us almost, because there’s a lot of fake news about how masks are not helping the spread,” he says. “I think there’s just a sense of abandonment almost where we feel like we don’t have the support of our community; this individual selfishness that we’re seeing in society is really upsetting. And I think psychologically it’s really affecting a lot of my nurses and staff.” Some of them, he says, are so frustrated and worried about getting sick themselves that they’re not coming to work as much, calling in sick, or just cutting their hours.
Akhter thinks there are a lot of people in Arizona who still don’t believe Covid-19 is bad. “If their mother gets sick, even with non-Covid, with appendicitis, for example, what do they think is going to happen if there are no hospital beds? I don’t know what else to say other than, like, ‘What if your loved one gets sick, where do you think she’s gonna go?’”
Some of his colleagues in emergency and critical care medicine say they are already running out of ICU beds. “We have patients who are admitted to the ICU, but there isn’t a physical ICU bed for them,” says the ER doctor at Banner Health who asked not to be named. “So they physically stay in the ER. And they have been staying in the ER for over 24 hours because there is nowhere else for these patients to go. And then we’re using ventilators that have previously been retired, that are more likely to cause lung injury on patients, because, again, there’s no other option, no other way.”
The crunch on beds is getting so tight that Tucson Mayor Regina Romero recently told CNN that Pima County might have to send patients to other states for care. “Any day, we’re going to have to be sending patients to other states because of our lack of capacity,” she says.
Banner Health system, the largest hospital network in the state, says it has been able to expand capacity so far to keep up with the heightened demand from Covid-19 patients, moving them and resources between hospitals to keep volumes balanced and manageable. In recent weeks, it has also brought in about 400 travel nurses and respiratory therapists from out of state, spokesperson Becky Armendariz told Vox over email. But she didn’t rule out the possibility of exceeding capacity. “It is certainly possible for us to reach max capacity if the trend in cases continues.”
The only way to avoid that at this point, the doctors say, is for more people to start wearing face masks and for officials to enforce mandates at the city level.
“If Arizona does not mask up, we are in big, big trouble,” says the ICU doctor. “That’s the ground reality of the situation.”
Florida hospitals are walking a path “with a precipice on either side”
In terms of sheer numbers of new cases, Florida — the third most populous state in the country — has consistently been in the lead this summer, with a record high of 15,300 new daily cases on Saturday. (On Tuesday, the number of new daily cases fell to 10,101.) More than 4,400 Floridians have died due to the virus, with an average of 81 deaths per day in recent weeks.
According to Justin Senior — CEO of the Safety Net Hospital Alliance of Florida, which advocates on behalf of 14 hospitals in the state that provide care regardless of patients’ ability to pay — the state’s hospital capacity has not been reached yet and there will still be many hospital and ICU beds available if hospitalizations continue to rise rapidly.
Even so, Senior says hospitals are in a precarious place, “with a precipice on either side” as they try to juggle the needs of non-Covid-19 patients with the rising number of Covid-19 patients. If they postpone elective procedures, like certain surgeries, they lose revenue at a time when they’re still reeling from losing, by his estimate, $5 billion to $6 billion overall from March to May when the state shut down. If they don’t postpone those procedures, it’s harder to care for patients in a Covid-19 surge, he says.
“This is the path that the hospitals are trying to walk, because you don’t want another shutdown completely when there aren’t enough patients to avoid layoffs and avoid a really bad financial situation on one side, and of course, overcapacity and overtaxing of resources with too many Covid patients on the other side,” he says.
In Florida, Senior says, staff is the biggest concern for hospitals at the moment — in particular making sure that they don’t burn out and have enough PPE to stay protected from the coronavirus. “This is a really stressful situation, and there’s a real recognition of that.”
According to CBS Local in Miami, Florida Gov. Ron DeSantis has requested that the Federal Emergency Management Agency (FEMA) send 1,500 nurses to the state to relieve the pressure on overworked hospital staff. “As of Monday morning, FEMA had not approved the request,” CBS reports. “DeSantis, meanwhile, said he is sending 100 nurses under contract with the state to Miami-Dade County.”
Some hospitals, particularly in Miami-Dade County, are already dialing back on some elective procedures to lessen the strain on staff and other resources. “The next step would be to declare surge capacity — this actually creates additional capacity by allowing a hospital to temporarily deal with an emergency by doubling up patient rooms and relaxing staffing ratios to exceed the hospital’s normal bed count,” he says. “You can’t keep that up for long. A final step would be to bring in field hospitals and significant outside resources.”
On Monday, Senior warned Vox that he was worried about hospitalizations exceeding 500 per day. “If daily hospitalizations shoot up over 500 a day, there will be serious stress ahead,” he says. “800 or 1,000 and it will be a wild ride.”
Unfortunately, the state is heading in that direction. On Tuesday, Florida hit 533 hospitalizations:
“If it grows exponentially from here, there’s no denying, you know, we’re gonna have to relook at everything at the beginning of August,” Senior notes.
Texas hospitals warn they are running out of staff, PPE, drugs, and other supplies
Texas hospitals thought they had already seen the worst of Covid-19 in the spring. This latest surge has surpassed that first surge several times over.
During the first wave, from late February to early May, Houston Methodist Hospital peaked with about 250 coronavirus patients. Today, they have nearly 700. “There are too many Covid patients, full stop,” Roberta Schwartz, executive vice president at Houston Methodist, told me. “We ran full before, we’re running full-plus now.”
Their experience mirrors the statewide trends: Hospitalizations in Texas had topped out at about 1,800 in early May, but now, after cases began to accelerate dramatically, they’ve surpassed 10,000.
“Every day, or every other day, we’re turning another unit of this hospital into Covid units,” Schwartz says. “It’s slowly starving out the other services that we offer.”
She ticked through the list: Half a dozen of the hospitals’ medical surgical units are now being used to house Covid-19. An orthopedics unit has been shut down and flipped for patients who require high-oxygen flow. Cardiology units have also shortened their surgery schedules so that their space can be used for the coronavirus surge.
Schwartz and John Henderson, president and CEO of the Texas Organization of Rural and Community Hospitals, say their hospitals are in better shape now with personal protective equipment than they were in March and April.
But that could change as the crisis gets worse. Schwartz says her facilities have sometimes had trouble getting gowns and disinfectant wipes. Henderson says he “got a couple of SOS calls this week.”
Staffing is a universal problem. Houston Methodist has already brought in out-of-state nurses and asked its administrative staff with nursing certifications to start doing medical work again. Nurses are also being asked to work longer and overnight shifts.
Rural hospitals in Texas aren’t running out of beds yet, but they are running into a staffing shortage. These facilities might typically have five patients in a given unit, and the hospitals have staffed them accordingly. But now, there might be as many as 20 patients.
“You’re working every nurse as much as you can work them and still not meeting the need,” Henderson says.
It’s not clear where more staff could come from. The state has already sent about 2,300 volunteers to the Rio Grande Valley, one of the hardest-hit areas in the state.
“Other areas are requesting that workforce support,” Henderson says. “But there’s not much more in terms of resources to be sent.”
Another concern is ventilators. Rural hospitals in Texas would ordinarily transfer their patients in serious condition, the kind who might be on a ventilator for days, to a larger hospital in the city. But because urban hospitals are already overrun with Covid-19 patients themselves, there is nowhere for the rural hospitals to send their patients. Instead, they are forced to keep those patients, causing their beds to fill up even more quickly.
And while the current coronavirus patients are younger than those seen in the spring, Henderson says his hospitals don’t have enough of the nasal oxygen hookups that are used to help those patients breathe on their own and prevent them from being put on a ventilator.
“They’ve shown to be effective but everybody’s trying to get them,” he says.
Hospitals are putting lessons from the early weeks of the crisis to use. Remdesivir, an antiviral treatment prescribed to Covid-19 patients with low blood oxygen or who need breathing assistance from a mechanical ventilator, is protocol now. The University Health System in San Antonio, which got firsthand experience in the initial wave when it was asked to treat some of the first patients from Wuhan and the Diamond Princess cruise ship, has adapted its standard of care to include remdesivir, anti-inflammatory drugs, and putting patients on their stomachs to help them breathe. They have also reduced their use of ventilators, only using them when absolutely necessary.
But those improvements in treatment require adequate staffing and supplies to implement them. And as the crisis grows, supples are starting to run low.
“We still don’t have a steady stream of enough remdesivir,” Schwartz at Houston Methodist says.
That is the situation on the ground as of early July. Cases are continuing to climb in Texas, and more people are expected to end up in the hospital as a result. The emergency plan to set up temporary facilities in convention centers or sports venues is suddenly on the table.
Hospitals like Memorial Hermann in Houston have already activated their surge capacity plans, but that might not be enough if current trends continue.
“We remain concerned about the current growth rate in new cases and the demand for hospitalization, as we could reach the limit of our surge expansion plans if the current trends do not reverse,” Drew Munhausen, a spokesperson for the hospital, says in an email.
The hope is that new cases will start to level off soon, now that Gov. Abbott has reimposed some social distancing restrictions and established a statewide mask mandate. But for now, Texas hospitals are just waiting and hoping and preparing.
“If you’re counting hospital admissions and ICU patients on vents, you’re weeks behind. We’re chasing it right now,” Henderson says. “There’s no optimism today for what the rest of July looks like.”
The worst-case scenario, in these moments, is that people will die who otherwise wouldn’t have because the shortage of beds or supplies or staff will lead to suboptimal care.
Even fear itself can be devastating to public health. As ProPublica and NBC News reported, the number of Houstonians dying at home has spiked in recent weeks, suggesting people who either had Covid-19 or another life-threatening condition didn’t make it to the hospital in time.
“When you are unable to take care of patients in the optimal circumstances, you do worry that you are not able to do as good of a job in not-optimal circumstances,” Schwartz says. “And we are about to get into not-optimal circumstances.”
It could be a difficult few weeks ahead. Youyang Gu’s Covid-19 Projections currently expects cases in Texas to peak at the beginning of August and deaths to peak in mid-August.
In Imperial County, California, a run on ventilators
El Centro Regional Medical Center in Imperial County, one of California’s biggest Covid-19 hot spots right now, has already brushed up against its worst-case scenario.
About 60 percent of the patients in the medical center were infected with the coronavirus as of last week, and there aren’t enough ventilators, Adolphe Edward, the hospital’s CEO, told Vox. The medical center serves a largely Hispanic community, with many patients who have diabetes or other preexisting conditions that make them more vulnerable to the virus and who require mechanical ventilator support for their breathing when the disease takes a turn for the worse.
The hospital recently saw its available ventilators dwindle to one. Edward convened an impromptu committee to evaluate the patients currently on ventilators so they could prioritize if another patient who needed one came through their door. They checked their lung capacity and considered whether they could risk taking one or two of the patients off the ventilator if the need arose.
Luckily, Edward figured out a workaround. He called another nearby hospital and asked if they had any ventilators available. They had two, which they shipped over to El Centro. For now, the machines are still there, though Edward says he and the other hospital have stayed in constant contact in case the ventilators need to be transferred again.
Edward sounds exasperated describing that makeshift solution and he wonders why the federal government hasn’t started manufacturing “half a million or a million” ventilators to meet the need that hospitals like his have.
“Somebody’s gotta figure that out,” he says. (The Trump administration signed contracts in April under the Defense Production Act that are supposed to yield a little fewer than 150,000 ventilators by the end of 2020.)
Statewide, only about 30 percent of all available units are currently in use, according to NPR. But there have been surges of patients in some regions like Imperial County that have nearly overwhelmed local hospitals. About 30 percent of ICU beds are still open statewide as well, but those numbers could start shrinking as the state outbreak shifts from the younger cohort less prone to serious complications to older people who are more likely to require hospitalization and ventilation.
A California plan to stockpile ventilators never materialized, and the available capacity could be stretched with the hardest-hit areas exporting their patients to facilities in other parts of the state.
El Centro Regional Medical Center is moving patients out of its building at a rate Edward would ordinarily have found unfathomable. During normal times, the hospital might send out one or two patients a day, he says. Nowadays, they’re averaging between six and eight.
“If you had told me at the beginning we’d be transferring that many patients, I would have told you: I don’t know what you’re drinking,” Edward says.
For the time being, hospitals elsewhere in the state have the extra space to accommodate them. But the worry is if the outbreak keeps spreading, that excess capacity will evaporate very quickly.
New Covid-19 cases and deaths in California are currently expected to peak by August or early September, according to Youyang Gu’s Covid-19 Projections, meaning the new surge has not peaked yet.
More hospitals could be faced with the kind of difficult decisions that Edward and his team were nearly forced to make.