The US doesn’t just need to flatten the curve. It needs to “raise the line.”

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Covid-19 deaths in the US have risen dramatically, and experts warn the coming days and weeks will be extremely grim. “This is going to be the hardest and the saddest week of most Americans’ lives, quite frankly,” US Surgeon General Jerome Adams said on Fox News Sunday.

After failing to avert the Covid-19 crisis or offering a coherent response or plan to end it, the Trump administration is resigned to a prediction of 100,000 or more total deaths from the coronavirus.

As of April 7, there were nearly 11,000 reported deaths nationwide, and many experts say that’s actually an undercount. A steep rise is now expected, particularly in hot spots like New York, New Jersey, Louisiana, and Michigan.

Hospitals in these states are rapidly approaching capacity as they see a surge of patients who were infected weeks ago, before social distancing measures were ordered or followed. (Data from China published in The Lancet shows that for those who lost their lives to the disease, the average time between the onset of symptoms and death was 18.5 days, with a range of 15 to 22 days.) Some hospitals in these hot spots are now running short on critical equipment and staff, some of whom are home sick after being infected.

Yet the focus on the current numbers and long-range predictions may obscure something else: that the United States still has an opportunity to save thousands, even tens of thousands, of lives in the coming days, weeks, and months.

To do so, experts say, the US has to continue to slow down the rate of transmission by staying home: flattening the curve with social distancing to relieve the pressure on the health care system. Flattening the curve reduces the burden by keeping the peak of hospitalizations (and potential deaths) lower and more spread out so that resources aren’t overwhelmed. In Washington state and California, there are already some early signs the curve has been flattened.

But to save more lives nationwide, experts say America must also raise the capacity of the health care system at lightning speed so there’s more lifesaving care for the patients who will develop severe Covid-19 illness in the coming weeks and months. Though 42 out of 50 states now have stay-at-home orders, experts worry that many people were infected before they were imposed, and others will be infected because they can’t, or won’t, follow the guidance.

Most people are now familiar with the chart that Vox (and others) published in early March of flattening the curve. We’ve created a new one to illustrate “raising the line” with the help of Kumar Rajaram, a professor of operations and technology management at the UCLA Anderson School of Management:

Several others have independently made similar arguments and created charts to raise awareness of this concept using the hashtags #raisethebar and #raisetheline:

#FlatteningTheCurve by #SocialDistancing isn't enough. We must also #RaiseTheBar by increasing healthcare system capacity



How? An immediate, massive whole-of-country response, mobilizing all of America's manufacturing, logistical & personnel capability. #DefenseProductionActNOW pic.twitter.com/TGW2wdbNyy — Matthew Cortland, Esq (@mattbc) March 22, 2020

Because this is such an important message, I made a 20-second video summary of the @OsmosisMed piece echoing some ways to #FlattenTheCurve & #RaiseTheLine (w/ a few additional bits). And thank you to all these creative educators- your efforts mean more than ever these days! [4/4] pic.twitter.com/bigzNtFwck — Benjamin Kerr (@evokerr) March 22, 2020

Increasing capacity doesn’t just mean more masks, beds, ventilators, or medicines for the 20 percent of cases expected to require hospitalization. It also means diverting resources to the least-resourced areas, training more staff to work in the ICU, and ramping up telemedicine for non-Covid patients to free up beds. Smaller cities and rural areas where hospitals and clinics have far less capacity are in desperate need of this kind of support.

Raising the line requires an extraordinarily rapid mobilization of resources (humans, money, and equipment), ingenuity and flexibility, and leadership and coordination. It’s on all of us: the federal, state, and local government; the military; hospital leaders and staff; the private sector; and even the general public to support our hospital staff now.

While some hospitals, like the University of Washington Medical Center, have found ways to increase capacity in time for the surge and save lives in the process, others are reaching the worst-case scenario of scarce resources that force them to ration care. Hospitals in future hot spots could easily reach this stage, too — with many more lives lost as a consequence — without immediate support and coordination with other institutions and the government.

“The institutions that are really faltering are city hospitals and municipal hospitals,” said an emergency medicine doctor in New York City who asked that his name be withheld because his hospital forbade him from speaking with the media. “They don’t have the funding of private institutions to increase capacity.” The same doctor is also gravely worried about the limited number of experienced pulmonologists to treat the most critical cases.

“There’s a lot of discussion of ventilators, and I hope there’s enough momentum to meet demand. My concern is we’re not focusing on other nitty-gritty details: shortages of ventilator medications and critical care personnel,” he said. “If the only pulmonologists at the hospital get sick, this is going cost a lot of lives.”

New York’s demand for beds and ventilators may peak in early April; the national peak may not come until a week later

The Institute for Health Metrics and Evaluation in Seattle has developed a series of models to gauge the capacity of the health care system to handle the surge in cases expected in the coming days and weeks. (IHME’s model is one of many academic models trying to estimate how the pandemic will play out; none can predict the future, all should be read with the understanding there’s still a lot of uncertainty.)

One IHME model, which is updated daily with data from around the country, predicts that resource use — when the most hospital beds, ICU beds, and ventilators will be needed — for New York state will peak April 8, and that the nationwide peak will come on April 15. It also shows that there are still significant national shortfalls: As of April 7, there was a shortage of 36,654 hospital beds, 16,323 ICU beds, and 24,828 ventilators.

That huge shortfall also influences the model’s estimate of total US deaths by August — about 82,000 as of April 7. So we asked Ali Mokdad, a professor at IHME and chief strategy officer for population health at the University of Washington who is working on the models, whether this means many doctors will have to choose which patients get a ventilator — the deadlier, worst-case scenario — because of scarce resources.

“I think we can come up with the beds and ventilators we need, and I think this country has the resources to do it,” Mokdad said. “I know for instance that the same ventilator is being used on multiple patients. Our physicians are becoming very creative. I am really hoping we can still avoid the peak by more people staying at home.”

He added that raising the line has to extend past the peak. “We are all concerned about the peak right now, but we should also be concerned after the peak, how we can reallocate resources,” he said. “Let’s avoid the peak, but also one week after let’s make sure we can provide the best medical care possible then for those who need it.” That won’t just involve moving equipment and supplies around the country but also transporting patients from overwhelmed hospitals to ones with more space and staff.

Mokdad notes that he’s inspired by the rapid increase in capacity he’s seen at his own hospital at the University of Washington; the state was the country’s first hot spot after the first US case and death were reported there. With more time fighting Covid-19 than anywhere else in the US, its lessons from preparing for its resource-use peak could help others, too.

Some hospitals are already raising the line; others are struggling and need help

Many hospitals are rapidly trying to build up capacity so they can handle a coming surge in Covid-19 patients. They have to do this now because the US entered this crisis behind a lot of other countries in some important respects. The US has fewer hospital beds, fewer doctors, and fewer nurses per capita than other rich countries. It’s quickly run low on protective masks and gear that help keep health care staff safe and healthy and able to keep working.

States are already setting up field hospitals (like tents in Central Park) and converting existing buildings (like dormitories) into temporary medical facilities. That is a necessary step just to make sure there are enough beds for Covid-19 patients, and to keep other patients routed away from the hospital to prevent further infection.

New York state has taken the extraordinary step of organizing all of its hospitals into one gigantic system overseen by the state government. Doctors and nurses from less affected areas upstate could be transferred to downstate hospitals. Patients could also be shuffled around, moved from overcrowded hospitals to those with open beds. This plan comes with plenty of logistical challenges — funding, most of all — but the goal is to lift the line for NYC facilities and slow the outbreak there in the hope that hospitals elsewhere in New York will never see as high a peak as New York City did.

Related Coronavirus is exposing all of the weaknesses in the US health system

“It’s to everyone’s benefit to work together to try to get people healthy,” Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Institute for Public Health at Washington University in St. Louis, said. “It’s bad for everyone else in New York state if the epidemic doesn’t get contained in NYC, economically and from a health perspective. It’s actually bad for the country, too, of course.”

Hospitals are also making key changes internally. At the University of Washington, Mokdad said they canceled elective surgeries and called in doctors who are retired to help. Recovery rooms have been converted into ICU rooms, and beds were brought out of storage.

“We feel such plans have really helped us with the medical response,” Mokdad said. “And we did the same thing for the county and the next-door county, and also diverted resources to Harbor View Hospital, which we were concerned about. It serves our prisons and the homeless.”

Raising the line also means increasing supplies

Manufacturing more supplies like ventilators, masks, and gloves — another key element of raising the line — isn’t easy, exactly, but it’s no mystery how the US can do it: by reengineering America’s immense manufacturing power to focus on the current crisis.

Ford is refitting its car assembly lines to produce ventilators, 3M is ramping up its production of protective masks, and so forth. If President Donald Trump fully exploits the powers of the Defense Production Act, the path to more medical supplies is pretty clear. So far, he’s been mostly reluctant, but he has the authority to make some big moves if only he had the will.

But the US doesn’t just need to make the supplies, it needs to get them to the workers who need them. Ad hoc efforts like Project N95 are trying to coordinate between those who have protective masks and other lifesaving equipment to give and those who need such reinforcements. As Ingrid Burrington recently wrote for Vox, the gray market for medical gear reflects a failure of US medical supply chains and the government’s inability thus far to fix them:

It’s possible this ad hoc market will dissipate as quickly as it formed when supply for N95s evens out; it’s also possible that the vacuum of government action to make mass purchases or jump-start domestic manufacturing by using the Defense Production Act will mean these informal efforts will be filling a void for weeks or even months to come. While the wherewithal, generosity, and determination of many of these efforts is incredibly inspiring, the fact that such a massive grassroots effort has to exist at all speaks to how weak medical supply chains already were before this crisis — and, unless they’re radically changed, how likely they are to break again in the future.

So America can build more ventilators and make more protective masks. Then it has to distribute them where they’re needed. With a Trump administration that sometimes seems vindictive toward states whose leaders criticize the president, that’s easier said than done.

Some states have said they aren’t getting enough equipment from the federal government, with New York recently relying on donations of ventilators from another state and a major Chinese company. The Washington Post reports that the Trump administration could end up giving Florida and other states favorable to him politically whatever they say they need.

But expanding the US health system’s capacity also requires increasing the number of people working to support it. America needs to make sure there are enough specialists to treat the most difficult cases during the surge.

The US needs more health care workers trained on Covid-19 care to increase capacity

Doctors and nurses are getting sick. We saw it happen in Italy and Spain, where medical staff account for 10 percent or more of their Covid-19 cases, and we’re starting to see it here. These two issues, staffing and supplies, are interrelated. More protective gear hopefully means more physicians and nurses. Every ventilator needs somebody trained to operate it.

But doctors and nurses across the country don’t feel like they are being protected right now, with lax protocols potentially exposing them to infection and requiring them to take time off when they are most needed. As an internal medicine physician at one of the major New York City hospitals previously told Vox:

“My frustration is that I have never felt like my safety is important,” this physician said. “When I’m going to work, I could endanger me and my family and I feel like my institution doesn’t even care at all.”

“I think one of the biggest limiting factors is staffing,” Cynthia Cox, who directs the Peterson-Kaiser Health System Tracker, told Vox. “We might be able to increase staffing by bringing back retirees and allowing early graduation from medical and nursing schools. But it’s equally likely staffing numbers could fall as nurses and doctors are exposed to the virus and fall ill or need to be quarantined.”

States are already taking action. New York has put out a call for retired doctors to volunteer their services. California Gov. Gavin Newsom is trying to build up a California Health Corps, calling on all kinds of retired doctors and non-MDs or RNs who work in the health space or are already training for it — medical residents, pharmacists, nursing students, paramedics, EMTs, and more — to sign up and be placed where they are needed as the virus spreads.

Newsom told the Los Angeles Times that he thought the state could recruit as many as 37,000 health care workers through the program. But the big question is, would that be enough?

Well, let’s do some crude math. Spain has about 450,000 doctors and nurses. As of March 27, about 9,400 of them had tested positive for Covid-19, or about 2 percent. California has about 1,670,000 health care workers; if 2 percent of them got sick and couldn’t work for a couple of weeks, the usual length of an infection for somebody with Covid-19, that means 33,400 medical personnel out of commission.

So Newsom’s health corps is maybe enough — based on what we’ve seen in other countries so far. But it would be close.

Complicating matters is the fact that many hospitals are also taking big financial blows by canceling many elective surgeries, one of their biggest sources of revenue; industry leaders are already warning some hospitals may need to lay off staff or even close. It’s not clear the money already allocated by Congress in the coronavirus stimulus bill will be enough and another funding infusion may soon be needed, as Stanford professor Ciaran Phibbs wrote for the Incidental Economist.

It’s also not enough to train doctors and nurses to help support ICU and emergency medicine staff, said the New York City emergency medicine doctor. Hospitals also need experienced pulmonologists on hand to treat Covid-19 patients who have severe lung injury and are rapidly deteriorating from acute respiratory distress syndrome.

“Each patient is different, the way they react, and a lot of us don’t have the expertise to know the best way to treat them,” he said. If the experienced pulmonologists who can provide that care get sick or if a small, rural hospital doesn’t have any to begin with, there will be more deaths, he said. Which is why raising the line should also involve flying in pulmonologists from parts of the US that don’t yet have a surge (or are past their surge) to the places that are in one.

“In Nebraska, they have a ton of pulmonologists; why can’t we bring some of those doctors here in New York? The federal government would have to coordinate, but it would be very helpful to have,” he said.

Raising the line is proving to be a frantic, stressful experiment for the US. It’s not clear yet how comprehensive it will be and whether it will reach the hospitals and clinics in rural areas that need the most support.

“The long-term lesson is that the US health system needs to think about slack or flexible capacity,” said Kumar Rajaram of UCLA, who helped us with the chart above. “While this may be costly, this is required to handle unforeseen public health emergencies in the future. If you value life, that’s all you need to do.”

What you can do to help raise the line

For most people, flattening the curve and lifting the line start with the same step: stay at home. “What is really helping us to reduce demand on our hospitals and our medical supply is the fact that people in Seattle and Washington state are staying at home,” Mokdad said. “What we are projecting now for maximum need, we can avoid it if people stay home.”

There have been early promising signs from California and Washington, states that acted early and aggressively to lock down society and maintain strict social distancing, that such measures can have a quick and substantial impact if they are followed.

4/ Is CA out of woods (for Phase I, at least)? Not yet, but @IHME_UW projections https://t.co/Q0aJHNZQsM awfully good. One wk ago (L), projected CA peak Apr 27, with 1896 ICU beds needed. Today’s projection (R), peak Apr 14; 798 ICU beds needed. Our curve is flat, unambiguously pic.twitter.com/Asc8GpdBRw — Bob Wachter (@Bob_Wachter) April 7, 2020

And even if you can’t staff a ventilator assembly line or volunteer your medical services, you can help increase America’s medical capacity. If you’re a little crafty, you can make masks for front-line workers. Vox’s Alanna Okun has a handy guide. You can also donate money or time to efforts like Project N95, a clearinghouse to connect health care workers with equipment.

If you have an elective surgery scheduled and it’s not urgent, consult with your doctor and think about postponing it until next year. Your hospital is already probably thinking about how to modify its planned procedures to free up staff and space; you, as the patient, can make that easier by being understanding and flexible.

Telehealth is an easy way for people who need routine medical check-ups or have mild symptoms to stay in touch with their doctor without exposing medical staff to a potential infection that would take them out of service. Medicare is temporarily paying for more telehealth services in response to Covid-19, and some major health insurers have waived cost-sharing for telehealth visits as well.

As with flattening the curve, we know what to do to raise the line — and just like social distancing, increasing the country’s health system’s capacity is a group effort.

Editor’s note, April 7: The article was updated to note other, independent efforts to raise awareness around increasing the capacity of the health care system.

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