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LEDGER IN-DEPTH

As coronavirus cases rise, Novant and Atrium gear up; Weeks of intensive planning but ‘can’t predict’ the future

Charlotte’s two largest hospital systems, Atrium Health and Novant Health, want you to know this: They don’t know exactly how the coronavirus is going to play out locally. But they’re getting as ready as they possibly can.

Like many of us, Atrium and Novant seem to be following the advice of the old adage “prepare for the worst, but hope for the best.” With hospitals, that means taking steps that sound kind of scary — like drawing up plans for tent cities, thinking about how to get ahold of more ventilators and receiving permission to add hospital beds in hallways and in rooms not designed to accommodate patients.

Overwhelmed: One of the biggest areas of concern for our local hospitals seems to be that they will become overwhelmed with patients — not necessarily because there will be too many people requiring hospitalization (though that’s possible), but because people might start showing up at hospitals even though they don’t need to be there.

“Even if you think you have it, it doesn’t drive you to the hospital,” said Dr. David Callaway, chief of Atrium’s division of operational and disaster medicine, in an interview with The Ledger. “It should not drive you to the hospital, because that is going to overwhelm the acute care facilities.”

Best advice: Instead of showing up to the hospital because you have a fever and fear you’re infected, the hospital systems say you should proceed as you would with any other illness: Start with your primary care doctor. And they’re encouraging patients to use online tools, such as video web chats with doctors and nurses, instead of showing up in person. They stress that at least 80% of people who contract the coronavirus have symptoms no worse than the flu and do not require hospitalization. Groups most at risk for experiencing severe symptoms include people aged 60+ and those with diabetes, heart conditions, cancer and other underlying health problems.

Asked to describe how confident Charlotte should be in Atrium’s preparations, Callaway said: “We are taking this outbreak very seriously,” and he elaborated on the preparations in a candid interview (below). He said he hopes Charlotte’s hospitals will not become overwhelmed like those in Wuhan, China, or in Italy, but added: “I can’t predict whether we will or not.”

Asked about its preparations, Novant released a statement from CEO Carl Armato that said: “The community needs to know Novant Health has immediately and appropriately activated all protocols for handling potential COVID-19 cases, for which we have been preparing since the onset many months ago.”

Drive-through screenings, triage tents

A lot of the recent attention locally has been focused on the shortage of testing kits. Those are expected to increase, and Atrium and Novant have been diagnosing patients. To conserve kits, state guidelines call for testing only those who are showing symptoms and have either had contact with somebody with a confirmed case or tested negative for the flu. Doctors often order a flu test first.

Doctors’ offices throughout the region are working to set up drive-through screening stations.

On Friday, Novant announced several moves to help screen patients worried that they have contracted the coronavirus, including:

Adding a 24/7 hotline (1-877-499-1697)

Opening two local screening centers. One, in Matthews, at 3330 Siskey Parkway, opened Friday. A second one, in Huntersville, at 16525 Holly Crest Lane, is scheduled to open Wednesday.

Opening a triage tent outside Novant Health Presbyterian Medical Center in Elizabeth.

Workers outside Novant’s Presbyterian Medical Center finish preparations Sunday on a mobile office and tent outside the emergency room.

“We understand people in our communities are feeling uncertain and stressed in these unprecedented times,” Armato said in Novant’s statement. “I’m hopeful that with these additional measures in place, our patients will have a clearer sense of how should they seek care if they feel they need to in the weeks ahead.”

Hospital beds: Are there enough?

One of the biggest areas of concern nationally is the availability of hospital beds. According to the Washington Post:

The U.S. Department of Health and Human Services estimates a pandemic influenza, such as the one that hit the United States in 1957, would result in 38 million needing medical care, 1 million needing hospitalization and 200,000 needing to be in intensive care. In a severe scenario, such as in the 1918 influenza epidemic, the numbers would go up to 9.6 million hospitalizations and 2.9 million needing intensive care. The United States, in comparison, has only about 924,107 hospital beds and 97,776 intensive care beds, according to a 2018 American Hospital Association survey.

In Mecklenburg County, Novant and Atrium are licensed for a combined 2,164 acute-care beds: 838 at four Novant facilities in Huntersville, Matthews, Mint Hill and the main Presbyterian Medical Center; and 1,316 at three Atrium facilities in Pineville, University City and Carolinas Medical Center.

Source: 2020 State Medical Facilities Plan, N.C. Department of Health and Human Services

Beds already full: The problem, nationally and locally, is that those beds are already full with patients who have a variety of ailments that have nothing to do with the coronavirus. Back in the fall, before anybody even knew what a coronavirus was, Atrium and Novant were each asking the state for permission to add beds. They said the need was so great that scheduling elective surgeries took too long, and some patients had to wait hours in the ER before a bed became available.

To free up bed space, hospitals could start rescheduling elective surgeries. The U.S. surgeon general said on Twitter over the weekend that hospitals should “consider stopping elective procedures,” and several hospitals around the country have begun rescheduling them.

National studies have estimated that about 25%-30% of acute-care beds are occupied by those recovering from elective procedures. Neither Novant nor Atrium has announced it is rescheduling those surgeries, and neither could immediately say how many beds that would free up.

Even if those beds suddenly became available, they might not be enough.

Waiving the rules: On Thursday, the state Department of Health and Human Services said it would waive the usual rules that require state permission to add beds, which are known as “certificate of need” laws.

That would free hospitals to add beds wherever they could put them, such as in hallways or in rooms not designed for acute care — provided that the hospitals had the actual beds, equipment and staff to handle such an increase in beds.

If needed, the hospitals could also work with the state and federal government to activate disaster medical assistance teams, or DMATs. They are composed of healthcare professionals who are available quickly to help communities struggling with natural disasters, terrorist attacks and other emergency situations.

Nobody is certain how many beds might be required in Mecklenburg. Confirmed cases seem to be growing quickly and are expected to accelerate once testing ramps up. Somewhere around 10% of those with the coronavirus require hospitalization. As of Sunday, there were four confirmed cases in Mecklenburg County. The county’s population is 1.1 million.

Slowing the spread: Doctors say the spread of the virus needs to slow, through methods such as social distancing and increased hand-washing. Otherwise, if everybody becomes sick at once, patients are more likely to overwhelm the hospitals.

Ventilator availability

Another critical issue could be access to ventilators, which help patients with severe symptoms from the coronavirus to breathe. Asked about the topic at a news conference on Friday, President Trump said the government has ordered a “large number of respirators.”

But demand internationally is high. ABC News reported:

The challenge could be daunting. While a number of companies around the globe make the ventilators used in the U.S. health care system, they are also fielding a surge in orders from medical facilities in other countries. Earlier this week, Italian doctor Daniele Macchini posted a searing description of the shortage, as patients who needed help breathing could not find an available machine: “Every ventilator becomes like gold,” she wrote. Firms that make the machines said they are ramping up for coming needs. An official from General Electric told ABC News the company is “taking steps to maximize our manufacturing capability and output while ensuring our plants can continue safe operations.”

Callaway, of Atrium, says the hospital system is “fine, right now” on its supply of ventilators and has access to more through contracts and the federal government.

A Novant spokeswoman asked about ventilators on Friday was unable to provide information on the topic.

The outlook

It’s hard to say what will happen. But if the number of confirmed cases continues growing rapidly, the hospital systems could be strained — especially if people don’t heed the advice and start showing up at hospitals demanding to be tested or admitted.

“An exponential increase of confirmed positives will definitely overwhelm the healthcare system in all phases,” said Dr. Dale Owen, CEO of Tryon Medical Partners, the largest primary-care practice in the Charlotte region. In preparation for the coronavirus, Tryon is rolling out mobile drive-through testing sites and is getting all of its doctors up to speed on online appointments, Owen told The Ledger.

His group spun off from Atrium in an acrimonious departure in 2018, and he has been previously critical of hospital-run medical systems. But he praises the planning by the big local hospital companies: “They have done a fantastic job with the resources that they have. … We can’t ask them to do more than what they have the ability to do.”

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Q&A: Inside Atrium Health’s coronavirus preparations

On Friday, The Ledger interviewed Dr. David Callaway, chief of Atrium Health’s division of operational and disaster medicine. The interview took place at Atrium’s Carolinas Medical Center and has been edited for brevity and clarity:

Q. How confident should the public be that Atrium and the health system are prepared for what’s coming?

What I would say is we are taking this outbreak very seriously. The balance is how not to overreact and how not to underreact. I’ll give you an idea of the effort ongoing, and you can determine whether that is legit or not.

For the last month, we have been holding what we call incident command meetings that have created a system response structure for this. We have 60 hospitals and emergency departments all across the region. We’ve been working with infection prevention, infectious disease, emergency medicine to prepare all of our front line facilities and to come up with a strategy to keep people healthy at home and try to keep them out of the hospitals if needed, and then if they do come to the hospitals, to be able to treat them effectively while still being able to care for all our other patients.

We work closely with the state, we’re working closely with Mecklenburg emergency management and public health, we’re working with Novant — this is really an all-hands-on-deck process. We are taking it very seriously.

Q: If someone is diagnosed with coronavirus, what do they need to do? Do they need to come in?

Eighty percent of people who get coronavirus have a mild illness. If you’re under 60 and you don’t have heart disease, asthma, COPD [pulmonary disease], cancer — the likelihood of you getting really sick is exceedingly low. The mortality is similar to the flu. Just a diagnosis alone does not drive you to the hospital. Even if you think you have it, it doesn’t drive you to the hospital. It should not drive you to the hospital, because that is going to overwhelm the acute care facilities.

The actions you should take are, No. 1, utilize virtual care options, either through Atrium or Novant. Know the community health hotline numbers. There are two of them. One is through the poison center [1-866-462-3821] and one is through county public health [980-314-9400]. Also contact your doctor and utilize the telephonic assessment. They have criteria that would make you need to go to the hospital. They can give you guidance.

What we’re trying to do, again, is avoid bringing people in who don’t need to be here because they are going to get other patients sick, and they will take up resources that would really start to strain the system.

Q. You have a fixed number of acute care beds.

We do.

Q. Some of those are elective. Do you know what percent are for elective surgery, typically?

I don’t.

Q. Is it high?

What number of beds are for elective surgeries?

Q. Right. What I’m really asking is what number of beds can be made available for this?

Let me talk to you about our strategy. Most hospitals across the region and across the country are operating at 100% capacity: 98% to 102% capacity.

Q. Normally.

On a normal basis. The question is then what do we do when we’ve got a surge like this. This is one of the challenges with healthcare in America: We don’t have a lot of surge capacity on a daily basis. The strategy we take has a couple components.

No. 1 is, we look at how we can expedite discharges of patients to other facilities. Think rehabilitation, nursing homes, long-term care. We look at how we can avoid admitting patients who don’t need to be admitted. We look at rescheduling elective surgeries and elective procedures. And the third thing we do is we are very focused on messaging people to stay out of acute-care facilities if they don’t need to be there. This is the virtual care, the media, public health engagement, primary care doctors.

The messaging piece is, “We know you may be sick. We know you are very concerned, that is legitimate. Here are the actions you can take to stay healthy, and here are the triggers that would make you want to go and get some more assessment.” That’s our three-pronged strategy.

The fourth one is where we access alternate care sites. That is now on the table because of the president’s declaration of a national state of emergency and the governor’s declaration of a state of emergency. That gives us other options in terms of access to beds, access to staff and access to other facilities.

Q. Where are those beds?

One of the main things it does it is it changes some of the criteria for beds and spaces we can use. For example, there is certain Atrium-level space. There are certain rooms or hallways that under normal circumstances would not be used for patient care. Because of the declaration, they are able to be retrofitted for patient care. We have some space in our facility. We have some space in our other hospitals.

Q. So if you have x number of beds in Mecklenburg County, your actual capacity might be larger?

We can accordion and expand space, but then we need to have physical beds to put in that space, and we need to have staff. Staffing is often the biggest problem, especially in a pandemic where people may be sick. Or they might be a single parent, and CMS has just cancelled school. Staffing becomes a big piece of it.

And then the final asset that we have that almost no one else has is Carolinas MED 1, which is a mobile hospital. We’re able to utilize that.

The emergency apocalypse thing is the state and federal government have DMAT teams. These are the tent hospitals. That gets coordinated through the state government and federal government.

Q. Are we going to get to that? You must have done some modeling. You must be looking at some of the other cities. What is it going to look like here?

I think if we are effective with our strategy to keep people at home, we’ll be able to mitigate a lot of effect on the health system. You probably have seen the graph — there is this thing all over the internet of flattening the curve. What that’s talking about is if you have a million people who are going to get really sick, and you have six months to take care of them, you can allocate your resources more effectively than if you have one month.

If we’re able to keep people away from the hospitals now who aren’t really sick, that allows us to conserve masks and gloves and rooms and staff so we can care for the people that are really sick. That will help us avoid what you’re seeing in Wuhan or what you saw in Italy.

The advantage we have is we have been planning for this. We are executing based on the lessons we have learned in the last several weeks. Hopefully, we’ll avoid that. I can’t predict whether we will or not.

There’s no toilet paper in the grocery stores, so who knows how the population is going to react? But we are aggressively trying to do that. … Our goal is to get people healthy, keep them at home and only take care of the sickest people in the hospital.

Q. And that’s going well?

I think it’s going alright. I think we have a pretty aggressive strategy that we need to keep ramping up. I think what it needs to counter is all the fear that’s out there. Fear is easier to sell than facts. We are trying to counter that fear with really aggressive facts. Not just saying, “You’re going to be fine,” but saying, “If you’re concerned, here is a resource that we will give you to access.”

It’s not just like, “Don’t worry about it. You’re going to be fine. Stay home.” It’s “Stay home, but if you’re concerned, here’s a link to virtual care.” We’ll do a face-to-face assessment over the computer. And if you are at risk, we’ll give you another resource — like our community care medics will come out to your house and will do an assessment on you at your house.

These are the things that are really innovative that we’re trying to roll out and bring healthcare resources to their home so they’re not having to come here.

Q. How are you on the number of ventilators?

We are fine, right now. From a ventilator standpoint, we have a tiered strategy. We assess what we have on the scene. We have redundant contracts for surge supply. The federal government has emergency stocks of ventilators through what’s called the strategic national stockpile. We coordinate with local emergency management and state emergency management to be able to access those. Plans are in place.

Q. What’s the best advice for people over 65?

Over 60 is where you start to see, if you took at the 100,000+ cases, over 60 tend to be the highest risk. For family members, know who in their family is over 65 and what medical problems they have. Make sure they have all the meds at home. Try to avoid large groups of people. Try to avoid coming to the hospital if you don’t need to.

Then all the same standard stuff. Hand hygiene. Coughing into your elbow. Washing your surfaces. That’s going to be the most important part. Then recognize that the trigger to come to the hospital will be significant trouble breathing, in concert with a fever. But even in those cases, call your doctor first. If you’re over 60, I’d say call your doctor now. Get in virtual care now. Say, “Hey, look, I have risk factors. I just want to let you know. If I start to get sick, what are the actions I should take?” This is important planning people could start doing now.

Q. How worried should that age population be?

You should just acknowledge that you’re at increased risk. It’s the same with almost anything as you get older and as you have other diseases, like heart disease or diabetes. You’re at more risk for other stuff: heart attack, stroke. This is just the same. You’re just at increased risk, and there are some simple things you can do to mitigate that risk.

In brief

New guidance on groups: New guidelines from the Centers for Disease Control and Prevention call for the cancellation of gatherings of 50 people or more. (CDC)

Retailers shut: Retailers including Apple , Patagonia , Urban Outfitters , REI , Abercrombie & Fitch and Nike said they are closing their U.S. stores until the threat of the coronavirus passes. (Axios)

Restaurants scale back: Chick-fil-A is closing its dining rooms and going to take-out only. Starbucks said it would close some stores in “high social-gathering locations” and shift others to to-go only. Governors in five states — California, Ohio, Illinois, Massachusetts and Washington — ordered the closure of bars and restaurants. (Chick-fil-A, USA Today)

Fed drops interest rate: The Federal Reserve is dropping the federal funds rate to 0% to 0.25% in a move to boost the economy to keep banks lending money. The only other time the rate has been that low was during the financial crisis of 2008. Futures indexes suggest a big stock plunge this morning. (CNBC)

Charitable giving: Foundation for the Carolinas and the United Way of Central Carolinas are expected to announce a partnership today “regarding a collaborative, community-wide response to the impact of the COVID-19 pandemic,” according to a news release.

Loves me some internet

Taking stock: Ugh, another ugly week

Unless you are a day trader, checking your stocks daily is unhealthy. So how about weekly? How local stocks of note fared last week (through Friday’s close), and year to date:

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The Charlotte Ledger is an e-newsletter and web site publishing timely, informative, and interesting local business news and analysis Mondays, Wednesdays, Fridays and Saturdays, except holidays and as noted. We strive for fairness and accuracy and will correct all known errors. The content reflects the independent editorial judgment of The Charlotte Ledger. Any advertising, paid marketing, or sponsored content will be clearly labeled.

Editor: Tony Mecia; Contributing editor: Tim Whitmire