With just 16 coronavirus cases to date, local doctors say Hawaii hospitals have the opportunity to prepare for worst-case scenarios but also begin to implement new strategies that will keep non-urgent cases out of the hospital and prevent patient surges.

Public cooperation with limiting social activity to slow the virus’ transmission will be crucial, they say.

Otherwise, Hawaii hospitals could easily be swamped by the onset of coronavirus if the number of senior patients surges, according to a new analysis from ProPublica and Harvard University.

Dr. Ryan Roth, a physician who works at hospitals on Oahu, Kauai and Hawaii Island, has witnessed how hospital space can be in short supply, even without the potential for a pandemic to hit Hawaii shores.

Neighbor island hospitals in particular will likely be limited in their ability to handle a swift increase in the number of patients.

“There’s not much room in the Hawaii health care system for a sudden surge,” Roth said. “We’ve been talking about it for two weeks, about how are we going to deal with triaging when we run out of resources.”

Roth, along with nearly 100 doctors and medical professionals, penned a public letter Wednesday urging Hawaii residents to take social distancing more seriously.

“Hawaii’s healthcare system does not have the capacity or resources to accommodate the flow of patients that will be needing care,” the letter stated. “We have a very narrow window to act: Hawaii is fortunate to have a relatively small number of patients right now. However, this number will continue to increase, and we already have our first case of community spread; if we wait to act until the situation gets worse, it will be too late.”

“I’m not an epidemiologist and I’m not a disaster planner, but it’s really concerning to me that we might be running low on resources, because it’s going to challenge doctors and nurses to make decisions that we’ve never ever made in our careers  — ones the doctors in Italy right now are dealing with,” Roth told Civil Beat.

Many Can Recover At Home

This week, President Trump acknowledged that this pandemic could last for months. It’s likely that many people will get infected, but based on the experience in other countries such as China, people 65 years and older will likely need the most hospital care. Other adults and children may be able to recover at home.

Everyone of all ages plays an integral role in preventing the spread of the virus, and slowing the rate of infection, or “flattening the curve,” Gov. David Ige said Tuesday.

Hawaii is fortunate to be “ahead of the game,” said Dr. Ali Chisti, an Oahu physician.

“We’re in such a critical time right now,” Chisti said. “It’s a crisis that the entire world is worrying about, but it’s fluid. If people do social distancing and we cut down on big groups, we should see a flatter curve than what Italy and other countries have dealt with.”

The Hawaii Department of Health is already urging those with mild to moderate symptoms to stay home in self-quarantine to prevent transmission to others in public. Not all COVID-19 patients will require hospitalization, based on the experience in China, where one study found that nearly 80% of cases were mild. The study was conducted by the Chinese Center for Disease Control and Prevention and published in the Chinese Journal of Epidemiology.

State Epidemiologist Dr. Sarah Park said Tuesday that even those who are confirmed to have mild cases of COVID-19 will be encouraged to recover at home unless their health worsens, so as not to overwhelm hospitals. Whether one gets tested or not, the medical advice will be the same: stay home to recover in isolation if your symptoms are mild.

To get tested, a physician referral is required. The health department recommends reaching out to your doctor before going to one of the 40 COVID-19 screening sites in person.

Opening New Beds Will Be Difficult

A new tally from the Healthcare Association of Hawaii shows that Hawaii has a total of 3,069 licensed beds and 340 intensive care units, including hospital beds at military hospitals.

In the event Hawaii needs to expand its hospital capacity, it will be a “very difficult task,” DOH Director Bruce Anderson told Civil Beat on Tuesday, when asked about the potential to open up more bed space.

“Hospital capacity is close to maximum even under normal circumstances,” he said.

Hawaii hospitals are already largely occupied, according to the most recent report from the Hawaii State Health Planning & Development Agency in 2018, which shows most facilities run at 60% to 67% occupancy, including critical care beds, skilled nursing beds, and beds that “swing” between acute and skilled nursing facility needs.

If COVID-19 patients do fill hospitals, Raethel said Hawaii Healthcare Emergency Management can stand up temporary units of 10 to 20 beds, for a total statewide capacity of 150 beds for non-COVID patients.

“These spaces would allow the hospital to treat those with less acute ailments, thus freeing up other spaces within the hospital for treating those with more serious illnesses,” HAH President and CEO Hilton Raethel said in a statement distributed to the press on Tuesday.

“All of the hospitals are taking important steps to ensure that services and capacity are available, and not just for those who are ill with COVID-19, but for everyone who needs acute care,” he added.

To some, the outlook looks especially bleak for neighbor islands. Kauai has nine ICU beds, Maui has 29, and Hawaii Island has 24. Regular hospital bed inventory is larger, with Kauai having 111, Maui 242, and the Big Island 242 state-licensed beds.

‘Preparing For The Worst’

Queen’s is “preparing for the worst,” said Jason Chang, chief operating officer of the Queen’s Health Systems and president of the Queen’s Medical Center, which includes both the Punchbowl and West Oahu campuses.

For about a week, Queen’s hospital campuses have had yellow tents designated for COVID-19 screening to relieve any pressure on the emergency room or inpatient facilities.

“What we’re trying to do is prepare our ICU, the critical care, ventilators and negative pressure rooms for an influx in the case that somehow there’s an explosion of infections,” Chang said. “In the case that we get overwhelmed, we have 34 ICU beds and 51 ventilators available and we’re making sure we’re using our equipment judiciously.”

Queen’s provided care for one of Hawaii’s 16 coronavirus patients. The person was treated in an airborne infection isolation room, colloquially known as a negative air pressure room, and discharged to recover at home the next day.

Ventilators Are Low In Stock

Hawaii’s hospitals own a collective 561 ventilators, with the bulk of them on Oahu.

Neighbor islands have the shortest stock of ventilators: Kauai County has 18 ventilators, Maui County has 27, and Hawaii Island has 39.

“When you’re talking about small hospitals that don’t have as many ventilators and one negative pressure room, if you get two to three patients, then all of a sudden you don’t have equipment to take care of them,” Chang said.

Ventilators can be sterilized within a day for the next patient’s use, but they’re in short supply nationally, especially as hospitals have been stocking up on them amid the coronavirus outbreak and an already severe influenza season, Chang said. STAT Medical, a local medical supply store, only has four to rent and Queen’s is currently renting three of them, according to Chang.

“We are looking into all options including repurposing of equipment and supplies, and triaging and prioritizing care needs,” said Mimi Harris, the Queen’s Health Systems chief nursing officer.

The Hawaii Healthcare Emergency Management coalition also has a backup supply of resources, she said.

The current supply would be sufficient in normal Hawaii scenarios, said Roth.

“That’s what I would expect from normal laws of supply and demand,” said Roth. “Five hundred and sixty ventilators is not a whole lot if we have a population of about 1.5 million, but it makes sense when we don’t have a pandemic on board.”

Potential Infection Scenarios

The recent analysis from ProPublica and Harvard University hypothesizes just how much the Hawaii health care system could be strained: In the event that about one-fifth of Hawaii adults are infected, the state would have to more than double its hospital bed capacity, according to the new analysis.

And that’s a best-case scenario projection, based on hospital bed availability and occupancy data gathered by The Harvard Global Health Institute.

The analysis takes into account the state’s already large population of seniors — approximately 240,000 Hawaii residents are older than 65. In a worst-case scenario, if 60% of Hawaii adults 18 and older were infected, the state would have to quadruple its current bed capacity.

But West Oahu physician Ali Chisti, who has also studied public health, says it’s important to not get caught up in ‘doomsday’ scenarios.

“I’m not a big fan of modeling,” he said. “It’s all the ‘what ifs.’ It’s useful for understanding the impact that could come, because it’s true if you look at the current statistics, but if you flatten the curve, it can alter the parameters.”

“It’s really a call to action,” Chisti added. “Everyone knows that there are not enough possible (hospital) beds in the U.S., but it doesn’t mean that the world’s going to end, we just need to innovate, figure out how to adapt and work together as we are.”