Are hospitals prepared for the COVID-19 pandemic? What’s the outlook on hospital staffing shortages, elective procedures, and disease triage? GLG’s Sarah Lim interviewed Dr. David Shulkin on March 20 for his take. He most recently served as the Secretary of Veterans Affairs from 2015 to 2018. Before that, he served as President of Morristown Medical Center in New Jersey, President and CEO of Beth Israel Medical Center in New York City, and Chief Medical Officer of Temple University Hospital. His comments have been edited for length and clarity.

If hospital contingency plans typically assume a surge in capacity of up to 20%, what will be the biggest bottleneck in hospital response?

In times of extraordinary emergencies like this, surge capacity can go way up. In this situation, capacity will probably surge by up to 50%. Hospital leaders are taking extraordinary efforts to empty their hospitals. The closest analogy is after 9/11, when New York City hospitals created hospital bed capacity of up to 80%.

The clear limitation will be staffing shortages. In past pandemics, such as H1N1, staff absenteeism was at about the 35% level, going up to 50%. In the U.S. outbreaks we’ve seen, about 30% of those being infected and hospitalized are healthcare workers. Probably an equal amount won’t come to work because they’re caring for people at home who are sick or they’re simply afraid to work. The remaining staff will therefore be stressed beyond normal levels. This ties in to the shortages of protective personal equipment: If staff aren’t given the appropriate masks, gowns, and gloves, the likelihood of them acquiring COVID-19 increases, which will create an endless cycle of more sick people and more people who will be afraid to work without protections.

As the number of COVID-19 cases increases, what can we expect hospitals, the federal government, and players in the supply chain to do to increase the supply?

We currently have 100,000 ICU beds and about 62,000 ventilators. If we surge capacity up to 20%, we will have a severe shortage of ICU beds. This will necessitate keeping patients in atypical places, like emergency rooms, until room can be made. The problem will be that demand and supply will be uneven as these outbreaks occur in specific geographies. Some communities are likely to be overwhelmed, and there may be empty ICU beds in other parts of the country.

This is what hospital leaders are worried about, and it all stems from the projected requirement for 200,000 ICU beds. We are somewhat flying blind in terms of epidemiologic projections because our testing is just beginning to kick in. We don’t have accurate numbers of patients in terms of community spread. The accurate numbers that we can track are those presenting to hospitals who require hospitalization and those who’ve died. Fortunately, we’ve not seen nearly as high presentations to hospitals, nor have we seen the mortality rate of that of Italy, Germany, Switzerland, or even France. That may mean a lower number than projections of 200,000 ICU patients.

Does our healthcare system have mechanisms in place for hospitals in less impacted areas to share supplies to harder-hit neighbors?

There is sharing, but it’s usually done under extraordinary circumstances or at the lower levels of institutions. The most common examples are when certain drugs aren’t available. Hospital pharmacies will share with another hospital even if it’s a competitor; certainly, some blood bank supplies as well. They tend not to share things like staffing or surgical equipment, which could be viewed as competitive.

We are now in a very different time. In my career, I’ve never seen anything quite like this. Republicans and Democrats are working together to get things done, and people are pulling together throughout the community. The same thing is happening in hospitals. I’ve been on phone calls with hospital leaders where they share information and a willingness to work together. There’s going to be not only a real need to act in a coordinated way but also pressure on people who aren’t chipping in.

While the situation is rapidly evolving, what percentage of decline in elective surgery volume can we expect, and how long will those deferrals last?

The hospitals I’m in touch with have completely stopped elective procedures. Surgical volumes are down, close to 60%; emergency rooms, even in inner-city hospitals, are relatively empty. It’s not just that hospitals stopped these services – patients themselves don’t want to be in a hospital. There are also significant declines in ancillary service use in laboratories and radiology and other outpatient ambulatory services and emergency room services.

Given the number of deferrals, will there be a severe impact on hospital finances in the longer term?

There will be a significant impact on hospital finances. Not only is there the decline in the case volume, but this is often some of the most profitable case volume that hospitals have. We’re also seeing increased supply costs in some areas. Staffing costs are rising with people working extra hours, particularly when staff don’t show up for shifts. Nurses and other staff are kept on overtime. That can often be time and a half to double time. At the same time, for a good percentage of many hospitals, particularly not-for-profit hospitals, margin was non-operating revenue because the stock market had performed well. Now that will completely disappear.

The Trump administration announced the possibility of invoking the Defense Production Act to force the manufacture of medical supplies in short supply. How might this rollout?

The Defense Production Act will go into effect, but the issue is the timing. If we are 11 days behind where Italy is in terms of infection, we will see this hit parts of this country relatively soon. By the time manufacturing and supply chains ramp up, the question is, are we going to meet demands when they’re needed? Ford, GM, and Chrysler are thinking about repurposing their plants to make ventilators, but it’s hard to believe they’ll do that quickly. Making masks and protective gowns should be far easier to do. The Defense Production Act will help and is the right thing to do, but I don’t believe it’ll help meet all the needs required by the healthcare industry.

How does U.S. hospital preparedness measures and issues around capacity compare to those of Italy or China? Any learnings to extrapolate from countries further along that timeline?

Everybody understands that the U.S. healthcare system is structured very differently than in China, Europe, or even Canada. If you look at the number of hospital beds per 1,000 people, the U.S. is clearly at the bottom of the list. Japan has approximately 12.8 hospital beds for every 1,000 people, compared to 2.8 in the U.S. Europe has about four to six hospital beds per 1,000 people. The U.S. generally has operated at decent census levels. There are exceptions by geography and type of hospital, but we don’t have the same capacity as in Italy or Asia.

Any closing remarks on U.S. hospital preparedness measures considering the COVID-19 outbreak?

I know hospital leaders are taking this extremely seriously, and they’re doing an incredible job. The big unknown is which epidemiologic curve the U.S. will take. The Imperial Study projected unbelievably aggressive numbers that would overwhelm our healthcare system. I don’t believe that will come to fruition; we’re going to have much more reasonable numbers. We may have a peak in two to three months and potentially 200,000 to 250,000 total infected patients. I hope the measures we’re taking seriously will lessen that projection. If so, I’m confident our healthcare system will meet the demands.

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About Dr. David Shulkin

Dr. David J. Shulkin most recently served as Secretary of the Veterans Affairs under President Donald Trump from February 2017 until March 2018. He previously served as President Barack Obama’s Under Secretary of Veterans Affairs for Health (VA). Prior to working in the VA, Dr. Shulkin was President of Morristown Memorial Hospital in Morristown, NJ, a part of a multi-hospital system in New Jersey.

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This article is adapted from GLG’s March 20 teleconference “Hospital Preparedness and COVID-19.” If you would like access to this teleconference or would like to speak with Dr. David Shulkin or any of our more than 700,000 experts, contact us.

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