Omicron broke many US hospitals. Why didn’t the federal government report that?
The fine print reveals that HHS basically publishes hospital fire capacity, not safe care capacity.
When the Omicron wave arrived in the United States, I became extremely worried that hospitals might be overwhelmed, even if the new Covid-19 variant turned out to be milder, as had been speculated.
There were two main reasons for this. First, hospitals were already busier than usual. Nobody is sure why, but a likely explanation is pent-up demand. Since early 2020, quasi-elective procedures have been delayed repeatedly. With every new Covid-19 wave, the usual pace of “non-emergent” care slows. Some of this is driven by hospitals delaying care to conserve critical capacity needed to treat the influx of Covid-19 and some by patients themselves effectively saying “no thanks” to getting anywhere near hospitals during surges.
The downtime between waves has been inadequate to allow communities to catch up. While most elective procedures go well, some complications are inevitable. (There’s a saying in medicine: there is no such thing as minor surgery). Some complications require immediate care, often filling up hospital beds for days. In addition, some “elective” procedures aren’t so elective. A biopsy of a suspicious mass may be considered elective because it doesn’t actually need to happen today or even next week. But months of delays mean that some of these cases will “declare” themselves to have been cancer all along. These late catches often spell more complicated care. In short, many hospitals entered Omicron already bursting at the seams, as doctors and patients tried to play catch up.
The second reason for my concerns about hospital capacity was an overall complacency I sensed, both from governments and hospital administrators. Because Omicron was shrugged off as mild practically before it landed here, wishful thinking prevailed.
But the back-of-the-envelope math was always pretty clear. That’s why I wrote memos to federal and local officials in December. Enough people remained unvaccinated (and enough high-risk individuals vaccinated but not boosted), that even if Omicron was considerably milder than Delta and earlier variants, that wouldn’t be enough to avert disaster—unless Omicron were truly no worse than a seasonal cold, which of course wasn’t true. It was obvious to me that Omicron had enough targets, and moved quickly enough, that our hospitals could be in big trouble.
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During the Omicron wave, my team and I correctly predicted that droves of US hospitals would have more patients—Covid-19 and otherwise—than they could safely treat. There were times when thousands of US counties were either over 100% hospital capacity or close to it (click below for a time-lapse of hospital capacity during the Omicron wave).
During a recent debate on whether we should cease Covid-19 protections for good (obviously I argued against that dangerous opinion, making the case for right-sized responses that leverage real-time data that we now actually have) my opponent pointed out that official US Health and Human Services data seemed to suggest that few hospitals ever exceeded capacity during Omicron. As I’ve written before, such a notion didn’t match ground conditions. My frontline colleagues around the country (particularly in trouble spots we identified) reported horrifying scenes. Some patients were flown across state lines to get care. Others having heart attacks were treated in beds lining hospital hallways, without basic cardiac monitoring. Fortunately, doctors did not routinely have to choose between patients needing a ventilator. But too often, patients did not get the care they needed. We know this costs lives.
How could HHS data not see this? The answer is both simple and maddening.
Since 2020, HHS has been instructing hospitals to report not the normal number of patients they can safely treat, but rather, the number of staffed beds they might possibly be able to scare up in worst-case scenarios. As a result, HHS’s public reporting on hospital capacity more closely resembles fire capacity than safe care capacity. Under the reporting current system, there is literally no distinction between inpatient beds in cardiac units and gurneys lining the hallways. Even chapel spaces and parking garages hastily converted into care areas "count" as "staffed inpatient beds," as far as HHS is concerned.
HHS’s public reporting on hospital capacity more closely resembles fire capacity than safe care capacity.
Some of this is legitimate, some clearly not. If a hospital usually has 750 staffed beds, it’s reasonable to assume that a 10% increase in the maximum amount of care would be possible to achieve temporarily. (Albeit functioning at over 85% capacity is known to be dangerous.) So, if a 750-bed hospital were to report that it actually had 825 staffed inpatient beds, I’d buy it, briefly. But broadly speaking, hospitals have been reporting far more staffed beds than they can safely handle for weeks or months on end; it appears that many hospitals have been reporting 25% more potential beds than their usual ceilings, according to pre-pandemic figures from the American Hospital Directory.
This is not the hospitals’ faults. They’re just doing what HHS explicitly asks of them. The result, though, is that the public—and even health professionals who haven’t read the fine print—has been misled into thinking that hospitals never exceeded their safe care capacity during the last surge. We know that many hospitals did exceed safe capacity, and for sustained periods.
Using accurate numbers, a different picture emerges: thousands of US hospitals were indeed stretched beyond their safe limits during the Omicron surge.
This matters because there are very few reasons for which the public appears willing to alter its behavior to slow the spread of Covid-19; keeping local hospitals safe for everyone remains one, seemingly. If during future spikes, people mistakenly believe local hospitals are fine (when in fact they aren't), they may not take precautions that lower case counts enough to keep hospitals from overflowing. Remember flattening the curve? We still need to do that at times.
Using accurate numbers, a different picture emerges: thousands of US hospitals were indeed stretched beyond their safe limits during the Omicron surge.
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Last week, the CDC announced new guidance that in part pegs masking recommendations to local hospital capacity. Additionally, as I’ve written before, temporary mitigation measures like decreasing indoor dining and large event capacity should occur during surges which threaten hospital capacity (which my team’s hospital capacity dashboard predicts). But if we think hospitals are less full than they are, we won’t act soon enough.
As a result, I’ve asked several well-placed federal officials to look into changing how hospitals report their safe inpatient capacity to HHS. I simply want hospitals to report their normal safe staffed bed capacity and their surge capacity. Currently, hospitals report these numbers combined as one number. Teasing this out should be easy. The officials I spoke to indicated that they understood the problem and recognized the importance of fixing it. I hope they follow through. Our hospital system was not sufficiently protected during the Omicron surge. We owe it to our communities to do better next time.
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