Twenty-three COVID-19 patients arrived Monday morning at the Ernest N. Morial Convention Center in New Orleans to find the massive hall converted into a field hospital of sprawling white tents outfitted with posters of inspirational quotes, tropical plants and orchids.
The “medical monitoring site,” which the National Guard erected in just a week, is expected to have 1,000 beds for COVID-19 patients who have been discharged from hospitals and be up and running by April 20. The facility will be for people who do not need ventilators but still need medical assistance, and is intended to help hospitals free up beds for the sickest patients as they contend with longer-than-average hospital stays for COVID-19 patients.
The center could be expanded to accommodate as many as 3,000 people, and another 250-bed facility is just across the street for patients who are presumed to have coronavirus but are awaiting test results. But operations started off slower than expected this week, with a trickle of patients in the last few days bringing the total to 41.
That could be a sign that social distancing measures ― which New Orleans solidified with a stay-at-home order on March 20 ― are working. At the end of March, when the state was scrambling to retrofit the building, models were showing that the state would exceed bed capacity by April 4 and ventilator capacity by April 7. Neither crisis point has been reached.
Still, Louisiana residents are highly vulnerable to contracting and dying from the coronavirus: New Orleans has disproportionately high rates of residents with health conditions that put them at high risk for the illness, plus entrenched poverty and substandard health care.
The coronavirus outbreak is already calamitous for Louisiana, with reported cases now numbering 18,283 and deaths numbering 702. Louisiana has the third highest death rate per capita in the country, with half of the top 20 counties in the country for coronavirus deaths per 100,000 residents are in Louisiana. The state recorded its most deaths in a single day on Tuesday: 70.
Now, the question is whether it will get worse. And if people don’t keep up social distancing, public health experts say, the state could see COVID-19 numbers continue to climb dramatically. The state’s current modeling shows the state on course to require 2,500 new hospitalizations a day in the New Orleans area by mid-May if the public does not adhere to social distancing. Like other states around the nation, Louisiana is both preparing for a worst-case scenario and hoping that residents will do their part to ensure that it doesn’t happen.
“We feel we are still at risk of another spike, certainly if people stop the distancing that they’ve been doing effectively,” Joseph Kanter, assistant state health officer at the Louisiana Department of Health, said on Thursday. “We would expect to see just what we were fearing initially, which is surge in demand, more patients than there are ICU rooms, more patients than there are ventilators and the need to house massive numbers of hospital-level patients outside of hospitals like we were planning to do at the convention center and other locations.”
Numbers of new COVID-19 cases are lower than experts feared just a week or two ago, which public health officials hope means the rate of infection is flattening, Kanter said. But he and other officials remain very cautious in their optimism, especially as they continue to see patients dying at alarming rates.
The state is continuing to plan for this worst-case scenario. In addition to the convention center site, the state leased the 1,110-room Sheraton hotel, the fourth-largest in New Orleans, to use as another medical monitoring site. It’s also considering leasing the nearly 1,200-room Hyatt hotel. Louisiana is also developing plans for medical monitoring sites in the capital city of Baton Rouge and in other coronavirus hotspots in the state.
“As our numbers ramp up, we may very well exceed the first medical monitoring station, so that’s why the plans are in place for the second and the third,” said Glennis Gray, assistant director at the state’s Center for Community Preparedness, who is serving as incident commander for the site. “We’re just planning for it, we hope that we won’t have to.”
A Vulnerable Population
New Orleans ranks above other viral hotspots in every condition on the Center for Disease Control’s list of heightened risk factors for COVID-19: high blood pressure, diabetes, coronary heart disease, COPD, chronic kidney disease and cancer, according to a report released in late March by The Data Center, a research organization based in New Orleans. Sixty-six percent of people who have died from the virus in Louisiana have hypertension, 44% had diabetes and 25% were obese. Only 3% of the people who have died from the virus in Louisiana did not have any underlying health condition.
“You add the health disparities and the inequity that we know plague us in Louisiana and it makes us vulnerable really during any emergency, particularly now,” said Kanter. “That’s something that we’re working to address but we know that we’re at risk for worse outcomes because of it.”
These conditions are most prevalent among African-Americans, who made up 70% of deaths in the state thus far, despite making up just 32% of the state’s population, according to data announced Monday.
Economic and housing instability makes residents even more vulnerable. The median income in New Orleans is just $38,423 and 36.6% of residents are severely housing-cost-burdened, according to The Data Center.
“People in poverty are much more likely to be living in close quarters,” said Allison Plyer, chief demographer at The Data Center. “They often don’t have the ability to quarantine a family member who gets sick, and spread among family members is going to be much more likely.”
That means patients often can’t stay home to get well. At local primary care and urgent care clinics in New Orleans, Meghan Maslanka, the medical operations manager at the convention center, says providers “tell us stories about some of their patients sleeping in the park or trying to sleep in the urgent care bathroom because they’re afraid to go home, they don’t want to infect their loved ones.” That’s driving the need for “step-down” facilities.
Across the country, as states watch their hospitals reach toward capacity, health departments are increasingly creating beds in nontraditional settings: In NYC, the Javits Convention Center has slowly begun to receive patients at its 2,500-bed facility. Field hospitals are being set up in cities across the country from Seattle to Miami to Chicago.
Louisiana’s facility is one of largest in the country and one of the first to accept patients. Its existence alone serves as a warning to residents, said Kanter, standing in a nurse station during a tour of the facility on Saturday.
“If anyone is at home and is wondering whether it’s time to let up on distancing and isolation,” Kanter said. “This here should be a message that it’s not time to let up. Look at what’s happened here, look at the magnitude of this. We are still very much in this — in fact, we haven’t even hit halfway.”
The Biggest Need: Hospital-Level Care
There are limits to how much the new medical monitoring facilities can do, because of supplies, staffing and the severity of the disease. The state’s biggest need for COVID-19 treatment continues to be hospital-level care, rather than the lower-intensity care that the medical monitoring sites are equipped for. Plus, the medical monitoring site won’t be able to accommodate patients that need ventilators, which remain in short supply.
“First and foremost is that we’re not going to have enough ventilators to make a difference in this. The point of [the convention center] is to offload the hospitals enough so that they have the capacity to care for the sickest of the sick,” Kanter said. “So, if they don’t have enough ventilators to do that, it’s going to be all for naught.”
The state obtained 390 ventilators so far from the federal government and private vendors and projects that it needs 1,000 more.
“What you have is every state competing amongst each other and competing with private hospitals all in the private market to buy the same stuff and then the feds are coming in and they’re competing as well and outbidding,” said Kanter. “So it’s like this crazy flea market where everyone is bidding against everyone else and the product is lives.”
Accessing sufficient materials could pose a problem at the medical monitoring sites, too, as doctors across the state reuse and ration personal protective equipment. “There’s not a hospital locally that I believe is not rationing,” said Joshua Denson, pulmonary and critical care physician at Tulane Medical Center.
He has firsthand experience with the crisis. Denson diagnosed Louisiana’s second case of COVID-19 in the second week of March. Since then, the crisis has rapidly escalated, and beds in his hospital have filled up at an unprecedented rate.
“We don’t have that many leaving,” Denson said. “There are some people getting better but honestly, if you’re in the ICU, it’s really bad. I would say in general, most people just don’t get better no matter what we do.”
The average mortality in the ICU tends to be somewhere around 10 to 15%, he says, but now he’s seeing a mortality rate in the ICU over 50% for COVID. Most of Denson’s patients have been between 50 and 80 years old, but he’s had many patients in their 20s and 30s, too. Denson and his colleagues are using a range of ventilator strategies with patients, including prone ventilation, in which ventilation is delivered to patients lying on their stomachs. “Usually what we do works. Nothing works as well as I’m used to, I guess,” Denson said.
Hospitals are expected to begin discharging patients to the sites in higher numbers once they approach capacity, but if patients aren’t ready to leave, the discharge rate will be limited.
“Some of those higher-level-care patients — maybe nursing home facility patients — maybe do require more than what the medical monitoring station is able to care for at this time,” said Jeff Elder, emergency medicine physician at the University Medical Center of New Orleans.
Gov. John Bel Edwards (D) has also expressed concerns about staffing at the medical monitoring sites.
“This is really one of the hardest things about standing up these stand-alone medical monitoring hospitals like we’re doing in the convention center — you still gotta be able to staff it and so you gotta be able to find the doctors and nurses, which are very difficult things to do,” Edwards said during a press conference last Friday.
The convention center is being staffed through San Antonio-based nonprofit BCFS Health and Human Services. A Navy medical detachment arrived in New Orleans from Jackson, Florida, over the weekend to staff the small facility across the street. Volunteers coordinated by the Louisiana Department of Health are expected to arrive on the site in the coming days. Tulane University has opened up hundreds of dorm rooms to accommodate volunteers from other states.
With current projections based on severely limited testing, the exact needs and challenges facing the sites for now remain unknown.
“Essentially it’s going to be the single largest expansion of hospital capacity that the state has ever seen,” said Kanter in an interview last week. “This has never really been done before — there is no published playbook for how to turn your municipal spaces into hospitals. So, we’re learning a lot as we go.”
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