Are metro Detroit hospitals prepared for the next COVID-19 wave?

As positive COVID-19 cases in Michigan increase to seven-day average highs not seen in more than a month, the looming question is whether hospitals are more prepared with staff, supplies, drugs, equipment and ICU beds for a second coronavirus wave.

Executives and physicians at several health systems in metro Detroit say they are more prepared now than in March and April for what they all believe will be another strong surge of COVID-19 patients in the coming months.

But the various predictive models that health systems rely on range from twice as many COVID-19 cases this fall that may again strain the health care delivery system to a simple slow burn of peaks and valleys of positive cases that the system has the capacity to handle.

At the height of the COVID-19 crisis in early April, Michigan hospitals were treating more than 5,200 inpatients, including more than 1,400 on ventilators. As of July 10, hospitals have 366 COVID-19 inpatients, up from 315 on July 2, the state said.

Over the past month, Michigan has seen increases in daily cases from about 262 on July 1 to 653 on July 11. The seven-day averages have increased to 451 July 10 from 150 on June 13 compared with a high of 1,632 on April 7.

On Thursday, a health care and business coalition advising Gov. Gretchen Whitmer released a statement that indicated concern over the rising positive COVID-19 rates in Michigan.

Tina Freese Decker, president and CEO of 14-hospital Spectrum Health of Grand Rapids, said "worrisome trends in Michigan" are emerging as other states, like Florida and Texas, have experienced serious outbreaks in recent weeks.

"We are seeing the early signs of an upturn in Michigan. We can lower our risk if we all work together," Freese Decker said. "We must continue to be vigilant by wearing masks, staying 6 feet apart and washing our hands."

Bob Riney, president of health care operations at five-hospital Henry Ford Health System in Detroit, said it is much more prepared to deal with another surge from an organizational standpoint. Henry Ford handled the second-largest number of COVID-19 cases in the state.

"We have made sure that we stockpiled 100 days of personal protective equipment and supplies based on maximum utilization so that we would not find ourselves in the (same) crisis (as before)," said Riney, adding that in March Henry Ford had 14- to 30-day supplies.

"We certainly remain very worried that certain things like isolation gowns and disinfectant wipes are still very difficult to come by," he said.

Nick Gilpin, D.O., eight-hospital Beaumont Health's medical director of infection prevention and epidemiology, said he is thankful COVID-19 cases have dropped significantly since the later part of April. Beaumont treated more hospitalized patients than any health system in Michigan.

"We prepared, but I don't know any amount of preparation back in March would have been enough. Since things have cooled down, we have had May and June to bolster personal protective equipment," Gilpin said. "I feel good about supplies. We have (more than 30 days) stockpile of supplies and we have secured more reusable N95 masks for our frontline staff."

But Gilpin and Riney said their biggest concern with a second surge is the impact it may have on staff and employees. They said Beaumont and Henry Ford have sufficient numbers of doctors, nurses and support personnel and a good staffing playbook for another coronavirus outbreak.

"The thing I am most worried about is the psychological and the emotional preparedness or readiness (of staff)," Gilpin said. "A lot of our staff are still fried. We've all been working extra hard even since COVID slowed down in Michigan.

"We all know it is inevitable there is going to be another surge and nobody's really taken a lot of time off to break from this mentally. So if we were to get hit again with another big wave, I think the amount of burnout you'd see among staff would be significantly greater than what we saw back March in April."

The health care workplace has long been known for its long hours, demanding pace and emotional intensity. Hospitals have tried to put in safeguards to address burnout and post-traumatic stress disorder caused by long-term stress reaction, but shortages of workers brought on by COVID-19 created almost impossible circumstances.

Jeff Desmond, M.D., Michigan Medicine's chief medical officer, said the academic health system learned many lessons from the initial COVID-19 surge.

"If we see increasing cases, and we are not seeing a big bump in hospitalizations now, we have our supply chains ready to respond," Desmond said.

Michigan Medicine, which includes the University of Michigan Health System's three Ann Arbor hospitals, accepted more than 300 COVID-19 transfers from metro Detroit hospitals in addition to its own patients.

"Every hospital was challenged with PPE, but we never ran out. We have a more detailed and rigorous way of supplying (PPE) than we did in the past," said Desmond. "Our hospital early on required masks for all. We have continued that policy for PPE for the pandemic."

The three health systems also have much greater ability to test patients and employees for COVID-19 testing ability for staff and patients.

"We have in-house (virus diagnostic) testing and also serology (antibody) tests now," Desmond said. "We test all patients who come into hospital whether symptomatic or not."

Riney also said Henry Ford has more experience setting up COVID-19 intensive care units and shifting staff around from ambulatory to inpatient to maximize patient support.

"We have very specific triggers as to what priority we would use to expand ICU capabilities if demand exceeded supply (on) a hospital by hospital basis," said Riney, adding: "Our clinical teams have continued to learn and evolve the best way to take care of and treat COVID patients."

But hospital officials say if COVID-19 hospitalizations start to spike again, they must take action to manage that influx along with thousands of patients they now have in their hospitals for elective surgeries and procedures that were postponed.

As Michigan set aside executive orders to stay-at-home and nonessential medical procedures in mid-June, hospitals began to ramp up services that are now between 60 percent to 80 percent of pre-COVID volume.

"We are in midst of that planning" to manage a more mixed patient population, Desmond said. "We can be a little more nuanced for services with cases and do more testing. We cohort those (COVID-19) patients and manage those and elective cases. We will see what decisions need to be made and adjust more nimbly as things progress."

Gilpin said Beaumont has since closed its COVID-19 ICU units, but could "flip a switch" and activate them again if the volume of coronavirus patients increase.

"We are managing things on a site by site basis, looking at capacity and judging if they have the bandwidth to performing elective surgeries or not," Gilpin said.

Riney said he hopes citizens wear masks and take common-sense precautions to avoid spreading COVID-19.

"We've run models that relate to (another COVID-19 wave) and what elective surgeries we would start to curtail," he said. "We just hope to avoid the wholesale shutdown of elective surgeries or other care because as we've all learned that prolonged deferment of care too long and ended up with more complicated situations."

Doctors have learned much about how best to treat COVID-19 patients. Deaths in hospitals nationwide have fallen by 50 percent since April and many attribute that to earlier treatment and limiting ventilator use.

Gilpin said mild COVID-19 cases presenting in the hospital are now handled differently. Patients are still evaluated closely, but doctors have learned to look for certain signs of deterioration.

"I personally believe the best place for people to recover is out of the hospital," Gilpin said. "Our protocols are guided toward stabilizing patients (in the ER), getting them off oxygen as quickly as possible and sending them home with instructions."

Standard treatment for moderate and serious COVID-19 cases also have improved based on hard-learned lessons.

For example, Gilpen said Beaumont documented improved mortality rates by reducing use of ventilators.

"We found out (by accident) that one of our eight hospitals performed better in terms of mortality and outcomes,," Gilpin said. "Our ICU capacity at the Grosse Pointe hospital was exhausted. We were actively trying to keep people off ventilators, purely for utilitarian reasons. We didn't know at the time, but that was the move ... keeping people off vents reduced mortality."

Desmond said Michigan Medicine also has learned to position patients face down when they require ventilator support for improved outcomes. "We have (heart-lung) bypass machines and found some success with patients needing oxygen," he said.

Gilpin said critical care doctors also use more the antiviral remdesivir and steroids such as dexamethasone, along with oxygen and fluids. Remdesivir, which raises blood levels of liver enzymes, has been used in the past to fight SARS and MERS.

Beaumont also is starting clinical trials on remsdesivir and convalescent plasma (COVID-19 antibodies in blood), he said.

Earlier this year, state and federal officials squabbled over responsibility to assist hospitals, doctors and other first responders on supplying personal protective equipment during the pandemic. There still is no resolution to the dispute.

And just in the past two weeks, COVID-19 cases have increasing in at least 40 states. Last week, the nation had its highest daily count last week at more than 60,000 positive cases, including 10,000 one day in Florida.

Hospital officials in some southern states say personal protective equipment is running low again as hospitalizations are rising, putting health care workers at risk of being infected by the virus.

"When I watch what is happening in Florida, I get flashbacks to when we were in the eye of the storm," Riney said.

But Jay Fiedler, the state's director of the division of emergency preparedness and response, said Michigan is better prepared from an increase in testing and diagnosis, contact tracing and personal protective equipment standpoint.

"No one knows what the future holds. We are looking at what is happening down south. It is very sobering," Fiedler said. "We are taking what is happening elsewhere into consideration and will do whatever we can to help support (health care providers)."

Fiedler said hospitals have more bed capacity, ventilators and have two large alternate care sites, including the TCF Regional Care Center in Detroit, that can open if necessary. Hospitals deluged by COVID-19 also can transfer patients to lower-volume facilities.

Michigan now has nearly a 90-day stockpile of supplies, Fiedler said. "We are on the open market (to purchase more supplies) and are working with vendors to create our own supply chain," he said.

Fiedler acknowledged the state was unprepared in March and April to support hospital and first responder needs.

"We had modest quantities of PPE from Ebola and left over from H1N1" outbreaks of several years ago, he said. "We pushed out what we received from FEMA and the national stockpile."

The White House has said that the national stockpile gave away 18 million N95 masks, all that it had by the end of April. It now has built up a supply of 36 million N95 masks with a goal of having 152 million masks by September and 314 million by December.

Gilpin said Beaumont has confidence the state has sufficiently ramped up its emergency management system over the past several months to support frontline workers and hospitals.

"I've been just disappointed with how politicized everything around COVID-19 has become," Gilpin said. "Everything from the masks, the testing and everything else you can think of. It does shake my confidence and how well our federal government can respond to a pandemic."

Riney said political and health care leaders should advocate more strongly for cooperation between all levels of government to improve supply chains.

"(Government) now has data that they can use to solidify the stockpile plans for both state and national levels," Riney said. "They may not have had the data or any understanding of the amount of PPE you can go through when you're in a pandemic. We know that now."