With weeks to go before the holidays bring families together, winter break sends students home from college campuses and colder weather forces people inside, Ohio already is setting record after record for newly reported COVID-19 cases as hospitalizations and fatalities climb.
Plus, the upcoming flu season, which typically brings a wave of hospitalizations, will add a layer of complexity.
Northeast Ohio hospitals have been preparing for these and other complications that the winter presents in stemming the spread of COVID-19.
Dr. Robert Wyllie, Cleveland Clinic's chief of medical operations, said he expects the challenges will be the most severe through December and January.
"I think we're going to have a rough six to 12 weeks," he said.
With more than 2,000 COVID-19 hospitalizations in the state, the current spike in cases is well above the April and July peaks, which each reached a daily hospital census of around 1,100 COVID-19 patients.
Ohio is not alone in the alarming rise in cases. The United States set its own bleak record in early November: surpassing 100,000 new confirmed cases in a single day.
These numbers foreshadow a likely growth in hospitals' COVID-19 censuses, given that hospitalization and death numbers lag a week to 10 days behind cases. The Clinic is at its highest census of hospitalized COVID-19 patients. Summa Health and University Hospitals are also nearing their peaks. The numbers show "no signs of plateauing," said Dr. Daniel I. Simon, chief clinical and scientific officer and president of UH Cleveland Medical Center.
The pandemic's initial anticipated surge here never reached the dramatic heights seen elsewhere in the country, and the bump in cases in the summer didn't pan out to be a stressor to systems, said Dr. John Baniewicz, chief medical officer for Lake Health. But what they're seeing right now is "somewhat unprecedented" and going up fast.
The past several months of the pandemic have given health care providers crucial time, experience and knowledge that will help them address this new surge.
Doctors have a better understanding of how COVID-19 is spread and have more treatment options for those infected, including the use of steroids and the antiviral medication remdesivir. They have found alternatives to ventilation and ways to shorten patients' length of stay in the hospital. Diagnostics have improved and testing capacity has grown exponentially. Plus, health systems have had months to be able to build up their inventory of personal protective equipment (PPE) and other resources.
"I think that the efforts in the spring have prepared us," said Dr. David Custodio, senior vice president and hospital president of Summa Health's Akron City & St. Thomas hospitals. "We're in a better position than we were then going into this fall resurgence and flu season."
Northeast Ohio's health systems have the needed PPE; they have the beds available and flex plans to add capacity. The problem could be in staffing and keeping providers healthy and able to care for patients.
"Staffing will be one of the great limiting factors that we have to consider," Custodio said.
Wyllie stressed that hospitals need the community's help in keeping their workforce healthy. Caregivers are getting infected at the same rate as the general public, indicating they're not getting sick in the hospital but in their communities, he said.
"If people will wear masks, then we can keep people working as the numbers go up," Wyllie said. "So it's not only protecting themselves and their relatives and people in their family, but it's also protecting people who are going to take care of them and others if they do get sick."
In addition to COVID-19 cases, hospitals are also preparing for flu season. Influenza and COVID-19 are not clinically distinguishable, said Dr. Amy Ray, MetroHealth's medical director of infection prevention. COVID-19's most common symptoms are consistent with an influenza-like illness with fever, cough and sore throat, said Ray, also an infectious disease doctor and health care epidemiologist.
She's hopeful for a mild flu season as she looks to the mild season experienced in the Southern Hemisphere, which usually signals the same for the North. Plus, the behaviors that reduce risk of spreading COVID-19 — hand hygiene, masking, distancing — can also slow the spread of influenza.
"In preparation for influenza season, coupled with the ongoing pandemic, we fully acknowledge that there will be an increased clinical demand for testing because of increased number of cases in the community, and so we have planned in advance for that, including the development of and expansion of testing guidelines internally," Ray said.
In past years, doctors could treat patients for the flu without testing them based on symptoms. But this year, it's critical that providers know exactly what they're dealing with, said Lake Health's Baniewicz, who's also a practicing internist.
Health systems are developing or obtaining testing methods that allow them to test for influenza A and B and COVID-19 in one swab. Some can also simultaneously test for respiratory syncytial virus, or RSV, a common virus that infects children.
"You're going to have to do this multichannel kind of testing, because we have to know more than we ever knew before," Baniewicz said.
Health systems are working together to make sure they're collectively prepared for whatever flu season, the COVID-19 surge and the winter might bring. Hospitals continue to communicate regularly about their PPE supplies, bed capacities and resource inventories, prepared to load balance across the state if necessary.
"What we won't do is let somebody get overwhelmed," Wyllie said.
But key in all of that is individual behavioral changes, which is the only way currently available to prevent transmission, Ray said.
"What we have to do is think about our individual activity and behaviors (and) keep the marathon thinking in place," she said. "We have to get through this together as a community."
For families getting together this holiday season, Simon urges continuing to practicing social distancing, masking and hand hygiene. He recommends keeping gatherings small and bringing back the "kids table" for returning college kids to sit separately when they unmask to eat.
As pandemic fatigue — or in some cases, denial — wear on everyone, compliance with public health guidelines is critical, Wyllie said. What this surge looks like will largely depend on the public's diligence in distancing, masking, washing hands and not congregating, particularly in large groups indoors.
"The question that we ask in terms of our own capabilities — and all the other major health systems are asking — is how high is it going to go? And how much is this going to stress the system?" he said. "We're at the end of this chain, so the public will decide the rate of infection eventually by their actions."