The news was suddenly bright: An updated model released Monday projected that Tennessee’s hospitals could handle an anticipated rush of COVID-19 patients — with plenty of beds, ICU beds and ventilators to spare.
Coronavirus had ravaged China, Italy, then Washington State and New York. It seemed Memphis was waiting — and preparing for — its turn.
But Gov. Bill Lee’s April 2 stay-at-home order prompted the Institute for Health Metrics and Evaluation (IHME) to downgrade its expectation of how hard and how soon the coronavirus would hit the state.
The new model moved the peak earlier — to April 15 — and predicted that the state would need about a tenth of hospital beds, ICU units and ventilators initially anticipated.
But barely 24 hours after IHME’s optimistic predictions generated hopeful headlines, city officials and local experts expressed doubts, noting that the model’s assumptions were “unrealistic,” even calling the model itself “junk.”
City of Memphis chief operating officer Doug McGowen said Tuesday he was skeptical of a revision that the surge “was not going to be as bad as we originally thought.”
Speaking at the April 7 Memphis-Shelby County COVID-19 task force briefing, McGowen said he’s “suspect” of any data that changes so dramatically overnight.
On April 1, the IHME model predicted that an April 19 peak for hospitalizations in Tennessee would require 15,618 beds, 2,428 ICU beds and 1,943 ventilators. Its April 6 update was dramatically different: Cases would peak on April 15, requiring just 1,232 beds, 245 ICU beds and 208 ventilators statewide.
“I was surprised because we’ve looked at that [IHME] model for two weeks and said, ‘Boy, this is just junk,’” said Dr. Jon McCullers, Pediatrician-in-Chief at Le Bonheur Children’s Hospital and professor at the University of Tennessee Health Science Center (UTHSC). “It doesn’t work at all. The models we’ve looked at [had] worst-case, [where] you’re looking at 2,000 to 4,000 deaths and a bunch of hospitalizations.”
The new IHME projections estimate 617 deaths statewide by Aug. 1.
With the stay-at-home orders in place in Memphis and Shelby County since March 24, and now statewide, local leaders hoped to see the curve flatten in coming weeks, especially compared to what would happen without social distancing being observed. But, the IHME report was still unexpectedly positive.
“We thought with all the social distancing, you cut that pretty significantly, but nowhere near as optimistic as [IHME’s model] came out,” McCullers said.
IHME’s April 6 update assumes 100% compliance with social distancing statewide through the end of May. Some city leaders don’t consider that level of participation to be realistic.
“We all know that [100% compliance] is not occurring today,” McGowen said.
The rosy IHME model presents two challenges to the city as it prepares for its own time in the clinch with peak COVID-19.
First, if it fails to portray what’s coming, leaders cannot adequately prepare. Local officials are working to validate the IHME model’s findings, and they are considering other models, including a hospital capacity model expected soon from Vanderbilt University as well as their own projections.
Relying on one model is “not a good idea,” said Dr. Manoj Jain, an infectious disease physician and UTHSC assistant professor who is advising Memphis Mayor Jim Strickland on the coronavirus response.
Second, premature good news can actually hurt matters in the long run. If residents slack off social distancing measures now, expect infection rates and hospitalizations to soar in two weeks, Jain said.
“Headlines can be quite deceiving,” he said. “I’m very concerned about us taking our foot off the pedal.”
A collaboration of The Commercial Appeal, Memphis Business Journal and MLK50: Justice Through Journalism recently surveyed local hospital systems to determine the current number of hospital beds, ICU beds and other key metrics.
Using those figures, the collaborative applied the two most commonly cited models — which account for numerous variables such as social distancing measures in place and rates of infection spread — to determine if Memphis’ health care system is prepared to handle the coronavirus peak.
If hospitalization rates for coronavirus patients in the Memphis metro continues on an upward trajectory, it will take about two to three weeks before the area’s 500 ICU beds are full and local hospitals have more COVID-19 patients than they can care for.
The analysis revealed a grim prognosis for meeting pandemic-level hospitalizations under more dire scenarios.
It’s a long way from the favorable picture painted Monday.
‘All models are wrong, but some are useful.’
FiveThirtyEight.com’s headline on a March 31 story — “Why it’s so freaking hard to make a good COVID-19 model” — encapsulates the difficulty in predicting COVID-19 infections, deaths or even hospitalizations.
A wide range of data variables — along with assumptions and flaws in that data — go into a model. And, variable is the right word, since infection rates, contact rates, even data collection can differ by locale.
Then, adding in the measures taken to stop the spread of the coronavirus, such as business closings and restricting residents’ movement, creates even more fluctuation in a model.
An analysis of that data using various coronavirus simulators — primarily models from IHME and the University of Pennsylvania — illustrate the significant effect social distancing has on hospital-bed needs.
The COVID-19 projections by IHME, developed at the University of Washington, are frequently relied upon by decision-makers from the White House to statehouses to untold scores of municipalities nationwide.
One simulated scenario — with no government-mandated social distancing out of four variables — tabulated on March 30 using the IHME model indicated needing 10,000 beds and 2,200 ICU beds in the Memphis metro at a peak COVID-19 date. That was extrapolated using the model’s results for Tennessee.
A similar scenario was entered into the University of Pennsylvania’s COVID-19 Hospital Impact Model for Epidemics (CHIME), which was developed to assist hospitals and public health officials in planning for hospital capacity needs.
Variables such as the metro population and social distancing, plus known hospitalizations for a hypothetical 100% market share hospital, predicted a need of 11,000 hospital beds and 1,900 ICU beds at COVID-19 surge peak.
But, if two of the four social distancing variables were added to the IHME model’s calculation — as they were on April 1 — the total beds and ICU beds needed in the metro dropped by 20% to 8,000 and 1,700, respectively.
Closure of educational facilities and of non-essential services register in the model to create those potentially lower hospital resource needs.
But, IHME has come under scrutiny from national experts.
In an April 6 Washington Post article, IHME’S stark deviation from other models was noted, as well as states scrambling to create their own models for guidance. A local model used in Washington, D.C., predicted needing 1,453 ventilators on a peak day; the IHME model predicted needing only 107, the Post said.
The State of Tennessee is working with Vanderbilt University on its own COVID-19 model but has cited the IHME model as a guide, as have other states.
Tennessee Gov. Lee’s stay-at-home order was a heavily weighted variable in the IHME model, based on the significant drop in hospital capacity needs the update reported.
Adding a third variable — Tennessee’s statewide stay-at-home order — translated to hospital needs on an April 15 peak dropping down to an estimated 700 hospital beds and 200 ICU beds in metro Memphis.
Social distancing is vitally important, but McCullers thinks the latest IHME model for Tennessee moved too far away from local projections that are based more on real-time data.
The news organization collaborative analyzed the current hospital capacity at Memphis’ largest medical systems — Baptist Memorial Health Care Corp., Methodist Le Bonheur Healthcare, Regional One Health and Saint Francis Healthcare.
One dire but realistic projection: 40% of metro area residents test positive for the coronavirus. More than 500,000 of the metro’s 1.3 million residents would have the virus, and, of those infected, 20% would require hospitalization, with 3% landing in intensive care units.
In 2018, the metro’s hospital bed count was relatively static compared to now, but current counts indicate there are about 100 more ICU beds and 200 more negative pressure rooms in place to face a COVID-19 surge.
McCullers’ model involves curve fitting to similar cities with the number of cases seen locally so far. His current calculations put the local surge in cases arriving the third or fourth week of April.
However, even with a later surge in cases in the metro and his view of hospital capacity needs — in the middle between the IHME model’s optimistic projections and an overwhelmed health care system — McCullers still sees capacity issues looming from COVID-19.
“I do think we’re going to exceed our capacity. … I just don’t think it’s going to be quite as bad as some other places,” he said.
Being about two weeks behind other metro areas provides Memphis with an opportunity to see what a patient surge looks like and what needs to be done to prepare, McCullers said.
Memphis has a much lower population density than a city like New York, which can aid in slowing the spread of the virus.
But, that doesn’t mean Memphis is out of the woods.
“We’re getting it a little bit later, so we can prepare a little bit more. We know what it’s going to look like,” McCullers said. “Maybe we took it seriously and did things earlier, though I’m not sure if that’s true.”
The first lab-confirmed case in Shelby County was announced by public health officials on March 8. Since then, the daily increase of confirmed cases has risen by an average of 29%.
That mirrors the rate in Tennessee, which reported its first case March 5, but it’s higher than the national rate, which has climbed 21% per day since the first case was made public Jan. 22.
A March 23 presentation given by Jain and Shelby County Health Department Director Alisa Haushalter to local officials prompted the “Safer At Home” orders and outlined how many hospitalizations and ICU stays would be seen if 1%, 14% or 30% of the metro area — including portions of Mississippi’s DeSoto and Arkansas’ Crittenden counties — were to be infected.
If 1% were infected, 675 hospitalizations and 338 ICU admissions would be expected in the next 12 months.
If 30% of the population were to be infected — which would mean many people ignore the shelter at home orders — more than 81,000 hospitalization and 40,000 ICU admissions would be anticipated over the next year.
According to an analysis by the Harvard Global Health Institute, if 20% of the Memphis metro area were to become infected over the next 12 months, it would push local hospitals to their maximum capacity. If more than 20% of the area were to become infected, or 20% become infected in less than a year, hospitals simply would not have enough beds for all the patients.
“Based on those [projections], if we were just like them, then we’d expect in the next couple weeks, two to three weeks at most, to be like New York City, where the hospitals are full of patients,” and we’re seeing more deaths, McCullers said in late March. “Maybe not even that long.”
‘This virus is not going away’
The timing of a surge in metro COVID-19 patients is crucial for the local health care infrastructure.
If 40% of residents contract the coronavirus, but it’s spread out over a longer time frame, hospitals can pivot resources.
Coming in a large, concentrated surge could overwhelm hospital capacity.
“If that 40% happens in the first month, then there’s a huge problem,” Jain said. “If it happens over six to 12 months, then we can manage.”
Under such a near worst-case scenario, 10,000 hospital beds and 2,000 ICU beds would be needed to handle a late-April metro peak of COVID-19 hospitalizations — twice as many total beds as are available in the eight-county area and more than four times as many ICU beds.
To remedy this looming shortage of hospital capacity, the U.S. Army Corps of Engineers, the City of Memphis and Shelby County Government are building an additional temporary hospital facility at Gateway Shopping Center. That facility, on Jackson Avenue, is expected to hold about 350 beds, Shelby County Mayor Lee Harris said April 7. Construction is expected to be done by April 27. Other temporary facilities are being planned, as well, that would collectively give the metro 1,000 additional beds to handle COVID-19 patients.
Even with that sizable addition of hospital beds, Memphis would still be about 5,000 beds short if it experienced a condensed surge of a 40% infection rate and a 20% hospitalization rate.
Le Bonheur’s McCullers said he and his colleagues have examined the rate of the spread of COVID-19 in areas such as Seattle, New Orleans and New York City. On March 28, he said Memphis could look similar to New York City in two to three weeks, with hospitals overwhelmed and death tolls mounting.
Averting such a worst-case scenario could come down to one of the few proven effective strategies for combating the coronavirus pandemic: social distancing, and lots of it.
However, McCullers said it’s too early to say if social distancing and shelter-in-place measures were put in place early enough to flatten the curve more effectively than some of the nation’s hardest hit areas.
The efficacy of social distancing is the key to how bad the peak is in Memphis, and how long it lasts, according to UTHSC’s Jain.
“The single most influential parameter on the curve of both the peak and the duration is the percentage social distancing,” Jain said. “If you do no social distancing and treat this like a regular flu season, where we really don’t make an effort [to curb it], then you see an astronomical peak.”
Jain believes the magic number for effective social distancing in the eight-county metro is 65%. At that level of isolation and other measures, the reproductive rate for the coronavirus drops below one person infected by each person who is ill.
At the usual rate of spread, each infected person gives the virus to more than two other people.
For people who do experience non-mild symptoms, cough and fever come first and it could be a week before significant lower respiratory problems start. That could last for a week or two, McCullers said, before patients feel the worst of the illness, and then it could be an additional week or two before recovery.
If local social distancing guidelines are not followed, the coronavirus could overwhelm health care infrastructure, from bed capacity and supplies to doctors, nurses and other hospital staff.
“It’s up to the people to recognize and realize the betterment of their community is at stake,” Jain said. “Buying time is so valuable.”
However, preparedness does not mean Memphis hospitals will not be severely impacted.
Tennessee has enough physicians and beds to put it in the top third of the nation, according to Adam Johnson, a research analyst with QuoteWizard, a website that analyzes health insurance data. Johnson examined data from the Kaiser Family Foundation on the number of hospital beds and physicians per state to identify which states should be best prepared to handle a large, sudden influx of people requiring hospitalization.
But, New York state was also one of the best prepared states in the country, Johnson said, and has struggled to keep up with the surge of patients. It highlights the fragility of the medical system.
“It’s interesting to see that states that are best prepared could be reaching capacity soon,” he said.
Locally, the area’s four primary hospital systems all have extensive plans to cope with an influx of patients.
Baptist Memorial Health Care, which housed Shelby County’s first confirmed COVID-19 patient on March 8, has nearly two dozen hospitals across the region, including some as far south as Jackson, Mississippi.
“Having a hospital system with 22 hospitals gives us a lot of creative options to meet the need,” said Jason Little, Baptist’s president and chief executive officer. Those “creative options” include moving supplies among facilities.
While most hospitals are trying to empty as many hospital and ICU beds as possible in preparation for a surge of patients, Regional One Health’s status as the region’s only Level 1 trauma center makes that tough. Its adult ICU beds are spread between its trauma intensive care, general intensive care and burn center.
At the end of March, about 70% of Regional One’s ICU 40 beds were occupied, said spokesperson Angela Golding.
In anticipation of an influx of patients, Methodist LeBonheur Healthcare is adding 205 additional negative pressure rooms to its existing roster of 128 such rooms and can transition even more rooms to negative pressure if the need arises, spokesperson Sarah Farley said.
Each of Methodist’s four adult hospitals have COVID-19 units to isolate infected patients, Farley said. And, like most hospital systems in the area, it’s turned to telehealth visits to see patients by video.
Saint Francis Healthcare, the smallest of the area’s primary hospital systems, said it was confident in its infection control procedures.
“We can safely care for our patients with the supplies we currently have,” spokesperson Valerie Burrow said by email.
When the peak hits, and how bad it is, will be answered soon enough. But, riding out the peak will not give an all-clear to the city.
On top of getting through the initial spike in cases, which potentially could put hospitals at or above capacity for three to four weeks, McCullers said there would be subsequent waves of new infections.
“China got through the first wave by totally shutting things down, and they did a good job of that. But, as soon as they started to open things back up, they were hit with another wave,” McCullers said.
Asked on April 7 about potential subsequent waves of infection, McCullers said — if he had to predict — the Memphis metro will most likely have another wave in fall or winter of this year. Beyond that, he speculated the coronavirus could become more of a seasonal type of wave.
“The broader point is that we’re going to have more waves,” he said. “We have to prepare differently for the second wave than we did for this one, because we really didn’t prepare for this one, which is why we’re having to go to extreme measures.”
And, there’s another huge hole in knowledge as leaders try to fight the pandemic: How many people have the virus.
It’s difficult to know exactly how many people — in a region with a population of 1.3 million — have been infected, due to how little testing has been done up to this point, McCullers said.
McCullers said as many people as possible should be tested — starting with health care workers — to identify those who have recovered from the disease or were infected but asymptomatic and allow those people to return to work.
Currently, the capacity to test is about 1,000 to 1,300 tests a day in the community. But, McCuller said April 7 the need is closer to 2,000 tests per day, including the ability to do testing in underserved areas. Getting to that higher testing level may take a week or two, he said.
“To me, this is only going to be fixed by testing,” McCullers said. “This virus is not going away.”
This story was a collaboration between The Memphis Business Journal, The Commercial Appeal and MLK50: Justice Through Journalism.
In collaboration with High Ground News, MLK50 is running first-person essays from area workers whose income and livelihoods have been rattled by the coronavirus pandemic. Here are some of their stories.
This story is brought to you by MLK50: Justice Through Journalism, a nonprofit newsroom focused on poverty, power and policy in Memphis. Support independent journalism by making a tax-deductible donation today. MLK50 is also supported by the Surdna Foundation, the Racial Equity in Journalism Fund at Borealis Philanthropy, Southern Documentary Project at the Center for the Study of Southern Culture, the American Journalism Project, the Community Foundation of Greater Memphis, and Community Change.