It can be easy to forget, considering all the COVID-related information deluging us daily, but the entirety of the U.S. pandemic response came down to ICU statistics.

Phrases like “flatten the curve” and “slow the spread” became ubiquitous in March and April of 2020, as New York City endured the country’s first deadly wave of COVID-19 and the rest of the country braced for more. Those strategies—flatten the curve and slow the spread—were intended to do one thing: avoid overwhelming hospitals with a surge in cases all at once. And that came down to ICU statistics.

What was our country’s ICU bed capacity, what percentage of those ICU beds were occupied, and in which communities? Those were the most important questions of the day and perhaps the year.

The goal, indeed the entire point of social distancing, as we were admonished over and over at the time, was to avoid a surge in cases so steep that hospitals ran out of ICU beds. March was full of warnings:

“Yep, as soon as we start testing US numbers are going to spike. It’s pretty clear that there has long been widespread community transmission in the United States. Again, the risk we face is that hospitals will get slammed and we will run out of ICU beds.” –Zeynep Tufecki, via Twitter, March 1, 2020

“Biggest risk in coming weeks: US cities produce so many critical cases that hospitals are overwhelmed. This creates a doom loop in which care quality suffers and mortality spikes.” –Jeremy Konyndyk, Executive Director of the USAID COVID-19 Task Force, via his personal twitter account, March 8, 2020

“So Italy, a well-off European country with 12th largest GDP in the world, is triaging ICU beds by likelihood of survival. It’s called catastrophe medicine. There isn’t enough to go around, and they have to choose who gets an ICU bed.” — Zeynep Tufecki, via Twitter, March 11, 2020

The goal? Don’t let that happen here.

The statistics on ICU capacity heading into COVID

In February 2020, physicians at Johns Hopkins and Georgetown Medical Center published a review of U.S. hospital and ICU capacity that went on to serve as an anchor for many of the “flatten the curve” graphs we saw in the weeks following. The authors, Eric Toner, MD, and Richard Waldhorn, MD, estimated the U.S. had approximately 46,500 medical ICU beds, and perhaps an equal amount above that available for ICU capacity in a crisis. The problem, they noted, were the projections for how many would be needed if we did nothing:

“These may be the best tools we have at the moment,” Toner and Waldhorn wrote. “But, they differ by more than 10-fold in the number expected to need hospitalization, intensive care, and mechanical ventilation.”

At the time, we didn’t know what percentage of people who caught COVID-19 would require hospitalization and what percentage of those would need mechanical ventilation or an extended stay in the ICU. But the projections were potentially grim indeed. If total ICU bed capacity in an emergency was around 90,000, then even the moderate scenario projected above would mean twice as many patients in need of ICU beds as there were beds to go around. And the “very severe scenario” described above is precisely why healthcare leaders urged us to “slow the spread” and “flatten the curve.”

It wasn’t just trying to limit the ICU beds needed, of course. Toner and Waldhorn cautioned us to contain the spread of the virus to “protect the healthcare workers and, thus, maintain a hospital workforce” to care for both COVID patients and non-COVID patients alike.

Hospital capacity and ICU statistics during COVID

At the virus’ peak in the U.S., approximately 30,000 people were filling ICU beds, with more than 100,000 hospitalized:

Source: Washington Post

The U.S. did, in fact, endure a tragedy unprecedented in our lifetime. However, we must also remember that, in a very real sense, it could have been much, much worse. U.S. hospitals, after the initial outbreak in New York, were for the most part not overwhelmed because we did slow the spread and flattened the curve.

The pandemic reached different parts of the country at different times. In many hospitals, beds and clinical staff were devoted almost solely to caring for COVID-19 patients for weeks. But, we never experienced care rationing on the level of Italy or—a far worse example—India in the early months of 2021.

This visualization, by, showing new U.S. COVID-19 cases over time, serves as a proxy for both hospital utilization and ICU surges from March 2020 to February 2021.

The clear takeaway from this is that surges happened in different parts of the country at different times, down to the city and county level.

The lessons of ICU statistics during COVID

The first lesson is that, in some sense, our healthcare system did rise to the challenge of COVID-19. Despite everything, our system adapted in ways that would have been difficult to fathom just a few months earlier, notably by rapidly expanding virtual care, including teleICU.

The second lesson is that, despite heroic efforts, it is true that an overwhelmed ICU does lead to increased mortality—even in the U.S. Several studies from around the world have confirmed this, including this one which analyzed mortality rates in Veterans Affairs hospitals in the U.S.

Finally, the third lesson is that we should think of our national ICU capacity as a system, one in which specialists from one location might leverage teleICU platforms to assist in caring for critically ill patients in another area. In Intensive Care Medicine in March 2021, more than a dozen authors from multiple countries emphasized the importance of a coordinated, system-wide response to critical care management. Individual hospitals that attempt to manage a surge in critical care cases without a coordinated strategy will be less successful. The authors recommend that “…the critical care response must be nested within a coordinated, system-wide delivery model. This includes strategies for relaxing or tightening ICU admission/discharge criteria so as to ‘spread’ disease burden optimally across the system.”

Just as ICU capacity waxed and waned during the pandemic, our ICU staffing strategy should be able to scale up or down, and specialists who connect virtually should be able to see patients wherever they are in the country.

As SOC’s Chief Medical Officer Dr. Jason Hallock wrote early in the pandemic, “We are dealing with a national challenge in hospital capacity management.” A big part of the solution, he wrote, then as now, is telemedicine.


For more on teleICU and how it can aid in hospital capacity management, read How teleICU Solves the Challenge of Cost-Effective ICU Staffing.

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