Dr. Jennifer Clark fears her colleagues might soon be forced into “unspeakable decisions” if COVID-19 trajectories stay pointed skyward — who receives life-saving treatment, and who won’t.
Interim state epidemiologist Dr. Jared Taylor on Friday said he fully agrees with Clark — who presents data weekly for Project ECHO’s COVID-19 virtual updates — regarding her concerns about moving toward crisis staffing in health care.
Tier 4 of Oklahoma’s surge plan authorizes Crisis Standards of Care in hospitals, a guide to inform ethical decisions during “resource shortfalls” such as pandemics or natural disasters. Six of the state’s eight hospital regions are in Tier 3 of 4 since December began.
Taylor said he sees no indication that transmission of the novel coronavirus is diminishing at this point in Oklahoma.
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“The demands upon the health care system are enormous, and showing no signs of relenting,” Taylor wrote in an email response to questions.
Clark said one of the most difficult moments for a physician is to decide “the greater good” in who might receive life-saving care because they are most apt to survive and who won’t in midst of a lack of resources when hospitals become overwhelmed.
They didn’t go to medical school for that, Clark says, and her heart breaks to think Oklahoma is approaching that precipice.
“I’m worried that my colleagues who are in healthcare are going to have to practice under Crisis Standards of Care and make decisions that will haunt them and their patients and those families for years to come,” Clark said. “That’s what keeps me up at night — that it could all be preventable if we would all just pitch in.”
Clark serves as an expert on health care delivery sciences and former hospital administrator for Project ECHO’s COVID-19 sessions, a program of OSU Center for Health Science.
On Friday evening, the state reported a record low number of intensive-care unit beds available statewide in its point-in-time survey of hospitals. There were only 33 of 1,007 ICU beds — or 3% — available overnight Thursday.
The state has hovered between 4% to 6% ICU bed availability since mid-November, ranging from 43 to 60 available ICU beds.
The governor’s office directed questions about modeling and projections to the Oklahoma State Department of Health.
On Nov. 24, former interim state epidemiologist Dr. Aaron Wendelboe said modeling of Oklahoma’s data projects new daily confirmed cases could breach 8,000 by early January.
For perspective, the seven-day moving average was at 2,551 as of Friday, down from a record 3,318 on Nov. 27. Clark and Taylor agree the recent downward trend is an artifact of Thanksgiving reporting lags and other factors.
Clark said that if Wendelboe’s modeling pans out, then math reveals a bleak reality.
About 15% of all positive cases in Oklahoma are in the 65-older age demographic, she said. Out of 8,000 cases, that would equate to 1,200 people in that high-risk category becoming infected on a daily basis at this wave’s projected peak.
The worst effects would follow in the weeks after when subsets of those positive cases convert into hospitalizations and ultimately deaths.
Clark said new hospital admissions in the 65-plus age group could reach 360 per day, given that Oklahoma demographic’s 30% chance of being hospitalized. For context, the seven-day moving average of new daily admissions in all ages was 150 people on Friday.
The mortality rate is about 6% of those infected in the 65-older age bracket, she said, meaning that 72 per day could be expected to die under this scenario. Again in comparison, the seven-day rolling average of deaths across all ages was a record 22 on Thursday and Friday.
Clark’s projection for about 8,500 infections among the 65-older population in November came in low. The actual number was 9,500 positive cases, which she said is driving the COVID records last week in hospitalizations, ICU patients and average daily reported deaths.
“I’m not sure what word I even want to use,” Clark said of how to describe or characterize the pandemic in Oklahoma. “Dire is obviously the first one that comes to mind.”
Taylor took over the role of state epidemiologist after Wendelboe’s contract expired in August.
Taylor said he respects both Wendelboe and Clark and appreciates what each is doing for Oklahoma.
That being noted, Taylor said he doesn’t consider the projected number of diagnosed cases as particularly meaningful in the absence of other data or descriptors and that he cautions against extrapolations from the projection.
He explained that Oklahoma’s current test positivity percentage is in the mid- to upper teens, meaning “we are assuredly missing a large number of infections.” If the positivity rate were much lower, like 5%, then that would indicate the state is netting most of the cases in the population, he said.
He said he’s cautious himself making estimates, especially far into the future given that “a great deal” could take place in the next four to five weeks to change the trend.
“These thoughts are not intended to diminish the facts or concerns expressed by Drs. Wendelboe and Clark,” Taylor wrote. “Rather, it is simply to move away from me speculating on their methods or conclusions.”
Taylor said he would speculate that 15% of diagnosed cases being among individuals age 65 or older is an overestimate because the state is most likely to diagnose cases in people with more severe symptoms.
He does expect an increasing number of cases, hospitalizations and deaths.
“In the absence of notable improvements in our state’s situation, I would envision 60 to 70 deaths daily as not improbable for the end of January,” Taylor wrote. “However, that is a long time from now, and many factors could alter that course.”
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