Houston’s approach is a model for how hospital systems should handle intense case surges.
As data out of Houston, the epicenter of Texas’s coronavirus outbreak, began to show a surge in cases and hospitalizations at the end of June, the doomsday projections began in full force.
“Three weeks from now, if these trends continue, the city’s I.C.U.s will be overwhelmed . . . the storm has arrived in Houston,” a local doctor wrote in a June 26 piece for The New Yorker. “It’s Like New York ‘All Over Again,’” blared a July 4 headline in the New York Times. Two days later, science reporter Donald MacNeil warned during an episode of the Times podcast The Daily that “in Houston, doctors who knew the situation in New York are saying that what’s happening there looks like what happened in New York in early April.”
And as the Texas Medical Center (TMC) reported 446 new coronavirus hospitalizations on July 5 — a record-high — the fear intensified. But, more than a month later, the numbers tell a different story.
Following its record-high spike in daily hospitalizations, TMC has seen a steady decline over several weeks, with Monday’s 127 new COVID hospitalizations marking the system’s best day since June 14. Data from the Southeast Texas Regional Advisory Council (SETRAC) shows that Harris County’s coronavirus bed census has been nearly cut in half, from almost 4,000 confirmed and suspected COVID hospital cases on July 15 to 2,083 on August 10.
Why, then, were the comparisons to New York and the predictions of mass-hospitalization made in the first place?
To get a better picture of what actually happened on the ground, National Review spoke to over half a dozen doctors and administrators in Houston’s public and private hospital systems. Ultimately, a number of key factors — and some good fortune along the way — explains why Houston’s COVID death-count represents just 6 percent of New York’s.
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On March 3, as New York City confirmed its second coronavirus case, TMC CEO Bill McKeon had already begun a daily coronavirus conference call for the city’s hospital CEOs. “We started planning that far in advance, so we were very confident of our capacity and our plans,” he told National Review. The collaboration set a precedent, as calls between the hospitals’ chief operating officers and their human-resources and critical-care departments became routine.
With 49 member institutions across the public and private sectors, TMC is the world’s largest medical complex and represents a large portion of Houston’s sizeable health-care system. TMC, which usually treats over 10 million patients a year, gave Houston a massive advantage in the COVID fight with its size and resources. The large and well-integrated health-care system stands in sharp contrast to the starkly divided public and private hospitals that exacerbated the pandemic in New York City.
When Houston’s public-hospital system, Harris Health, began to run out of options amid the surge’s peak in mid July, TMC’s other hospitals pitched in to keep things under control by taking on patients and providing additional testing, according to Harris Health CEO Dr. Esmaeil Porsa.
“I honestly think without that degree of collaboration, I think the story would have been very different,” Porsa admitted. He said that, fearing the worst, he had even prepared the “kitchen sink option” of turning post-anesthesia recovery beds into additional ICU space, but was fortunately never forced to utilize that option.
“All the TMC hospital CEOs, getting together every morning to touch base over the data, trying to understand what’s going on, and creating a situation where we were already helping each other in terms of distributing patients, that, to me, has been the most significant part of this whole thing,” he stated.
Houston also had some good fortune. Unlike in New York, Houston’s surge took months to come to fruition. Early on, Houston’s 85-plus hospitals saw less than 100 COVID hospitalizations a day, a trend that continued for several months and gave the city’s hospitals vital time to prepare. At the same time, inpatient and outpatient procedures fell dramatically, in part due to a ban on “all surgeries that are not medically necessary,” which Governor Greg Abbott implemented on March 22. The pause on visits, coupled with the slow burn of cases, allowed Houston’s hospitals to gain experience with treating the virus — as well as to gain a secure handle on PPE.
“We were desperately trying to get on top of the supply chain for the personal protective equipment,” Dr. James McCarthy, executive vice president and chief physician at Memorial Hermann Health System, explained. “We couldn’t go burning through all of our masks and gowns doing ambulatory elective surgery when we needed them in the hospitals.”
And the reliable supply of PPE, much of which is now sourced locally, has paid off. Multiple doctors who spoke to National Review stressed that with the proper gear and the proper precautions, COVID-19’s threat could be mitigated.
“If you wear a mask, maintain six feet, and wash your hands, we’re going to be okay,” Dr. Glenn Davis, an internist and pediatrician who runs a private clinic on the north side of Houston, stated. “It really is that simple. Basically, I bathe in coronavirus all day. I’m bathing in coronavirus, and I haven’t gotten it yet, and neither has my family. Because I wear my mask, I maintain six feet, and I wash my hands.” Davis added that “90 percent” of the patients he has seen contracted the virus because they were not careful. “I could pretty much tell you where they got it,” he said.
Dr. Reynolds Delgado, a cardiologist at Baylor St. Luke’s Medical Center who handles “the really bad COVIDs,” said he has closely examined patients “multiple hundreds of times,” and has been perfectly fine with an N95 mask. He added that none of St. Luke’s six infectious-disease doctors have gotten sick, despite examining “every single COVID case” since the pandemic began — an anecdote the hospital confirmed as accurate.
“The masks really do work. That’s the point of all that,” he stated.
Abbott eventually allowed his state to begin reopening in May, after a New York–type surge never materialized. As Memorial Day rolled around and Texans resumed life as normal — largely without masks or social distancing — Houston’s health professionals saw the impending wave and prepared accordingly.
“The modeling told us it was coming, and we were able to prepare fairly well,” Dr. Pat Herlihy, head of critical care at St. Luke’s, told National Review. To prepare for the surge, TMC began rolling out additional ICU spaces by refitting units and recommissioning older facilities. Additional staffing, including traveler nurses, were brought in, and some doctors and nurses within the system were reassigned to boost critical care. While Herlihy said the prospects were “intimidating,” having months with the novel virus before the real wave hit proved invaluable.
“Surge One, we were very nervous, we didn’t know we could handle the volume, the acuity, new disease,” he stated. “By the time Surge Two came around, we were much more practical, focused, and it was much more systems management than this looming catastrophe.”
As TMC’s daily hospitalizations surged past 250, Abbott decided to pause reopenings, and pulled the trigger on a statewide mask order. Houston’s hospital leaders gave him credit for being willing to change course when the moment demanded it.
“Our governor made a great decision to pull the trigger on this before the Fourth of July weekend,” McKeon said, adding he believed Abbott has been “very data-driven in his approach.”
“I really do think that the mandatory wearing a face mask in public was the catalyst to get things turned around,” Porsa told National Review.
The comments offer a different image than how much of the press has painted the Texas governor — “If the virus has presented a leadership test, Abbott’s metrics are getting worse,” the Texas Tribune reported last month.
And compared to the fawning national coverage of New York’s Andrew Cuomo, who was provided the opportunity for months to be interviewed by his brother, CNN host Chris Cuomo, without questioning over New York’s alarming rate of nursing-home COVID deaths, the differences are even more glaring.
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Facing the surge was no small task. But Houston’s months-long experience of treating COVID, coupled with the observation of the virus in other cities, taught the doctors much about how to handle the virus effectively, including how and when to deploy ventilators.
“When this first started, anyone who got really sick from a pulmonary pathway, we put them on a ventilator early. And we’ve learned that if we can keep them off the ventilator, they do much better,” McCarthy said, explaining that doctors had shifted to more “non-invasive ventilation” treatments, like BiPAP and CPAP machines, which are commonly used to treat sleep apnea.
“I think that’s really, really helped us in terms of outcomes,” Herlihy added. “Ventilators in this particular pathology really can hurt the lungs.”
In New York, an April study found that 88 percent of COVID patients who were put on a ventilator ultimately died. But Herlihy said that Baylor St. Luke’s has slashed its mortality rate from 23 percent overall on March to 9 percent in July, in part by changing its treatment strategy. He said that the hospital’s mortality rate for patients on ventilators is “somewhere in the 30 to 35 percent range.”
“I’ve been doing this for a long time, 35 years, I’ve never seen a viral pneumonia act like this — it damages the lungs but it really damages the pulmonary vasculature all over the body, a really different thing than what we’ve seen before,” he told National Review. “In medicine, the way we operate is we spend ten years doing randomized control trials. And then we have another five years of expert bodies going over it, and they come out with standardized recommendations. That’s how we operate, but in this — the acuity, the volume, the fact that it was very new and different — we didn’t have luxury of time to really operate in that way.”
With time of the essence and a complete dearth of knowledge surrounding the virus, Houston’s doctors have benefited immensely from the city’s status as a hub of medical research.
According to McCarthy, Memorial Hermann is involved in “over 30” clinical trials of experimental treatments, with the hope that a new antiviral coronavirus treatment will be available in the next one to two months. Additionally, doctors have been working with experimental treatments such as Remdesivir and blood plasma from recovered COVID patients — albeit with mixed results.
“Remdesivir barely works. It’s very weak in its effect, which is unfortunate,” Delgado said. “The convalescent plasma definitely works — very important. I’ve personally seen that saved many lives.”
“We have not seen a lot of success with plasma, we have done a lot of it. I can’t honestly tell you that it has been a ‘wow’-type treatment. I know that we are continue to use Remdesivir, even that, it has not been a life-saving medication, let me just put it that way,” Porsa added.
But across the board, doctors told National Review that the implementation of steroids such as Dexamethasone were helping — Delgado called the treatment a “game-changer.”
“We’ve really figured out optimal timing of steroids, so we absolutely think the steroids are helping,” McCarthy stated.
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Overall, Houston’s collaborative and innovative approach demonstrates a clear model for how hospital systems can handle intense surges — despite the pressure, TMC never surpassed 25 percent of its surge capacity. Even with the positive developments, however, there were still issues.
Early on, hospital coronavirus testing took two days to return results, forcing staffs to make judgement calls on suspected cases and heightening concerns that non-COVID patients could be unwittingly exposed during emergency-room visits.
According to McCarthy, Memorial Hermann saw a 30 percent decline in the number of heart attacks and strokes it saw during April and May. “There’s nothing about COVID that protects people from heart attacks and strokes,” he stated.
By Surge Two, TMC — which runs its own testing — had cut the lag to an average of two to three hours. “Anybody who comes into the hospital is tested,” Herlihy told National Review. “We know pretty quickly if it’s COVID or not COVID, and that allows us to route them correctly and keep those infection control walls up for their sake, our sake, other patients sake.”
But the initial logistical shortcoming — coupled with apocalyptic headlines like NBC’s “‘All the hospitals are full’: In Houston, overwhelmed ICUs leave COVID-19 patients waiting in ER” — led to a spiraling crisis.
“All of that was overblown. We never even got close to capacity,” Delgado stated. “It’s just crazy. Crazy, crazy, out of control, overblown stuff. It’s fear, basically. It’s a fear-factor so the patients, particularly older patients, are afraid to death to do anything. There’s elderly people with chest pain staying at home and just dying, or coming in late — someone brings them in — they’ve already had a big heart attack. A lot of that is going on, and it’s really unsettling.”
“Hospitals are probably the safest place you can go to. If you’re worried about contracting coronavirus, hospitals are extremely safe — they’re safer than a grocery store, they’re safer than a restaurant,” McKeon added.
Davis told National Review that he estimates 5 to 10 percent of his patients are choosing to avoid necessary treatment. “The longer you let that go, the bigger the number will get,” he warned.
“We always had the idea that we would not be overwhelmed quickly like New York,” Delgado said. “A lot of people got infected very quickly in New York because the population density there is just many orders of magnitude greater than Houston, Texas. That is the problem, the problem is all of them getting infected at a short period of time. That’s the problem, and that’s what screwed up everything in New York. That never was going to happen in Houston.”