Department of Veterans Affairs health leaders are preparing for a second wave of the coronavirus, coupled with complicated, lengthy recovery for some patients already infected with the virus.
Some of the sickest patients hospitalized because of the virus may need three to four weeks of intense rehabilitation care, according to VA.
Veterans Health Administration head Dr. Richard Stone told Connecting Vets he's weighing the need for space, ventilators, staff, medication and other resources for recovering patients with a resurgence of the virus later this year. VA is planning to have "about 600 patients as inpatients for COVID-19 all the way through the fall," Stone said, adding he believed VA has the capacity to safely handle that many, but is watching for a possible surge.
He's also balancing that with the need to begin reopening VA hospitals and clinics to appointments put off by the pandemic and stay-at-home orders nationwide.
Recovery for many of the sickest patients has taken place at VA nursing homes, Stone said, where occupancy for those in need of COVID-19 care is about 67 to 70 percent.
"But I'm watching that," he said. "I have the ability to restructure ourselves and create the room for longterm recovery."
Pulmonary recovery from COVID-19, especially in older patients, "is tough work, it's really tough work," Stone said. "I'm comfortable with where we are but make no mistake, if we hit a really big second peak like was seen in late 1918, we'll be in the need to really grow even further ... Early on in this we bought a very large number of ventilators ... I think I've got about 2,500 extra ventilators that have come in now and will be distributed across the country."
The flu epidemic of 1918 is the closest medical experts can come to evaluating how the COVID-19 pandemic might play out based on past experiences in the United States, Stone said, adding that 1918 saw a much deadlier second wave in the fall and winter.
"We'll be prayerful that there's not a second wave, but I don't think we can predict it," Stone said.
VA has hired thousands of new staff and expanded its capacity already to handle the pandemic, not just for veterans, but to fulfill the department's Fourth Mission, a mandate to serve as a last line of defense for the American healthcare system should hospitals be overwhelmed. VA already activated that mission to care for non-veteran patients in some of the areas of the country hardest hit by the virus.
The department recently deployed a 30-bed mobile ICU to Chicago, Stone said, to test it against major demand. The mobile unit can create its own oxygen supply using water, he said, and can deploy within two days. And that unit could come in handy, since converting stadiums or convention centers into hospitals to care for "really critically ill patients is a tough process," he said.
"This is not going to zero, any place," Stone said of virus cases nationwide.
Last week, prompted by a member of Congress, Stone revealed that his college-aged son had contracted the virus, but is recovering.
"My son... did very well," Stone said, emotional. "He developed bilateral pneumonia from COVID. (He) literally could not get out of bed for two weeks."
As of June 16, VA had 17,283 COVID-19 cases, 1,712 of which were considered "active" and at least 1,478 patient deaths. The rates of cases and deaths at VA have trended upward in recent weeks, though Stone said hospitalizations are not increasing.
Last month, VA leaders issued a memo to the heads of its hospital networks obtained by Connecting Vets warning them to prepare for "a significant surge" of COVID-19 patients who will need major rehabilitation care after being hospitalized for the virus and sharing details about what that could look like.
The memo urged hospital network leaders to expand their surge plans to include "creating and/or converting beds for post-acute care for COVID-19 patients."
Post-acute care is the recovery and rehabilitation stage. The memo said VA hospital networks should plan for recovery space that can provide "pulmonary rehabilitation" and other services to "convalescing COVID-19 patients" because of serious health conditions arising from the virus and intensive care treatment required.
Experiences at three VA networks so far "and other projections suggest that a significant surge in the demand" for rehabilitation care following patient hospitalization for the virus "is on our horizon," the memo said. Those networks were VISN 2, 10 and 16, which include VA hospitals in New York, New Jersey, Ohio, Indiana, Michigan, Louisiana, Arkansas, Mississippi and parts of Texas -- among the areas veterans were hit hardest by the virus.
And rehabilitation options "are already limited" because of "high demand and restricted admission policies due to concerns of facility infection risk," the memo said.
Patients who have been infected with the virus may require longterm rehabilitation care after being hospitalized and VA "estimates suggest three to four weeks or longer recovery," according to the memo.
Patients recovering from the virus are facing serious, complex health conditions that will require significant care after they leave the ICU, VA said.
Patients recovering from COVID-19 have "several debilitating complications from ICU/intubation such as delirium and encephalopathy; cardiopulmonary limitations; neurological limitations; renal failure and need for dialysis and decreased muscle strength -- and these symptoms have been found to last beyond the expected acute hospitalization stages," the memo said.
Stone described the minutes it takes to intubate a patient versus the nearly hour and a half it can take to place a COVID-19 patient on a ventilator, complicated by multiple factors including thick secretions "like putty."
Initial models suggested 30 percent to 50 percent of all COVID-19 patients treated for the virus in intensive care units will need rehabilitation care.
Once VA hospital networks identify "potential shortage" of rehabilitation beds, networks should find ways to "expand, convert or repurpose space to support" recovering patients, the memo said. Network leaders also were told to consider how to use home-based care and other "alternative settings" for particularly vulnerable patients "to reduce demand."
VA officials have repeatedly refused to provide information on VA's capacity, arguing such information is "sensitive in nature" but refusing to cite any specific statute or rule that would keep that information from the public.