‘The Wolf Is At The Door:' How Missouri’s Garbled COVID Data Misled The Public Until It Was Too Late
As coronavirus infections grew exponentially in Missouri in the fall, many hospital leaders found themselves in the unusual position of explaining that the official state data about their bed space was wrong.
Though Missouri’s data showed that hospitals had plenty of beds available for patients, the numbers were inflated for months, in part because many hospitals themselves failed to follow reporting guidelines.
An analysis by KCUR found that the data remained uncorrected for weeks even after hospital doctors warned they had reached a critical point, leaving local leaders scrambling to respond after hospitals were nearly full. The data is used to determine local stay-at-home restrictions as well as gauge how hospitals are faring during the pandemic.
Today, Missouri hospitals remain near capacity even as they brace for an expected winter case surge, a situation that might have been avoided if the public had better data on hospitals, according to Ryan Panchadsaram, co-founder of the website "COVID Exit Strategy," which tracks COVID-19 data in the U.S.
“Every step of the way, if we could’ve had any of this information earlier and made more transparent earlier, it absolutely would’ve made a difference,” said Panchadsaram, the former U.S. deputy chief technology officer.
A Kansas City area nurse who treats COVID-19 patients describes the current mood in their hospital as “very bleak.” The nurse, who requested anonymity for fear of retaliation, said that the stress that many hospital providers have felt has been made worse by the lack of understanding of just how strained their facilities actually are.
“No one knows there are no beds,” the nurse said, “that we’re in this crisis, and we’re coming to a point where we’re going to be completely overwhelmed. But no one’s talking about it, and no one knows about it.”
Missouri governor’s use of encouraging data
During much of the fall, Missouri’s Gov. Mike Parson often talked about the capacity of hospitals during his regular briefings about COVID-19, assuring the public that the state was prepared.
“Of Missouri’s 22,000 hospital beds, 49% nearly, are still available,” Parson said at a press briefing in October. “I want to assure you that overall, our health care system is still meeting the demand.” The Missouri Department of Health and Senior Services data that Parson referred to also boasted of more than 2,700 intensive care unit beds, which are included in the total bed count.
Parson’s coronavirus briefings in the fall marked a change from earlier months, when he often cited lower case numbers and encouraging testing data that showed Missouri was far less affected by the virus than other parts of the country. But as new cases and deaths began climbing steadily since August, Parson shifted to focusing on hospitals’ capacity to handle the growing numbers of patients.
So in late October, when hospital doctors in Kansas City and St. Louis held their own briefings to warn the public that they were nearly full, they had their work cut out for them.
In a briefing on November 6, University of Kansas Health System chief medical officer Dr. Steven Stites explained that the data that was guiding leaders’ decisions provided an inaccurate picture of hospitals’ ability to handle patients.
“Our elected officials had information prior — and this is true around the country, unfortunately, and just a vagary of how [the U.S. Department of Health and Human Services] reported the data — but they were acting on information that showed them that there was not a shortage of beds,” Stites said. “And today, and over the last few days, we’ve been sharing with them that there is a shortage of beds, and we’re running low.”
Earlier in the pandemic, Missouri had put out much more conservative numbers of hospital beds.
For the first half of the year, public data on hospital beds and capacity was created for the state by the Missouri Hospital Association, and Parson had also referred to numbers in these reports, which are no longer publicly available, in his briefings and on social media.
In mid-June, Parson tweeted hospital association data showing the state had 10,795 medical/surgical beds and 2,129 intensive care unit beds. Only a fraction were in use at the time.
“This is GOOD NEWS. Our Hospitals are NOT overwhelmed,” Parson’s tweet read.
However, new case numbers quickly climbed higher, and three weeks later, Missouri’s hospital data disappeared.
A change in federal reporting, upending Missouri data
In mid-July, the Trump administration changed the way that hospitals report capacity data to the federal government. Instead of reporting to the Centers For Disease Control and Prevention, hospitals were directed to report to a system developed by TeleTracking Technologies Inc., a private company based in Pittsburgh.
Unlike in many states, Missouri’s hospital association and state health department depended on the federal databases for data from Missouri hospitals, and when the abrupt switch was made, the hospital association and the state lost access to their own hospitals’ data.
“All evidence suggests that Missouri’s numbers are headed in the wrong direction, and, for now, we will have very limited situational awareness. That’s all very bad news,” Missouri Hospital Association spokesman Dave Dillon wrote in an email to KCUR at the time.
Missouri appears to be one of few states — if not the only state — to be so affected by the federal switch. While only minor disruptions were reported in other states, Missouri reported no hospital data for more than two and half weeks, even as new cases continued to climb. Even now, Missouri’s archive hospital data remains blank for most of July.
The hospital association and others across the country urged the federal government to slow its implementation of the new system.
When the transition to the new system took place, Dillon said that the hospital association was looking into starting its own data collection system, so that it would not need the federal data. But that didn’t happen. The state and hospital association would continue to lose access to hospital data several more times when the federal system went down later in the summer and fall.
Data change drives dramatic spikes
Following the reporting change, the numbers of beds reported by the hospital association, and on a separate dashboard launched by the state health department, appeared to jump dramatically.
Under the new system, the Missouri hospital data counted essentially all physical beds within hospital facilities, a much larger number than the inpatient hospital bed numbers that had previously been reported.
This included psychiatric, obstetric, and outpatient beds, as well as pediatric beds, even though children comprise only a tiny fraction of patients needing hospitalization.
The expanded bed count was being reported “to provide a full sense of health care system capacity,” according to Missouri health department spokeswoman Lisa Cox, but hospital doctors say it would not be feasible for many of these beds to be used to treat COVID-19 patients.
“That clearly muddied the view of what we have available,” said Dr. Mary Anne Jackson, dean of the University of Missouri – Kansas City School of Medicine and an infectious disease specialist who serves on a COVID-19 task force that advises the governor.
And despite the apparent abundance of beds being reporting, at least two major hospital systems in Missouri were warning about capacity problems as early as September.
In late September, leaders of Springfield’s two large hospital systems, CoxHealth and Mercy, told the local city council that climbing case numbers were straining their bed capacity.
“We’re seeing the surge right now,” Mercy chief operating officer Brent Hubbard said. “We’re seeing a record number of COVID-positive patients being hospitalized, and that’s not just overwhelming our [emergency rooms], it’s overwhelming our inpatient staff and is a growing concern for us.”
CoxHealth senior vice president Karen Kramer said that the health care system was bringing in agency nursing staff from outside of the area to fill staffing shortages created in part by large numbers of hospital workers who were sick or in quarantine. Kramer and other Springfield leaders urged the creation of mask mandates in communities where they had not already been adopted.
Governor ignores White House task force urging mask mandate
A White House Coronavirus Task Force report issued days later identified Missouri as a “red zone” state. The state’s percentage of coronavirus tests coming back positive had risen to 9.2%, the eighth highest in the country and double the national average. Most Missouri counties had positivity rates exceeding 10%, indicating that not enough people were being tested to provide reliable data about transmission of the virus.
The weekly task force reports, which were not officially released to the public but KCUR obtained through public records requests, had urged Missouri leaders to implement statewide mask orders, boost testing, improve public data and take additional steps to limit transmission in nursing homes.
However, at Gov. Parson’s next COVID-19 briefing, which had been delayed a week because he had tested positive for the virus, the governor did not mention either the situation in Springfield or the White House report, and he did not take any additional steps related to the virus. He insisted that the “four pillars” of the state’s coronavirus strategy — improving data, protecting hospital capacity and boosting testing and personal protective equipment supplies — were well-managed.
“I want to assure everyone that all four of these pillars are stable,” Parson said. “We monitor this every day, and we are constantly working to improve.”
A week later, on October 6, the federal Health and Human Services hospital reporting system switched to reporting only adult ICU beds that were assigned with staff, a move that would better reflect hospital resources.
Data released later showed that pediatric ICU beds comprised more than a quarter of all ICU beds in Missouri, even though children only account for about 2% of COVID-19 hospitalizations.
The bed data reported in Missouri, however, remained unchanged.
New COVID-19 cases and deaths continued to rise and a month later, hospital leaders in Kansas City and St. Louis were holding press conferences to alert the public about their capacity concerns.
Following the hospital leader’s warnings, hospital association spokesman Dillon wrote in an email to KCUR that it would be shifting “to a ‘staffed bed’ model,” of reporting.
But the changes in the association’s data were minor, and state and local leaders took no immediate additional steps.
Hospital officials beg governor for mask order
On November 13, Missouri Hospital Association president Herb Kuhn wrote an impassioned letter to Gov. Parson, pleading for him to implement a statewide mask mandate.
“The wolf is at the door,” wrote Kuhn. “We urge your immediate action at this time.”
Then, nearly a month after the Kansas City area doctors’ warnings, the Missouri hospital data finally changed significantly.
On the Monday before Thanksgiving, the Missouri Hospital Association’s dashboard showed the number of usable hospital beds dropped to about 15,000. The ICU bed count dropped to 2,616. The total of adult beds shown dropped to just 13,545 inpatient beds, including 1,867 ICU beds.
“We had a handful of hospitals true-up their staffed bed numbers,” Dillon wrote in an email to KCUR.
The new inpatient bed count added up to only about two-thirds of 22,000 beds that the state and governor had previously claimed.
Hospital doctors said that their numbers of available staffed beds had declined in recent weeks due to staffing shortages, but the revised data show that only 18,000 to 20,000 staffed inpatient beds had been available during most of October, and that at no point during the pandemic did Missouri hospitals have 22,000 staffed inpatient beds.
Dillon says the hospital association had sent letters to hospitals on October 29, urging them to update their reporting methods.
He refused to disclose, however, which hospitals had continued to report the larger bed counts, stating only that “a number of large hospitals” had only recently revised their data. He said hospitals may have been confused about the reporting process and that the nearly month-long delay in updating reporting appeared to be due to a data automation problem within a hospital group.
No data while cases nearly triple
But the data issues had persisted during a particularly critical stretch during the pandemic.
Daily new cases grew from 1,530 per day at the beginning of October to 4,523 per day in mid-November. The positivity rate climbed from 9% to 25%, and an exponential increase in hospitalizations broke new records day after day.
The hospital nurse who treats COVID-19 patients in the Kansas City area says that the situation inside hospitals in recent weeks had been more dire than data suggested, as some patients have been left waiting, sometimes in hallways, to receive inpatient care.
“What it looks to us is we’re consistently holding large volumes of inpatient downstairs in the ER because there’s no beds upstairs,” the nurse says. “We have very limited access to ICU beds. We’re just having an extremely high volume of very sick people that we can’t place immediately, which then puts a tremendous strain on our department to continue caring for the patients that are coming through the doors.”
The nurse and others who treat COVID-19 patients told KCUR that they have been assigned higher numbers of patients than normal, potentially compromising the quality of care they receive.
Though many hospital doctors spoke up about being overrun in September and October, Dr. Rex Archer, the head of Kansas City, Missouri’s health department, said in late October that the data continued to be inaccurate in part because other hospitals had dragged their feet on reporting.
“They have almost an unconscious fear of reporting data and concerns about their competitors and their market share,” Archer said. “It’s just not a priority to report accurately.”
Ryan Panchadsaram, of the COVID Exit Strategy website, said that while many hospitals around the country have struggled with the daily reporting, it is essential to guide pandemic strategies.
“Is this a burden, and is it needed?” said Panchadsaram. “The answer is ‘yes’ to both. This truly is, absolutely, a burden on hospitals. They are really the foundation for our communities and the response to this, but without reporting this information, local officials, state officials and the federal government won’t have a clear picture of what’s happening on the ground.”
After the hospital data was changed, hospital association spokesman Dillon wrote that “we think the data that is presently being reported is much closer to the actual availability of bed assets,” though he acknowledged that the association still lacks any way to verify what hospitals are reporting.
Last week, Parson announced an agreement with the health performance company Vizient to boost staffed bed capacity by bringing 760 nurses to work in Missouri. However, some hospital leaders have expressed skepticism that enough highly-trained nurses will be available to provide the level of care needed.
When asked about the hospital data Parson had cited, his spokeswoman, Kelli Jones, said the governor has relied on hospital-reported data in his statements about the coronavirus.
“Our entire administration is here to support our health care workers and health care delivery system,” Jones wrote in an email to KCUR.
Parson, however, again tweeted this week that Missouri has 22,000 hospital beds, including 2,700 ICU beds. That's around 9,000 more than the number of adult inpatient beds that are actually available to treat patients.
Missouri data still an outlier; Just 17 ICU beds open
But Missouri’s hospital data still doesn’t completely align with other sources.
While the Department of Health and Human Services and the Mid America Regional Council now report only staffed adult ICU beds, the Missouri health department continues to report the much larger all staffed ICU beds in its total numbers, so it includes pediatric beds.
Though the state’s count of all ICU beds showed this week that around 18% remain available for use, the count used by MARC and the federal government showed just 11% of staffed adult ICU beds were available in the state.
Within Kansas City, Missouri, a total of just 17 staffed adult ICU beds, fewer than 10% of the total, were available.
The Missouri Department of Health and Senior Services is currently considering breaking down ICU beds by type on its dashboard, according to spokeswomen Lisa Cox.
In mid-November, many local governments in the Kansas City area introduced new “safer at home” measures, including restrictions on business, public events and social gatherings, and a joint statement released days before the new restrictions were announced, local health department heads cited the hospital leaders’ warnings about their bed space.
However, the new restrictions weren’t enacted until after coronavirus cases and hospitalizations had surged far higher than at any other point during the pandemic.
Since the hospital bed data was updated and new restrictions were issued, the total numbers of staffed beds have continued to decline due to staffing shortages, falling to a total of just 13,000 staffed adult beds statewide this week, according to the hospital association. Almost half of the hospitals in the Kansas City area are currently reporting staffing shortages.
As hospitalizations continue to surge, Dr. Mary Anne Jackson of UMKC worries that counts of beds will become less relevant. Instead, hospitals' capacity to treat patients will be largely limited by the shrinking numbers of nurses available to staff them.
“Where we’re going is fail is, we’re going to find the beds, more than likely” Jackson says. “But we’re not going to find the health care workers to man those beds. That’s what I’m most concerned about.”
Alex Smith is a reporter at KCUR 89.3 in Kansas City.