Florida's COVID Response: From Storm Watch to Cautious Calm

Maureen Salamon

May 20, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center

Florida is used to coping with natural disasters, so its incident-command structure was prepared to quickly incorporate lessons from early coronavirus hotspots.

"It's like a hurricane was coming for the whole state of Florida," said Joshua Lenchus, DO, regional chief medical officer at the 716-bed Broward Health Medical Center in Fort Lauderdale. "The difference between a hurricane and what we've been dealing with is really in the length of time — hurricanes blow through, they don't stay for 2 months — and in the total effect."

Hospitals in the nation's southeastern-most state had plenty of warning that they would face the encroaching COVID-19 storm. Healthcare leaders watched it blow in from China, from Europe, from Washington state, and from New York City as they readied their well-honed statewide incident-command structure.

They took copious notes and planned their response, yet they couldn't predict whether the vortex would resemble a category 5 storm or a summer monsoon.

Part of the concern was that Florida faced challenges, including still-open beaches with spring breakers and cruise ships disembarking sickened passengers at its ports.

It's also home to a large retiree population, something of special concern to officials hoping to stem losses in a state where nearly 27% of residents are older than 60 and are more vulnerable to severe COVID-19 infection.

Florida was the third state to confirm patients within its borders, but was slower than many other regions to implement lockdown measures. By the third week of March, Gov. Ron DeSantis was taking heat for deferring decisions about beach closings to local governments. Although Florida followed other states and implemented a statewide stay-at-home order on April 1, the action did not close public beaches.

The state has 67 counties, but the three most populous, at its southeast tip — Miami-Dade, Broward, and Palm Beach — account for more than half of its 46,944 cases and 2052 deaths as of May 19.

Lockdown measures in all but those three counties eased on May 4, allowing limited reopening of restaurants and stores. Hospital leaders report fewer cases — the state's projected peak happened in early April without over-taxing ICU capacity — but they have not sounded the all-clear.

Health officials are aware that the relative calm they've seen since the limited reopening could be just the eye of the storm and they are watching for red flags that could signal a new wave of cases.

I think there was value in looking at different communities with a different lens.

"Situations like this are about small wins," said Wael Barsoum, MD, chief executive officer and president of Cleveland Clinic Florida. The system runs five hospitals throughout the state that, combined, treated up to 50 COVID-19 inpatients each day during the peak. By early May, though, the norm was fewer than 20.

A lot of people worried when they saw so many crowded beaches, said Lawrence Antonucci, MD, president and chief executive officer of Lee Health in Fort Myers. However, "we never really had that spike of cases that was going to overwhelm us."

Lee Memorial Hospital — which, with 1400 beds, is the third-largest public hospital in the United States — is treating 80 to 100 COVID-positive inpatients on any given day, Antonucci reported.

"It was pretty concerning," Lenchus said about watching Florida's cases increase throughout March. "But things sort of plateaued during the first week of April and have slowly decreased since then." At the peak, his facility treated dozens of infected inpatients, he reported.

Now, "we're seeing additional cases in the state and county but the amount of time it takes to double cases is becoming longer and longer," he explained.

Barsoum defended the state's scattershot approach to lockdown measures, saying there was a "clear sense at a government level that the state had different needs in different areas."

The three counties with the largest concentration of COVID-19 are "very different counties than in the panhandle, north Florida, and the west coast, just in terms of human density," he said. "I think there was value in looking at different communities with a different lens."

Beyond the state level, however, the lack of a cohesive national response weighs heavily on Dipen Parekh, MD, chief clinical officer and interim chief operating officer at University of Miami Health System. His mother in India can download data on her cell phone to track "red zones," or areas with high concentrations of COVID cases.

"South Korea and Singapore have done something similar," said Parekh, whose hospital has treated more than 150 COVID-19 inpatients since March. "All of these countries are comparable to the United States but have done some very simple yet helpful things to take care of their population."

"I feel let down," he said. "It boggles my mind that every state is doing its own thing. There's just no coordinated effort or partnerships between industry and government to have a cohesive response." That explains, he said, why the United States has more COVID-positive patients than any other country in the world.

But Florida already had a finely tuned incident-command structure before COVID-19 arrived because it is accustomed to coping with natural disasters. Health facilities, which under normal circumstances might compete for patients, are experienced balancing the deficits between facilities, Barsoum explained.

Teamwork buttressed the preparations individual facilities made in the weeks before the pandemic descended. Preparations included converting floor space to COVID isolation units and boosting supplies of test kits and PPE, which dipped to worrying levels but never ran out.

And healthcare systems throughout Miami-Dade County have shared data.

The incident-command structure also appears to have blunted the impact on Florida seniors, especially compared with places like New York City, which has logged the deaths of nearly 5000 nursing-home residents since the beginning of March.

Impact on the Elderly

"We've certainly had our share of people dying in nursing homes, but it's nowhere near what other places have seen," Antonucci said.

Lessons learned from New York's well-publicized death toll in the institutionalized elderly population fueled Florida's requirement for two negative COVID tests before seniors can be sent back to skilled nursing facilities after hospitalization.

And older residents deserve some of the credit for mitigating the severity of the outbreak in their own ranks, hospital leaders say. They watched the news and heeded the advice to stay home.

"Once the stay-at-home order went into place, people took that very, very seriously," Antonucci said. "March and April are usually a very busy time here, with a lot of snowbirds. But once the order came in, our roads were empty, stores were empty, and as people ventured out for essential activities, they wore masks and social-distanced."

But as the state gradually reopens, healthcare leaders say they're staying open to what that will mean for their caseloads in 2 or 3 weeks, and beyond.

"Anything we do, we're going to learn from," said Barsoum, whose recent keynote at the American Medical Student Association virtual conference offered tips on crisis leadership, exhorting physicians in training to stay visible by being a leader who shows up in a crisis, to be transparent when communicating, and to always show gratitude.

"As outdoor seating at restaurants opens, we'll watch to see if we get a bump in hospital admissions," he said.

Parekh will be watching for clusters of cases or a sudden surge, and Antonucci said he'll be observing trends in his own hospital's inpatient COVID numbers, along with volume in the emergency department.

"What I worry about is complacency," Antonucci said. "I worry that people will start feeling we've got this thing licked and they can relax social distancing. What worries me is people will start relaxing too much."

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