As the coronavirus swept across California, San Luis Obispo County officials, doctors and community leaders came together to create a facility that would ensure that a surge of sick patients wouldn’t catch us unprepared.
Within weeks of the first confirmed COVID-19 case in San Luis Obispo County, the Cal Poly Recreation Center transformed from a workout spot for college students into a makeshift hospital equipped to care for 165 sick patients.
Rows of beds cover a basketball court, racquetball courts have been converted into changing rooms for medical staff, and hallways serve as hand-washing stations. Thousands of dollars of medical supplies — including scrubs, gowns and gloves — are stored in stacks of boxes.
If necessary, the facility could expand to more than 900 beds, staffed by a Medical Reserve Corps that already has 250 volunteers. So far, the price tag is at least $3.5 million for initial medical supplies and equipment.
A month into the shelter-at-home order, there are more beds ready at the care site than there are local confirmed cases. The most COVID-19 patients to occupy hospital beds at one time in the county, so far, was 10 on April 1.
It’s possible the facility might never be used by a patient.
But, the ability to handle a surge of patients and supplement existing health care facilities gives the county the resources it needs to move toward a slow rollback of the shelter orders.
“We’re hoping we never have to use a single bed in this facility,” county spokesperson Whitney Szentesi told The Tribune. “But, if our community gets hit hard by this disease, we will be prepared.”
SLO County Saw a Catastrophe on the Horizon
The Cal Poly facility was one of the first alternate care sites completed in California, meant to relieve the health care system from a potential surge in patients recovering from the new coronavirus.
Conceptual planning for the facility began on March 17. At the time, there were eight confirmed cases of COVID-19 in SLO County.
“The trajectory of cases across the country and COVID-19 modeling showed that the number of dead and ill could become catastrophic very quickly without intervention,” county Public Health spokeswoman Michelle Shoresman told The Tribune.
If community spread infected 20 percent of adults within six months, parts of the U.S. health care system would be overwhelmed, according to data released by the Harvard Global Health Institute. If spread of the virus was slowed to 20 percent infected over an 18-month period, then hospital capacity could meet demand.
“We have to provide the capacity in the system, and make sure we procure that capacity before we enter into that next phase,” Gov. Gavin Newsom said April 15. “So every one of those beds, from my perspective, are important in terms of our capacity to deliver on the hope and promise that we can start to ease up on the home orders.”
On March 23, he said the state would need 50,000 extra beds by late May. By that point, the county was already underway with its project.
The next day, county Emergency Services Director Wade Horton announced at a press conference that the county was already “aggressively moving forward on this issue.”
“We have not waited for the governor. We have not waited on the federal government,” he said.
What would become the only alternate care site on the Central Coast was planned and funded locally, led by a team of county officials, doctors and community leaders — several with military backgrounds — and paid for with county tax dollars set aside in a contingency fund. Hundreds of volunteers stepped up to help.
“Short of anything that the military is doing right now in New York and other places, I think this is probably one of the premiere facilities that we’ll see in the United States, and certainly in California,” said Mark Lisa, CEO of Tenet Health Central Coast, who helped lead planning efforts.
Doctors, County Staff Decide to ‘Go Big’
By late March, the county seemed to be emerging as a potential hot spot for coronavirus activity, with more cases than any area between Ventura and San Jose counties.
“At the time, we didn’t know what to expect,” said Dr. James Malone, French Hospital Medical Center’s chief medical officer and a colonel in the U.S. Army Reserve. “But, as we say in the military, luck favors the prepared.”
He was pulled into county planning early on as one of three medical directors for the site, and made quick use of his military experience.
For the past 12 years with the 7305th Medical Training Support Battalion, Malone helped design and host medical gameplay exercises at Fort Hunter Liggett and Camp Roberts, where soldiers train to build combat hospitals from cargo containers to fully operational within 72 hours.
In 2003 and 2004, Malone was chief medical officer of the largest combat hospital in Kosovo during NATO peacekeeping operations. In 2008, he found himself named chief medical officer at Camp Bucca, a prison that held as many as 20,000 detainees a time in southern Iraq.
Others working on the alternate care site also have military experience. That made planning easy, Malone said, because “you can just drop us in with a bunch of like-minded people, and we’re going to figure out how to get it done.”
He’s joined by top administrators at Tenet Healthcare’s Central Coast market, CEO Mark Lisa and COO Michael Lane, both retired from the U.S. Navy, Medical Service Corps. A manager in the county Information Technology Department, Paul Porter, is coordinating logistics to order medical supplies and equipment. He’s a captain in the U.S. Navy Reserve.
Andrew Hackleman, with the economic development coalition Hourglass Project, is a retired lieutenant colonel in the U.S. Air Force with expertise in crisis action planning. During the public health emergency, he volunteered as an adviser to the county’s top administrator, Horton, a lieutenant commander in the U.S. Navy Reserve.
Having been trained to over-prepare, they asked for a worst-case scenario.
County Public Health officials projected a potential need to care for up to 800 patients outside the existing health care system, which includes 403 beds in four hospitals, 56 of which are intensive care.
“We were all looking around, worried, thinking, ‘OK, this could really happen,’” Malone said.
Sure, he said, “we’re the ones least likely to need it. We’re not a huge population center, people live kind of fairly remotely, we don’t have a bunch of high-density housing, we don’t have the type of situation that’s ripe for having lots of sick people such as New York City, such as New Orleans.
“But, if we don’t get it done, nobody is likely to come to our rescue if we get in trouble.”
Federal and state resources are more likely to go hundreds of miles away to the population centers, Los Angeles and the Bay Area, which had more cases than the Central Coast. That was already coming into play as FEMA trailers passed rural counties on their way to Orange County, and places like SLO County received a fraction of the amount of money larger areas received to prepare emergency services for people experiencing homelessness.
“No one is going to help us,” Malone said. “You’ve got to take care of yourself, have contingency plans, and hope you never have to use them. It’s that whole Army thing, ‘Army of One.’”
That’s why, with marching orders from county Public Health Officer Penny Borenstein, they decided “let’s go big or go home.”
An Elbow-Bump Agreement at Cal Poly
The project team decided the care site would be ready by April 8, a target date picked based on projections of a surge in patients and when they thought they could actually get it done.
The next challenge was finding a location.
Emergency preparedness documents included plans for an alternate care site at an elementary school or community center in the case of a surge of patients. Organizers realized fairly quickly those were too small and too far from hospitals.
They looked at the fairgrounds in Paso Robles, the Madonna Expo Center, Camp Roberts and, finally, Cal Poly’s Recreation Center, a 165,000-square-foot facility with large open spaces that could easily be cleaned.
Cal Poly President Jeffrey Armstrong came ready with detailed maps of the facility and eagerness to help.
They walked through gyms that could become a field hospital, wheelchair ramps could be used to move patients in from an ambulance, and rooms for group fitness classes could become break areas. At the end of the tour, Malone and Armstrong agreed on the location with an elbow bump instead of a handshake.
A team of doctors worked to determine what kind of care should be provided at the temporary site.
It wasn’t just about adding to the number of beds in the county. It needed to take patients who might otherwise be in a hospital, without jeopardizing their health.
The care site could relieve pressure on hospital staff so they can focus on sicker patients, who might be going into, or recently coming out of, an intensive care unit. It also had to serve the role usually provided to the community by skilled-care facilities.
“That resource is just not available,” Malone said, explaining that skilled-nursing or transition facilities aren’t really taking new patients now out of a fear of introducing COVID-19 into a vulnerable setting. “Their fear is warranted. They are huge care providers in this county, but their ability to help in this fight is limited.”
He and a team of doctors determined they could provide patients at the Cal Poly gym with oxygen, limited IV fluids, oral medicines for symptoms, and “a safe place to sleep and someone attending to your needs.”
That would require a lot of medical equipment and temporary infrastructure to deliver oxygen.
Within days of being pulled into the project, the doctors shared the plans with a logistics team, and Hackleman took on coordinating people to do the electric, plumbing and building work to transform the space, Malone said.
Government Work Can Move Fast in Emergencies
Local government work is often slowed by bureaucratic processes meant to provide transparency and fairness.
Generally, project proposals of this size would go through a series of approvals, including by the county Board of Supervisors or city councils. Governments are required by law to go through a competitive bid process to solicit proposals from potential companies before hiring contractors.
None of that happened in the development of the alternate care site.
Days before planning began, an emergency proclamation ratified by county supervisors gave Horton “authority to take all action to protect life and property,” Shoresman said.
And, the governor’s Proclamation of a State of Emergency suspended bidding requirements “to allow public agencies to quickly respond to the threat of the spread of COVID-19.”
Contracts acquired by The Tribune through a public records request detail the local businesses paid to perform the work.
McCall Plumbing & Mechanical Inc. has two contracts for up to $325,000 to design and install temporary oxygen supply equipment and piping.
Trust Automation was hired for up to $500,000 to design and construct overhead truss structures and partition walls.
Thomas Electric was hired for up to $350,000 to install temporary connections and furnish standby generators to power mechanical equipment that would serve patient beds in five basketball court areas.
Spectre Security was contracted to provide five guards through June 30 at $30 an hour, and Kare Teem janitorial services has an open-ended one-year term contract for $9,240 a week.
A contract between the county and Cal Poly CSU Board of Trustees and Associated Students Inc. for use of the Recreation Center ends on June 27. The agreement states there is no cost to the county except for any necessary repairs.
‘We’ve Already Done the Hard Work’
With the first phase completed, activity at the Cal Poly alternate care site this past week was focused on training physicians and hearing their feedback on protocols in preparation for patients who might never arrive.
With no patients, the massive center feels nearly empty. A security guard sits outside a gym filled with thousands of dollars of supplies, and administrators work on computers set up in impromptu offices. Last week, nurses performed a walk-through training with a volunteer acting as a patient to learn the intake and care process and procedures.
Public Health officials say the shelter-at-home order that went into effect March 19 is effectively flattening the curve, preventing what might have otherwise been an early surge in local cases.
However, public health experts say the risk of heightened community spread increases as society begins to open up, a lesson California learned in a 1918 pandemic when a second wave of the flu killed more people than the first.
“I think a surge could happen later,” Malone said. “We don’t expect it at all in the next few weeks, that the hospitals would be overrun so we’d have to start putting patients there. But we’re going to keep training and be ready to do it.”
How quickly the virus spreads is up to social-psychological determinants, based on what people will do. Malone said, every man, woman and child are “the boots on the ground.” It’s up to everyone in the community to fight the virus, to stop it from spreading.
In the meantime, as preparations continue, neighboring counties have asked if they can use the Cal Poly alternate care site should the need arise. That’s looking to be more likely than local residents filling the beds.
On Tuesday, the Santa Barbara County Public Health Department reported the outbreak at Lompoc federal prison had grown to 99 confirmed cases among inmates, killing one and infecting at least 30 staff members.
If people from that outbreak fill local hospitals in northern Santa Barbara County, Horton agreed that nonprisoner, noncritical patients from the area could use the care site, Assemblyman Jordan Cunningham said in a letter to public health officials.
If the worst-case scenario does develop, hundreds of additional beds can be made available in phases in the various gyms that make up the Rec Center. If it comes to it, the next phase would have staff and volunteers erect 136 beds over a large, two-court gym.
That’s the Main Gym, the facility where winter graduation ceremonies are held, along with trade shows and conferences, and its where Shoresman saw Toad the Wet Sprocket in the 1990s.
Five hundred beds could be rolled out with very little additional set-up or construction, she said.
For now, though, activity at the facility is calm.
If the beds aren’t needed, if businesses open up, the economy gets rolling again and people stay safe, Malone said, in a few months, “we’ll take the policies and procedures, the equipment and lessons learned, and will pack this thing up.
“And, if something goes wrong, we’ve already done all the hard work.”