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With its ICU beds filling up and more patients going on ventilators, Banner Health, the largest hospital system in Arizona, is warning about tough times ahead for the state.

This week, that the state's steady climb in COVID-19 cases over the last 2 weeks was "concerning" and that it "correlates with a rise in cases that we are seeing in our hospital ICUs."

The number of patients on ventilators in the Banner system has quadrupled since mid-May, reaching 116 patients on June 4, .

Banner also said it has reached its capacity for extracorporeal membrane oxygenation (ECMO), though it did not say how many machines it has and state officials insist that enough ECMO machines are in place at other facilities.

"If these trends continue, Banner will soon need to exercise its surge plan to increase ICU capacity," the health system said in a press release.

About half of the state's 1,234 hospitalized COVID-19 patients as of June 4 were being treated at Banner hospitals.

The hospital system also from Marjorie Bessel, MD, chief clinical officer, showing increases in hospitalizations and ventilator use, as well as a spike in cases that occurred after the standard incubation period following the state's reopening.

Arizona Department of Health Services (ADHS) Director Cara Christ, MD, on June 6 urging them to "fully activate" their emergency plans, including preparing for crisis care and suspending elective surgeries if they start experiencing staff or bed shortages.

On Tuesday, that the state is "watching the metrics" and that "we do still have capacity, inpatient and ICU beds, but we are noticing that's creeping up."

In its communications, Banner has emphasized wearing a mask in public -- something that Gov. Doug Ducey (R) appears to downplay in his communications. He does not wear a mask in public, and an about good practices for avoiding infection did not include wearing a mask.

"What's this #COVID response in Arizona?" , an emergency physician who just completed his residency in New York City and moved to Arizona for a new job. "It says nothing about wearing masks which slow down the transmission of COVID. There is also no mention of physical distancing. Essential workers will die b/c customers are not required to wear masks. Unacceptable!"

A only emphasizes handwashing and staying home when sick, although the lists social distancing and mask wearing at the top of its precautions residents should be taking.

Christ, the agency's director, emphasized that people should be socially distancing and, if they can't, "you should wear a face covering."

"We're working with the public to make sure they're wearing masks and getting that message out there," she said. Various estimates have put the proportions of Arizonans wearing masks at about 50%.

Christ also noted that shutting down Arizona's economy again was "not on the table at this time."

Arizona lifted its stay-at-home order on May 15. Maricopa County, which includes Phoenix, has been the hardest hit, with a total of . Pima County, which includes Tucson, the state's second largest city, of confirmed coronavirus on June 10, up 189 cases from June 9.

Will Humble, MPH, former director of the ADHS and current executive director of the Arizona Public Health Association, said a May 15 re-opening wasn't too early. Rather, the issue was that it wasn't a phased reopening and there were no penalties for businesses not in compliance with public health guidance.

"With the new executive order that replaced the stay-at-home order, there was no compliance component," Humble told MedPage Today. "It said to businesses, 'You can open on the 15th, and when you do, please do the right thing and follow CDC recommendations' -- the key word being 'please' instead of 'you shall.'"

"That was a big missed opportunity," he said. "This could have been a phased process. We need to have real compliance requirements in place."

"We could very well end up squandering the progress we made during the stay-at-home order because of the way it ended," Humble said.

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