Massachusetts hospitals are beginning to scale back elective procedures in an effort to free up beds as coronavirus pushes hospitals towards capacity.

Because of reduced capacity, hospitals in all but the western third of the state were moved this week into the second of four tiers in a plan for dealing with a surge COVID patients.

"The practical implications, unfortunately, mean that hospitals are getting ... stretched to a very concerning point," said Dr. Paul Biddinger, medical director for Emergency Preparedness at Massachusetts General Hospital. "Unfortunately, what we're hearing from others is what we're experiencing ourselves, which is we're getting really full. We're really getting strained.

"We continue to see rising numbers of COVID patients," he continued. "And that means at some point, unfortunately, you have to defer other care in order to make sure you have hospital beds, ICU beds and available staff. So moving into Tier 2 is a recognition that all hospitals or many hospitals in each of the regions are under significant strain."

Four of the state's five regions are now at Tier 2. That means the seven-day average of the number of available ICU and medical/surgical beds in those regions was less than 25 percent for five consecutive days.

The development comes as another 5,192 cases of COVID-19 were reported on Friday. Biddinger said there were just over 90 COVID-19 patients at Mass General in Boston Friday morning, including many in the ICU.

"We have only a couple of open ICU beds and only a couple of beds overall that are open in the hospital," Biddinger said, adding that the number continually fluctuates as they admit and discharge patients. But, he said, the number of patients with COVID-19 is "continually rising."

The state doesn't mandate what kind of care should be deferred to create more capacity for COVID-19 patients. Under the plan, each hospital has determined its own steps for opening up more beds.

For now, Biddinger says MGH is focusing on deferring things like inpatient cosmetic procedures that have the least health consequence. Just because a procedure is deemed elective, he said, doesn't mean it's not important.

"If someone doesn't get a cardiac catheterization, doesn't get a stent, they may not need it immediately," he said. "However, the longer you go without that procedure, the greater risk you're facing. So we've tried really hard in the hospital system and we've actually worked really well with our health department to try and avoid getting to that kind of circumstance."

That's why the system is phased, he said. If the state were to get to Tier 3 or 4, more serious procedures would be deferred.

Health experts fear a coming surge of patients will lead to just that. Massachusetts set a new record on Thursday for the number of newly reported COVID-19 cases — 6,477 were recorded — breaking the previous record set just the day before by more than 1,800 cases. And public health experts say an increase in hospitalizations tends to lag an increase in confirmed cases by about two weeks.

While a spike in cases has been predicted as a result of Thanksgiving celebrations, some public health experts say it may be too soon to see those new cases reflected in the state total.

That means a new surge could be coming on top of the one we're already seeing, said epidemiologist Michael Mina of the Harvard T.H. Chan School of Public Health.

"Prior to Thanksgiving, we were already in an exponential explosion of cases," Mina said. "We anticipate that the people who got infected, for example, on Thursday, they should generally be starting to show their symptoms over the last couple of days. There's usually another few days delay before people arrive in the hospital. So I would say that right now is the time to start watching for that."

And with more holidays on the way, public health experts worry there could be yet another surge.

"What we would see in the next one week or two weeks, it's the damage that has already been done. So that cannot be controlled," said Jagpreet Chhatwal, associate director of the Institute for Technology Assessment at Massachusetts General Hospital. "But around the Christmas holidays ... we still have an opportunity to minimize the damage by taking appropriate social distancing precautions, common sense measures. That will be very useful."

Dr. Shira Doron, hospital epidemiologist at Tufts Medical Center said she's worried about a coming surge of patients infected over Thanksgiving.

"Every health care worker's biggest fear in this is having to choose between one person and another for care," Doron said. "And we didn't really get there with the first surge. And so our worry, and what we lose sleep over, is that we will get there with this one, that it will be worse and we will get to the point where we have to choose which person gets medical treatment."

Over the next couple of weeks, she said, hospitals will have to watch carefully if they have enough beds and staff.

"Will we be asking people to take care of a number of patients that's not safe, that they can't handle, that overwhelms them?" she asked. "Will our health care workers stay healthy and able and mentally well? And then if we have the staff but not the beds, where will we put them physically?"

Doron said unlike the last surge, they're not as worried about having enough PPE and ventilators.

"But, you know, there are lots of other little items that that keep giving us heartburn when they don't come in as shipped, periodically," she said.