HELENA, Mont. (AP) — Montana’s most populous county is limiting gathering sizes and urging bars and restaurants to enforce masking and distancing requirements to slow the spread of COVID-19 as the CEO of a Billings hospital warned that facilities and healthcare workers are overwhelmed as hospitalizations are rising.

Meanwhile, an uptick in cases in Flathead County has the health department recommending some additional restrictions.

Yellowstone County health officer John Felton said Monday he would limit public or private gatherings to no more than 25 people, inside or outside, starting Wednesday. Mask-wearing and physical distancing would still be required. The limit does not apply to schools or daycares.

Churches can have more than 25 attendees as long as they are physically distanced and wear masks and the number does not exceed 50% of the church’s capacity.

On Oct. 5, Felton said if the county averaged more than 50 cases of COVID-19 per day per 100,000 residents for a week, he would restrict bar, restaurant and church capacities to 25% and require businesses that sell alcohol to close at 10 p.m.

After owners said such a restriction would put them out of business, Felton told the Billings Chamber of Commerce on Thursday that he would allow bars and restaurants to be open at 50% capacity. On Monday he maintained it at 75%, which matches the statewide directive.

“I’m cognizant that our case rates last week escalated so rapidly that we did not have time for enhanced compliance efforts undertaken by our citizens and businesses to take effect," Felton said Monday. “I’m also very cognizant of the many losses we have all faced over the last seven months."

The county health order will be re-evaluated in four weeks, Felton said.

Billings Clinic CEO Scott Ellner told chamber members last Thursday that the virus is putting a strain on healthcare workers, "so much so that people are talking about giving up their careers in healthcare.”

If case numbers continue at the current rate, Ellner said he expected around 250 more hospitalizations in the next four weeks.

The hospital is adding capacity, moving some patients to other facilities and may look at putting two patients in some rooms, he said.

“I want to leave a sobering image in your mind,” Ellner told chamber members on Thursday. “Today we're having to call one of those companies that provides reefer trucks. And if you don't know what that means, it's the refrigeration trucks were we can put the bodies.”

Nancy Iverson, a registered nurse and director of patient safety and infection control at Billings Clinic, said Monday that bringing in a refrigerator truck is part of the hospital's “surge plans.”

“We had four deaths last weekend and our current morgue holding area only holds two," Iverson said.

Yellowstone County has reported 74 deaths due to COVID-19.

In Flathead County, the health department is asking the county Board of Health on Thursday to authorize new restrictions if the case numbers average 50 per day per 100,000 people during the week of Oct. 26-Nov. 1, or any Monday through Sunday following that. The health department is recommending 25% capacity for bars, restaurants and churches and limiting gatherings to no more than 25 people.

As of Oct. 9, there were 10 long-term care facilities in Flathead County with COVID-19 outbreaks, health officials said, and case numbers were straining the health care system and the ability to investigate cases.

Montana reported 423 new cases of COVID-19 on Monday, including 94 in Flathead County and 81 in Yellowstone County. Nearly 300 people are hospitalized and 212 people have died.

The state's total cases since mid-March have topped 19,000. The numbers are believed to be far higher because not everyone has been tested and people can have coronavirus without showing symptoms.

More than 7,400 people are considered to still have COVID-19, meaning they are under quarantine or isolation orders. Nearly 11,500 have recovered, meaning they no longer test positive for the virus.

For most people, the coronavirus causes mild or moderate symptoms, such as fever and cough. For some, especially older adults and people with existing health problems, it can cause more severe illness, including pneumonia, and death.