Medical staff prepare for an intubation procedure on a COVID-19 patient in an intensive care unit in Houston. In some parts of the US, with hospitals overcrowded, hospital managers fear that they may have to implement crisis standards for care. Go Nakamura / Getty Images Hide caption
Go to Nakamura / Getty Images
Go to Nakamura / Getty Images
Far more people are currently hospitalized for COVID-19 in the United States than at any other time in the coronavirus pandemic – more than twice as many as a month ago.
Hospitals in some of the hardest hit states are exhausting every health worker, room, and device to avoid the worst-case scenario where contingency plans must be initiated and care may need to be rationed.
Many states warn against standing on the sidelines. On-site equipment and staff shortages are already straining the system and changing the way hospitals provide care. NPR data analysis supports what health care executives and researchers have warned: This stress can even contribute to higher death rates.
“We take a small risk every time we expand our capacities,” says Dr. John Hick, a committee member of the Disaster and Emergency Forum on Medical and Public Health Care for the National Academies of Science, Engineering and Medicine. “It is by no means unexpected that we will get worse results.”
The nursing crisis is already here
Hospitals have a roadmap for dealing with disasters. Called the nursing crisis standard, it guides clinical and ethical decisions about how nursing should be investigated when resources are scarce.
It’s a last resort – a fundamental change from being able to do everything for one patient to maximizing benefit for many, says Dr. Dan Hanfling, who worked with Hick on the crisis standards committee for care at NASEM.
And while most places have not officially enabled crisis standards for care, hospitals are already resorting to workarounds to “maximize standard care standards as much as possible,” says Hanfling.
Hospital capacity expands like an “accordion,” but at some point, he says, “even those skills become overwhelming. And you come to a point where space, staff, and materials really no longer match the level of care we use. ” to deliver. “
Some experts believe clinicians are already making informal decisions that are similar to rationing care.
“There has been a lot of language around ‘we are about to enter the Crisis Capacity’, but I’m concerned that there is some kind of fuzzy entry,” says Dr. Kate Butler, nephrologist and acting teacher at the University of Washington School of Medicine.
Butler researched how healthcare workers handled these clinical dilemmas during the spring COVID-19 surge.
“Everyone is a bit poorly cared for,” said a staff member she interviewed, referring to shorter dialysis sessions for patients when the devices were in great demand.
In an interview with NPR, Butler said, “There has been far less preparation for this gray area where resources are limited, and we are seeing an impact on patient care – people may die – because they are not receiving the care they would otherwise.” offered to them. “
During the current surge, hospitals are once again faced with difficult decisions about how far to extend care.
In Wisconsin, where the state has set up makeshift beds for mild COVID-19 cases at Wisconsin State Fair Park, the Mayo Clinic healthcare system has moved beds to waiting rooms and even a parking garage.
“Every bed in northwestern Wisconsin was literally full and hospitals just couldn’t take in new patients,” said Dr. Paul Horvath when describing a recent move in the emergency room to Wisconsin Public Radio. “And that means I had the challenge of managing intensive care-level care in my emergency room for hours, which is obviously not a routine.”
Rising Mortality Rates?
NPR data analysis provides preliminary evidence that the death rate can be influenced by crowded hospital conditions.
Since the beginning of the pandemic, COVID-19 death rates in hospitalized patients have decreased, in part due to improvements in treatment. But in places where hospital stays have increased rapidly, deaths have risen even faster, suggesting a link between hospital occupation and deaths.
These death rates – measured as the ratio of average daily deaths to hospital stays in a state – are increasing in countries like South Dakota, Wisconsin, and Montana. For example, last week South Dakota had 4.4 deaths for every 100 patients hospitalized each day. Overall, there were less than two deaths per 100 hospital stays per day in the United States.
Without detailed data on hospital stays, which the federal government does not publish, it is difficult to say whether this trend is due to hospital capacity issues or other factors such as patient age and severity. However, researchers and public health experts fear that hospital overcrowding is at least contributing to this.
“It’s definitely something we need to pay more attention to,” says Dr. Bilal Mateen, a Data Science Fellow at the Alan Turing Institute in the UK. There he used detailed government data to study the COVID-19 death rate. His findings from London mirror the experience in New York City: the highest death rates were recorded at the beginning of the pandemic, when the hospitals were full.
Mateen says that while there isn’t enough research yet to definitely prove that overcrowded hospitals lead to higher death rates, it would be better to embrace this and act aggressively now to stop the surge in hospital stays.
“Why in the world when [doctors] tell you that you are at the end of your ability why not do the reasonable thing and realize that the health system is at a breaking point? “
Separate research, published in the Journal of General Internal Medicine in August, found that the number of deaths rose over the next week when more beds were occupied by COVID-19 patients, although it didn’t look to see if a higher percentage of those were Patients died when hospitals were filled up. Pinar Karaca-Mandic, professor at the University of Minnesota and lead author of this study, told NPR that the latest available data shows roughly the same trend.
Care on the verge of the crisis
Across the country, the surge has resulted in some hospitals generally providing care, and health care workers making difficult decisions on the ground.
In the spring, doctors expected a shortage of ventilators to force them to avail themselves of crisis standards for care, but now hospitals are overwhelmingly saying that the limiting factor is emerging as qualified staff who can care for seriously ill patients – not machines or beds.
How many ICU patients can a single nurse treat? When is it okay to discharge patients early to free up space? Who is brought to a field hospital with fewer employees?
“I don’t really see these decisions as black and white, you get cared for or not,” said Hick, who is also an ambulance doctor at Hennepin Health in Minnesota.
Utah warns it is dangerously close to implementing its nationwide contingency plan. The state is moving COVID-19 patients who are not quite as sick to designated COVID-19 care facilities to free up hospital space, says Kevin McCulley, director of preparedness and response for the Utah Department of Health.
“We realize that even with deeper and deeper emergency strategies, it may not be enough,” he says.
Utah-based hospital chain Intermountain Healthcare has deployed bedside nurses, adjusted staffing quotas as needed, and hired nursing students who are almost finished school to help in hopes of avoiding crisis standards in care. says Jim Sheets, its chief operating officer.
“That is our biggest goal, to avoid that at all costs,” says Sheets. “This week our intensive care unit and our hospitals were over 90% and this is really full, that can be problematic, but we’ve been stabilizing there for a few weeks.”
At St. Luke’s Health System in Idaho, hundreds of COVID-19 patients are sent home with blood pressure cuffs, pulse oximeters, and iPads so that their vital signs can be remotely monitored as their condition worsens. The hospital has also set up intensive care physicians to look after multiple patients via telemedicine so that their expertise extends as far as possible.
However, the health system is on a dangerous path if cases continue to rise, says Dr. Robert Cavagnol, Executive Medical Director of St. Luke’s Clinic.
“We will no longer have staff to take care of the people. They will just be overwhelmed and there is only so much people can do,” says Cavagnol. “At some point we’ll reach this capacity, but we’re not there today.”
In Illinois, Chicago nurse Consuelo Vargas says seriously ill patients are held in her emergency room for up to several days.
“This leads to an increase in patient falls; this leads to pressure ulcers; this leads to delays in patient care,” says Vargas.
Ambiguity is a burden for healthcare workers
Under rapidly growing pressure from COVID-19 patients, hospitals are running out of alternative strategies to make room for patients without compromising care.
The goal of contingency plans is to prevent clinicians from making difficult ethical decisions about patient care.
In a report released Tuesday, a group of doctors in the intensive care unit in New York City said it was unclear to them whether or not their hospitals were officially operating in crisis standards of care during the spring surge.
“Many attendees firmly believed that the dividing line between an extremely busy – ‘a bad Saturday night’ – and a [crisis standards of care] The event was not as clear as the plans assumed, “the report says.” The situation was much more dynamic. ”
The crisis is putting an enormous strain on healthcare workers who are working hard to save people’s lives. And communities may pay the price, even after the pandemic ends, warns Mateen.
“We’ll get through the pandemic, but you’ve ragged a generation of doctors who may not be able to give you all of them for the next 10 years,” Mateen says. “I don’t want to paint them as a martyr, but it’s not easy and I really worry about them and how much they can go through physically, emotionally and mentally.”