Near Crisis, Some Hospitals Face Tough Decisions In Caring For Floods Of Patients



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Medical staff prepare for an intubation procedure on a patient suffering COVID-19 in an ICU in Houston, Texas. In some parts of the country, as hospitals get crowded, hospital leaders are worried they may need to implement crisis standards of care.

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Without detailed data on hospitalizations, which are not made public by the federal government, it’s difficult to tell if this trend is driven by hospital capacity issues or other factors like the age and severity of patients. But researchers and public health experts worry that overcrowding in hospitals is, at the very least, a contributing factor.

«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 U.K. He used detailed government data there to study the COVID-19 death rate. His findings from London echo the experience in New York City: The highest death rates came in the beginning of the pandemic when hospitals were full.

Mateen says even though there’s not enough research yet to definitively prove that crowded hospitals lead to higher death rates, it would be better to assume so and act aggressively now to stop the surge in hospitalizations.

«Why on earth if [doctors] are telling you that they’re at their wit’s end of what they are capable of, why would you not do the sensible thing and recognize the health system is at a breaking point?

Separate research published in the Journal of General Internal Medicine in August found when more beds were occupied by COVID-19 patients, the number of deaths rose over the next week, though it did not examine whether a higher percentage of patients died as hospitals filled up. Pinar Karaca-Mandic, a professor at the University of Minnesota and the lead author of that study, told NPR that the most recent data available show roughly the same trend.

Care on the brink of crisis

Around the country, the surge has upended how some hospitals typically provide care and health care workers are making tough on-the-ground decisions.

In the spring, physicians expected that a shortage of ventilators would force them to call on crisis standards of care, but now hospitals overwhelmingly say the limiting factor is turning out to be skilled staff who can care for severely ill patients — not machines or beds.

How many ICU patients can a single nurse handle? When is it okay to discharge patients early to free up space? Who gets moved to a field hospital with fewer staff?

«I don’t really see these choices as being black and white, you’re going to get care or you’re not,» says John Hick, who’s also an emergency physician with Hennepin Health in Minnesota.

Utah is warning it’s perilously close to implementing its statewide crisis plan. The state is moving COVID-19 patients who are not quite as sick to designated COVID-19 nursing facilities to free up hospital space, says Kevin McCulley, director of preparedness and response for the Utah Department of Health.

«We recognize that even with deeper and deeper contingency strategies, that it may not be enough,» he says.

The Utah-based hospital chain Intermountain Health has deployed nurses who aren’t usually at the bedside, adjusted staffing ratios when necessary and brought in nursing students who are almost done with school to help, all in hopes of avoiding crisis standards of care, says Jim Sheets, its chief operating officer.

«That’s our biggest goal, is to avoid that at all, at all costs,» says Sheets. «This week, our ICU and our hospitals were over 90% and that’s really full, that can be problematic, but we’ve been able to be stabilized there for a couple weeks.»

At St. Luke’s Health System in Idaho, hundreds of COVID-19 patients are being sent home with blood pressure cuffs, pulse oximeters and iPads so their vitals can be monitored remotely in case their conditions deteriorate. The hospital has also set up ICUs doctors to look after multiple patients via telehealth so their expertise can go as far as possible.

But the health care system is on a dangerous trajectory if cases keep climbing, says Dr. Robert Cavagnol, executive medical director for St. Luke’s Clinic.

«We’re going to run out of staff to take care of people, they’re just going to be overwhelmed and people can only do so much,» Cavagnol says. «At some point, we will reach that capacity, but we’re not there today.»

In Illinois, Chicago nurse Consuelo Vargas says critically ill patients are being held in her emergency room for up to several days.

«This leads to an increase in patient falls, this leads to bed sores, this leads to delays in patient care,» says Vargas.

Lack of clarity burdens health care workers

Under the rapidly growing pressure of COVID-19 patients, hospitals are running out of alternative strategies to make room for patients, without somehow compromising care.

The goal of crisis plans is to prevent clinicians from making tough ethical decisions about patient care on their own.

Yet, in a report published Tuesday, a group of New York City ICU physicians said it was unclear to them whether their hospitals were formally operating in crisis standards of care or not during the spring surge.

«Many participants felt strongly that the dividing line between being extraordinarily busy — ‘a bad Saturday night’ — and a [crisis standards of care] event was not as clear as plans had assumed,» according to the report. «The situation was much more dynamic.»

The crisis is putting enormous strain on health care workers, who are striving to do everything they can to save people’s lives. And communities may be paying the price for this even after the pandemic ends, says Bilal Mateen.

«We’ll get through the pandemic, but you’ll have worked ragged a generation of doctors who might not be able to give you their all the next 10 years,» says Mateen. «I don’t want to paint them as martyrs but it’s not easy, and I’m genuinely worried about them and how much they can physically and emotionally and mentally go through.»

  • COVID-19 hospitalizations
  • hospital capacity



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