- As space, staff, and supplies run thin in the intensive care units (ICUs), hospitals will face significant delays and challenges in providing care.
- This is already playing out in various locations, such as Los Angeles, where patients line the hallways, waiting for care.
- Some states have already distributed guidelines instructing healthcare workers on how to ration care if resources are strapped.
- When ICU capacity is exceeded, the quality of care drops — not only for COVID-19 patients, but also for people being treated for heart attacks, strokes, and injuries from accidents.
As the current COVID-19 surge continues, health officials are issuing warnings that intensive care units (ICUs) are near or in some cases past capacity.
Health officials in California recently said the state could burn through ICU capacity, including its makeshift surge facilities, by early January.
New Mexico has already exceeded its ICU capacity. Arizona is dangerously close. And the same scenario is playing out in Arkansas, Idaho, Missouri, Oklahoma, and Rhode Island.
As people move forward with their holiday plans and gather indoors, more states could face a similar fate.
So, what happens when hospitals reach and exceed capacity?
If there’s room, patients are transferred to other hospitals or makeshift wards. If there’s not, staff shortages increase, care is rationed, and space runs out.
Dr. Daniel Fagbuyi, an emergency physician who served as a biodefense expert in the Obama administration, told Healthline there are four S’s to consider in a surge situation:
- staff
- space
- supplies
- other stuff
Let’s start with staff.
If frontline healthcare workers treating people with COVID-19 get sick, there’s less staff available to treat patients in the ICU.
Additionally, if there’s an influx of patients, there won’t be enough staff to adequately treat everybody, including not only people with COVID-19 but also people who’ve had heart attacks, a stroke, or been involved in accidents.
Combine the two and there’s the potential for a significant staff shortage. In such a scenario, hospitals will need to hire extra employees to meet the demand.
Healthcare workers from different departments may step in, some of whom don’t have an ICU or critical care background.
“They’re asking nonpulmonologists and noncritical care specialists to start helping with ICU cases,” said Dr. Matthew Heinz, a hospitalist in Tucson, Arizona.
While this is both safe and necessary, it’s definitely not optimal, Heinz said.
Hospitals may also recruit retired doctors and nurses — some of whom haven’t worked for years and might be rusty, Fagbuyi said — or even healthcare workers from other states or countries.
“We’re already in that space where we’re seeing critical staff shortages,” Heinz told Healthline.
The next thing to go is space.
Elective surgeries will be canceled (which is already happening in certain locations), and ICU patients may be put on floors typically designated for other types of care, Fagbuyi said.
Patients may also be held in the emergency department until space in the ICU opens up.
Dr. Ashely Alker, an emergency medicine physician outside of Washington D.C., has faced significant delays in moving emergency patients to the ICU.
“I called three states today trying to get an ICU bed for a patient… none available,” Alker tweeted on Tuesday.
Alker told Healthline that people typically aren’t kept in the emergency department for more than 8 hours, but they’re currently being held for longer.
Keeping patients who need to be sent to the ICU complicates care because there’s only so much that can be done in the emergency room, Alker explained.
“You can only have so many critical patients,” Alker said.
Emergency department nurses are also overwhelmed.
“ICU nurses are one nurse to one patient, we don’t usually have that luxury in the [emergency department],” Alker said.
If there’s room in nearby hospitals or makeshift surge facilities, overflow patients will be transferred.
States have set up hotlines to help hospital personnel quickly figure out where a patient can go. But some areas are seeing such large surges that no nearby ICU beds are available.
If this happens, it’s not out of the question for people to be treated in the hallways, the waiting room, or in the ambulance they arrived in.
Just look at Los Angeles, where critically ill patients hooked up to oxygen tanks line the hallways.
As more people require ICU-level care, hospitals will need to figure out how to work with a limited supply of lifesaving tools such as ventilators.
Some hospitals may choose to switch ventilators, or beds, between patients.
Another option is placing multiple people known to have COVID-19 in one room (called co-horting).
“We’re putting people who have the same disease processes together,” Fagbuyi said.
Heinz added that co-horting isn’t unsafe, but it’s also not ideal.
“Everything is so suboptimal at this point,” Heinz said.
States are already enacting policies advising healthcare workers about how to decide which patients should receive lifesaving devices when supply is limited.
“We have to decide: Are we worried about life years saved, lives saved, or quality of life? These are questions, ethical questions, hard questions,” Fagbuyi said.
Arizona, for example, issued guidelines on how to ration care when resources in the ICU are strapped.
Los Angeles County also recently distributed guidance for rationing care.
Doctors are advised to allocate ventilators based on a patient’s expected outcome. Generally, this means younger, healthier people will be prioritized.
“It goes to the person who is most likely to survive,” Heinz said, noting how traumatizing this can be for healthcare workers.
When ICU capacity is exceeded, the quality of care drops.
Remember: The ICU treats not only COVID-19 patients, but a range of critically ill people who need around-the-clock care.
This includes people who have a heart attack, a stroke, or are in a car crash — events you can’t plan for.
Without the staff, space, and supplies, health officials say it will be a challenge for people to get the level of care they deserve.
Patients will be seen and stabilized as soon as possible, but there will be significant delays and challenges.
“People who come in with car accidents, who come in with strokes, who come in with neurological issues — these all [could be] blocked or put on a back burner in a sense,” Fagbuyi said.
“It’s just about first come first served, and if you’re overwhelmed and bursting at the seams, you can’t get to them,” he said.