The first Monday of 2021, Nancy Blake says, “was the worst day I’ve ever seen.” Blake is the chief nursing officer at Harbor–University of California, Los Angeles, Medical Center. She looked at the intensive care unit, which had twice the number of patients as standard critical care beds. Noncritical patients were lined up in gurneys in the hallways. At other hospitals in the area, ambulances were waiting for eight to 12 hours to move patients into beds. Most of those people had COVID.
And still today, Blake continues, “patients keep coming and keep coming and keep coming.” The staff is keeping up quality care, but she worries there may not be enough hands to take care of all of those who are seriously ill. “It’s been pretty stressful,” she says. Every day she looks at her coworkers and sees “the moral distress in the faces.”
In Birmingham, Ala., Kierstin Kennedy says, “in some ways, it feels like you’re in a war zone or a Third World country.” Kennedy is chief of hospital medicine at the University of Alabama at Birmingham Hospital, where 98 percent of ICU beds are filled with COVID patients. “Things are stretched so thin,” she adds. At these facilities and many other hospitals across the country right now, patients are not getting the care that doctors and nurses want to provide because the current COVID surge means staffers are stretched among more and sicker patients. As of January 25, California’s ICUs were at an average of 90 percent occupancy for the entire state. In Texas, the average was 92 percent. In Alabama, it was 95 percent.
This problem is affecting people who are in the hospital for ailments other than COIVD. At the University of California, San Diego, Medical Center, where Jess Mandel is the division chief of pulmonary, critical care and sleep medicine, the hospital has been canceling all but immediately lifesaving surgeries—including those for cancers and aneurisms—and dramatically restricting the number of admitted patients. “It’s been very challenging,” Mandel says. “These are cancer surgeries where we’re saying, ‘We want to take it out today, but I guess we can try and wait four weeks.’” In many places in California, supplemental oxygen is conserved among outpatients and time on dialysis machines is sometimes reduced.
Although nurses, doctors and hospital administrators are working overtime to ensure as many lives are saved as possible, research shows that large numbers of very sick patients and seemingly minor adjustments in care can impact the likelihood of survival. A mid-January update to a preprint study in the U.K., which has not yet been peer-reviewed, found that as ICUs fill up, a patient’s risk of death can increase by as much as 69 percent. Prepandemic studies have shown that as nurses add more ICU patients to their shifts, the risk of patient death increases. And they have also found that delaying ICU admission for critically ill patients heightens the rates of mortality for these individuals.
To try to avoid these outcomes, hospitals are now working hard to expand their facilities and draw in extra staff. But they are also beginning to consider plans for other ways to cope, including some forms of rationing care, if the flood tide of patients continues to rise.
Most hospitals have been able to stretch intensive care staffing by assigning surgical nurses or nurse aids to work alongside ICU nurses or by pulling in nursing students. But these trained individuals and their attention and energy are still a finite resource. “Common sense and practical experience tell us there are limits even if we can’t clearly define what those limits might be,” says Jeff Dichter, an intensive care physician and associate professor in the division of pulmonary, allergy, critical care and sleep medicine at the University of Minnesota Medical School.
By many accounts, staff who have been caring for critically ill COVID patients for so long are approaching those boundaries. “People are exhausted,” Blake says. She has worked in disaster preparedness for 35 years, but “nobody prepared me or the staff for 10 months of this,” she says.
“Our nurses are taking care of patients who can’t have visitors, and they don’t want someone to die alone, so they’re going to hold patients’ hands,” Blake says. “It’s really difficult for staff to see so many deaths—and to know there are people in our community who are having superspreading events and parties or having protests about masking and saying [the virus] is a hoax. It’s just really demoralizing.”
Hospitals are also prepared to take further steps if the situation becomes even more dire—a possibility as cases and deaths keep climbing and new, more contagious variants of the coronavirus begin circulating more widely.
These steps involve rationing care resources based on clinical assessments of patient needs. One such evaluation is called the Sequential Organ Failure Assessment score. It assigns numerical values to different essential body systems in an effort to determine a patient’s likelihood of survival. This could come into play as one metric in Minnesota, for example, if the state faces a shortage of ventilators. If no other options are available, the Minnesota Department of Health recommends evaluating all patients’ conditions regularly and ultimately removing ventilators from those with a poor survival prognosis, worsening condition and/or long-term need for the equipment. In such heartbreaking cases, the equipment would be reassigned to patients who could benefit from it more.
Although seemingly clear-cut, these guidelines can become tricky in the real world, especially with a new, complex and variable disease such as COVID that has impacted different groups disproportionately. For example, Massachusetts drew criticism for its early 2020 plans to make people with other underlying health conditions, such as heart disease and asthma, a lower priority for care if resources became scarce. Those plans were rescinded in revised guidelines because they amounted to racial discrimination: they would have made many people of color, for whom generations of systemic racism have produced a higher probability of having these conditions, less likely to receive lifesaving care.
This potential for bias is why some experts, such as political science professor Julia Lynch of the University of Pennsylvania, recommend hospitals create dedicated scarce resource allocation teams. “Bioethical principles don’t implement themselves,” she says. And when decisions are left to individuals—especially when they are already under strain—“you tend to fall back on unconscious heuristics,” or mental shortcuts. That “can really increase bias,” Lynch says. It is essential to guard against discriminatory treatment, she notes, because “people are coming into this pandemic on an unequal footing.”
Standing committees to make such decisions also remove the weight from the people already providing care to these patients. “It’s very protective for the bedside clinician,” says Lewis Kaplan, president of the Society of Critical Care Medicine and a professor of surgery at the Hospital of the University of Pennsylvania.
Reaching the Limits
Nevertheless, “even though the decision may be pretty clear, it still feels difficult,” Kaplan says after finishing a 36-hour shift. For example, some hospitals’ current decision processes might require a very sick patient to remain in the emergency department for two days while waiting for a critical care bed to open up in the ICU. “While you’re insulated from [making] the actual decision, you still feel engaged in the care that is being provided differently than what you would usually provide,” Kaplan says.
Even if it is necessary to deviate from the normal standards of care, doing so can also be worrisome from a legal perspective by opening the specter of malpractice charges. California recently joined a handful of other locations and states, including Arizona and New York City, in specifying standards of crisis care both to clarify them and protect hospitals and care providers from any allegations about departing from treatment norms for the situation.
Still, Kennedy emphasizes that “every clinical scenario is different.” She is among the team members at her hospital that get on the phone with other medical providers to decide if they can let patients into one of their scarce beds. They were recently able to make room for a critical COVID patient who was in dire need of a liver transplant. But finding a bed for that one individual “was a monumental task,” she says, because it meant having to decide how they could shift other patients around without impacting their care.
All of this has been weighing particularly heavily on Kennedy, who has a background in health care quality improvement. She says that she has felt positive overall about the level of care her hospital has been able to deliver to patients—even under difficult circumstances. “But I honestly don’t know how long we can continue to do that,” Kennedy says.
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