The results in many of those hospitals is a form of “rationing” of care, or triaging patients by determining who is likely to survive or not, and thus who should get the treatment.
“There’s no question that rationing is occurring nationally, it’s just worse in some areas than in others,” said Dr. John Hick, medical director for emergency preparedness at Hennepin County Medical Center in Minneapolis.
The rationing doesn’t mean taking someone off of a ventilator to give the ventilator to someone else, but it could mean a patient who needs a ventilator to survive may not get it.
Hick said there are a lot of implicit triage decisions being made at hospitals that lack the staff or beds to care for all of the very sick patients they may have. An example would be a very sick, elderly person who is taken to a rural hospital because of his worsening respiratory stress and needs an ICU bed. “So you talk to him and his family about the fact that he probably won’t survive this and we’re not going to intubate him,” Hick explained.
One in four COVID-related deaths may be attributable to the overcrowding at hospitals that has occurred since the pandemic began. “The busier the hospitals are the higher the mortality rate gets for COVID,” Hick said.
“The biggest issue is staffing, including nurses and respiratory therapists,” wrote LaWanna Halstead, vice president of quality and clinical initiatives at the Oklahoma Hospital Association, in an email. “It’s being mitigated by changing the nurse-to-patient ratio, identifying any tasks that can be performed by someone other than a nurse and using ‘emergency’ documentation standards, postponing non-urgent surgeries, and utilizing staff from outpatient areas,” she wrote.
“It’s a little bit of everything, really,” said Dr. Hamad Husainy, an emergency physician in Alabama and an American College of Emergency Physicians spokesperson. “It’s a lack of staff, but also we’re having a hard time getting patients transferred to the facilities and I can only assume it’s because of staffing capacity issues.”
“We’re short on both beds and providers,” Hick said. “There are definitely patients being taken care of in intermediate care monitored settings that we would normally have in the ICU, but we just don’t have the option right now.”
The staffing issue is a common refrain from hospitals around the country as nurses, having been burned out over the course of the pandemic, have stopped volunteering for extra work or quit altogether.
“It’s actually worse in a lot of ways than it was months ago,” Hick said. “Providers are so stressed and we depend on a lot of nurses to pick up extra shifts because a lot of them are contracted for less than full time and routinely pick up extra hours.”
But that’s not happening as nurses are too fatigued and would rather go home with family. “They know it’s going to be a really awful and crazy shift and nobody’s stepping up,” Hick said.
And there is always a different standard of care between rural and urban areas, but that gap has widened with COVID-19.
“You know that if you live in a rural area, you’re more likely to die from a motor vehicle accident with the same injuries that you could survive in an urban area,” Hick said. “It’s just response times to transfer to a trauma center.”
“Right now, there is a much wider gap and that’s shown by the fact that if you come to a tertiary care center, a hospital that provides a fair amount of critical care services, you’re in line for those services and people are going to make it happen,” Hick said.
But, he continued, when you go to a smaller, critical access hospital, say in a rural area, the provider has to find a place for you to receive care. “Time’s wasting and the provider is probably out of their depth as far as that critical ongoing care.”
Some patients in rural hospitals needing a higher level of care have been sent out of state because of the shortage of beds in Oklahoma, according to Halstead.
In Minnesota, an emergency declaration by the governor meant hospitals were forced to take transfer patients and care for them. Once the declaration was lifted, those hospitals can now decline transfer patients.
“Why does it require five calls?” Husainy asked. “Why can’t we just have surgeons that are willing to take that patient that is awaiting placement?”
Hick pointed out also that the vast majority of COVID-19 patients in the ICU are unvaccinated. Vaccinated patients, he said, even when infected with the virus, are much less likely to be hospitalized and even less likely to wind up in ICU.
“If there’s one thing health-care providers hate, it’s bad things that could have been prevented,” Hick said. “You have four teens in a car accident and three walk away because they were wearing a seat belt while the other dies or is never the same. It’s the same thing with COVID. We see these patients coming in that have to get intubated and they’re like, ‘I wish I’d gotten the vaccine,’ and all you can think to yourself is, I wish you had too.”
Another factor making things worse is that cities are seeing more violent crime, and the result is more trauma patients in hospitals.
“Our trauma numbers in general are through the roof, and couple that with an incredible chemical dependency and mental health issue during the pandemic this past year and you have incredible pressure on the emergency departments and hospitals,” Hick said.
It’s a combination of problems that the health-care industry does not prepare for.
“Hopefully we learn a lesson from this,” Husainy said. “We need to be more diligent in our search and our desire and drive for working toward true inter-facility coordination, to tear down those barriers, those silos that we have.”
“We’ve got to have better standards for hospital preparedness,” Hick said. “We’ve got to have better and more coordinated systems for moving patients and resources and having visibility on those resources across state lines.”
He said there is no incentive to invest money for problems that may or may not occur down the road. “Whether it’s a mass shooting or anything else, you’re not going to be as prepared as you want to because the drivers are simply not there, and until we make sure health care is an integrated part of emergency response, we’re going to continue to fail at this.”