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Hospital intensive care models are filling up. It's worse than it sounds.

By mid-December, hospitals only had 22 percent of their ICU beds across the country on average, and many were fully occupied. As the rise in Covid-19 continues to mount, the lack of beds in the intensive care unit can have serious consequences, including the inability to properly care for the sick Patients, potentially rationing life-saving care.

But even these bed capacity numbers don't tell the whole story.

Adding extra beds for intensive care in other departments or buildings costs valuable time, resources and space. However, adding trained staff is much more difficult, especially deep in a pandemic.

When trained staff is scarce, it is even more difficult for hospitals to best meet the needs of ICU patients. These patients include people who are very ill with Covid-19, but also many who have to be in the intensive care unit for other reasons, e.g. B. Those who have had a heart attack or stroke, are recovering from major surgery, or have the flu. among other.

The number of people with Covid-19 currently in intensive care in the United States hit an all-time high in mid-November and has risen since then.

Our world of data with data from the COVID Tracking Project and the COVID19 Tracker

Only about a dozen states had more than 30 percent ICU capacity as of December 15, and the number of coronavirus cases has only accelerated since then. And the reality on the ground is much worse in many areas, as the coverage of the New York Times has shown.

According to the Times data collected by the U.S. Department of Health from about 100 hospitals in the Los Angeles area, more than 65 said the intensive care unit was 90 percent or more busy. The Cedars-Sinai Medical Center was 112 percent busy.

In Dallas, the fourth largest metropolitan area in the country, 80 percent of the 47 hospitals with more than 20 Covid 19 patients had no or only one ICU bed left. The most open beds in a hospital were five.

In Minneapolis-St. In the Paul region, half of the hospitals with more than 20 Covid-19 patients had a bed capacity of more than 95 percent in the intensive care unit.

In Oklahoma, which has the third highest per capita rate of new cases in the country, the majority of hospitals with more than 20 Covid-19 cases were more than 90 percent in intensive care.

Nancy Nagle, a pulmonologist and intensive care doctor with Integris Health System in Oklahoma City, who reported the HHS to the HHS as full ICU occupancy in the latest data, says she has turned regular patient rooms into intensive care rooms to help cope with the onslaught of harder-to-be-ill people. Even so, she said: "Occasionally, Covid-19 patients have to stay in the emergency room for several hours waiting for a bed to become available."

And in many places in the country, there is little sign of relief. Since the beginning of December, an average of more than 200,000 new Covid-19 cases have been reported every day.

"Patients keep coming back and we need to take care of them regardless of our workforce," wrote Gisella Thomas, a respiratory therapist at Desert Regional Medical Center in Palm Springs, Calif., In an email to Vox. "I'm concerned that it will only take the staff so long to hold up before the break, which could ultimately limit the capacity itself."

Covid-19 can be a long, unpredictable, and complicated disease

The sickest Covid-19 patients can stay in the intensive care unit for weeks or longer. And although we have learned a lot since the spring about how to better treat seriously ill Covid-19 patients, it is still difficult to tackle the disease on our own and we have no cure for it. This means that 2 percent of people who receive Covid-19 and end up in intensive care are often in intensive care units until they can either recover – which often includes invasive intubation treatment – or die.

One of the reasons intensive care units have filled up is because a patient with Covid-19 is unlikely to stabilize very quickly once they get this sick. A September study found that the average ICU stay for a Covid-19 patient was around a week – almost double the typical 3.8 day ICU stay for other patients. Other individual reports show that many patients can be in the intensive care unit for weeks or even months. Setting that number is crucial in predicting how many beds might be available in the future if cases continue to rise.

An October study found that an average ICU stay of 10 days means there is only a 10 percent chance a new bed will open each day. If admissions exceed this rate, the intensive care units are likely to become overwhelmed.

This is something that people who work with critically ill coronavirus patients have to deal with on a daily basis. "Unfortunately, Covid-19 patients stay in intensive care for a long time," said Nagle. "The disease progresses very slowly and this contributes to the lack of available beds."

And while Covid patients are there, it can be extremely labor intensive to meet their needs. "Covid-19 patients can be incredibly ill, with multiple devices to watch and adjust, multiple drugs to give, and lab results to draw and results to watch," said Nagle. And although we now have a better understanding of possible treatments for critically ill patients, "patients still react differently, and their progress and possible outcome are always unpredictable." This is another reason why hospitals do not always have a good prognosis about it how many ICU beds they might have in the coming weeks or days.

Caring for Covid-19 patients also requires many more steps and precautions than working in the intensive care unit with other patients, which leads to further disruption. All employees who enter a Covid-19 room in the intensive care unit must wear full robes and PPE every time, which is resource-intensive. "This also creates real trouble when someone falls because it slows our response," said Thomas. "The need to clean all equipment more thoroughly also creates delays and makes normal staffing inadequate for the pandemic."

In the meantime, doctors, nurses, and other health care workers strive for the best possible care while being asked to treat more and more patients. "Critically ill patients are very complex," said Orlando Garner, a pulmonologist at Baylor College of Medicine. “There are many moving parts at the same time that require the same priority.” But he said, “If you go beyond capacity, the only way to deliver the same quality is to create more skilled healthcare workers. As we found out, it does this is a scarce resource. "

The staff is even scarcer than the beds in the intensive care unit

Although hospitals can often slightly increase the number of beds and the amount of care, the staff is much shorter. "The most valuable resource in any hospital is having people who know and are able to care for patients," wrote Sarah Delgado, an acute nurse and clinical practice specialist with the American Association of Critical-Care Nurses, to Vox rolled into one E-mail. "It's the limiting factor." Without enough of these people to care for everyone who is very ill, "patient outcomes are likely to suffer," she said.

And it's not just doctors and nurses in the intensive care unit who are in short supply. "Critical Care is more of a team sport," said Garner. "This means medical care and interventions, but also careful dosing of drug selection from pharmacists, qualified nurses, respiratory therapists, mid-level providers, nutritionists, and early mobilization from physiotherapists." To that list, Nagle also adds any other hospital staff required for other critical ICU tasks, including bathing patients, changing sheets, and other functions.

To compensate for the increase in very sick Covid 19 patients, many hospitals have had to revise their personnel structure. At Christiana Hospital in Delaware, nurse Lauren Esposito and her colleagues typically work with critical heart patients. But this year her unit served as an overflow for critical Covid-19 cases. "It was a little uncomfortable at first," she wrote for the American Association of Critical-Care Nurses.

Your hospital implemented a tiered human resources strategy where cardiac nurses would work under trained intensive care nurses. "During the shift, if a patient fell, we could bend over and have the ICU nurse go to that patient to treat him," she wrote. They were also able to quickly train the nursing staff, for example in working with intubated patients. Even so, the overflow duties have been strenuous and have not been relieved given the intense isolation these patients are in to stop the spread of the infection. "I remember the first time I walked into a patient's room. It really hits you that you are the primary nurse and no one else can come in."

In addition, employees now often have to look after more patients at the same time. In California, where an average of more than 44,600 people a day tested positive for the coronavirus last week, Governor Gavin Newsom cut the state's nurse-to-patient ratio from 1: 2 to 1: 3 to match the rising numbers of Covid- 19 hospital stays.

In Oklahoma, Nagle discovers that the intensive care nurses she works with typically care for one or two patients during a shift. "Due to the lack of nurses in the intensive care unit, each nurse can take care of three and in extreme conditions even four patients."

This increase in the number of patients that every nurse sees – especially with a complex disease like Covid-19 – is a major adjustment. "Nurses are by the patient's side every day and every hour, administering life-saving medication, working with other members of the health team, translating information to families, and providing end-of-life presence when those families are absent due to strict isolation requirements," Delgado said . "This work cannot be done if the number of patients exceeds staff capacity."

And the employees themselves often get sick with the virus. Up to a quarter of Covid-19 infections are healthcare workers in some states, according to a November report.

"It could have been me"

Garner, whose entire family contracted Covid-19 earlier this year, including his 4-month-old daughter, said the disease itself gave him a new perspective on the patients who are now flocking to intensive care units in Texas.

"It could have been me, my wife, or one of my children in that ICU bed," he said. “It's easy to rationalize the number of sick patients by thinking, 'Well, they haven't distanced themselves' or 'They haven't worn masks,' but the fact is, no one deserves it, to get this virus and get sick with it, not even the people who doubt it. As the top continues to grow, compassion is the only thing that can keep us from getting exhausted and burned out.

The flip side of this is the reminder of the compassion for the health care workers who care for these patients, especially as the holidays approach. Not only will many of these workers continue long shifts during the holidays, but they also know that many people disregard public health warnings to avoid gatherings.

"We need the public to do their part," said Delgado. "Stop unnecessary travel, strictly adhere to guidelines on wearing masks and social distancing, and limit gatherings with people outside your household," Delgado said.

Katherine Harmon Courage is a freelance science writer and author of Cultivated and and Octopus! Find her on Twitter @KHCourage.

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