POST 76. November 23, 2020. CORONAVIRUS. “No battle plan survives contact with the enemy.” Ventilators..”just keep people alive while the people caring for them can figure out what’s wrong and fix the problem. And at the moment, we just don’t have enough of those people.”

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“As record numbers of coronavirus cases overwhelm hospitals across the United States, there is something strikingly different from the surge that inundated cities in the spring: No one is clamoring for ventilators.

The sophisticated breathing machines, used to sustain the most critically ill patients, are far more plentiful than they were eight months ago, when New York, New Jersey and other hard-hit states were desperate to obtain more of the devices, and hospitals were reviewing triage protocols for rationing care. Now, many hot spots face a different problem: They have enough ventilators,  but not nearly enough respiratory therapists, pulmonologists and critical care doctors who have the training to operate the machines and provide round-the-clock care for patients who cannot breathe on their own.

Since the spring, American medical device makers have radically ramped up the country’s ventilator capacity by producing more than 200,000 critical care ventilators, with 155,000 of them going to the Strategic National Stockpile. At the same time, doctors have figured out other ways to deliver oxygen to some patients struggling to breathe — including using inexpensive sleep apnea machines or simple nasal cannulas that force air into the lungs through plastic tubes.

But with new cases approaching 200,000 per day and a flood of patients straining hospitals across the country, public health experts warn that the ample supply of available ventilators may not be enough to save many critically ill patients.

“We’re now at a dangerous precipice,” said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine. Ventilators, he said, are exceptionally complex machines that require expertise and constant monitoring for the weeks or even months that patients are tethered to them. The explosion of cases in rural parts of Idaho, Ohio, South Dakota and other states has prompted local hospitals that lack such experts on staff to send patients to cities and regional medical centers, but those intensive care beds are quickly filling up.

Public health experts have long warned about a shortage of critical care doctors, known as intensivists, a specialty that generally requires an additional two years of medical training. There are 37,400 intensivists in the United States, according to the American Hospital Association, but nearly half of the country’s acute care hospitals do not have any on staff, and many of those hospitals are in rural areas increasingly overwhelmed by the coronavirus.

“We can’t manufacture doctors and nurses in the same way we can manufacture ventilators,” said Dr. Eric Toner, an emergency room doctor and senior scholar at the Johns Hopkins Center for Health Security. “And you can’t teach someone overnight the right settings and buttons to push on a ventilator for patients who have a disease they’ve never seen before. The most realistic thing we can do in the short run is to reduce the impact on hospitals, and that means wearing masks and avoiding crowded spaces so we can flatten the curve of new infections.”…

“If we want to make sure that someone who’s hospitalized in the I.C.U. with the coronavirus has the best chance to get well, they need to have highly trained personnel, and that cannot be flexed up rapidly,” he said in a news briefing on Tuesday.” (A)

“They’ve stockpiled masks and gowns. They’ve reopened the COVID-only patient units created as the pandemic peaked last spring. But as New Jersey hospital officials brace for another rising tide of sick coronavirus patients, the resource they worry most about is human.

Will there be enough doctors, nurses, respiratory therapists, patient-care technicians, and others to care for everyone who needs them?

“That is the one thing that I think keeps us up at night,” said Gov. Phil Murphy. “The staffing piece.”

The one concern that will “determine what happens with this second wave is staffing,” said Dr. Daniel Varga, chief physician executive at Hackensack Meridian Health, which runs multiple acute-care hospitals as well as in-patient behavioral health and children’s facilities. “Remember, we’re trying to run a full-service hospital as well as take care of COVID patients.”…

But three possibilities worry health care officials: If Thanksgiving gatherings spread the disease more widely among older people, if nursing home outbreaks continue to worsen, and if the virus morphs in unpredictable ways — then all bets are off.” (B) 

‘With a combination of luck, new hires and creative reorganizing of staff and patients, Utah’s hospitals haven’t had to eject anyone from intensive care units due to the coronavirus.

But several doctors say the solutions still amount to rationing, with the quality of care deteriorating as hospitals are stretched thinner and thinner….

As of Thursday, there was room for about 45 more ICU patients statewide, said Greg Bell, president of the Utah Hospital Association….

“Standard ICUs are full. Period. We’re now talking about ‘extended access’ ICU. So the care is different,” said Dr. Eddie Stenehjem, an infectious disease physician at Intermountain Medical Center in Murray. “We’re having to ask providers to do things that they aren’t comfortable with.”

ICUs usually are staffed by doctors and nurses who have training and experience specific to intensive care. But to staff the overflow ICUs that have opened around Utah, hospitals are moving doctors and nurses from other departments. And Intermountain Healthcare has hired about 200 nurses from out of state.

“We’re asking them, ‘Take care of the most complex patients that you’ve ever had, in a health care environment that you’ve never been in.’ And so the health care is changing.”

Meanwhile, the patients who are in the ICUs, particularly the ones with COVID-19, are likely to be in precarious condition, with multiple organs at risk of failure, Stenehjem said.

“The margin of error is really low,” he said. “…You’re potentially going to have more errors, and you’re potentially not going to have as good of care that you would have if you had the [regular] ICU team that works together as a cohesive unit … every day.”

At the U., a coronavirus-only overflow ICU has doubled the number of patients per nurse in order to expand intensive care to patients who do need it, but who are on the more stable end of the ICU spectrum, Callahan said. Treating only patients with coronavirus does save time, Callahan said; the tasks are more consistent from patient to patient, and providers don’t have to change personal protective equipment every time they cross a threshold, as they do in the standard ICU.

But coronavirus patients are just like any others requiring intensive care: monitoring is constant, alerts are frequent, and patients don’t have minutes or seconds to spare. The lower staffing ratios mean nurses are sometimes facing more urgent tasks than they have hands for, Callahan said. And when patients in the overflow unit unexpectedly destabilize, setting off more alarms than the staff can respond to, they have to be moved back to the regular ICU — a time-consuming task in its own right, Callahan said…

When overcrowding affects the quality of care across the board, Callahan said, it still amounts to rationing — even without the formal shift to “crisis standards of care,” which require authorization from the governor and give priority to the ICU patients who are likeliest to survive when there aren’t enough beds to go around.”…

It’s going to be even harder, Callahan said, to let hospitals move the very sickest patients out of their ICUs, even if “crisis standards” are necessary to save the most people.” (C)

“Cleveland Clinic has about 1,000 employees away from work due to COVID-19…

Due to a surge in cases, Cleveland Clinic has taken steps to ensure enough staffing to meet patients’ needs, said Ms. Pacetti. This includes shifting some employees to different areas of the health system to enable Cleveland Clinic to expand bed capacity for COVID-19 patients.” (D)

“New York City to open field hospital for first time since spring as Covid-19 cases spike

Gov. Andrew Cuomo announced the Staten Island emergency facility as he pleaded with New Yorkers to stay put for the holidays.

Spiking cases of coronavirus in at least one New York City borough forced the re-opening of a field hospital not used used since the early, dark days of the pandemic, official said Monday.

The temporary facility at Staten Island University Hospital had been operated from early April through the end of June during initial action against the pandemic, authorities said.

The first patients to enter this re-opened field hospital are expected to arrive Tuesday or Wednesday. It’ll be able to hold up to 108 patients for now and could be expanded to 250 if necessary.” (E)

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• A.Now the U.S. Has Lots of Ventilators, but Too Few Specialists to Operate Them. By Andrew Jacobs, https://www.nytimes.com/2020/11/22/health/Covid-ventilators-stockpile.html?referringSource=articleShare
• B.’I do not have hope this will turn out well’: Hospitals brace as NJ COVID second wave hits, by Lindy Washburn, https://www.northjersey.com/story/news/coronavirus/2020/11/23/hospitals-brace-nj-covid-second-wave-hits-state/6349225002/
• C.Utah hospitals have begun informal rationing of care, doctors say, as they cope with surge of COVID-19 patients, by Erin Alberty, https://www.sltrib.com/news/2020/11/22/utah-hospitals-have-begun/
• D.1,000 Cleveland Clinic workers sidelined due to COVID-19, by Kelly Gooch, https://www.beckershospitalreview.com/workforce/1-000-cleveland-clinic-workers-sidelined-due-to-covid-19.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content
• E.Cuomo: Emergency facility for Covid patients at South Beach due to Staten Island capacity issue, By David K. Li, https://www.nbcnews.com/news/us-news/new-york-city-open-field-hospital-first-time-spring-covid-n1248661