POST 94. December 21, 2020. CORONAVIRUS. “A doctor at an L.A. County public hospital said the number of COVID-19 patients is “increasing exponentially, without an end in sight.”.. “I haven’t done ICU medicine since I was a resident — you don’t want me adjusting your ventilator,” he said. “That’s the challenge, actually — it isn’t so much space, it’s staff…”

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“A doctor at an L.A. County public hospital said the number of COVID-19 patients is “increasing exponentially, without an end in sight.”

Many parts of that hospital are being converted to COVID-19 wards, and ICU teams are being staffed up with workers from other departments that are temporarily halting services. The doctor, who was not authorized to speak to the media and requested anonymity, said it appears that by early January, the hospital will have to begin rationing care….

Already, UCLA Health is scheduling multiple infectious-disease doctors to be on call at any time, due to the unprecedented numbers of COVID-19 patients needing hospitalization, he said. The biggest issue is that hospitals may quickly run out of providers who can administer ICU-level care and will be forced to draft doctors from other specialties.

“I haven’t done ICU medicine since I was a resident — you don’t want me adjusting your ventilator,” he said. “That’s the challenge, actually — it isn’t so much space, it’s staff. It’s the physicians, the nurses, the respiratory therapists, all of the trained people to do that highly specific work that you can’t just pull out of a hat.”…

Many hospitals are preparing for the possibility of rationing care in the coming weeks as the number of patients exceeds their staffs’ abilities to care for them. A document obtained by The Times, outlining how to allocate resources in a crisis situation, was recently circulated among doctors at the four hospitals run by Los Angeles County.

The guidelines call for a shift in mindset that is unfamiliar to many medical providers. Instead of trying everything to save a patient, the goal during a crisis is to save as many patients as possible, meaning those less likely to survive will not receive the level of care they would have otherwise. In other words, doctors will no longer be pulling out all the stops to save a life but, instead, will be strategizing about how to keep as many people as possible from perishing.” (A)

““I’m not going to sugarcoat this. We are getting crushed,” said Dr. Brad Spellberg, chief medical officer at Los Angeles County-USC Medical Center, which has more than 600 beds and is one of the largest in the county.

It’s a scene playing out across California. According to state data Friday, all of Southern California and the 12-county San Joaquin Valley to the north had exhausted their regular intensive care unit capacity and some hospitals have begun using “surge” space….,

Spellberg said that every day for the last week at his hospital has begun with no available intensive care beds and a scramble to find room in spaces that don’t usually handle critical patients, like post-surgery recovery areas.

Los Angeles County Health Services Director Dr. Christina Ghaly said hospitals “are adding three beds to a room that maybe was a double room, or turning a single room into a double room,” dangerously stretching staff.

John Chapman, president and chief executive at San Antonio Regional Hospital in Upland, said telemetry nurses who monitor vital signs of patients should be overseeing no more than four people but could wind up taking on five or six because of the crush of cases.

“It definitely increases the risk of something going wrong,” he said…”  (B)

“California’s remaining intensive care capacity is alarmingly low, just 2.1% as of Friday. What happens if that number drops even further and hits 0%? Gov. Gavin Newsom explained in a video update Friday afternoon.

“When you see 0%, that doesn’t mean there’s no capacity, no one’s allowed into an ICU. It means we’re now in our surge phase, which is about 20% additional capacity that we can make available,” Newsom said.

Four alternative care sites have already been set up to help handle overflow patients. The sites are located at Imperial Valley College, Sleep Train Arena in Sacramento, Porterville Developmental Center in Tulare County and Fairview Developmental Center in Orange County.

Some sites are accepting COVID-positive patients while others are just helping decompress local hospitals, Newsom said.” (C)

“Brad Spellberg, the chief medical officer of LA County USC Medical Center — one of the largest hospitals in the state — told NPR member station KPCC that means some patients are waiting hours for care as hospitals struggle to free up beds as quickly as possible.

“We are the safety net — that is the point,” Spellberg said. “The safety net itself is being stretched to the limit.”

Some hospitals are now preparing for the possibility of rationing care in the coming weeks, according a document obtained by the Los Angeles Times. The document, which was circulated among doctors at four hospitals run by Los Angeles County, outlined guidelines on how to allocate resources in a crisis situation, shifting from a goal of trying to save every patient to instead saving as many as possible. This would mean that those less likely to survive would not receive the same care that they would in a non-crisis situation.

“Some compromise of standard of care is unavoidable; it is not that an entity, system, or locale chooses to limit resources, it is that the resources are clearly not available to provide care in a regular manner,” the document reads, according to the Times.

In an email, L.A. County Health Services Director Dr. Christina Ghaly told the Times that the guidelines were not in place as of Friday night.

“We have enough beds, supplies, and equipment for now, but we don’t have enough trained staff for the number of patients who need care. We have brought in new staff, retrained and redeployed staff from other areas of the system, and have requested additional resources from the state,” Ghaly wrote. “But these measures are not anticipated to be enough to meet the continuously escalating number of patients that are presenting across the county for care.”

Last week, California was forced to activate its “mass fatality” program, which coordinates mutual aid across several government agencies. According to the California Office of Emergency Services, a mass fatality is an incident in which more deaths take place in a period of time than can be handled by local coroner or medical emergency personnel.” (D)

“Late Wednesday, the Orange County Health Care Agency issued an order suspending the ability of hospitals that take part in the 911 system to request a diversion of ambulances to other medical centers.

Dr. Carl Schultz, the agency’s EMS medical director, said in a statement that hospital emergency rooms have become so overwhelmed due to the COVID surge that “almost all hospitals were going on diversion.”

“If nothing was done, ambulances would soon run out of hospitals that could take their patients,” Schultz said. Therefore, we temporarily suspended ambulance diversion. While this will place some additional stress on hospitals, it will spread this over the entire county and help to mitigate the escalating concern of finding hospital destinations for ambulances.”

Schultz added: “To the best of our knowledge, this has never happened before.”

On Monday, Schultz issued a memo to authorize ambulance providers to take patients up to 29 years old to Children’s Hospital of Orange, but another memo released Tuesday from Schultz scrapped that.

“Multiple logistic complications have occurred as a result of this directive and it would be in everyone’s best interest to cease this activity, effective immediately,” Schultz said.” (E)

“Tennessee Department of Health officials announced Sunday that the state could “break” its hospital system if a Christmas surge of COVID-19 cases matches that of Thanksgiving.

Commissioner Lisa Piercey said there have been multiple household gatherings where people have been affected statewide, as Thanksgiving surges proved.

Piercey said Tennessee requested National Guard staff in the northeastern system and to the Memphis and Shelby County region to go into the hospitals, not just serve testing services. Five large health care systems across the state have also been given flexibility to allow paramedics to practice inside hospitals.

Workers who have tested positive for COVID-19 and “feel up to the challenge” are now allowed to work in long-term care facilities. The same doesn’t apply to hospitals.

Piercey said the state is running out of options for staffing.

“I tell you this because we are looking under every rock. We are turning over every stone to help hospitals. We are running out of options,” she said.

Piercey said the state did identify more than 700 health care professionals, including some from the education system, who could volunteer or seek employment.

“All of the money in the world can’t buy more staff,” Piercey said. “That money will only go so far. We have spent all the money we can spend on staff. There are no more staff to spend money on.” (F)

“A swamped ICU and escalating COVID-19 crisis forced a turning point at VCU Health last week: The Richmond area’s anchor hospital formally deployed the next level of its surge capacity plan, signaling the end of normal operations to prepare for significant strain on its resources.

In Virginia’s hard-hit Southwest, a front-line physician at Ballad Health said weeks and weeks of escalating numbers are threatening a “second pandemic”: the physical and mental exhaustion of its workforce.

At hospitals across the state, a workforce firm is helping backfill 926 health care jobs, three-fourths of which are for the care of the state’s sickest patients.

A relentless surge in COVID-19 cases is threatening to overwhelm Virginia’s hospitals and health care resources — the front lines of the fight against the coronavirus — before new vaccines can change the course of the pandemic…

The state and hospital association declined to publish the levels for each of the state’s hospitals, but said all of the state’s regions remained at a level one. Carey said Ballad Health and VCU Health were the only hospital systems reporting a level two.

“Normal operations is a level one. Two is contingency. And that is the middle ground where you know that you’re starting to either feel the stress, so you have to alter operations, or you’re anticipating that you could in the very near future. And VCU is a good example of that, whereas Ballad Health would be an example of where they definitely have altered their normal operations,” Carey said.

“Then you have the third level, which is crisis standards of care, and that means there is a true crisis where all of the need cannot be met,” he added. “We pray and we’re working very hard to not get there, where you can’t care for everyone the way you want to.”

Carey was briefed by VCU Health officials on the decision Wednesday. Asked about his reaction, he said: “I would recommend that this is clear evidence that Virginia’s health care system is strained, and it’s not just in far Southwest Virginia.”

One way hospitals are managing staffing challenges is by turning to temporary, contracted staff, like traveling nurses.

Qualivis, a South Carolina-based workforce firm that contracts with the Virginia Hospital and Healthcare Association, is working to fill 926 vacancies across Virginia hospitals, said Sherry Kolb, the firm’s president.

Three-quarters of those jobs are for “high-acuity” positions, meaning they work with the sickest patients. That includes ICU nurses, surgical nurses and telemetry nurses.

Kolb said Virginia’s numbers match nationwide trends. The need for temporary hospital staff to help with shortages has spiked. Before the pandemic, Qualivis was working to fill 10,000 health care jobs nationwide; that number is now 29,000. Most of those are “high-acuity” jobs.”  (G)

“California’s most recent stay-at-home order zeroes in on a region’s ability to care for their sickest COVID-19 patients.

But for rural hospitals that don’t have an intensive care unit, administrators say the worsening surge is presenting new challenges.

“The critical access hospital program was designed such that these hospitals would primarily be available to accept and stabilize patients and then transfer those patients to a higher level of care,” said Peggy Broussard Wheeler, vice president of rural health for the California Hospital Association. “Now that is whittling away because the larger facilities are all tremendously impacted by COVID and other patients.”…

Wheeler, with the California Hospital Association, says she’s heard stories from many of the rural member facilities that have had to “MacGyver” solutions to treat COVID-19 patients that a few months ago they might have transferred.

“You now have to ask a nurse or maybe even a physical therapist or a respiratory therapist assigned to the COVID beds to be the deliverer of food so that you’re not exposing other people in your hospital,” she said. “You’re having to do this on the fly to keep those patients safe.”

The hospital association says the larger facilities are hitting a bottleneck with staffing. ICU capacity is measured not just by the number of physical beds, but by who is available to treat critically ill patients.

“A hospital might have beds available for patients but they don’t have the staff to support those patients,” said Read of Plumas District Hospital. “Usually they’ll say ‘we don’t have any beds’, but that’s really not true. They have the beds, they don’t have the staff. So opening up whatever bottleneck exists to have more staff available in our hospitals will be really helpful”

Gov. Gavin Newsom took a step in that direction this week when he loosened the required nurse-to-patient staffing ratio in ICUs. Under the change, a nurse can be assigned to three patients at a time instead of just two. The temporary order also loosens rations in other areas of the hospital.

Nurses unions have criticized the measure, arguing it could lower the quality of care, but the California Hospital Association says it will strengthen facilities’ ability to respond to the pandemic.

“California’s ability to care for COVID-19 patients depends on staff, not beds,” the association wrote in a statement. “Without this temporary staffing flexibility, very sick patients will wait on gurneys in the emergency department until a specially trained ICU nurse is available.”

The state has also deployed medical workers from the California National Guard, asked the federal government for medical personnel, and renewed calls for medical or nursing school students to join the volunteer California Health Corps, which launched earlier this year but initially yielded few qualified workers.” (H)

• A.‘We’re going to be New York’: L.A. hospitals brace for the worst, By ALEX WIGGLESWORTH, SOUMYA KARLAMANGLA, https://www.latimes.com/california/story/2020-12-21/los-angeles-coronavirus-hospitals-crisis
• B.California hospitals ‘crushed’ as virus patients flood ICUs, by JOHN ANTCZAK and AMY TAXIN,  https://abcnews.go.com/Health/wireStory/california-hospitals-crushed-virus-patients-flood-icus-74809987
• C.What happens when California’s ICU capacity reaches 0%? Gov. Gavin Newsom explains, By Alix Martichoux, https://abc7.com/california-icu-capacity-by-region-bay-area-covid-gov-newsom-update-beds/8879527/
• D.As COVID-19 Cases Soar, Overwhelmed California Hospitals Worry About Rationing Care, by KAT LONSDORF, https://www.npr.org/2020/12/20/948523206/as-covid-19-cases-soar-overwhelmed-california-hospitals-worry-about-rationing-ca
• E.OC issues unprecedented order to hospitals against diverting ambulances amid COVID surge, https://abc7.com/oc-hospitals-ambulances-covid-surge-vaccine-icu-coronavirus/8846599/
• F.Tennessee Department of Health warns of ‘broken’ hospital system if COVID-19 cases surge around Christmas, by Emily R. West, https://www.tennessean.com/story/news/health/2020/12/20/tennessee-department-health-broken-hospital-system-covid-19-cases-surge/3982859001/
• G.Strain on hospitals intensifies in Virginia; VCU Health deploys surge capacity plans, by Mel Leonor, https://richmond.com/news/local/strain-on-hospitals-intensifies-in-virginia-vcu-health-deploys-surge-capacity-plans/article_2cb29bf6-256d-55d9-8bbe-318873e74ab6.html
• H.‘No Capacity’: COVID-19 Surge Leaves Some Rural Hospitals Scrambling, by Sammy Caiola, https://www.capradio.org/articles/2020/12/17/no-capacity-covid-19-surge-leaves-some-rural-hospitals-scrambling/