Post 226. January 5, 2022. CORONAVIRUS. New York City – “The city’s ambulance corps are so understaffed because of the COVID-19 surge, they’re now under new orders to try to convince stable patients with flu-like symptoms not to go to the hospital.”

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The directive from the FDNY puts EMS crews on notice that “effective immediately, stable patients with influenza-like illness … should not be transported to a 911-receiving facility” unless they meet certain criteria: being over 65 years old, having a fever above 100.4 degrees or a history of diabetes or heart conditions, according to a copy obtained by The Post…

Under the new order they’ll call an FDNY emergency doctor on duty to help decide whether a patient who appears stable should be taken to a hospital, he said.

The doctor could get on the phone and directly ask the patients questions to help make a decision, he added.”,,,

The FDNY acknowledged the order was due to “high medical leave” among EMS workers because of the COVID surge, but didn’t immediately respond to further questions Saturday.” (A)

“As the state broke another record Thursday with nearly 9,000 new COVID-19 cases driven by the severely transmissible omicron variant, Utahns were warned hospitals are overwhelmed and treatments for the virus are so limited, there’s only enough for 1 in 100 patients.

“Unfortunately, we’re beginning the new year in a really dire position when it comes to COVID-19,” Dr. Michelle Hofmann, deputy director of the Utah Department of Health told reporters during a virtual news conference as said Wednesday’s record-setting case count was broken with 8,913 new cases reported Thursday.

“There are more people hospitalized than yesterday, 530. There are more people in the ICU than yesterday, 188,” Hofmann said, and another 13 lives have been lost in the state to COVID-19, including a child. There have now been three Utah youths who died from the virus.

The situation is only going to get worse, she said, citing a U.S. Centers for Disease Control and Prevention model that estimated Utah will face somewhere between 12,600 and 38,800 new COVID-19 cases a day by the end of January.

Even though omicron is considered milder, the sheer volume of cases is already sending the state’s health care systems into crisis mode.

Both testing facilities and hospitals — many dealing with staff sickened by COVID-19 — are “bursting at the seams,” Hofmann said, as the omicron variant first identified in South Africa around Thanksgiving roars through the state. Until this week, the most cases reported in a single day was just over 4,700, in late December 2020.” (B)

“A Florida hospital has been forced to close its maternity unit and tell expectant moms to give birth elsewhere after the state’s record-breaking COVID surge caused staff shortages.  

Holy Cross Health Hospital in Fort Lauderdale announced on Sunday afternoon that it is shutting down its Labor and Delivery delivery unit ‘until further notice’ due to ‘critical staffing levels.’

That means pregnant women who’d planned to give birth there and are almost at their due dates must now go through the stress of finding a new hospital.

However, the hospital said in a statement that its neonatal intensive care and post-partum units will remain open.

‘People are out sick due to the surge in Covid cases,’ Holy Cross spokesperson Christine Walker added in an interview with NBC Miami. She spoke after Florida recorded 85,000 COVID cases on Saturday and Sunday, and almost 50,000 new infections on Monday.

The hospital did not mention a re-opening date for its Labor and Delivery Unit. Its emergency service division was also shut down on December 29 for similar reasons….

More hospitals throughout the state have simultaneously reported staffing shortages last week, according to the Department of Health & Human Services, and are among many services affected by the labor shortfall…” (C)

“More than 3,000 Michigan health care workers are off the job because they tested positive for coronavirus or were exposed to it, forcing hospitals to postpone some elective procedures as they brace for an influx of more patients in a COVID-19 surge fueled by the highly transmissible omicron variant.

Strained workers, who have been on the front lines treating patients for nearly two years, are exhausted, but their work is far from over as the surge pushes on, driving up cases and hospitalizations, including among children.

“We have an obligation to take care of the COVID patients,” said Dr. Jeffrey Fischgrund, Beaumont Health’s chief of clinical services. But the health system also must be able to take care of people who’ve been injured in car accidents, those who’ve had heart attacks and other illnesses.

“We’ve really asked our physicians to postpone, if safe, any procedures that can be postponed. … We’re trying to take care of the community, but we’re also trying to take care of our staff. … We know our 33,000 staffers are working as hard as they’ve ever worked.

“We are really at a breaking point. … We are really at a point where it’s the worst it’s ever been and … we’re afraid it’s going to get even worse next week. So we’re trying to be proactive. We’re cutting back on things that we don’t have to do today, but we still want to take care of our patients.”

On Thursday, Beaumont Health said more than 430 employees are out with coronavirus symptoms.

By postponing the less urgent procedures and tests, Beaumont can shift more staff to caring for COVID-19 patients along with those with cancer, traumatic injuries and other acute medical issues.” (D)

“At UMass Memorial Medical Center in Worcester, hospital epidemiologist Dr. Richard Ellison said he’s hoping staffing issues don’t get bad enough to require reductions in crucial care.

“Nurses who give chemotherapy for cancer patients get special training, and we can’t train our entire hospital workforce nursing staff to give cancer chemotherapy,” he said.

If too many of those nurses are out, Ellison said, the hospital may not be able to provide that care.

“So we have great concern that we could actually impact our ability to provide care for some patient populations,” he said.

The demand for emergency room beds is so high at UMass Memorial Medical Center, Ellison said, that some patients are being cared for in hallways, with privacy barriers put up between beds.

“There is no bed capacity right now in the UMass system,” he said. “As soon as someone gets discharged, the bed is being filled immediately.”” (H)

“In Los Angeles, where the fast-spreading omicron variant reigns, roughly two-thirds of covid patients in the county’s public hospitals were initially admitted for other causes, officials said Wednesday.

But at CoxHealth in Springfield, Mo., where officials say the older delta variant remains a ferocious threat, the coronavirus remains the immediate cause for 81 percent of covid hospitalizations…

Many hospitals are reporting record surges of covid cases even as staff shortages hit their highest levels nationally during the pandemic, according to federal health data reviewed by The Washington Post — a one-two punch that is forcing hospitals to turn away ambulances, cancel procedures and warn would-be patients to stay away because they can’t promise prompt care.

While most hospitalized patients are adults, the number of pediatric covid inpatients has doubled since Christmas to a seven-day average of 3,800 children.

But the emerging picture varies dramatically from one region to the next, according to interviews with hospital leaders and health workers across 18 states. It ranges from omicron epicenters such as New York City, where many patients aren’t aware they’re infected until testing positive while visiting the hospital for other procedures, to Michigan and Minnesota, where health workers continue to treat patients fighting for survival against the more severe delta variant.

The Centers for Disease Control and Prevention projects that delta may have accounted for as much as 41 percent of covid cases across parts of the Midwest last week and as little as 1 percent of cases in Texas and surrounding states, although the CDC has repeatedly revised its national map of variant spread in recent weeks, struggling to keep up with the fast-moving omicron.” (E)

“The U.S. documented a record number of COVID-19 pediatric hospital admissions on Wednesday, with federal data showing almost 1,000 children with confirmed infection were admitted.

Department of Health and Human Services data updated Thursday shows that 951 children were hospitalized with COVID-19 on Wednesday — the highest number throughout the pandemic.

These daily new pediatric admissions skyrocketed in the last weeks of December into January, almost tripling in the last two weeks as the omicron variant spreads rapidly throughout the country.

The numbers surpassed previous records set during the delta wave this summer, when daily children hospitalizations reached a peak of nearly 400 in one day.

In total, more than 3,100 children are hospitalized with confirmed COVID-19 as of Thursday, with another 1,300 suspected to be infected with the virus.

The government’s top infectious diseases expert, Anthony Fauci, noted during a press briefing Wednesday that even though the omicron variant “appears to be less severe” than the delta strain, the “caveat” is that omicron’s high transmissibility leads to more cases and the “inevitability” of more hospitalizations.

“The sheer volume of infections because of its profound transmissibility mean that many more children will get infected,” he said. “And as many more children will get infected, a certain proportion of them — usually children that have underlying comorbidities — are going to wind up in the hospital. That is just an inevitability.”” (F)

“Chicago-area hospitals are postponing many elective surgeries, as Illinois on Sunday set a record for COVID-19 hospitalizations.

The news of postponed surgeries comes just days after Gov. J.B. Pritzker and the Illinois Health and Hospital Association urged hospitals to delay nonemergency procedures as needed, without risking patient harm. They issued the plea in anticipation of a post-holiday, omicron-driven surge and potential shortage of staffed intensive-care beds.

Chicago-area hospitals are stressed as they deal with influxes of COVID-19 and non-COVID-19 patients amid industrywide staffing shortages. The vast majority of hospitalized COVID-19 patients are unvaccinated, doctors say.

NorthShore University HealthSystem, which has six hospitals, has largely suspended elective surgeries for the next two weeks, said CEO and President J.P. Gallagher.

Advocate Aurora Health, which has 26 hospitals in Illinois and Wisconsin, is delaying and rescheduling certain procedures to times and places where it has the staffing and capacity to perform them, said Dr. Jeff Bahr, chief medical group officer. It is continuing to do surgeries in situations where not performing them might result in a person needing hospitalization, or losing a limb. Advocate is also continuing to perform cancer treatments and diagnoses, he said…

Though the term “elective” may bring to mind cosmetic surgeries and other optional procedures, it actually encompasses a wide range of necessary, if not emergency, treatments — everything from heart valve replacements and repairs of herniated discs to certain cancer therapies…

Delaying elective surgeries is just one way Illinois hospitals are trying to manage the surge of patients.

NorthShore is again dedicating its inpatient beds at Glenbrook Hospital in Glenview to only COVID-19 patients, Gallagher said. It’s generally sending COVID-19 patients who need hospitalization, across most of its system, to Glenbrook — something NorthShore did earlier in the pandemic as well.

Rush University Medical Center has again transformed its lobby into an expansion of its emergency department.

Hospitals are also, in some cases, redeploying staff and paying extra to nurses who pick up additional shifts.” (I)

“With the fast-spreading omicron variant now upon us, some of the rhetoric around the pandemic has changed. Government officials, starting with President Joe Biden, are pointedly differentiating between the risks for vaccinated and unvaccinated people. This could create the perception that some places face more of a risk than others: Perhaps omicron will threaten rural communities (where vaccination rates are lowest) and their health systems, but perhaps more vaccinated cities and their hospitals will be better off.

Such thinking would be misguided. As convoluted and sometimes siloed as the US health system may seem at times, it is still a system. Patients transfer between facilities based on capacity or clinical need. If rural hospitals are shipping seriously ill patients to their urban neighbors, which already tend to run close to capacity even in normal times, a rural Covid-19 crisis could quickly become a crisis for everybody.

One hospital being overwhelmed isn’t a one-hospital problem, it’s an every-hospital problem. Even if your community is not awash with Covid-19 or if most people are vaccinated, a major outbreak in your broader region, plus all the other patients hospitals are treating in normal times, could easily fill your hospital, too. That makes it harder for the health system to treat you if you come to the ER with heart attack symptoms or appendicitis or any acute medical emergency.

Already, because of existing staffing shortages, rural hospitals are finding it difficult to find room for their patients at larger hospital systems. With omicron spreading rapidly, increasing the number of patients seeking care while sidelining health workers who have to quarantine, systemic overload may not be far off….

The feedback loop works in reverse as well. Recently, the HCA hospital in Conroe, Texas, about 40 miles north of Houston, was dealing with such a staffing shortage in its emergency department that the facility temporarily asked ambulances to bypass it because the ED couldn’t handle any more patients, according to a spokesperson. Suddenly, hospitals in the heart of Houston were seeing an unexpected surge of patients who needed emergency care, causing long wait times at their facilities.” (G)

“As the number of Covid-19 hospitalizations surpasses those during the Delta variant surge over the summer and fall, more states are enacting emergency protocols to deal with growing staff shortages at hospitals.

The greater transmissibility of the Omicron variant — which in just one month has led to millions of new cases — has left frontline workers at a higher risk of exposure, needing to quarantine and recover after positive tests. And health officials are working to plug any gaps in coverage.

In the last week, states such as Ohio, Maryland, Delaware and Georgia have mobilized National Guard members to assist with patient care.

“We still face a very serious situation with Covid-19 in Delaware, especially in our hospital facilities,” Gov. John Carney said Monday as about 100 members of the National Guard are training to become certified nursing assistants.

At the MetroHealth Medical Center in Cleveland, officials told CNN that not only is the hospital filled with people needing treatment, but roughly 400 employees are out with Covid-19.

Ohio Air National Guard Cpt. Lanette Looney, who is overseeing the mission at the hospital where 28 Guard members are helping with medical and non-medical tasks, noted they have faced Covid-19 infections as well.

“Within two days of being here, we had four Guard members that were symptomatic with sore throats, headaches, body aches, fever, nasal congestion, and they all tested positive for Covid,” she told CNN’s Gary Tuchman…

Teams of military medical personnel are working with the Federal Emergency Management Agency to aid with health care staffing in multiple states, including Arizona, Colorado, Indiana, Michigan, Minnesota, New Mexico, Pennsylvania and Wisconsin, US Army North said in a statement Tuesday.

A 15-person team from the Air Force is due to support a hospital in Manchester, New Hampshire, and another 20-person team from the Navy will assist a medical center in Buffalo, New York, the statement said.” (J)

“When health systems are moving toward crisis conditions, the first steps we take are to do all we can to conserve and reallocate scarce resources. Hoping to keep delivering quality care – despite shortages of space, staff and stuff – we do things like canceling elective surgeries, moving surgical staff to inpatient units to provide care and holding patients in the emergency department when the hospital is full. These are called “contingency” measures. Though they can be inconvenient for patients, we hope patients won’t be harmed by them.

But when a crisis escalates to the point that we simply can’t provide necessary services to everyone who needs them, we are forced to perform crisis triage. At that point, the care provided to some patients is admittedly less than high quality – sometimes much less.

The care provided under such extreme levels of resource shortages is called “crisis standards of care.” Crisis standards can impact the use of any type of resource that is in extremely short supply, from staff (like nurses or respiratory therapists) to stuff (like ventilators or N95 masks) to space (like ICU beds).

And because the care we can provide during crisis standards is much lower than normal quality for some patients, the process is supposed to be fully transparent and formally allowed by the state….

So, hospitals around our state are yet again facing triage-like decisions on a daily basis.

In a few important ways, the situation has changed. Today, our hospitals have plenty of ventilators, but not enough staff to run them. Stress and burnout are taking their toll.

So, those of us in the health care system are hitting our breaking point again. And when hospitals are full, we are forced into making triage decisions.”

In early 2020, we were looking for the patients who would die with or without a ventilator in order to preserve the ventilator; today, our planning team is looking for people who might survive outside of the ICU. And because those patients will need a bed on the main floors, we are also forced to find people on hospital floor beds who could be sent home early, even though that might not be as safe as we’d like.

For instance, take a patient who has diabetic ketoacidosis, or DKA – extremely high blood sugar with fluid and electrolyte disturbances. DKA is dangerous and typically requires admission to an ICU for a continuous infusion of insulin. But patients with DKA only rarely end up requiring mechanical ventilation. So, under crisis triage circumstances, we might move them to hospital floor beds to free up some ICU beds for very sick COVID-19 patients.

But where are we going to get regular hospital rooms for these patients with DKA, since those are full too? Here’s what we might do: People with serious infections due to IV drug use are regularly kept in the hospital while they receive long courses of IV antibiotics. This is because if they were to use an IV catheter to inject drugs at home, it could be very dangerous, even deadly. But under triage conditions, we might let them go home if they promise not to use their IV line to inject drugs.

Obviously, that’s not completely safe. It’s clearly not the usual standard of care – but it is a crisis standard of care.

Worse than all of this is anticipating the conversations with patients and their families. These are what I dread the most, and in the last few weeks of 2021, we’ve had to start practicing them again. How should we break the news to patients that the care they are getting isn’t what we’d like because we are overwhelmed? Here’s what we have to say:

“… there are just too many sick people coming to our hospital all at once, and we don’t have enough of what is needed to take care of all the patients the way we would like to …

… at this point, it is reasonable to do a trial of treatment on the ventilator for 48 hours, to see how your dad’s lungs respond, but then we’ll need to reevaluate …

… I’m sorry, your dad is sicker than others in the hospital, and the treatments haven’t been working in the way we had hoped.”

Back when vaccines came on the horizon a year ago, we hoped we’d never need to have these conversations. It’s hard to accept that they are needed again now.” (K)