How COVID-19 has tested the limits of hospitals and staff
By John Keefe, Yuliya Parshina-Kotta and Sheri Fink
In hospitals, intensive care units treat critically ill patients with life-support technology and close monitoring by specially trained doctors, nurses, respiratory therapists, pharmacists and other professionals.
Over the past year, as hospitals have battled the coronavirus, COVID-19 patients who develop severe pneumonia and other organ dysfunction have often been treated in ICUs, which have been overwhelmed at times by the influx of COVID patients and the complexity of care they require.
Even as new cases in the United States have fallen since their peak in early January, almost three-quarters of the nation’s ICU beds were occupied over the week ending Feb. 18.
‘We’re all exhausted’
Before COVID-19, hospitals generally kept their intensive care units somewhat full, typically with people recovering from surgery or being treated for illnesses or accidents. The national average for adult ICU occupancy was 67% in 2010, according to the Society of Critical Care Medicine, though this number and all hospitalization figures vary depending on the place, time of year and size of hospital.
When the coronavirus rips through a community, ICUs fill up. Hospitals have been forced to improvise, expanding capacity by creating new ICUs in areas normally used for other purposes, like cardiac or neurological care, and even hallways or spare rooms.
These big surges happened in New York City last spring, in the South over the summer and in Southern California and many other areas of the country, some for the second time, this winter.
Elective surgeries often get put on hold to keep beds available, and early in the pandemic, hospitals saw huge drops in people admitted for any reason other than COVID-19. ICU staff members, regardless of specialty, often spent most or all of their time on COVID patients.
“We’re all exhausted,” said Dr. Nida Qadir, co-director of the medical intensive care unit at Ronald Reagan UCLA Medical Center. “We’ve had to flex up quite a bit.”
As the pandemic has progressed, medical workers have learned how to better manage COVID, often without resorting to the more invasive treatments, such as breathing tubes and ventilators.
Hospitals have reported that fewer of their COVID patients ended up in the ICU. But occupancy rates remained high — often near or sometimes well over their regular capacity — as ICUs handled the most severe COVID cases plus the return of other kinds of patients.
In the first week of this year, when known U.S. coronavirus cases were reaching a new peak, more than one-fifth of American hospitals with ICUs reported that their intensive-care beds were at least 95% occupied.
At the same time, COVID patients made up one-third of the ICU patients, on average, at hospitals reporting any COVID patients in their ICUs.
Under typical circumstances, an ICU nurse might care for two patients. But COVID patients can require more attention and tend to stay in the ICU longer — a median of seven days instead of about four.
The virus’ rampage through the body can take unexpected turns, throwing a relatively stable patient into an urgent crisis with little warning. This and other complications sometimes lead ICUs to dedicate individual nurses to certain COVID patients.
To help, hospitals can draw staff members from other parts of the hospital. Where that’s not possible, or not enough, it can affect the number of patients cared for by each nurse.
“We’ve been swamped,” said Judy Carver, an intensive care unit nurse at Martin Luther King Jr. Community Hospital in Los Angeles. “We were having to take three patients. It was really heavy, super heavy.”
In California, Gov. Gavin Newsom temporarily altered the rules to allow one ICU nurse to care for three patients instead of the previous maximum of two. In some hospitals, the ratios have gone even higher.
COVID patients are often rolled onto their stomachs, called “proning,” which has been shown to increase oxygen flow. Turning someone over carefully can take several people, and some hospitals have created “proning teams.”
Once patients are face down, even simple tasks such as bathing them become more challenging — and require more time than nurses might need for a non-proned patient.
Proned patients must be watched carefully and moved regularly, so sores do not develop on their faces.
Many COVID patients are on ventilators, which need to be finely adjusted; some are on continuous dialysis machines; and all must be watched for blood clots, which present a greater risk with COVID patients.
In some hospitals, medical staff members try to balance this extra attention with reducing the amount of time they are in the closest contact with their COVID patients, to decrease the time they must wear full protective equipment and lower the risk of contracting the disease.
COVID’s contagiousness presents an additional responsibility for ICU nurses and other staff members: Connect patients to their families, who in many hospitals are not allowed to visit, over iPads and video-chat apps.
The added pressures, and the high number of COVID deaths, have been hard on many of those working in ICUs.
“You don’t have time to really cry; you have to be strong for the next patient,” said Lean Precilla, also an intensive care unit nurse at Martin Luther King Jr. Community Hospital. “After work, that’s when you reflect.”