Each time communities experience surges of Covid-19, concerns arise over the availability of hospital and intensive care unit beds in affected regions. To monitor ICU capacity, several states have begun to track and publicly report hospitalization rates and the availability of intensive care unit beds.
In our zeal to understand how our health systems are coping with Covid-19, a key issue is often overlooked: human capacity. Contractors can build new hospitals in a week. But training competent doctors, nurses, respiratory therapists, and other clinicians to work in intensive care units takes years. If we build ICU beds, patients will come. But who will care for them?
As Covid-19 patients filled ICUs in New York City in the spring, hospitals adopted four strategies — often in concert — to meet the rising demand for ICU clinicians. Each of the strategies, born of desperation, can help achieve the goal but also has the potential to harm ICU patients.
Hospitals asked their intensive care nurses and doctors to work overtime — and lots of it. For short periods, this is a good solution because it ensures that patients continue to be cared for by clinicians trained and experienced in managing their illness working in familiar teams and in familiar settings. Working in the ICU, however, can be emotionally and physically draining. Up to 47% of intensive care clinicians experience burnout, and burned out clinicians provide worse ICU care.
Hospitals asked providers to care for more patients than they normally cared for. ICU nurses typically work with one or two patients at a time. Studies show that patients do worse if their nurses cover more patients. California law restricts nurses from managing more than two ICU patients. The data for ICU physicians is less robust, but research several colleagues and I did in the United Kingdom showed that ICU patients cared for by doctors managing larger numbers of patients were more likely to die.
Hospitals recruited non-ICU nurses and doctors to provide care for patients in the ICU. Having someone doing this work is clearly better than having no one. And as an ICU physician, I am truly grateful for my colleagues in other specialties who have jumped in to help. Yet, clinicians are not interchangeable.
You wouldn’t expect a stellar professor of graduate-level English literature to be star preschool teacher, or let a tax attorney defend you in a criminal trial. The same holds true in medicine. You would never voluntarily let me operate on your heart, just as you should want me and not a cardiac surgeon at your bedside if you are critically ill from Covid-19.
Hospitals also brought in ICU clinicians from around the country. All of us are indebted to these clinicians who chose to work in communities far from home, risking their own health to help others. But as anyone who has worked in an ICU knows — and research supports — the key to delivering the best ICU care is a functioning ICU team made up of clinicians used to working together.
It’s a bit like the NFL’s Pro-Bowl: even the best individual players can’t immediately coalesce into the best team; that takes practice. Reliance on excellent ICU clinicians working with people they don’t know in a system they are unfamiliar with is not optimal.
Health systems can build more ICU beds and buy more ventilators, but the ICU workforce is less easily expandable. For decades leading up to Covid-19, we have known that a mismatch exists in the U.S. between the need for ICU beds and the number of qualified ICU practitioners. Covid-19 has simply widened this gap.
The spring surge lasted two months in a few epicenters, and hospitals managed (albeit suboptimally). With the current increased ICU demand — which is both more prolonged and occurring simultaneously in more regions across the U.S. — the strategies employed in the spring simply will not be enough.
So what can we do? The first and most important step is to limit the spread of Covid-19: all Americans need to wash their hands, use face coverings when in public, and socially distance. Second, the number of patients requiring not only hospitalization but also ICU-level care must be publicly reported, along with the number of available hospital and ICU beds in each region and the number of available “well-staffed” beds — the number that can be covered by the typical clinicians working under normal conditions. Tracking these figures can help us all understand how much demand for ICU care can truly be optimally met in each community.
All patients deserve the best: care by a compassionate, energized clinician trained and practiced in the management of their disease. At the current rate, many of our critically ill Covid-19 patients may receive something less.
Hayley B. Gershengorn is a critical care physician and associate professor of clinical medicine at the University of Miami Miller School of Medicine, and a Public Voices Fellow of the OpEd Project.