October 12, 2021 – The filling of intensive care unit beds across the country has been in the headlines for months now. As waves of COVID-19 multiply across the country, hospitals have been pushed to capacity.
You can read the headlines about the lack of intensive care beds, but it can be hard to imagine what that looks like exactly. What is its impact on patient care across the hospital? How are things going for the staffing? And what about getting resources to the right people?
Here is an overview of the domino effect of a system in crisis.
From normal to overflow
To understand the impact of full or overcapacity intensive care units, it is important to understand what is happening in these vital hospital units.
“Before the pandemic, intensive care units typically cared for patients with respiratory distress, sepsis, strokes or severe heart problems,” says Rebecca Abraham, an intensive care nurse who founded Acute on Chronic, which offers help to patients navigating the healthcare system. “These are people who are very sick and need constant care.”
Assignment of nurses to these units is generally recommended at a ratio of 1 to 1, or sometimes 1 to 2. These are patients who require specialized equipment not found elsewhere in the hospital. , such as ventilators, bedside dialysis, specialized cardiac catheterization machines and drains, among others.
These patients also need several laboratory measurements, often taken every hour, and rapid medication changes. “Their conditions change quickly and often, so you don’t want to miss an assessment,” says Abraham. “But when we need to increase our nurse-to-patient ratio, we can’t monitor patients the way we should. “
Today, intensive care units are now full of very ill COVID patients, in addition to these “normal” critically ill patients, with dire consequences. “The ratios had to extend well beyond what is standard,” says Abraham. “You could have four to six nurses involved with a patient. “
COVID patients often have to be placed face down by staff, for example. To do this correctly and safely, a full team must be in place to prevent tubes and lines from exiting the patient’s body. And when sick COVID patients require intubation, nurses, doctors, respiratory therapists and others need to be involved. All of this takes these essential staff members away from their other normal care tasks and activities.
Comprehensive intensive care units also require the intervention of nurses and other staff who are not specifically trained and certified in intensive care. “These nurses are always caring for other patients as well,” says Abraham. “When a patient collapses and nurses aren’t trained for it, the quality of care suffers.
Where intensive care once had an admitting nurse and room for a new patient, that would now be a luxury, says Megan Brunson, intensive care nurse at Medical City Dallas Hospital who spoke on behalf of the American Association of Critical-Care Nurses. “Everyone is hoping that they don’t have a new admission on their shifts,” she admits.
There was already a shortage of nurses before the pandemic, and the pressure from intensive care units on healthcare is only making the problem worse.
Brunson says the COVID crash has reached a national crisis.
“More important than the conversation about the number of beds available is the number of nurses we have,” she says.
“As intensive care units get busier and stretched, care suffers,” she says. “This is not what nurses want, nor why they are in the field.
A survey by healthcare staffing company Vivian in April found that 43% of nurses were considering quitting during the pandemic, including 48% of critical care nurses.
It’s not just nurses. Doctors are also considering leaving the professional. An April study published in JAMA network open found that 21% of all healthcare workers were “moderately or very seriously” considering leaving the workforce, and 30% were considering reducing their hours.
Beyond the ICU
As the intensive care units fill up, the effect multiplies throughout the hospital. “One thing nobody talks about is our supply closets getting emptied,” Brunson says. “We are trying to solve this problem. We also always ration PPE [personal protective equipment], after all this time.”
Every 4 hours, says Brunson, staff at his hospital assemble to determine where to send the resources. “In a triage situation, there’s not much you can do with what you have,” she explains. “We can only take care of priority needs. “
Abraham says that often today emergency rooms have to accommodate critically ill patients. “Emergency care doesn’t stop there,” she says. “Patients always arrive. There is less oversight, less titration [adjusting meds], and in some cases, sending ambulances to other hospitals.
The bottom line, Abraham says, is that full intensive care units require hospitals to bypass all of their standard procedures.
“It’s never a good thing because it causes delays in care,” she says. “Critically ill patients go upstairs without specialist staff, and mistakes can happen. “
On top of all this, the nurses and other staff are exhausted.
“Nurses are leaving or moving to less stressful environments,” explains Brunson. “Many become itinerant nurses because they can make a lot of money in a short time and then take a break. “
Brunson says the most important thing in her opinion is having the right nurse for the right patient. “I’m in an adult unit, but I had to call a pediatric nurse the other day,” she says. “She learned quickly, but is still limited by her training.”
Still, Abraham and Brunson both have hopes for a better future in hospitals across the country.
“I hold my breath, but I’m optimistic,” says Brunson. “I have hope for 3 years, but we need to train new nurses for the system, people to be vaccinated and a long term strategy.”