Amid the worst pandemic in a century, the severity of “0%” needs no explanation.
We know California’s hospitals are in dire shape, as beds frantically fill across much of the Golden State during a record surge of COVID-19 infections, hospitalizations and deaths. On Friday, just an alarming 2.1% of the state’s intensive-care units were available, according to the state’s latest figures.
But what exactly will it mean if we fall to a dreaded zero?
Hospitals in the Southern California and San Joaquin Valley regions already reached that point this past week, while ICU capacity slipped Friday in the Bay Area region from 13.1% to 12.8%. But with the dynamics of patient loads, medical staffing and other factors frequently changing, even dropping to 0% doesn’t mean no ICU care is available.
Patients who need critical care are not turned away or left unmonitored in the lobby or hallway. But the quality of care begins to drop off, with doctors and nurses having to care for more patients than normal and getting overworked.
“As hospitals reach capacity and stretch, exhaustion is real,” said Dr. Ahmad Kamal, Santa Clara County’s COVID-19 Director of Health Care Preparedness. “The hospitals would definitely make sure every patient gets the best care possible. Having exhausted staff is not the ideal way to provide care.”
On Friday, California continued shattering records, topping 50,000 new cases for the third consecutive day and more than 250 deaths for the fourth day in a row.
ICU capacity was thrust into California’s consciousness earlier this month when Gov. Gavin Newsom made it the state’s newest metric for imposing the most restrictive curbs on business and activities to reduce spread of the coronavirus.
It refers to the number of staffed beds in hospital units that care for the most critically ill or injured, a figure that isn’t set in concrete and fluctuates daily. Hospitals have some flexibility in reassigning staff, space and equipment. Kamal said that Santa Clara County has been doing that, which is why its ICU capacity hasn’t changed much — it’s now 13% — even as they see more and more patients needing that level of care.
“We do that by converting non-ICU beds to ICU beds,” Kamal said. “You need to have the equipment and the staffing, but there is some ability to do that.”
That flexibility, however, is limited — there are only so many doctors and nurses. And not all the nurses are trained for intensive care.
Intensive care units normally run near capacity, and hospitals have “surge” capacity to expand them. For purposes of managing the pandemic, the state defines ICU capacity as the number of regular and surge ICU beds available, which hospitals report daily.
But it excludes those dedicated for pediatric and neonatal care. ICUs still need to ensure care for other critical patients. In Santa Clara County, COVID-19 patients occupy 37% of ICU beds. In Los Angeles County, 35% of ICU beds are occupied by COVID-19 patients.
Staffing levels are set by the state, which normally requires a nurse for every two ICU patients. The state can waive that for emergency shortages due to the pandemic and allow one nurse for every three patients.
But the California Nurses Association earlier this week warned that allowing hospitals to lower nurse-to-patient staffing for the current COVID-19 surge will mean higher risk of infections and deaths for patients, nurses and other health care workers.
“Heavier patient assignments sharply cut the time nurses can provide individualized patient care, properly monitor a patient’s condition and increase the likelihood of mistakes, as studies have documented for years,” Zenei Cortez, a registered nurse and president of the California Nurses Association and National Nurses United, said in a statement.
Kamal said they haven’t had to do that in Santa Clara County — yet. But if needed, hospitals could implement “team-based nursing,” he said, where an ICU trained nurse is assisted by another nurse without that training to care for a larger number of patients. “That is not an ideal situation by any means,” he said.
The state says it has some 3,000 additional beds available beyond what exists in hospitals, including 22 field hospitals that could be set up with 50 beds each, some of which are being deployed in Southern California.
There are also 11 “alternative care sites” that could be used on short notice. Two are in the Bay Area — one in San Francisco and the other in Contra Costa County. Neither have been activated yet, but together they could provide 375 beds. Kamal said those types of facilities could be used for patients who don’t have COVID-19 and would be easier to care for in a remote setting.
The biggest limitation, Kamal said, is staffing. Newsom has indicated the state has looked to hire nurses from overseas. Some patients could potentially be transferred to different hospitals that have room. But with the whole country and much of the world battling a COVID-19 surge, nurses are in short supply.
That doesn’t mean patients wouldn’t be taken in and cared for. It just means those caring for them might be overworked and exhausted.
“It’s definitely the most challenging situation we’ve faced in the pandemic,” Kamal said. “We’re hoping we can bend that curve so that not only are there hospital beds but the highest quality of nursing care for everyone.”