Earlier this month, with a new wave of Covid-19 cases looking likely after the omicron variant was identified, Rhode Island emergency doctors wrote their state leaders to warn that any new surge of patients would “lead to collapse of the state health care system.” In Kansas, patients in rural hospitals have been stuck in the ER for days while they wait for a transfer to a larger hospital with the capacity and resources to care for them.
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.
“When you have a Covid patient who needs ICU care, those hospitals are turning away patients,” Carrie Saia, CEO of Holton Community Hospital, located in a town of 3,000 people about 90 minutes east of the Kansas City metropolitan area, told me earlier this month. “We’re sending our patients farther away. Not because they’re full, they’re just out of staff.”
At earlier points in the crisis, large hospitals would limit transfers from smaller facilities in order to preserve their capacity to treat the most seriously ill patients. As a new wave driven by the omicron variant takes off, that could happen again.
As Karen Joynt Maddox, a practicing cardiologist and associate professor of medicine at Washington University in St. Louis, told me in August: “During Covid surges, we were told to limit transfers only to patients who had needs that could not be met at their current hospital (i.e. decline transfers because the family requested it, but equal services available at both places) because that was the only way we could make sure that we did have the ability to accept patients that only we (or another major referral center) could handle.”
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.
America’s hospitals are all in this together. So what can we do quickly to relieve the burden for all of our hospitals and prevent unnecessary deaths?
How we can all help hospitals handle a surge in omicron patients
Last week, the Biden White House detailed a new plan for helping hospitals handle the coming surge of Covid-19 patients. They are deploying emergency medical personnel to six states: Michigan, Indiana, Wisconsin, Arizona, New Hampshire, and Vermont. They are also planning to deploy another 1,000 military doctors and nurses in January and February, as well as ordering FEMA to work with states to add hospital beds. The White House also said it had 100,000 ventilators in the federal stockpile that could be deployed as needed.
Those policies could certainly help to alleviate the pressure on hospitals in places facing particularly acute crises. But the truth is, they can only do so much. US hospitals cannot suddenly grow the staff and physical capacity to handle another enormous surge of Covid-19 patients.
Infected medical workers add to the strain on hospitals. Hospitals have seen a spike in nurses and doctors testing positive; by late December, the El Centro Regional Medical Center, about two hours east of San Diego near the US-Mexico border, was seeing 5 to 10 percent of its staff either infected or being tested for exposure at any given time, according to CEO Adolphe Edward. Other hospitals have told me they are also seeing a growing number of workers test positive, which requires them to stop working and isolate.
The Centers for Disease Control and Prevention recently revised its isolation protocols for health care workers who test positive for Covid-19, shortening the standard isolation period from 10 days to 7 (if accompanied by a negative test). But that still takes doctors and nurses out of commission for several days if they contract the virus. (On Monday, the CDC released new guidelines for the general public stating that those who test positive can stop isolating after five days if they do not have symptoms.)
“You can send all the ventilators you want,” Roberta Schwartz, executive vice president at Houston Methodist Hospital, told me. “I have no one to staff them.”
Nearly 99 percent of rural hospitals said in a survey released in November they were experiencing a staffing shortage; 96 percent of them said they were having the most difficulty finding nurses. According to a September study commissioned by the American Hospital Association, the average cost of labor expenses for each discharged patient has grown by 14 percent in 2021 — even as the number of full-time employees has dropped by 4 percent.
“The only things I can think of could not be accomplished in two weeks,” Peter Viccellio, associate chief medical officer at Stony Brook University Hospital in New York, said. “We have a severe staffing shortage everywhere, and it’s not going to go away. It existed before Covid, and Covid just exacerbated it.”
Some policy changes — smoothing schedules that better distribute surgeries (and therefore patient volume) throughout the day or week, earlier discharges or more weekend discharges — could help. “But this won’t happen without a mandate,” Viccellio said.
“We won’t prevent future catastrophes because of a very simple reason. It requires that we think of the future and plan for it,” he added. “You can see how that’s working out. We can’t frigging plan for one month from now.”
More money from the federal government could also allow hospitals to beef up their staffing, said Beth Feldpush, senior vice president of policy and advocacy at America’s Essential Hospitals, which represents critical access facilities. But all of these policies targeted directly to hospitals may only help at the margins. The American health system’s capacity is what it is — the time to act was long ago. Instead, the US health care system is behind many of its wealthy peers in the number of practicing medical staff in its hospitals.
So the quickest and surest action to prevent hospitals from being overwhelmed is actually to prevent people from needing to go to the hospital with Covid-19 in the first place, hospital leaders said. Get vaccinated — with three doses. Wear masks indoors in public places. Test before you see people who don’t live in your house.
Following the pandemic playbook can make a difference for hospitals bracing for another grim winter in this pandemic.
“The more we can help keep the public protected, the more we can keep our workers here,” Schwartz said, “and lessen the burden of this.”