Like other largely rural states bearing the brunt of the brutal SARS-CoV-2 holiday spike, Oklahoma hospitals are scrambling to care for patients amid overcrowding, understaffing, and bed shortages. The state estimates that at present there are at least 1,000 Covid-19 in Oklahoma hospitals, and the health care system is at risk of splitting along its seams.
“And that’s the way it is in Oklahoma…”
According to Tulsa World, “Some hospitals are putting patients in hallways, renovating conference rooms into ERs, converting entire wings into COVID units, limiting nonemergency procedures and surgeries, and admitting only the “sickest of the sick” COVID patients.” The new year is having a harsh beginning. Last Wednesday, at a weekly Project ECHO meeting at Oklahoma State University, Dr. Jennifer Clark, who leads COVID-19 data sessions, said, “January is already stacking up to be a pretty significant month. My guess is we’ll probably see doubling of most of our numbers” She noted, “It’s no big secret that our nursing shortage existing prior to the pandemic is now kind of crippling us to some extent. We don’t have the staff to take care of between 1,000 and 2,000 extra hospitalizations.”
On average, 26 Oklahomans are dying of Covid-related complications each day, making it the third leading cause of death in the state, after heart disease and cancer. Clark remarked, “So you can see that our hospitals are not only full based on regular hospital folks who get sick in the wintertime, but now we have COVID on top of it. It’s almost overtaking our ability to take care of folks.” Clinicians in a range of specialties are being called upon to pitch in. Pediatricians, for example, are helping in adult hospitals, outpatient primary care providers are working shifts at their area hospitals, and doctors at rural health facilities are cramming to learn unfamiliar treatment techniques so they can treat incoming Covid patients.
“Our Covid patients are some of the sickest I’ve seen”
At a virtual news conference, ICU nurse Amy Petitt (who works at SSM Health St. Anthony Hospital in Oklahoma City) said that exhausted nurses are working 50-60 hour weeks. She said of current conditions: “We’re seeing more patients — more critically sick patients. Our COVID patients are some of the sickest we’ve seen. When they come to us in the ICU, a lot of them require intubation, lines, they have to be turned on their bellies, they require being paralyzed pharmacologically, sedation, blood pressure medication, dialysis…” Petitt added, “Everybody has stepped up, taking higher acuity patients and higher patient loads. [But] it’s not sustainable in the long run, and we need the community’s help.”
During the Covid surge, Oklahoma health officials are urging people with other serious illnesses to stay in touch with their HCPs via telemedicine visits and to contact community services for home health care or palliative care services.
For more on Oklahoma’s battle with Covid, see the coverage in Tulsa World.
As Los Angeles hospitals give record numbers of covid patients oxygen, the systems and equipment needed to deliver the life-sustaining gas are faltering.
It’s gotten so bad that Los Angeles County officials are warning paramedics to conserve it. Some hospitals are having to delay releasing patients as they don’t have enough oxygen equipment to send home with them.
“Everybody is worried about what’s going to happen in the next week or so,” said Cathy Chidester, director of the L.A. County Emergency Medical Services Agency.
Oxygen, which makes up 21% of the Earth’s air, isn’t running short. But covid damages the lungs, and the crush of patients in hot spots such as Los Angeles; the Navajo Nation; El Paso, Texas; and in New York last spring have needed high concentrations of it. That has stressed the infrastructure for delivering the gas to hospitals and their patients.
The strain in those areas is caused by multiple weak links in the pandemic supply chain. In some hospitals that pipe oxygen to patients’ rooms, the massive volume of cold liquid oxygen is freezing the equipment needed to deliver it, which can block the system.
“You can completely — literally, completely — shut down the entire hospital supply if that happens,” said Rich Branson, a respiratory therapist with the University of Cincinnati and editor-in-chief of the journal Respiratory Care.
There is also pressure on the availability of both the portable cylinders that hold oxygen and the concentrators that pull oxygen from the air. And in some cases, vendors that supply the oxygen have struggled to get enough of the gas to hospitals. Even nasal cannulas, the tubing used to deliver oxygen, are now running low.
“It’s been nuts, absolutely nuts,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor based in El Paso. He provides oxygen to several temporary hospitals set up specifically to treat people with covid.
In November, he said, he was answering calls in the middle of the night from customers worried about oxygen supplies. At one point, when the company’s usual supplier fell through, they were hauling oxygen from Houston, more than a 10-hour drive each way.
Branson has been sounding the alarm about logistical limitations on critical care since the SARS pandemic nearly 20 years ago, when he and others surveyed experts about the specific equipment and infrastructure needed during a future pandemic. Oxygen was near the top of the list.
Oxygen as Cold as Neptune
Last spring, New York, New Jersey and Connecticut faced a challenge similar to what is now unfolding in Los Angeles, said Robert Karcher, a vice president of contract services for Acurity, a group purchasing organization that worked with many hospitals during that surge.
To take up less space, oxygen is often stored as a liquid around minus 300 degrees Fahrenheit, about as cold as the surface of Neptune. But as covid patients filling ICUs were given oxygen through ventilators or nasal tubes, some hospitals began to see ice form over the equipment that converts liquid oxygen into a gas.
When a hospital draws more and more liquid oxygen from those tanks, the super-cold liquid can seep further into the vaporizing coils where liquid oxygen turns to gas.
Branson said some ice is normal, but a lot of ice can cause valves on the device to freeze in place. And the ice can restrict airflow in the pipes sending the oxygen into patients’ rooms, Karcher said. To combat this, hospitals could switch to a backup vaporizer if they had one, hose down iced vaporizers or move patients to cylinder-delivered oxygen. But that puts additional strain on the hospitals’ cylinder oxygen supply, as well as the medical gas supplier, Karcher said.
Hospitals in New York began to panic in the spring because the icing of the vaporizer was much greater than they had seen before, he added. It got so bad, he said, that some hospitals worried they’d have to close their ICUs.
“They thought they were in imminent danger of their tank piping shutting down,” he said. “We came pretty close in a couple of our hospitals. It was a rough few weeks.”
The strain on Los Angeles health care infrastructure could be worse given the now-common treatment of putting patients on oxygen using high-flow nasal cannulas. That requires more of the gas pumped at a higher rate than with ventilators.
“I don’t know of any system that is really set to triple patient volumes — or 10 times the oxygen delivery,” Chidester said of the L.A. County hospitals. “They’re having a hard time keeping up.”
The Oxygen Shortage Doom Loop
In and around Los Angeles, the Army Corps of Engineers has so far surveyed 11 hospitals for freezing oxygen pipe issues. The hospitals are a mix of older facilities and smaller suburban hospitals seeing such high demand amid skyrocketing cases in the area, said Mike Petersen, a Corps spokesperson.
One of the worst examples he saw included pipes that looked like a home freezer that had not been defrosted in some time.
The problem gets worse for hospitals that have had to convert regular hospital rooms to intensive care units. ICU pipes are bigger than those leading to other parts of a hospital. When rooms get repurposed as pop-up ICUs, the pipes can simply be too narrow to deliver the oxygen that covid patients need. And so, Chidester said, the hospitals switch to large cylinders of oxygen. But vendors are having a hard time refilling those quickly enough.
Even smaller cylinders and oxygen concentrators are in short supply amid the surge, she said. Those patients who could be sent home with an oxygen cylinder are left stuck in a hospital waiting for one, taking up a much-needed bed.
In early December, doctors serving the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to get oxygen to patients in the hospital and recovering at home.
“We’ve never reached capacity before — until now,” said Dr. Loretta Christensen, chief medical officer for the Navajo Area Indian Health Service, in mid-December. Its hospitals serve a patient population in the southwestern U.S. that’s spread across an area bigger than West Virginia.
The buildings are aging, and they aren’t built to house a large number of critical patients, said Christensen. As the number of patients on high-flow oxygen climbed, several facilities started to notice their oxygen flow weaken. They thought something was broken, but when engineers took a look, Christensen said, it became clear the system was just not able to provide the amount of high-flow oxygen patients needed.
She said a hospital in Gallup, New Mexico, put in new filters to maximize oxygen flow. After delays from snowy weather, a hospital serving the northern part of the Navajo Nation managed to hook up a second oxygen tank to boost capacity.
But medical facilities in the area are always a little on edge.
“Honestly, we worry about supply a lot out here because — and I call it extreme rurality — you just can’t get something tomorrow,” said Christensen. “It’s not like being in an urban area where you can say, ‘Oh, I need this right now.’”
Because of the small size of certain hospitals and the difficulty of getting to some of them, Christensen said, Navajo facilities aren’t attractive to big vendors, so they rely on local vendors, which may prove more vulnerable to supply chain hiccups.
Tséhootsooí Medical Center in Fort Defiance, Arizona, has at times had to keep patients in the hospital and transfer incoming patients to other facilities because it couldn’t get the oxygen cylinders needed to send recovering patients home.
Tina James-Tafoya, covid incident commander at Fort Defiance Indian Hospital Board, which runs the center, said at-home oxygen is out of the question for some patients. Oxygen concentrators require electricity, which some patients don’t have. And for patients who live in hogans, homes often heated with a wood stove, the use of oxygen cylinders is a hazard.
“It’s really interesting and eye-opening for me to see that something that seems so simple, like oxygen, has so many different things tied to it that will hinder it getting to the patient,” she said.
Published courtesy of Kaiser Health News (KHN), a nonprofit news service covering health issues. KHN is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
In March, out of 1,724 people hospitalized for COVID-19 in the three New York hospitals, 430 died. In August, 134 were hospitalized and five died. This change in the raw numbers could be driven by who was arriving at the hospital – if only older people were getting sick, the death rate would be higher, for example – but the researchers controlled for this in their calculations.
To better understand what was causing this decrease in hospitalization death rate, the researchers accounted for a number of possible confounding factors, including the age of patients at hospitalization, race and ethnicity, the amount of oxygen support individuals needed when they got to the hospital and such risk factors as being overweight, smoking, high blood pressure, diabetes, lung disease and so on.
The study in England looked at hospitalized coronavirus patients who were sick enough to go to a high-dependency unit (HDU) – one where they were monitored closely for oxygen needs – or the intensive care unit (ICU). As in the New York study, the researchers also accounted for confounding factors, but they calculated survival rates instead of mortality rates.
Looking at 21,082 hospitalizations in England from March 29 to June 21, 2020, the authors found a continuous improvement in survival rates of 12.7% per week in the HDU and 8.9% per week in the ICU. Overall, between March and June the survival rate improved from 71.6% to 92.7% in the HDU and from 58% to 80.4% in the ICU. These increases in survival after hospitalization for the coronavirus in England mirrored the changes in New York City.
Along with these new treatments, physicians gained experience and learned simple techniques that improved outcomes over time, such as positioning a patient with low oxygen in a prone position to help distribute oxygen more evenly throughout the lungs. And as time has gone on, hospitals have become better prepared to handle the increased need for oxygen and other specialized care for patients with the coronavirus.
Treatments have undoubtedly gotten better. But the authors of the New York City study specifically mention that public health measures not only led to the plummeting hospitalization rates – 1,724 in March vs. 134 in August – but might have helped lower death rates too.
As hospitals across the country weather a surge of COVID-19 patients, in Seattle — an early epicenter of the outbreak — nurses, respiratory therapists, and physicians are staring down a startling resurgence of the coronavirus that’s expected to test even one of the best-prepared hospitals on the pandemic’s front lines.
After nine months, the staff at Harborview Medical Center, the large public hospital run by the University of Washington, has the benefit of experience.
In March, the Harborview staff was already encountering the realities of COVID-19 that are now familiar to so many communities: patients dying alone, fears of getting infected at work and upheaval inside the hospital.
This forced the hospital to adapt quickly to the pressures of the coronavirus and how to manage a surge, but all these months later it has left staff members exhausted.
“This is a crisis that’s been going on for almost a year — that’s not the way humans are built to work,” said Dr. John Lynch, an associate medical director at Harborview and associate professor of medicine at the University of Washington.
“Our health workers are definitely feeling that strain in a way that we’ve never experienced before,” he said.
Until the late fall, the Seattle area had mostly kept the virus in check. But now cases are rising faster than ever, and Washington Gov. Jay Inslee has warned a “catastrophic loss of medical care” could be on the horizon.
“This is the very beginning, to be honest, so thinking about what that looks like in December and January has got me very concerned,” Lynch said.
Lessons Learned From Spring Surge
When the outbreak first swept through western Washington, hospitals were in the dark on many fronts. It was unclear how contagious the virus was, how widely it had spread and how many intensive care beds would be needed.
Intensive care unit nurse Whisty Taylor remembers the moment she learned one of her colleagues — a young, active nurse — was hospitalized on their floor and intubated.
“That’s really when it hit — that could be any of us,” Taylor said.
Concerns over infection control and conserving personal protective equipment meant nurses were delegated all sorts of unusual tasks.
“The nurses were the phlebotomists and physical therapists,” said nurse Stacy Van Essen. “We mopped the floors and we took the laundry out and made the beds, plus taking care of people who are extremely, extremely sick.”
A lot has changed since those early days.
Staff members besides just nurses are now trained to go into COVID rooms and be near patients, and the hospital has ironed out the thorny logistics of caring for these highly contagious patients, said Vanessa Makarewicz, Harborview’s manager of infection control and prevention.
How to clean the rooms? Who’s going to draw the blood? What’s the safest way to move people around?
“We’ve grown our entire operation around it,” Makarewicz said.
The physical layout of the hospital has changed to accommodate COVID patients, too.
“It’s still busy and chaotic, but it’s a lot more controlled,” said Roseate Scott, a respiratory therapist in the ICU.
Harborview has also learned how to stretch its supplies of PPE safely. And as cases started to rise significantly last month, the hospital quickly reimposed visitor restrictions.
“In the past, we’ve had visitors who then call us two days later and say, ‘Oh, my gosh, I just came up positive,’” said nurse Mindy Boyle.
Boyle said months of caring for COVID patients — and all the steps the hospital has taken, including having health care workers observed as they don and doff their PPE — has tamped down the fears of catching the virus at work.
“It still scares me somewhat, but I do feel safe, and I would rather be here than out in the community, where we don’t know what’s going on,” said Boyle.
‘We’re All Tired of This’
Preparation can go only so far, though. The hospital still runs the risk of running low on PPE and staff, just like so much of the country.
During the spring, the hospital cleared out beds and recruited nurses from all over the nation, but that is unlikely to happen this time, with so many hospitals under pressure at once.
“All things point to what could be an onslaught of patients on top of a very tired workforce and less staff to go around,” said Nate Rozeboom, a nurse manager on one of the COVID units. “We’re all tired of this, tired of taking care of COVID patients, tired of the uncertainty.”
Already, COVID’s footprint at Harborview is expanding and bringing the hospital close to where it was at its previous peak.
“The fear I have personally is overwhelming the resources, using up all the staff — and the numbers are still going to go up,” said Scott.
And she said the realities of caring for these desperately ill patients have not changed.
“When they’re on their belly, laying down with all the tubes and drains and all these extra lines hanging off of them, it takes about four to five people to manually flip them over,” Scott said. “It feels intense every time. It doesn’t matter how many times you’ve done it.”
Hospitalized patients are faring better than in the spring, but there are still no major breakthroughs, said Dr. Randall Curtis, an attending physician in the COVID ICU and a professor of medicine at the University of Washington.
“The biggest difference is that we have a better sense of what to expect,” Curtis said.
The few treatments that have shown promise, including the steroid dexamethasone and the antiviral remdesivir, have “important but marginal effects,” he said.
“They’re not magic bullets. … People are not jumping out of bed and saying, ‘I feel great. I’d like to go home now,’” Curtis said.
Taylor said nursing has never quite felt the same since she started in the COVID ICU.
“These people are in the rooms for months. Their families can only see them through Zoom. The only interaction they have is with us through our mask, eyewear, plastic,” Taylor said. “We’re just giving their body a runaround trying to keep them alive.”
This story is from a reporting partnership that includes NPR and KHN.
Republished courtesy ofKHN (Kaiser Health News), a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
The Texas Nurses Association (TNA) has a rich history of accomplishments and has played a key role in setting educational and workplace standards for nurses in the state. Today, the TNA is still tirelessly advocating for nurses and patients in Texas. As the state struggles with a frightening surge of Covid-19 cases, DailyNurse asked Cindy Zolnierek, PhD, RN, CAE, CEO of the TNA, about the most pressing healthcare issues in America’s second largest state. In Part One of this two-part interview, Zolniek spoke about the challenges of fighting Covid-19 in Texas. (Part Two will publish tomorrow.)
DailyNurse: Some aspects of Texas geography must present serious healthcare challenges even in the absence of a major public health crisis.
Cindy Zolnierek: “We do have these great expanses, and they tend to rely on critical access hospitals. [Critical access] hospitals take care of basic emergencies, but they’re very used to shifting patients off to larger facilities and other communities. This has long been standard practice in the areas of the state that have those largest expanses like West Texas. After you leave that El Paso, you go a long ways before you hit another decent sized city. [It’s] the same with Amarillo and Lubbock, Laredo, and the Midland Odessa area, which are some of the hardest hit areas [by Covid-19] in Texas. And now, with those hospitals being full, overflowing with patients to critical access, hospitals are left with no place to send their patients to. So it’s not just the communities themselves that are impacted—it’s the whole system, the whole infrastructure for providing health care, and care for cases like strokes and heart attacks and highway accidents is being impacted significantly.”
DN: So the whole healthcare system is being placed under severe strain during the pandemic?
Zolnierek: “Well, [normally] patients go to the nearest facility, like a critical access hospital, which patches them up, does the assessment and anything you need to do for life-saving. They then send the patient to a trauma facility. [During the pandemic] the problem has been. . . Click here to read the rest of this article.
Caring for today’s acutely ill hospital patients calls for a collaborative, interdisciplinary approach. When it comes to rating collaboration, however, physicians rate their collaboration with nurses more highly than nurses rate that collaboration, notes a recent study.
As the bar chart shows, some 63% of hospitalists rated the collaboration with nurses as high or very high, while roughly 49% of nurses rated the quality of collaboration with hospitalists as high or very high.
The article notes that the discrepancy between nurses’ and physicians’ perceptions of collaboration mirrors findings from other studies conducted in operating rooms, ICUs, and labor and delivery units.
The explanation for differing perceptions between nurses and physicians, the study notes, may be partially explained by differences in status/authority, gender, training, and patient care responsibilities. Workflow differences, poorly designed communication technology, and strained relationships also serve as barriers to collaboration. What’s more, the article notes, hospital-based physicians are often spread across multiple units, giving them little opportunity to collaborate with nurses and other professionals who work on designated units.
Healthcare Hierarchy: “Hint and Hope” v. Direct, “to the Point” Communication
Two forces may be at play in these different ratings of collaboration: the hierarchy of healthcare and the different ways doctors and nurses communicate, says Milisa Manojlovich, PhD, RN, one of the study researchers and Professor, Department of Systems, Populations, and Leadership, University of Michigan School of Nursing, Ann Arbor. “Whenever you have a hierarchical structure, it causes discrepancies in perception. So the physicians may perceive that they’re collaborative, but the nurses feel that they’re being told what to do. They’re not necessarily being invited to participate. And so this discrepancy is part of the problem.”
In addition, physicians use a “quick, to the point way of communicating,” notes Manojlovich. In contrast, nurses often use a form of communication known as “hint and hope” – hinting at what the nurse wants, in the hope of getting that from the physician.
Direct is Best
To address these issues, Manojlovich suggests that nurses speak more directly: “Directly ask for something that you want, and say why you want it.” The nurse then is doing more of the “cognitive work” needed, she notes.
Second, clinicians should develop a good relationship with each other, she notes. Once a good working relationship exists, “our collaboration actually improves.”
The results of this study are part of a larger project called the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) project, funded by the Agency for Healthcare Research and Quality. The project, notes the article, seeks to establish and disseminate the optimal model of care to improve interprofessional teamwork and outcomes for hospitalized patients.