I'm not a researcher, that is not the point of this blog. But I went on a bit of a deep dive on USA's recent "crisis" in intensive care units across the land and felt like I had to post about it.
The healthcare industry is in an all day, every day fight to manage the cleavage between supply and demand. In healthcare (unlike most other industries), optimally there will always be more supply than demand; but (just like every other industry), oversupply is wasteful and undersupply diminishes revenue. So how do we correct for undersupply?
I wanted to see what an ICU "crisis" looked like before our current period of pandemic. I'd say it mostly looks exactly the same. And I can more or less sum up all of these papers, articles, abstracts, etc., in two phrases: we need more beds and we need more nurses. That was true in 2000, 2006, 2011, 2016 and today.
Check them out for yourself.
Millbank Quarterly: "The Transition from Excess Capacity to Strained Capacity in US Hospitals" (June, 2006)
"After many years of concern about excess hospital capacity, a growing perception exists that the capacity of some hospitals now seems constrained. This article explores the reasons behind this changing perception....we observed that adjustments to the supply of hospital services tend to be slow and out of sync with changes in the demand for hospital services. Those hospitals reporting capacity problems are often teaching hospitals, located near previously closed facilities or in population growth areas. These findings suggest therefore that approaches to dealing with capacity problems might best focus on better matching individual hospitals' supply and demand adjustments."
First, note that in 2006 there was no particular pandemic problem in USA. Also, note that this article is not about "strained capacity" as it is the "changing perception" of capacity. Problems aren't merely problems but the "perception" of problems. Supply and demand ebb and flow, knowing how to stay ahead of them is the fundamental task of healthcare.
"One particular concern has been the growing number of emergency department diversions, in which ambulances are instructed to bypass particular hospitals, especially because this could have a domino effect in the community (California HealthCare Foundation 2002; Shute and Marcus 2001). Evidence of the rising rates of emergency department diversion was found in round 3 of the Community Tracking Study (CTS), which was conducted by the Center for Studying Health System Change in 2000 and 2001. The CTS researchers reported that hospitals frequently were bypassed because they could not admit emergency patients due to the lack of medical/surgical floor beds or intensive care unit (ICU) beds (Brewster and Felland 2004; Brewster, Rudell, and Lesser 2001). A study of emergency room overcrowding by the General Accounting Office (2003) yielded similar findings, suggesting that strained capacity in various hospital units led to backups in emergency departments. "
Notice that strained emergency rooms were frequent occurrences in 2000, 2001, 2002, 2003 and 2004. Not a function of global pandemcis, merely a function of supply and demand.
"Two CTS issue briefs examined emergency department diversions and how their occurrence and severity had changed over time (Brewster and Felland 2004; Brewster, Rudell, and Lesser 2001). Bazzoli and her colleagues (2003) looked at the degree to which specific hospital services were viewed as constrained and what contributed to these problems. They found that those service areas perceived as highly strained were the emergency department, medical/surgical ICU beds, and general medical/surgical beds. The main contributing factors reported by the CTS respondents were nursing and other personnel shortages and an insufficient supply of beds."
The solution in 2006: more beds, more nurses.
Biomedical Central.com: "Working With Capacity Limitations" (August 16, 2011)
"ICUs are faced with nearly the same throughput and capacity problems as the companies in our examples. The vast majority of critical care costs are fixed, resulting in substantial revenue increases with each additional patient [7]. ICUs also frequently operate at or near capacity, with subsequently large waiting times for admission [8]. Simply expanding capacity is not feasible due to space limitations within hospitals, workforce shortages, and government regulations [9]. Neither is expanding capacity necessarily desirable. As the above examples teach us, in the face of variable demand, expanding capacity can ultimately result in higher fixed costs, excess capacity, and long-term inefficiencies."
2011: Not uncommon for ICU's to be at/near capacity because there are is a latent and permanent and constant need for more beds and more nurses.
"The next step is to apply queuing theory to mathematically formulate the current process and determine the point on the utilization curve that will maximize responsiveness and productivity. Increasing capacity might be necessary to achieve optimal throughput, or might only result in excess resources. Sometimes these results can be surprising. For example, an empiric analysis of ICU readmissions in the cardiac ICU at the University of Pennsylvania Hospital found that an aggressive early discharge policy resulted in an increase in overall capacity, even accounting for the increase in readmissions [10]."
But plans for emergency overflows have already been formulated and ready to put into practice, (although sending patients home early is one of the suggested strategies).
Realias Media: "ICU Capacity Strain" (May 1, 2016)
"Intensive care in the United States accounts for nearly 1% of the gross domestic product, and it is forecasted that there will be increasing demand for this type of care in the future as the population ages.1,2 Given current projections that the supply of ICU staff and beds will be constrained rather than expand to meet this increasing demand, ICUs will be faced with the challenge of continuing care delivery under conditions of increasing strain.2 Thus, there is growing interest in studying ICU capacity strain, defined as the temporally varying influence on a given ICU’s ability to provide high-quality care for patients who are or could be cared for in that ICU on any given day.3"
Decreasing, rather than increasing, the amount of beds creates more potential revenue. And dealing with that forced decrease is the mission of future (as of 2016) health care professionals. (Wow! ICU accounts for 1% of American GDP? Is this true in other countries as well?)
PLOS.org: "Perspectives on Strained ICU Capacity" (August 22, 2018)
"Interpretation: Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies “outside” of ICU settings were priorities for managing strain."
The "strain" here refers to health care workers (HCW) themselves reacting to conditions of caring for ICU patients. "Burn out" in the health care industry is the dragon that must be slayed and we've known this for years.
North Carolina Rural Health Research Report (March, 2020)
There's a table of data about rural and urban hospitals that I found eye opening.
In the USA (as of March, 2020, presumably) 2,169 rural hospitals and 2,367 urban hospitals. Okay, slightly more urban than rural but not a huge disparity.
Avg. daily census: in rural hospitals is 36,615 and in urban hospitals is 350,452. Uhh...that's not even close. The urban hospitals have 10 times more daily traffic?
Total acute care beds: in rural hospitals is 99,942 (37% occupancy) and in urban hospitals is 562,492 (62% occupancy).
The lesson here is skip the big city hospitals and go find a hospital out in the middle of nowhere--which is probably not what people in the middle of nowhere would tell you to do. But it is the urban hospitals that have the most traffic and presumably would be the most backed-up during a period of "crisis".
Fact Check.org: Hospital Payments and the Covid-19 Death Count" (April 21, 2020)
"It is true, however, that the government will pay more to hospitals for COVID-19 cases in two senses: By paying an additional 20% on top of traditional Medicare rates for COVID-19 patients during the public health emergency, and by reimbursing hospitals for treating the uninsured patients with the disease (at that enhanced Medicare rate). Both of those provisions stem from the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act.
The CARES Act created the 20% add-on to be paid for Medicare patients with COVID-19. The act further created a $100 billion fund that is being used to financially assist hospitals — a “portion” of which will be “used to reimburse healthcare providers, at Medicare rates, for COVID-related treatment of the uninsured,” according to the U.S. Department of Health and Human Services.
As the Kaiser analysis noted, though, “it is unclear whether the new fund will be able to cover the costs of the uninsured in addition to other needs, such as the purchase of medical supplies and the construction of temporary facilities.”
Either way, the fact that government programs are paying hospitals for treating patients who have COVID-19 isn’t on its own representative of anything nefarious."
"Berenson said revenues appear to be down for hospitals this quarter because many have suspended elective procedures, which are key to their revenue, forcing some hospitals to cut staff. He surmised that potential instances of patients being wrongly “upcoded” — or classified as COVID-19 when they’re not — are “trivial compared to these other forces that are affecting hospital finances.”
It further indicates that if a “definite diagnosis of COVID–19 cannot be made, but it is suspected or likely (e.g., the circumstances are compelling within a reasonable degree of certainty), it is acceptable to report COVID-19 on a death certificate as ‘probable’ or ‘presumed.' If we think it’s presumptive … we can go ahead and put down COVID-19,” Jensen said, “or even in some situations, even if it’s negative.” He pointed to the example of a 38-year-old man in Minnesota whose death was attributed to the coronavirus even though he tested negative."
So hospitals have an incentive to call everything Covid-19. And Covid-19 causes them to hold off elective procedures (the real moneymaker for hospitals), which also causes them to cut staff. So the more Covid-19, the more hospitals...cut staff?
Also, these gov't programs that overpay hospitals to cutback on staff are really about the uninsured, right? So shouldn't we be condemning the uninsured rather than the unvaccinated? (Seems like its time to deny the uninsured service, right? Isn't that how we do things now?)
CBC: "Why Ontario Hospitals Are Full to Bursting Despite Few Covid-19 Patients" (November 2, 2020)
"The data suggests many hospitals have returned to the overcrowding levels seen before the pandemic, when CBC News revealed hospitals filled beyond capacity nearly every single day, with patients housed in hallways, conference rooms and cafeterias not as exceptional cases, but as a matter of routine."
"We're back to where we were pre-COVID with the risk of hallway health care. And you can't have hallway health care in a pandemic because of the need for infection prevention and control.""
"The increased funding to add bed capacity does not necessarily mean hospitals will hire more nursing staff to care for the additional patients, said Vicki McKenna, a registered nurse and president of the Ontario Nurses Association."
Wait....'we're back to where we were pre-Covid'? Yeah, check out the dropdown menu in there: Ontario hospitals were mostly at above 100% capacity in January 2020, before known Covid-19 cases even got to North America. WTF is going on in Canadian healthcare if the Covid-19 "crisis" is considered a return to the good times?
Sharp.com: "What ICU Capacity Tells Us About Covid-19" (December 21, 2020)
"Additionally, there might not be enough appropriately trained providers, such as ICU nurses and respiratory therapists, to safely care for a greater number of patients.
“The safety of our patients and staff is our top priority,” Jenkins says. “We separate COVID from non-COVID units to limit exposure and conserve personal protective equipment. Patients requiring ICU care require special technology, monitoring, nurses and physicians. And while there has been a significant increase in patients, there has not necessarily been a surge of health care workers.”"
"...it has become clear that the general public’s actions directly impact case numbers, hospitalizations, ICU capacity and the number of deaths we might see in the coming weeks. As such, experts are renewing their call for everyone to do their part to reduce their chance of contracting COVID-19 and spreading it to others.
“Safe, high-quality care is always the top priority of our staff and physicians, but they have grown weary and tired,” Jenkins says. “In order to break this pattern with the upcoming holidays, we need everyone’s cooperation in following the county’s guidelines of masking, social distancing and staying away from gatherings outside of your household.”"
Before the vaccine the advice was the same...as after the vaccine: social distancing is the only way to avoid the virus and masking helps to limit the spread.
Lexington Herald-Leader: Beshear: Covid-19 Surge Means Kentucky Will 'Be Out of Hospital Capacity Very Very Soon" (August 19, 2021)
"The governor said 21 hospitals across the commonwealth now face “critical staffing shortages,” as the number of new cases and rate of Kentuckians testing positive for the virus continues to rise. To “allow for additional help,” Beshear said he signed an order on Wednesday that grants licensed health care providers in other states permission to practice on an emergency basis in Kentucky."
More beds, more nurses.
Physicians Weekly: Covid-19 Related ICU Workforce Shortage Projected to Push Hundreds of US Counties Into Crisis (August 31, 2021)
"For these counties, the analysis recommends implementing a variety of contingency workforce strategies, including increasing patient counts per team, using float pools, and granting overtime pay."
"In a recent Washington Post-Kaiser Family Foundation poll, roughly 30% of healthcare workers reported contemplating leaving their profession, whereas in the Medscape National Physician Burnout & Suicide Report 2021, 42% of physicians surveyed reported burnout, with ICU physicians reporting the highest levels at 51%."
Yeah. More beds, more nurses, beware of burnout. Every study says the same thing, we've known this for years. Which begs the questions: are our hospitals actually enduring a "crisis" right now or is this simply the exact same perception of Intensive Care Units that we've long had?
And is this the solution to the problem? LA Times (June 22, 2021), Washington Post (August 14, 2021), Advisory.com (August 18, 2021), Business Insider (September 3, 2021), Yahoo News (July 2, 2021). There are many more of these stories and I never even got off the first page of the Google search. The overwhelming lesson of all the reports cited above is that the "crisis" is an undersupply of nurses!
What do we value: nurses or the vaccine? What do we need to overcome this crisis: nurses or the vaccine? Whose medical opinion should we follow: nurses or the vaccine?
I'm all for the vaccine, but why are we firing nurses for following their own beliefs in the face of a "crisis", when we know good and well that the "crisis" is not enough nurses? Why do we need nurses to believe what the mainstream media wants us to believe?
HHS Hospital Utilization (September 20, 2021)
As of roughly 1pm, Tuesday, September 21, 2021 (*) of the 4 hospitals located within 5 miles of my current location (one of the hottest hot spots in the Commonwealth, I might add), one has 44% of ICU beds available, one has 10%, one has 19.6%, one has 62.5%. Granted, 10% available is probably the limit of what a health care provider would like to have (ideally, more supply then demand is desirable for positive health outcomes), but the other three available hospitals do not seem to be dangerously overstuffed. I can, of course, look to other hospitals in other places if I really wanted to worry myself but why would I? My paranoia is most naturally directed at my own safety and by extension the safety of those most immediately around me. And for now, the local hospitals seem to be bearing up just fine.
(*) These stats are virtually identical to roughly 4pm, Monday, September 20, 2021, incidentally. This suggests that either nothing has changed or that this website is a faulty accumulator of data.
My two cents: the "crisis" in hospitals is the inherent conflict between supply and demand which is more acute in healthcare than in other industries. I don't see anything different in fall of 2021 as in 2000, 2006, 2011, 2014, 2016, etc.
And....what are we blaming the unvaccinated for, again? What is the problem they are creating? And bear in mind there is no way to ascertain (from this data) what types of maladies the ICU beds are currently filled with or the relative vaccination status of those people. You are free to use your ignorance to blame whoever you like for whatever you like. But, personally, I don't see anything out of the ordinary in our hospitals right now.
Furthermore, the "crisis" was never the amount of patients but the paucity of staff. Hospitals are in perpetual crisis (re: more beds, more nurses) and if we can afford to fire nurses right now, then apparently everything is just fine...right?