Hospitals could face severe shortages of nurses, beds and blood. How California is responding
California is facing the frightening prospect of local hospitals overwhelmed by thousands of patients with COVID-19 in the coming weeks, as they confront potentially severe shortages of ventilators, bed space, donated blood, respirators and nurses.
On Wednesday, the federal government said it would move 1,000-bed hospital ships into New York to deal with the new coronavirus pandemic. That followed an offer by the U.S. Department of Defense to open up its strategic supply of ventilators, single-use masks and other supplies, potentially easing a shortage of life-saving equipment.
And in Oregon and Colorado, Kaiser Permanente was temporarily closing some clinics so it could redeploy staff and equipment to hospitals in anticipation of a surge in patients.
Sacramento hospitals are bracing for the worst as well. Even without a pandemic, many in the region are stretched thin. In intensive care units, which have the highest level of care, California requires one nurse for every two patients. And if a spike in cases comes, they will need more beds, too.
About 74 percent of intensive care unit beds in Sacramento’s five largest hospitals were occupied at any one time in 2018, a number far above the statewide average. Roughly two-in-three ICU beds are already being used across the 50 largest intensive care wards in California’s hospitals, according to a Sacramento Bee review of state hospital data.
The potential exposure to nurses and other medical workers to coronavirus also has medical experts alarmed. Unlike with floods or wildfires, the dangers of a surge in patients from COVID-19 put health professionals at greater risk than most — especially the nurses who are often at the bedside and at risk of infection.
The age of many nurses and their proximity to exposure could create difficult circumstances. Nearly one-third of the 27,000 registered nurses in the Sacramento region, including Sutter and Yuba counties, were over the age of 55. That puts many of them in a higher risk group for contracting more-severe symptoms of COVID-19.
In addition, hospitals are already facing a shortage of donated blood. The American Red Cross said the coronavirus pandemic had forced the cancellation of nearly 2,700 blood drives around the country as Americans avoid mixing with other people. That has created a severe shortage of blood, they said, for surgeries, car crashes and other emergencies.
The Sacramento region currently has only one Red Cross blood drive scheduled soon. A donor event is scheduled for Friday downtown.
Also of major concern: A shortage of ventilators for patients to help them continue breathing and N95 masks to protect hospital staff. A respiratory pandemic could outstrip the state’s supply of ventilators, and force doctors to make painful life-and-death decisions about which patients receive treatment and which ones don’t.
The military offered some help with ventilators this week but acknowledged it wasn’t enough. Defense Secretary Mark Esper said the military will provide 2,000 ventilators and up to 5 million respirator masks from its strategic reserve to assist the U.S. government’s response to the spread of the coronavirus.
“When you look at the numbers of people who are projected who may need ventilators, 2,000 doesn’t put much of a dent into it,” Esper said. “But we can offer what we have.”
The California Department of Public Health earlier this month said it would tap into its emergency stockpile of 21 million N95 masks to ease any shortages in hospitals. In 2007, the state also purchased and stockpiled 2,400 “Cardinal Health LTV 1200” ventilators for the purposes of disaster or emergency response. The total number of ventilators in the state remains unclear.
At least one California physician, Jake Scott, an infectious diseases specialist at Stanford University, is calling for a more aggressive attack from the federal government and more robust leadership.
“No more pretending or stalling,” Scott said on Facebook. “We need to buy a massive number of vents and other equipment. We need to dramatically increase testing capacity. We need the military to build hospitals. There is only so much individual hospitals, counties, and states can do. This wave has been slowly crashing on this country for months.
As the crisis mounted this week, Gov. Gavin Newsom said he and his staff have been in contact with the federal government reviewing other resources that might be made available for state and local providers.
In a news conference Tuesday night, Newsom said California’s overall hospital capacity was about 78,000 beds, with the ability to surge in extreme circumstances to near 90,000. But limitations in supplies and staff, especially if health care workers become sickened, are especially concerning.
Newsom said he was particularly interested in the U.S. Navy ships for California.
“Those medical ships are, we believe, are uniquely positioned and conditioned to help support the efforts of the state of California,” he said, “as we plan for the epidemic and some of the worst-case scenarios.”
All of these moves, along with recent shelter-in-place orders and quarantines for vast sections of the state, are designed to reduce the number of COVID-19 cases from flooding hospitals and their intensive-case units.
It will take weeks to determine if those efforts to “flatten the curve” of the disease are working. But experts said the efforts give physicians and hospitals time to prepare and stock up.
“I still think we have a window of opportunity, and that window of opportunity is rapidly closing,” said Thomas Tsai, a surgeon and health policy researcher at Harvard who is studying hospital capacity and response to the pandemic. “If you flatten the curve, it basically decreases the risk of overwhelming the U.S. healthcare system, which is what is happening in Italy.”
ICU units already under pressure
It’s clear already that adequately preparing for a COVID-19 surge is a difficult task. Medical experts are learning day-by-day about infection rates, how the disease spreads, and effective treatments. That makes knowing exactly how many beds and staff will be needed — and when a spike could happen — a constantly moving target.
“We have an ability to shift and reshape and change that capacity based on our needs,” said Carmela Coyle, the California Hospital Association’s president and CEO. “We want to maintain and reserve the hospital capacity for those individuals who are acutely ill and in need of that hospital care.”
The scattershot nature of the disease is made especially difficult in a state as vast as California.
Hospitals in densely populated urban areas naturally have more intensive care beds. An outbreak in the Bay Area could overwhelm those hospital systems because of widespread infection while others in the state see a more gradual spread, experts say. And in rural areas, where healthcare access is more limited, a small outbreak could see resources stretched thin even quicker.
But the state knows in detail how much capacity its hospitals have. The numbers show a hospital system already straining to take care of its patients, particularly in ICU wards that require no more than two patients for every one nurse.
In 2018, there were 7,274 ICU beds licensed in California, according to state data. About 58 percent of those beds were occupied. That’s almost exactly the same as five years earlier.
Sutter Health’s hospital in Midtown had 80 licensed ICU beds in 2018, data show, with an occupancy rate of 71 percent. A spokeswoman on Wednesday declined to speak about the bed space data and deferred to the state, though did say they were taking “proactive measures” to plan for a surge in COVID-19 cases.
UC Davis Medical Center, with 116 licensed ICU beds, is the region’s largest hospital and among the biggest critical care wards in the state. It reported an ICU bed occupancy rate of 77 percent, The Bee’s analysis found.
“We constantly strive to make the best use of our facilities at all times,” said Charles Casey, a hospital spokesman who added they have not yet seen any change in patient counts. “Having empty ICUs is not a good use of resources when there are patients in need.”
And with 30 ICU beds, Kaiser’s hospital in Roseville reported a 59 percent occupancy rate in 2018, closer to the state’s average.
“Like all health care providers, we are concerned about the demand for these resources,” a spokesperson said in a statement. “We are working with our supply chain vendors and other sources to be prepared to meet the needs of our staff and patients.
Now, the question is how much stress can the system take?
Research published this week from the Harvard Global Health Institute uses different scenarios to give a sense of which regional health care systems will be particularly stressed.
Spread over 18 months, American hospital beds would be about 95 percent full, assuming no capacity changes. That’s a difficult but manageable demand, experts said. A faster spread that more dramatically strains the system is increasingly likely, and researchers cautioned that Northern California is among the places that could suffer most.
About 15 percent of the Sacramento region is over age 65, meaning it is especially prone to severe cases of COVID-19, according to an analysis of the Harvard data published by ProPublica. Roughly one in 12 adults would require hospitalization within a year, with thousands requiring intensive care treatment.
Repurposing a shuttered hospital, delaying some surgeries and moving patients who don’t absolutely need to be in hospitals to other facilities are ways to expand bed capacity, said Dr. Ashish Jha, director of the Harvard Global Health Institute. But that all takes time.
“Even under those circumstances, under our main model, the vast majority of communities are going to end up not having enough beds,” Ashish told reporters Wednesday. “Additional capacity has got to be part of everybody’s strategy.”
California officials said they are focusing on the next eight weeks and have continued to stress the importance of slowing the spread of the new coronavirus and easing the burden on health care workers.
”We are not victims of fate. We are victims only of bad decisions,” Newsom said. “If we make better decisions, we can create conditions that are much more advantageous. And we can reduce the stress on personal protective equipment, the need for more ICU beds and the need for more surge capacity.”
California nurses allege shortages
May Suen, a non-union traveling registered nurse working at Kaiser’s San Leandro Medical Center, said she was fired Tuesday by hospital management after she complained when a supervisor handed her a single N95 mask in a paper bag to use for her shift in the hospital’s intensive care unit.
Kaiser Permanente said late Wednesday that because Suen was working for another company under contract, she wasn’t fired by the hospital chain — just sent home for not doing her duties..
She said the mask was given to her only after she complained that the hospital directed all nurses to no longer wear those masks in most cases, saying guidelines from the Centers for Disease Control and Prevention now no longer call for it. She said she suspects the real reason is that the masks are so hard to find.
She said she didn’t feel safe without an N95 mask, and she was troubled by the order to use just one in her shift because nurses typically are told to replace them after each interaction with a patient.
Suen described other shortages, too. While the hospital had enough ICU beds for the time being, there weren’t enough “negative-pressure” rooms designed to prevent microbes from escaping. “They’re all full with COVID-19 rule-outs,” she said, referring to symptomatic patients awaiting test results for the virus.
“We were told last week that face shields, we need to reuse them,” Suen said. “We need to bleach them. They went around and said, ‘Listen, we don’t have enough supplies for the face shields. When you use this to go into a COVID-19 rule-out or a COVID-19-positive room, please take bleach to wipe it down, put it on a piece of paper let it dry, and then save it because it’s going to be yours to use for the shift and we don’t have enough.’ “
She said she felt fortunate in that regard, though. She said her nursing friends in Washington state were so low on face shields they were forced to make their own out of office supplies.
In a statement, Kaiser officials didn’t refute Suen’s claims about masks. Rather, Dr. Stephen Parodi, associate executive director of The Permanente Medical Group, said the hospitals’ COVID-19 protocols are based on “the latest science and guidance from public health authorities” and are in “use by the major hospital systems in California and the U.S.”
“As the virus is now spreading quickly through our community, equipment and supply needs have increased dramatically,” Parodi said in an emailed statement. “We are prudently managing our resources to ensure this equipment is available for our health care workforce for the duration of this pandemic. We are committed to the safety of our patients and staff now and into the future.”
Ashlee Langston-Struempf, a union-covered medical-surgical nurse at Kaiser San Leandro, works on a different floor than Suen did, but she was just as frustrated by the lack of masks.
“They won’t provide us any surgical masks, basic or N95, unless we’re caring for patients with those specific precautions,” she said. “If I was going to take a patient that had contact precautions, I was given one mask and one shield in a paper bag and I had to sign for it.”
She said nurses are told to reuse the masks and wash the face shields so they can be reused throughout the day.
“What they’re doing is wrong,” Langston-Struempf said. “Federally, they’re in the clear, but they’re wrong.”
Nursing help from other states unlikely
In February, shortly after UC Davis Medical Center announced that a potential COVID-19 patient had arrived, three dozen nurses and 88 other health care workers were sent home to isolate. Similar issues have occurred in parts of China and Italy where health care workers, suspected of being infected, have also become patients.
National Nurses United, a lobbying group, said the handling of the UC Davis “case was a failure and not a success” and faulted the CDC’s “insufficient” guidelines.
If the state’s nurses are inundated by infection or a crush of patients, help is unlikely to come from another state. California is one of 16 states that does not have a nurse licensure compact agreement in place, an idea opposed by the nurses union. The accord allows nurses from other states to work in hospitals during emergencies when the existing workforce is strained.
Stephanie Roberson, government relations director for the California Nurses Association, said the licensure compact is a flawed idea and that it puts regulatory power in the hands of a nonprofit. Questions to the California Board of Registered Nursing were not answered.
“If the way compact licensure worked was that the highest standards of any participating state applied, that would be ideal,” Roberson said in an email, “but that’s sadly not the case.”
The lack of an agreement was one of the reasons the state’s preparedness for a public health emergency was ranked in the “middle tier” by the group Trust for America’s Health, along with Arizona, Florida and Texas. The report said California also had one of the lowest shares — about 70 percent — of hospitals that are members of coalition groups that allow them to share resources.
These issues could come into focus now as health systems gird for an expected rise in COVID-19 cases, said Rhea Faberman, who co-authored the report. It’s unclear which area will be the epicenter of the next outbreak, she said.
“At this point, it’s important that all communities and hospital systems are gearing up to surge their capacity,” Faberman said. “Will hospitals be able to handle the surge demands that may be coming in the next few weeks? Being a part of the coalition is often a part of making sure that you can surge resources to a particular community when needed.”
The Nurse Licensure Compact, run by the National Council of State Boards of Nursing, has more than 5 million nurses registered from across the country. The advantage of the compact is that all of them are already vetted, said Dawn Kappel, a spokesperson for the group.
“That’s the kind of thing that a board of nursing even in an emergency could do, but it just takes longer,” Kappel said. “And it slows the ability of nurses to be able to come in and serve patients and citizens of the state. It can still be done but it just takes longer.”
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This story was originally published March 18, 2020 at 3:36 PM with the headline "Hospitals could face severe shortages of nurses, beds and blood. How California is responding."