Hospitals in the Midwest Strapped for Beds, Staff

Maureen Salamon

November 25, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

 

Marta Van Beek, MD, chief of staff, University of Iowa Hospitals and Clinics (center).

The plea from 300 miles away tormented clinicians at University of Iowa (UI) Hospitals and Clinics: A Missouri father of five with a rapidly worsening brain infection needed neurosurgery and an ICU bed. Two dozen hospitals in four states had already turned him away. Could Iowa offer a lifeline?

With the number of COVID-19 inpatients nearly tripling in the past 2 weeks alone, the Iowa City hospital is as strapped for beds and staffing as scores of hospitals across the United States, which are also in the crosshairs of skyrocketing pandemic caseloads.

Saying yes to the Missouri man and others desperate for care is far more fraught than hospital leaders ever envisioned when they were developing their surge plans in the spring. Admitting him to the hospital was a small but meaningful win for staff members, whose mounting distress is a palpable casualty in a very real form of combat.

"It's like being called to go to war," said Theresa Brennan, MD, chief medical officer at the 845-bed UI Hospitals and Clinics. "Just like putting yourself out on the front lines of war, you wonder if you're going to continue to be safe," she said.

"As with war, sometimes you don't know the enemy," she explained."COVID-19 is the same; this is a nasty virus. We've learned a lot about it and we're fighting a good battle, but it's still a cruel virus and, for sure, the enemy."

In April, when Medscape Medical News first checked in with Brennan, her "incident command team" was painstakingly formulating initial surge plans. They envisioned a worst-case scenario — believed to be highly unlikely — in which the center would be full, overflow units would be needed, and 80% of patients would be COVID-positive.

The real surge took another 7 months to materialize. And the reality has been every bit as bad as their worst fears.

"We're battling fatigue and people are just tired," said Marta Van Beek, MD, a longtime Mohs surgeon who is now chief of staff there.

Concerns of Collapse

Back in April, Iowa had about 3650 confirmed COVID-19 cases and 80 deaths. In early May, the state hit a peak of about 400 people hospitalized for COVID-19.

But those numbers seem almost tame in light of the pandemic's current stomp through Iowa. On November 24, more than 1300 patients were hospitalized in the state, and 275 of those were in the ICU.

The past month alone has seen record highs across the board, with nearly 86,000 new cases, 532 deaths, and a current positive testing rate of 51%.

Gov. Kim Reynolds, who previously called mask mandates "feel-good" actions, reversed course on November 16 by issuing a statewide mask mandate for indoor public spaces, with certain exceptions. If residents don't comply, she said at a news conference, "our healthcare system will fail."

Brennan agrees that is a possibility.

"There's great concern that the healthcare system is stressed and if we don't do things differently, there could be a collapse," she told Medscape Medical News. "The aim is to make sure people understand the dire situation we're in if we don't change the transmission rate, if we continue to have hospitals exceed our capabilities to care for patients in our present structures, and if we surge into patients using beds and care models that are not what we do on a day-to-day basis."

Tipping Point

 

Theresa Brennan, MD, chief medical officer at Iowa Hospitals and Clinics.

UI Health Care added 16 new ICU beds two weeks ago — a 15% boost in capacity — which will help offset an exponential rise in COVID-positive inpatients. Earlier this month, more than 30 beds were occupied by coronavirus patients; that number tripled in just 2 weeks.

But surge plans from last spring didn't account for a census that also included non-COVID patients. Hospital leaders moved to postpone nonessential surgeries to free up beds and staffing, but they are still unable, on many days, to accept transfer patients.

The earlier surge plan "was predicated on the fact that everything else was shut down in the hospital and there was a moratorium on elective cases," Van Beek explained. "That's not the case right now. So the team prepared a surge plan that allowed us to still take care of some pretty sick patients already here and on the schedule."

The need to pivot started becoming clear with the return of college students to Iowa's dozens of universities earlier this fall. Small clusters of younger patients steadily gave rise to larger and larger groups of middle-aged and older adults, Brennan said, reaching a tipping point as November arrived.

This dynamic also merged with a seeming sense of invincibility among the public. Iowa had sidestepped the crisis levels of COVID-19 patients and deaths that engulfed the coasts at the start of the pandemic; maybe the public thought things would never get that bad.

"It's hard to know exactly why" Iowa is so hard-hit now, Brennan said. "But postulating, I think everyone is tired; tired of wearing masks, not seeing loved ones, and not gathering together with friends and celebrating."

"I hear from patients that the safety practices we know are effective are not being utilized," she added. "People think, 'it's been this long, we've done great,' and now they're not following the practices we know have to be followed."

Outpatient Program Balances Losses

Fewer COVID-19 patients are dying at UI Health Care now, mirroring the rest of the country, which has seen fatality rates drop 30% since April. Van Beek and Brennan attribute this trend to improved treatment.

Still, Iowa has far surpassed early projections from the Institute for Health Metrics and Evaluation, which estimated that 600 COVID-19 deaths would occur by early August. By mid-November, the statewide toll had risen to more than 2000.

Some of the credit for the lower death rate in the Iowa City area belongs to a relatively unique home-treatment program for COVID-19 patients considered to be at high risk, Brennan explained. A blood pressure cuff and pulse oximeter is delivered to each patient in the program — predominantly older adults and those with chronic conditions, such as diabetes or heart or lung disease — and UI clinicians teach them how to take their vital signs and monitor their progress virtually.

By late April, 200 patients had been managed in the program; nine were eventually hospitalized. Seven months later, more than 1000 patients had been enrolled, 9.0% of whom required eventual hospitalization, but 99.7% have survived.

Word spread to other Iowa centers about the program's success, which helped broaden its reach and spawn similar initiatives.

"We really rely on each other in the state," Brennan said. "It helps us keep as many of those beds open as we can."

With no end in sight, hospital staff face daily forces that take a toll, both mentally and physically. They're simultaneously overwhelmed by the sheer number of coronavirus patients needing treatment and crestfallen when they have to turn any patient away. They're scared for their own safety, yet accustomed to the extensive PPE needed to maintain it. Many don multiple hats: teachers to home-schooled children, caregivers to loved ones with the virus, and front-line warriors at work.

"We're focused on the core group of caregivers who, from the beginning, have taken care of these patients," Brennan said. "They're feeling a lot of moral distress."

The current surge has prompted hospital leaders to step up support measures. They've reinstated a 24/7 mental-health hotline, added childcare benefits for urgent use, and scheduled virtual cocktail hours.

"We all told ourselves this was going to be a long haul, but we may have secretly wished we were wrong," Van Beek said. "Last March, we were telling ourselves this would be a marathon, not a sprint. But we didn't want to believe it."

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