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Heart-breaking, chilling, horrifying...pick your adjective. #COVID19 has amplified every socioeconomic & racial disparity that exists in healthcare & beyond. The distance b/w MLK & Ronald Reagan hospitals is only 20 miles, but mortality is ~2.5 times higher. Some thoughts on why: https://twitter.com/jschaenman/status/1358819547608829955
We talk a lot about #ventilator shortages but the most precious resource is actually #ICU personnel. Caring for critically ill patients is a highly specialized skillset, whether you’re a physician, RN, or resp therapist, & shortages in staffing have impacted hospitals differently
Not only is #ICU care highly specialized, it also requires meticulous attention to detail. The care of an ICU patient generates >1,000 individual data points/patient/day. Too many patients —> too much data —> information overload —> errors & details slipping through the cracks.
So even if you have critical care trained clinicians in your ICU, appropriate clinician:patient ratios are also crucial. In terms of differences between MD staffing ratios between the sites, they don’t sound terribly different on the surface...
Up to 20 patients per attending intensivist is not ideal, but also not unusual in either hospital. However, at an academic center, I also have a team of residents & fellows as opposed to running solo. That’s a lot of extra sets of hands.
The roster of attending (faculty) intensivists is also generally much larger at academic institutions. We’ve been able to pull people off research as well as other clinical services that have slowed down. Community hospitals generally don’t have this luxury.
#ICU #nurses are even more crucial & yet even more scarce. Typical #ICU nursing ratios are 1-2 critically ill patients/RN. Because of nursing shortages, some hospitals have had to 
the patient:nurse ratio or even use “team-based nursing.”
the patient:nurse ratio or even use “team-based nursing.”
Team-based nursing = non-ICU nurses caring for ICU patients under the supervision of an ICU nurse. IMO, changing nursing ratios & having to deploy non-ICU-trained RNs to the ICU may be the biggest factor in quality of care.
Putting a floor nurse in the #ICU would be like having me do orthopedic surgery. Or having an orthopedic surgeon do critical care. Even with the best efforts & supervision, quality of care is not going to be the same because skills & areas of expertise are dramatically different.
Hiring more nurses also has become less of an option. Traveler RNs have been increasingly difficult to secure as the pandemic has raged on because demand has been so high, and there are only so many ICU-trained nurses in the US.
Our nurses are stretched, but fortunately we haven’t had to mobilize non-ICU RNs to the ICUs & appropriate ratios have been maintained so far. Not being able to do this was my biggest pandemic fear - again, I think this may be the biggest factor in quality of ICU care.
Yes, you need enough vents & dialysis machines, & while there have been shortages, these shortages are not the rate limiting step at many hospitals at this point in the pandemic. Many (if not most) places will run out of ICU RNs well before they’ll run out of vents.
How do we balance these inequities? Some have suggested that academic hospitals just “do more.” Many larger centers have indeed taken transfers & shared supplies & equipment, but this only goes so far.
It’s important to first remember that it’s not “business as usual” at the large academic centers in LA. I’m on a text chain w/ ICU leadership at Cedars & LAC/USC & for a while it was a daily stream of “are you guys ok because you won’t believe how much crazier things got today.”
At my hospital, we’ve pulled in additional MD teams & turned non-ICU spaces into ICUs at various points. We’ve brought in transfers when we thought we could help. Do we stretch further & break nursing ratios? It creates more capacity but also inevitably decreases quality of care.
These are difficult & uncomfortable questions. If you’re only able to take more patients by compromising on something else that results in a reduction of quality of care & an increase in your hospital’s mortality, is it worth it?
Perhaps one could make an argument that it is, but then what amount of drop off is acceptable? Is it a 10% increase in mortality? 50%? What if the increase in your hospital’s mortality doesn’t translate into a similar decrease in the less well-resourced hospital’s mortality?
The issues of systemic racism & differences in patient demographics have also (appropriately) come up. Yes, the patient population at places like UCLA or Cedars is in general whiter & wealthier than at MLK. However, these differences decrease substantially when it comes to COVID.
Because the pandemic has disproportionally impacted the Black & LatinX communities, the majority of our hospitalized COVID patients are also non-white. So when you consider stretching academic centers to the point where you’re compromising patient care,
I don’t really see how that rectifies systemic racism, as some have suggested. It seems that this approach just takes things away from one set of Black and Brown people to give to another.
Another issue: what happens to patients without #COVID19 who need quaternary care that can’t be done at a community hospital? Transplants, VADs, ECMO, etc? It’s worth mentioning that 70% of organ transplant recipients in CA for the last 2 years were non-white.
These patients already comprise a very vulnerable group because they are limited in where they can receive care. Decisions about increasing capacity due to the pandemic impacts these patients too & can compromise our ability to care for them.
Ultimately, there is no doubt that the MLKs of the world deserve relief and more resources. But making that happen is not as easy as saying “why don’t academic hospitals just help more” in a setting where resources overall are limited.
The bottom line is that, overall, we need to have the ability to create more ICU capacity, with adequate staffing, than we have done so far. Resources need to be increased rather than simply redistributed. Not all hospitals in LA are broken right now, but all are stretched.
Federal & state investments in emergency preparedness & increasing the number of ICU-trained clinicians in the US will go a lot further than spreading all hospitals more thin than they ever should be. Asking already stretched hospitals to just “do more” is not a viable solution.
