In recent weeks, the intensive care unit at UC San Diego Medical Center reached 109 percent capacity. That meant ICU patients were overflowing into the emergency department and post-operation rooms usually used for other purposes.
The consequences of an overflowing ICU aren’t isolated. It has ripple effects throughout a hospital. In this case, it meant 10 essential surgeries had to be postponed – someone couldn’t get a liver transplant, others could not have their cancer removed and still others weren’t able to have their hearts operated on.
The ripple effects hit emergency departments as well. Sharp Healthcare – the county’s largest hospital network – declined to say quite how full its ICU has been in recent weeks. But one doctor with Sharp described dangerously overcrowded hospitals, with patients waiting for hours and even days at a time to be transferred from the emergency department to the ICU.
Delaying a patient’s transfer out of the emergency department can increase the likelihood they will die, according to at least one study, and delaying essential surgeries can also have deadly consequences. But these are some of the last strategies available – before a more severe rationing of care – that hospitals can use to make room for the massive surge of COVID-19 patients flooding San Diego hospitals right now.
“The one thing that we all fear is that we get to a point where we have to start asking, ‘Within essential surgeries, what’s really essential?’” said Dr. Michael McHale, who is managing the surgery schedule for UC San Diego Health during the pandemic. “Having to make that decision gets really, really hard. Trying to say, ‘This cancer is more important than this cancer.’ That’s hard to do.”
One chart demonstrates how the number of COVID-19 patients in ICUs has surged but how others have been lowered.
As COVID-19 cases requiring ICU treatment have surged over the past seven weeks, hospitals have simultaneously been able to reduce the number of other patients in the ICU. They’ve done that by reducing the number of surgeries they perform. Some surgeries – like a complicated spinal surgery – can require a patient to go directly from surgery into the ICU.
Doctors at UCSD have been gradually reducing those types of surgeries for weeks. That’s how they’ve maintained enough ICU space to deal with the COVID surge. But at a certain point it gets difficult, and eventually impossible, to reduce surgeries any further.
“The number of surgeries we can cancel that are truly elective is small. We don’t do that many nose jobs,” said Dr. Jess Mandel, who oversees critical care for UC San Diego Health.
Take heart surgeries as another example. Some cases need to be dealt with right away. Others might be able to be delayed without much fear. As the premium on ICU space increases, cardiothoracic surgeons, for instance, may have to start grading the severity of cases in a way they are not used to doing.
In a case where a patient has an aortic aneurysm (which is a bulge in the aorta, the main artery carrying blood from the heart) a doctor might have to decide how close the artery is to rupturing.
“If there’s no sign of rupturing, maybe you can wait four weeks to fix it,” said Mandel. “That’s not the ideal way we would handle it if we had capacity. There’s a non-zero risk in waiting.”
McHale added that few heart surgeries have needed to be delayed so far.
Throughout the county “important procedures” are being delayed, wrote Dimitrious Alexiou, president of the Hospital Association of San Diego and Imperial Counties. But exactly what kinds of surgeries at which hospitals is unclear.
Spokesmen for Sharp Healthcare and Scripps Health – the two largest hospital networks in the county – both acknowledged that procedures are being delayed. But when asked for specific surgeries, both declined to provide details.
“We aren’t doing surgeries that will require hospitalization that are not essential,” wrote Stephen Carpowich, a spokesman for Scripps. “We leave that to the discretion of the clinicians at the hospitals to determine what is essential and what is not.”
Here’s what we know: The more ICUs get jammed up, the more surgeries must be delayed.
In early December, the ICU at Scripps Memorial Hospital Encinitas reached 125 percent capacity, Scripps’ CEO said. A spokesman for Sharp said its ICU space has been hovering around 90 percent, but declined to say the highest capacity that has been reached in recent weeks.
At times, ICUs in all of Sharp’s hospitals have been seriously over-capacity, according to a doctor there who spoke on the condition of anonymity, because they were not authorized to speak on the record.
In those cases, the ICU could not accept new patients. Instead patients were forced to receive critical care in the emergency department for hours, or in some cases days, before they could be transferred, the doctor said.
Sharp’s Chula Vista hospital has been the most backed up, the doctor said. But Coronado, Grossmont and Memorial have all had patients languishing in the emergency department.
Mandel, of UCSD, also confirmed that UCSD has held patients in the emergency department when there was no room to transfer them to the ICU.
According to at least one study, patients who spent more than 12 hours waiting in an emergency department bed were nearly twice as likely to die.
Sharp Memorial has been so backed up at times that patients have waited in ambulances in the parking lot, the doctor said. In those cases, the ICU was full and the emergency department was also full. So patients stayed under the care of paramedics for hours at a time, waiting for space to clear up.
That might also happen during a busy flu season in the past, the doctor noted, but not with such frequency for such extended periods.
As recently as Dec. 29, Scripps only had 12 available ICU beds, Carpowich said. He also noted the Scripps network is already operating in “surge” mode, meaning doctors have converted non-ICU beds to provide ICU-level care.
Doctors at UCSD noted they had not taken that step yet, but would if necessary. Exactly how much new space they might be able to create is unclear. Finding nurses to staff the beds is a much bigger problem than finding physical space, representatives from all the local hospitals have previously acknowledged.
There’s one last troubling tidbit to consider when it comes to hospital capacity: The holidays may have helped ease the burden – and they’re over.
Hospitals have been able to cope with the COVID surge, not just because they’ve been delaying surgeries, but because people in general tend to schedule less procedures during the holidays and because they delay essential care. That usually leads to a January rush at the turn of the year, said Mandel.
Perhaps someone who is diabetic or someone with congestive heart failure comes into the emergency department because they’ve been feeling bad but avoiding going to the hospital. That person will likely need care right away, not care that can be put off, Mandel said.
If the hospitals get much fuller, more essential care may need to be delayed.
“That’s a hard, hard thing to do and we hope we don’t need to do that,” said McHale. “But it may happen.”