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The mayor of Tulsa, Oklahoma complained in a November news conference that the bar to be admitted to one of the city’s hospitals was so high that patients had to be “in danger of collapse” before they could get a bed.
Similar anecdotes and hospitalization data have led some experts to suggest that hospitals are already subtly rationing care by changing their criteria for admission in the midst of a surge of patients with COVID-19.
Physicians from five hospitals in different parts of the country told Medscape Medical News a different story. Some are not admitting patients with COVID-19 that they otherwise would have in the spring, but doctors say the decisions are based on greater knowledge of the disease, not necessity — yet.
“Right now, I don’t think there’s really anybody that we’re saying, ‘We’re so busy, we don’t have any beds, we normally would admit you but we’re not going to admit you,’ ” said Robert Saldana, DO, an emergency medicine provider at Houston Methodist Hospital in Houston, Texas. “That is just not happening anywhere that I know of.”
Understanding the Disease
In response to the Tulsa mayor’s statement, doctors and a spokesperson from three of the city’s hospital systems assured the Tulsa World that they were still admitting all patients that warranted admission. Anuj Malik, MD, director of infection control at Ascension St. John, told the newspaper that admission criteria for COVID-19 had been refined over the course of the pandemic as healthcare experts learned more about the disease, but also said, “I don’t think anybody is being turned away just because there’s a surge in cases.”
Admission criteria changed in the first surge, said Faisal Masud, MD, medical director of critical care at Houston Methodist, when “we were admitting anyone with any symptoms.” Then physicians learned about the COVID-19 disease course, which patients had the worst outcomes, and how to treat the disease. The COVID admission criteria hasn’t changed further in the two following surges, Masud said.
At Harborview Medical Center in Seattle, physicians have made subtle adjustments to admission criteria based on which patients with COVID-19 they now know are able to cope at home, perhaps for example with a pulse oximeter to track oxygenation; otherwise, the criteria remain mostly unchanged since the spring, said emergency department medical director Steven Mitchell, MD.
In the Bay Area, which has so far been less affected by the three COVID waves compared with Seattle and Houston, admission criteria for COVID-19 patients at the University of California, San Francisco have generally followed guidelines that were in place before the novel coronavirus came to light, said Jeanne Noble, MD, emergency medicine specialist and director of COVID response for the UCSF Emergency Department. If a patient’s oxygenation level dips below 92%, he or she is admitted.
A spokesperson for Nebraska Medicine told Medscape Medical News that the health system had “gotten very close” to changing hospital admissions criteria to accommodate COVID-19 patient volumes, but then hospitalizations have trended downward since mid-November’s count of 1000 statewide.
Slower Emergency Rooms, Sicker Patients
Rather than dissuading people from going to the hospital given the mounting COVID-19 caseload, some physicians are imploring patients to seek help when they need it. Masud, the critical care physician in Houston, said he and his colleagues would greatly prefer if more patients came in earlier, when they are not as sick. “It’s when they come in really late for us, then we run out of things to do for them.”
It’s not just COVID-19 patients who are potentially seeking help too late. Nationwide, emergency department volumes have dropped during the pandemic. In March and April, ER volumes declined by 42% compared with the year before, according to the Centers for Disease Control and Prevention. In many areas, patients still haven’t returned to the ER, and those who have are coming later and are much sicker as a result.
“During this third surge, we’re still seeing people not come to the ER as much,” said Saldana in Houston.
In Seattle, patient volumes have increased but not yet returned to normal, said Mitchell. The acuity of patients he has been admitting in recent weeks, however, has been “at or very, very near all-time highs.” The reason is likely a mix of factors, he said: COVID-19, the expected uptick of serious illness in winter months, and the hard-to-trace impacts of patients delaying needed medical care during the pandemic.
Recently, Mitchell has seen “unbelievably tragic” cases, he says, including a patient who had cancer that progressed to a point Mitchell had only previously seen in pictures — and usually in countries with fewer health resources. The patient had resisted getting help, for fear of catching COVID-19, until he had reached a point where he could barely walk without becoming short of breath.
The situation in the Bay Area is similar: ER volumes have been way down and have only just started to rebound to normal volumes, says Noble from UCSF. Some of the patients coming in now are dangerously ill, some past the point of helping. She recounts seeing patients with strokes several days old, well outside the window to receive life-saving treatments.
Avoiding Crisis Standards
In New York City, case numbers are ticking steadily up, but are not yet near spring surge levels. The gradual nature of the increase, compared with the sudden onslaught in March, is making the current wave feel more manageable so far, said Nancy Kwon, MD, Department of Emergency Medicine at Northwell Health’s Long Island Jewish Medical Center in New Hyde Park, just outside Queens.
In the spring, Kwon’s 538-bed hospital served nearly twice as many patients. Already, the hospital has been taking steps to prepare for increasing caseloads this winter by expanding the number of ICU beds, bifurcating COVID and non-COVID patients, and moving patients quickly out of the emergency department and upstairs.
On the other side of the country, Noble said UCSF is similarly prepared with surge plans to greatly expand the hospital footprint if needed. In Washington state, a coordinated effort between all the hospitals statewide, called the Washington Medical Coordination Center, will allow hospitals in hard-hit areas to transfer patients to areas with more hospital capacity and lighter COVID caseloads. By using every hospital and bed, the hope is no hospital will have to resort to crisis standards of care, said Mitchell.
Telemedicine, virtual ICUs, and adapted workflows are helping Houston Methodist stay on top of the Texas outbreak, according to Masud and Saldana. The hospital system also recently started offering outpatient monoclonal antibody treatments to high-risk patients who are not yet sick enough to warrant hospitalization, said Saldana. The hope is that some of these treatments, as well as telemedicine support, will help keep patients at home and out of the hospital.
Even if hospitals are able to expand the number of beds, adequate staffing is the critical and central problem facing healthcare systems from coast to coast.
“Just my frustration with all of this, reliving the whole thing again and again, it’s taking such a toll on my team members, my nurses, my colleagues,” said Masud. “If one person goes out sick that’s a huge blow to us. Everybody counts, I can’t tell you how precious every single person is.”
Jillian Mock is a freelance science journalist based in New York City. She writes about healthcare, climate change, and the environment and her work has appeared in many publications including The New York Times, Audubon Magazine, and Scientific American.