ICUS: Vill speeding up shutdown slow surge?

Centers are boosting ICU capacity by adding beds, nurses and technology

Will the Bay Area’s early adoption of the state’s new coronavirus lockdown measures keep hospitals here from being overwhelmed?

Hospital and public health officials say they are confident it will, and the result could save hundreds of lives. They are already preparing for a crush of COVID patients, scrambling to add beds, hiring traveling nurses and even arranging for ICU doctors to monitor patients from miles away in a bid to boost their capacity.

Tom Sugarman, an emergency physician at Sutter Delta Medical Center in Antioch, experienced the gruesome toll that the virus took on hospitals in New York when he volunteered there during the country’s most deadly wave of the pandemic.

“We are not in the place that New York City was in March or April in the Bay Area now,” he said, but “I am more and more concerned that more and more areas will find themselves in that position at Christmas time.”

ICU capacity in particular has become a hot-button issue now that the state has focused on the measure to trigger when regions around the state should adopt the strictest stay-at-home orders since the spring. When a region’s number of available ICU beds falls below 15%, the new rules automatically kick in. While the Bay Area still had about 25% of its intensive- care units available on Friday, most of the region said it would still move ahead with the new rules starting as early as Sunday night.

Simply increasing the number of ICU beds isn’t easy.

John Swartzberg, clinical professor emeritus of infectious diseases and vaccinology at UC Berkeley, said ICU capacity is fluid, changing daily and even hourly based on the number of physical beds available, the number of people who can staff them and the number of people who need the space.

Typically, there are licensing requirements for ICU beds, hospitals want to keep critically ill patients together in the same ward, and ICU patients require electronic monitoring and other technology. Hospitals have to consider ventilation and other factors. Staffing, too, is in short supply and high demand.

And unlike in the beginning of the pandemic when treatments

“It’s not easy to convert acute care beds to ICU beds, even with the appropriate staffing levels, which are higher in ICUS.” — Kristen Bole, a spokesperson for UC San Francisco

were more experimental, ICU capacity changes faster than regular acute hospital bed capacity because the turnover is faster — those who end up in the ICU are either stabilized and moved to another ward, usually relatively quickly, or they die.

The upshot?

“I don’t think it’s realistic to think you could just add beds willy-nilly,” Swartzberg said, adding that “staffing is the major limitation.”

Kristen Bole, a spokesperson for UC San Francisco, agrees.

“It’s not easy to convert acute care beds to ICU beds, even with the appropriate staffing levels, which are higher in ICUS,” she said. “The ICU rooms are set up to handle more complex equipment (such as ventilators and other monitoring devices) than acute care rooms, some of which is needed in COVID care.”

While a nearly full hospital sounds alarming, for many hospitals, operating close to full isn’t all that unusual. For example, UCSF’S ICU typically operates at about 85% capacity, Bole said, but is actually only about 74% full now. And Julie Greicius, a spokesperson for Stanford, said “it’s normal for Level 1 Trauma Centers, such as Stanford Health Care, to operate near full ICU capacity.”

What’ s worrisome, though, is what’s coming. The number of COVID patients in Bay Area hospitals has tripled since the beginning of November and that number will continue to rise as people who contracted the virus over Thanksgiving get sick. Christmas gatherings are also a major concern.

Bay Area hospitals are taking steps to boost capacity.

If surge space is needed, Bole said, UCSF could convert operating rooms or space where patients typically go after being under anesthesia into a place for critical care patients. For now, the hospital has space and is even still accepting transfer patients — including 18 with COVID-19 since Nov. 1. Most of the transfers, Bole said, require ICU level care and they are largely coming from Northern California.

Swartzberg said hospitals can also try to preserve some ICU space by postponing some surgeries, such as elective heart or lung surgeries where the patient would need to spend time in the ICU after the operation. But most surgeries don’t require an ICU stay, so cancelling procedures has a limited impact on ICU space.

Regional Medical Center and Good Samaritan Hospital in San Jose are boosting ER capacity by doubling COVID rooms, spokeswoman Sarah Sherwood said.

“The situation is not dire,” Sherwood said, in part because patients are younger, meaning they heal faster, and doctors and nurses have better treatment options, meaning people don’t linger in the ICU as long as before.

Sherwood praised the latest Bay Area order to limit activity, saying “we need more restrictions, not less.”

Stanford said it has prepared plans to accommodate more patients, but is currently able to continue normal operations. Kaiser said it also has plans to increase staffing and bed space to handle a surge.

Sutter Health is using electronic intensive care units in San Francisco and Sacramento, the health care giant said in an email, “to monitor a large number of critical care patients from a single location.”

Doc tors and nurses trained in ICU care can keep tabs on patients remotely, which allows them to reduce staffing onsite, from those two hubs “using live interactive video, remote diagnostic tools and other specialized technologies to assess critical changes in a patient’s condition,” Sutter said. The technolog y has become particularly useful during the coronavirus pandemic.

Like in the spring, Sugarman. who also serves as senior director with Vituity, an organization that provides staff to Bay Area hospitals, is worried that all of the talk about a surge in coronavirus hospitalizations will deter people who need help from going to the emergency room. Recently, he said, a patient of his waited several days too long to go to the hospital and ended up dying.

“There was nothing we could do,” he said, “and I really believe if he’d shown up three or four days earlier… there’s a really good chance he would have walked out of the hospital.”