State hiring freelance ICU nurses to bolster swamped hospital staffs
Bay Area hospitals are struggling to ensure they have enough intensive care beds, and the highly trained nurses to staff them, as a surge of critically ill COVID19 patients threatens to overwhelm these indispensable medical units.
Daily admissions to Bay Area ICUs have more than doubled since last month, as have the number of people going into the hospital, a Chronicle data analysis shows. This month, 984 Bay Area residents a day were admitted to the hospital on average, compared to 484 a day in November. Of those, 266 patients a day have needed ICU care in December, compared to 129 a day last month. In all, about 1 in 4 hospitalized patients needed the higherlevel care.
To bolster California’s shortstaffed intensive care units, the state is hiring 435 temporary ICU nurses, including some from out of state. Gov.
Gavin Newsom announced the plan Monday, as hospital admissions from COVID-19 rose 69% in the last two weeks. The help should arrive by Monday, with an additional 380 freelance medical providers, he said.
But the governor also alarmed many ICU nurses this week by announcing a program offering “twoday, very effective, focused training looking at bringing nurses into the ICUs.”
Unlike regular hospital rooms, intensive care has complex medical machinery by every bed and outside each room. Nurses are assigned to just one or two patients and require at least a year of additional training to operate reliably in the specialized, life-and-death environment.
Bombarded with criticism at the suggestion that a brief training could prepare a nurse for the ICU, Dr. Mark Ghaly, secretary of California’s Health and Human Services Agency, said that “no one expects the nurses who complete just two days of training to go in and solo.” Instead, the lessons are a “refresher” for “nurses who may find themselves in a situation of pitching in and helping out with critical patients,” he said.
Amid the shortage of critical care nurses, and with just 19 ICU beds for every 100,000 Bay Area residents, regional hospitals are looking at how to expand ICU space and staff if they reach their limit. No one wants to run out of room, as happened in New York and Texas during earlier surges — and now in hot spots in California and across the country.
“In a pandemic, it’s like being in a war. Everything is not equal. You triage as needed, and there’s always that eye on safety,” said Vicki White, chief nursing officer at St. Joseph Health, a group of North Bay hospitals that includes Santa Rosa Memorial and Petaluma Valley.
If the surge becomes untenable, she said, hospitals will have to remove some patients from the ICU and place them in less intensive environments.
Several areas are frighteningly close. Just 15% of Sonoma County ICU beds were free Tuesday, the second most crowded county in the Bay Area. Only Santa Clara County, with 14% availability was more crowded.
“We are very concerned about our health care system’s capacity, in particular when it comes to ICU beds,” said Dr. Ahmad Kamal, director of health care preparedness, noting that 62 new COVID19 patients were hospitalized on Sunday alone. In the county of 2 million people, just 50 ICU beds were open for people with any serious need. “Many of our hospitals continue to have five or fewer vacant ICU beds.”
Solano County was not far behind, with 16% ICU availability this week. Statewide, just 14% of all 7,802 ICU beds were available this week. In particularly bad shape was the San Joaquin Valley, with just 6.3% free, and Southern California, with 10.9% of beds open. And while Marin County’s ICU beds stood at 43% available, the state moved it into the most restrictive purple tier Wednesday, the last Bay Area county to do so.
Federal data shows that some Bay Area cities are in an even more precarious position in terms of ICU availability. In Santa Rosa, just two of 42 ICU beds were free this week, and in Daly City, all nine staffed beds were taken.
To alleviate the strain, hospitals with greater capacity, like UCSF in San Francisco — a city with 28% of ICU beds free — are helping those that are overcrowded.
But even San Francisco is on extreme alert, and expects to run out of ICU space by Dec. 27. “And that’s if things don’t even get worse,” said Grant Colfax the city’s public health director, who warned that San Francisco’s ICUs have the most COVID19 patients they’ve ever had, with 30. “The virus is raging throughout our city.”
What hospitals desperately want to avoid is rationing care.
“The reality is, we need to take collective action to protect our ICU capacity so we’re ready for increased cases,” said Dr. Stephen Parodi, infectious disease specialist and associate
executive director at Kaiser Permanente.
During the last surge, multiple Kaisers transformed their postanesthesia care floors into intensivecare spaces — no small feat, given the ICU’s complex requirements. Now, Parodi said, they are prepared to do it again.
Some hospitals are working with state regulators to relax rules that require certain beds to be dedicated to certain types of patients.
“I call this the silver lining. We’ve been faced with challenges and have been able to think creatively,” said White, of St. Joseph Health, noting that the state and its licensing authority have been flexible during the surge. She also cited lessons from three years of wildfire emergencies, where ICU units learned that “we have to really listen to the people doing the work and say, ‘ Why not try this?’ ”
Dr. Chad Krilich, chief medical officer for St. Joseph Health, said the wildfires proved that staff is “resilient in being able to respond to such an event. I’d hope we’d have the same capability” in a growing surge of the coronavirus.
Another approach both helps ICU patients leave earlier and frees up beds — if hospitals can modify the approach during the dangerous pandemic.
“ICU Liberation” is a set of techniques hospitals have learned in recent years that can reduce patients’ stay in the ICU by up to three days, on average.
Nurses give fewer mindaltering drugs to reduce the common ICU side effect of delirium. They perform frequent breathing tests to keep the patient from needing a ventilator. Mobility is also important — even for patients on
breathing tubes. And to reduce anxiety, family is encouraged to visit.
“I think it’s one of the most critical interventions that we could be performing, keeping patients’ length of stay in the ICU as short as possible,” said Dr. Jennifer Walker, an ICU doctor at Santa Rosa Memorial Hospital.
Hospitals don’t want to stop using those techniques, but they can be dangerous when patients are infected with the coronavirus. So practitioners are modifying their approach, Walker said. For example, walking is considered essential. But now, only patients able to wear a mask can flex their muscles with a walk, and only in their room, according to the journal of the Society of Critical Care Medicine.
The journal also recommends reducing nurses’ time in patient rooms by allowing other health care workers to conduct the breathing tests that reduce patients’ need for a ventilator.
But some staffing workarounds during the pandemic — from efforts to increase the number of patients that nurses are required to care for, to the state’s twoday training to prepare nurses for ICU work — have caused strong concerns.
“Unless the rapid training is going to be for ... nurses that already have at least a yearplus experience in the ICU, that is perhaps the most dangerous and irresponsible thing I have ever heard,” said Mawata Kamara, an ICU nurse at San Leandro Hospital, who said the plan could increase medical errors.
Ghaly said the idea was not to “create a cadre of ... trained ICU nurses,” but to help guide anyone helping out.
And help is needed.
Tamara Hinckley, a night nurse in Sutter Santa Rosa Regional Hospital’s ICU, prefers to work every other week so she can recover from the powerful emotions of her work.
“I have cried more tears this year than I have my entire nursing career,” said Hinckley, who still loves her job.
But each day off, texts flood in seeking nurses to fill in for shortages.
“I’m really torn,” she said. “I want to help my coworkers. But that would not fix staffing in the long term. We need longterm staffing fixes.”
ICUs are shortstaffed not only across California, but across the country. “The concerns you’re hearing from the nurse in Santa Rosa are valid,” said Dr. Matt Aldrich, executive medical director of adult critical care medicine at UCSF Health in San Francisco, noting that UCSF feels the shortages less than hospitals in smaller cities. UCSF has 102 ICU beds and has opened more at its Mount Zion facility to help with the surge.
Meanwhile, the state has set ICU availability as the single criteria for determining whether a region’s economy can remain open. If availability falls below 15%, the economy must shut down. Last week, five Bay Area counties — San Francisco, Alameda, Santa Clara, Contra Costa and Marin — voluntarily shut down, although none but Santa Clara had dropped that low.
Ghaly offered a simple reason. “ICU is a very important metric,” he said. “Preserving it is going to save lives.”