What happens when the ICU is full?

Editor's note: This story was updated on July 27 to include news about the establishment of ethics committees to decide which COVID-19 patients receive ICU care. The original article was published July 23.

COVID-19 outbreaks are often followed by headlines saying that intensive care units (ICUs) have hit capacity. But what does it really mean for an ICU to be full?

In normal times, ICUs typically run at roughly 70% to 80% capacity, a sweet spot where a unit can maintain enough resources to run, without being overstaffed, and still allow wiggle room for additional patients, experts told Live Science. Hospitals can increase their ICU capacity to accommodate for surges, such as those caused by COVID-19, but there does come a point when resources and staff start to stretch uncomfortably thin.

"If we exceed that [capacity], we start doing things we don't want to do," such as asking medical workers to care for more patients than they normally would at a single time, or placing several beds in the same room, said Dr. James McDeavitt, senior vice president and dean of Clinical Affairs at the Baylor College of Medicine in Houston, Texas. COVID-19 also places a particular strain on hospitals' supply of personal protective equipment (PPE), as well as the mental health of both patients and medical staff, especially given that COVID-19 patients cannot receive visitors, he added.

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But even if ICUs are at capacity, "if you need medical care, please come to the hospital," said Dr. Craig Coopersmith, director of the Emory Critical Care Center and a professor of surgery at the Emory University School of Medicine in Atlanta. Unlike in a grocery store, where people with COVID-19 might unwittingly mingle with uninfected people, hospitals identify probable and confirmed coronavirus infections and isolate those patients from others, he said. 

If you require care in an ICU, such as for a heart attack or stroke, "you are significantly safer coming to the hospital and getting the care you need than staying at home," Coopersmith told Live Science.

Stretching ICU capacity 

In May, the Society of Critical Care Medicine, an organization of intensive care professionals, issued guidelines for how hospitals can expand their ICU capacity to contend with the COVID-19 pandemic. Rather than the number of ICU beds, "the biggest challenge is actually staffing," said Coopersmith, who served as president of the organization from 2015 to 2016.

"A bed's a bed," McDeavitt told Live Science. Provided that a bed can be equipped with the appropriate monitors and equipment, such as ventilators, any bed can be turned into an ICU bed, he said. "The most important thing is that qualified staff take care of the patient."

To bolster ICU staffing, medical workers normally assigned to other departments can be redeployed to help care for critical care patients; these workers must have "complementary skill sets" that suit their new positions in the ICU, Coopersmith noted. 

For example, early surges of COVID-19 prompted hospitals to postpone many elective surgeries, leaving anesthesiologists available to manage ventilators, breathing tubes and blood pressure medication drips in the ICU, as these are tasks they might normally manage during surgeries. Nurse practitioners, physicians assistants in surgery, surgeons, cardiologists and trainees in pulmonary care also have skills that can ease the burden on ICU physicians tasked with caring for COVID-19 patients, Coopersmith said. 

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Nurses at South Bay Hospital in Sun City Center, Florida, received similar cross-training to equip them for so-called team nursing in the ICU, where one ICU-trained nurse is supplemented by others who handle tasks like monitoring patient vitals and clearing bed pans, said Marcy Frisina, Chief Nursing Officer at South Bay Hospital. In addition, hospital staff members such as radiology technicians, physical therapists, medical record keepers and administrative assistants can be called on to deliver PPE, run samples to the lab and fetch water, among other tasks, when the ICU gets busy, she said. Only select staff actually enter the ICU rooms to care for COVID-19 patients, so although ancillary staff help with certain tasks outside, the hospital conserves PPE for those who need it most, she added.

Baylor College of Medicine, along with other member institutions of the Texas Medical Center, similarly prepared for COVID-19 surges by assessing the skills of their physicians and conducting extra training to better equip them for the ICU, should they be redeployed, McDeavitt said. In addition, the hospitals hired traveling nurses from outside the local community to further increase staffing. 

Baylor's preparation allowed it to handle the current surge of COVID-19 in Harris County, "because we had more warning than New York did," McDeavitt noted. 

If there does ever come a point when an ICU does not have enough trained staff to take in a new patient, the hospital can transfer that patient to another medical center, Frisina told Live Science. But in general, an ICU can technically be "'at capacity,' but have enough staff to do more," she said. In other words, patients don't necessarily get turned away when an ICU hits 100% capacity; the hospital typically makes more room, she said. 

That said, Starr County Memorial Hospital in Texas recently announced that, due to mounting strain on its ICU, the hospital will establish an ethics committee to decide which COVID-19 patients will be admitted and which will be sent home, according to CBS News.

Cases started surging in Starr in early July, after Texas began to reopen, and the local hospital must now transfer patients to medical centers elsewhere to conserve its limited resources, Dr. Jose Vasquez of the Starr County Health Authority told KGBT-TV. At least two to three patients are transferred out of the area each day, and as many as six to seven on some days; but as ICUs also fill in neighboring counties, the hospital will now have to decide which patients have the best chance of pulling through, Vasquez said.  

"The reality is that science and statistics are against those people with multiple medical conditions," Vasquez said during a press briefing, CBS reported. "For all of those patients who most certainly do not have any hope of improving, we believe that they are going to be better taken care of within their own family in the love of their own home, rather than thousands of miles away dying alone in a hospital room."

Unique challenges of COVID-19 

While COVID-19 patients aren't "inherently sicker" than other patients in the ICU, they do present unique challenges that other patients may not, Coopersmith said. For example, medical staff must be equipped with adequate PPE to ensure that they don't catch the highly transmissible virus while tending infected patients.

In a packed ICU, time is a precious commodity; time spent donning and discarding PPE must be factored into all protocols concerning COVID-19 patients, McDeavitt noted. But primarily, the need for layer upon layer of protection can place an emotional toll on medical staff, he added. "You typically don't go into work concerned that you're going to come away with an illness," he said.

The lack of visitors to the ICU only adds to the stress, Coopersmith said. "The 'no families [rule]' puts a massive emotional burden on the care teams … and the patient, if they're conscious," he said. Families and other visitors to the ICU can help calm patients and facilitate communication between those patients and health care workers attending them, he said. Without any visitors, both the staff and the patients themselves must shoulder that emotional burden alone.

For health care workers, "the stress of just exposing one's family members … has been a recurring theme," Frisina noted. South Bay Hospital has showers for staff to use and clean scrubs for them to travel home in, but also provides hotel rooms where staff can stay if they prefer not to risk going home once exposed.    

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In addition to protecting their physical health, those who take care of patients must be given adequate mental health support to cope with the prolonged stress, McDeavitt said. To this end, Baylor College of Medicine provides self-assessment tools to help staff gauge their stress levels and offers telehealth sessions with licensed psychologists and psychiatrists, as well as group therapy sessions with other staff members. Given that "this is an ongoing slog that's going to continue for months," the hospital also encourages staff to take time off when needed, McDeavitt said. 

In face of all these challenges, hospitals have improved the care of COVID-19 patients throughout the pandemic by adopting new care strategies in the ICU. "I don't want to call it routine ... but in some senses, this is the new normal," Coopersmith said. For example, since the early days of the pandemic, new evidence showed that many COVID-19 patients in critical condition may not benefit from ventilation, despite low blood-oxygen levels. Back in April, when they were mostly guided by these blood-oxygen levels, Baylor physicians placed roughly 44% of critical COVID-19 patients on ventilators; that percentage is now closer to 15%, McDeavitt estimated.  

While being more selective about who to place on a ventilator, hospitals are now quicker to prescribe blood thinners to COVID-19 patients in order to prevent dangerous blood clotting associated with the infection, Coopersmith added. Of course, while learning to better care for COVID-19 patients, and adjusting protocols based on brand-new research, hospitals must also plan for another impending surge of infection, Frisina said — the one caused by seasonal influenza.

Come winter, influenza season might compound the strain COVID-19 has already placed on ICUs, depending on how well communities contain the virus in the coming months, she said. And given that influenza and COVID-19 share some symptoms, extra pressure would be placed on diagnostic testing services to differentiate flu cases from coronavirus cases, McDeavitt added. Any delays in testing trickle down to the hospitals and could place extra strain on the ICU; that said, hospitals like Baylor avoid testing delays associated with commercial labs by conducting tests internally, he noted.

But whatever the coming months have in store, Frisina noted that people should not put off visiting the hospital for medical care, coronavirus-related or otherwise. "We're going to keep you safe; that is our number one priority," she said. And "the longer you wait, the harder it is to fix."

Editor's note: This article was updated on July 23 to correct the location of Baylor College of Medicine to Houston, Texas.

Originally published on Live Science.