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St. Louis-area hospitals struggle as COVID cases remain dangerously high
ON THE EDGE

St. Louis-area hospitals struggle as COVID cases remain dangerously high

Under pressure: Soaring COVID-19 cases press local hospital to the limits

RN overnight Riccia Robinson, center, huddles with dayside nurses Heather Doherty and Meagan Drepes to update them on patient status on Monday, Nov. 23, 2020, in the Intensive Care Unit at SSM Health DePaul Hospital - St. Louis in Bridgeton. Photo by Laurie Skrivan, lskrivan@post-dispatch.com

CREVE COEUR — This time, Mercy Hospital Washington was the one facing the most trouble.

Its intensive care unit was full — “and they are eight nurses down,” Robyn Weilbacher, chief nursing officer for Mercy’s eastern Missouri region, told about 60 hospital leaders Wednesday during an early morning online conference.

They’ve been meeting daily since mid-November, when COVID-19 patient numbers began to swell into dangerous territory, to address capacity and staffing issues in the Mercy system.

Kellie Meehan, regional director of nursing logistics, was leading Wednesday’s meeting. She urged everyone to do what they could to make room as they attempted to transfer some of Washington’s 13 intensive care patients to other hospitals and offer relief. An emergency could come through the hospital’s doors at any moment.

“Whatever we can do to keep our throughput moving so we can help out our sister facilities, that would be awesome,” Meehan said before ending the 20-minute meeting.

But there were few options that day. Mercy St. Louis was reporting 92 COVID-19 patients under its roof. Mercy South had 103 — entering into its fourth week of hovering in the triple digits. About 10 patients were waiting in each of their emergency departments to be admitted. And the intensive care units at Mercy’s smaller hospitals in Jefferson and Lincoln counties were nearly full.

“Unfortunately what happens a lot — and today is a perfect example — is we are all struggling,” Meehan said.

The start of a new year, which typically signals a fresh start and change, is fast approaching. But for families with sick loved ones and overwhelmed health care workers, the year seems like it refuses to end.

On Monday, the first shipments of COVID-19 vaccines arrived at area hospitals to inoculate front-line staff, providing the signs of light at the end of a tunnel toward the pandemic’s end. But back at work, employees are teetering on the edge of disaster.

The dramatic rise in hospitalizations for COVID-19 through October and November has leveled off across the state, but the levels are still dangerously high, said Dr. Alex Garza, who leads a pandemic task force of 22 hospitals in St. Louis and its surrounding 14 counties.

For over a month, an average of more than 100 COVID-19 patients have been admitted every day to task force hospitals, filling 20% of general hospital beds and 30% of ICU beds with COVID-19 patients, Garza said.

The hospitals’ intensive care and medical units are about 85% full on average. More than 20 COVID-19 patients are dying every day.

With community transmission levels of the coronavirus still high, Garza expects this impossible burden on hospitals to continue well into the winter.

“You just can’t maintain this sort of operations tempo at this rate, because it gives us very little room to maneuver. Even the slightest uptick in admissions above what we are seeing as normal now can really tip us into crisis management,” he said. “Beyond that, we can’t keep up this tempo because we are burning our staff out.”

Crisis management means doctors have to make difficult decisions on who gets the best care and who doesn’t.

“Make no mistake,” Garza said, “we continue to be in the most serious and deadly part of the pandemic.”

Creating capacity

Hospitals implement crisis management, officially called “critical standards of care,” when all their efforts to extend their resources to handle critically ill patients no longer work.

These efforts include all the things area hospital systems are doing now: delaying surgeries, sending adult patients to pediatric hospitals, moving operating room and other staff to support the ICU and relying more on telemedicine.

Hospitals are quickly expanding units to care for COVID-19 patients, while contracting other units. They are doubling rooms that are usually private.

“We have expanded within our individual hospitals,” said Patti Crimmins Reda, the operations section chief for BJC HealthCare’s incident command center. “We have converted what may have been a general patient care area, we’ve made into an ICU. We have reduced our elective surgical cases in order to reassign those staffs to care for those patients in the areas where we have changed their purpose.”

The biggest challenge, Meehan said, is finding separate spaces for the non-COVID patients and COVID patients.

“We are kind of shuffling where everybody is at … and making sure we give everybody the same quality of care they expect and deserve,” Meehan said.

The shuffling makes pinpointing the maximum number of available beds fluid as hospitals work to create capacity and deal with staff out sick or having to quarantine.

The most recent federal data shows Mercy Hospital South has the most overwhelmed ICU in the St. Louis region, at 101% capacity.

“What I can tell you is that (Mercy) South has exceeded their ICU capacity under normal circumstances, and we’ve expanded the ICU capabilities into other areas,” Meehan said.

Dr. Zafar Jamkhana, the medical director of SSM Health’s St. Louis regional transfer center, called the hour-by-hour effort of matching each center’s capabilities with patient demand a “complex orchestra.”

Jamkhana is worried, however, the volume is becoming too much for area hospital systems.

“I think even with increasing capacities and opening up more beds and really expanding our capability to take care of patients,” he said, “we still are probably behind in being able to provide care that we should, for not just all the COVID patients, but also the regular patients.”

In a press conference earlier this month, Garza said hospitals are changing the threshold for admitting patients. Patients are instead being sent home with home monitoring equipment, instructions and advice to return to the hospital if they get worse.

“The reason for that is we have precious little capacity right now, and we are reserving that capacity for people that we are absolutely sure are going to need a bed in the hospital. So, we are being more conservative with who we admit,” Garza said.

Doctors are also pushing the limits on how soon they discharge patients, he said.

“And we know that patients are coming back to our hospitals because they have gone home and done poorly and need to be readmitted to the hospital. And all of that is in order to preserve the capacity that we have,” Garza said. “Certainly, it’s not optimal.”

Hospital transfers

Each hospital system has a transfer center that works much like an air traffic control tower directing airplanes needing to land and takeoff.

A team of nurses takes calls from rural hospitals requesting higher-level care for their patients, and the nurses see if they have the bed and expertise available, while also keeping an eye on how sick the patients are coming into their own emergency rooms.

If no beds are available, the nurses maintain a list of requests so they can call hospitals back to get updates on the patients and let them know when space opens.

One recent morning, Jamkhana had the names of 19 patients waiting for transfers. “That is a long list,” he said. Many of them have COVID-19. It’s not uncommon, he added, to start the day with no beds available in SSM Health’s seven adult hospitals in the St. Louis area.

On Wednesday, the day when the Post-Dispatch monitored the Mercy conference, St. Louis-area hospitals had zero requests for transfers from rural hospitals, “which can be good or bad,” Meehan said.

She worries it means the small hospitals have instead decided to hang on to their patients rather than try to transport them.

Recently, Meehan said, patients needing to transfer from outstate areas have sometimes had to wait 24 to 48 hours for a bed as the transfer center nurses pick who is the sickest among the requests, those coming into emergency rooms and those coming out of surgery.

“Being part of the city and being the bigger facilities, it is our responsibility to help out those rural communities and support them as best we can,” Meehan said. “Unfortunately, as the COVID cases swell and take over the bigger hospitals, it is those smaller hospitals that are also impacted by it, because they don’t have a place to transfer those higher-acuity patients that they truly just don’t have the resources to support.”

Hospitals also rely heavily on ambulance services to spread the patient load and free up beds by moving patients among hospitals or to rehabilitation facilities. But they are swamped, too.

Jamkhana said noncritical patients are often waiting more than eight hours to get moved.

Joe Grygiel, vice president of regional operations for the company that owns Abbott Ambulance which serves the St. Louis area, said 911 calls take priority.

“Our response time for hospital transfers are down,” Grygiel said. “We simply can’t transport as many patients a day as we typically could.”

First responders wear protective gears to prevent spread of coronavirus

An Abbott Ambulance EMS provider wears a protective mask, gown and eye protection as he pulls away from the scene of medical call in the 5200 block of South Grand Boulevard on Wednesday, March 18, 2020. Photo by David Carson, dcarson@post-dispatch.com

Many EMS staff are out sick or having to quarantine. An ambulance must be decontaminated after calls, which can take it out of service for up to an hour. The calls they respond to involve sicker patients who have put off seeking help.

Nick Harper, deputy chief of the Monarch Fire Protection District which covers a large section of west St. Louis County, said the district is on track this month to respond to more heart attacks than it has in an entire year.

Because of hospitals’ no-visitor policies, Grygiel and Harper say many patients refuse to be taken to the hospital because they don’t want to die alone.

Jamkhana said everyone is stretched thin.

Missouri Gov. Mike Parson announced on Dec. 2 that he was hiring a Texas-based private company to provide up to 760 health care workers across Missouri. Just 117, however, are scheduled to arrive over the next few weeks, with the first group starting Monday.

“The fear for us is that we will reach a breaking point,” Jamkhana said. “At some point, it is a finite resource. We can’t just create nurses, physicians, respiratory therapists and EMS staff out of thin air.”

Total priority score

A breaking point will prompt crisis standards of care, which have been created and refined over several decades for mass casualty incidents like earthquakes or war. They guide clinicians on how to choose who gets limited critical resources by prioritizing who is likely to survive.

At the start of the pandemic, the Missouri Hospital Association pulled together resources and created such guidance for hospitals across the state should they become overwhelmed.

The guidelines suggest that each hospital have a triage team of acute care specialists in charge of making the decisions. Patients will be given a “total priority score” based on their health conditions. If there is a tie, the team can consider things such as age or whether the person is a health care worker, or even implement a lottery.

How the decisions are made must be “transparently communicated to the public to distill fears that patient lives are not appropriately valued by a particular facility,” the guidelines state.

A group called the St. Louis Medical Officers Center, made up of a dozen representatives from area hospital systems, will decide when crisis standards are implemented. They will begin working more closely together, sharing real-time information about available resources across their systems, said Harper, who is an EMS liaison to the group.

Harper is working with the center on how to get that information as quickly as possible to ambulance crews in the field should the crisis standards come into play, since it no longer means they simply head to the closest hospital. “You are going to see EMS running their tails off,” Harper said.

Earlier this month, Garza said there’s no question whether health care workers will take care of everybody no matter the situation.

“The question is,” he said, “how well will we take care of everybody and how much stress are we willing to put on the backs of our health care workers?”

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