As ICU Beds Fill, the Dominoes Fall Throughout Hospitals

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The filling up of the nation’s intensive care unit beds has been headline news for months now. As waves of COVID-19 cascade across the country, hospitals have been pushed to capacity.

You can read the headlines about a lack of ICU beds, but it might be hard to picture what that looks like, exactly. How does it impact patient care throughout the hospital? What is it like for staffing? And what about getting resources to the right people?

Here’s a snapshot of the domino effect of a system in crisis.

From Normal to Overflow

To understand the impact of ICUs that are full or over capacity, it’s important to understand what goes on in these vital units of the hospital.

“Prior to the pandemic, ICUs generally cared for patients with respiratory distress, sepsis, strokes, or severe cardiac issues,” explains Rebecca Abraham, a critical care nurse who founded Acute on Chronic, which offers help to patients navigating the health care system. “These are people who are very sick and need constant care.”

Allocation of nurses to these units is generally recommended on a 1-to-1, or sometimes 1-to-2 ratio. These are patients who require specialized equipment not found elsewhere in the hospital, like ventilators, bedside dialysis, specialized heart-catheterization machines, and drains, among other things.

These patients also require multiple lab measurements, often taken hourly, and rapid changes in medications. “Their conditions change quickly and often, so you don’t want to miss an assessment,” says Abraham. “But when we have to expand our nurse-to-patient ratio, we cannot monitor patients like we should.”

Today, ICUs are now full of very sick COVID patients, on top of these “normal” critically ill patients, with dire consequences. “The ratios have had to expand far beyond what is standard,” Abraham explains. “You might have four to six nurses involved with one patient.”

COVID patients often need to be placed face-down by staff, for instance. To do this properly and safely, a full team must be in place to prevent tubing and lines from coming out of the patient’s body. And when sick COVID patients require intubation, nurses, doctors, respiratory therapists, and others must be involved. All of this pulls these essential staff members away from their other duties and normal care activities.

Full ICUs also require that nurses and other personnel who are not specifically trained and certified in critical care step in. “These nurses are still taking care of other patients, too,” says Abraham. “When a patient crashes and the nurses aren’t trained for that, quality of care suffers.”

Where ICUs once had an admitting nurse available and a place for a new patient, now that would be a luxury, says Megan Brunson, a critical care nurse at Medical City Dallas Hospital who spoke on behalf of the American Association of Critical-Care Nurses. “Everyone hopes not to get a new admission on their shifts,” she admits.

There was already a nursing shortage before the pandemic, and the strain that packed ICUs is putting on health care is only making the problem worse.

Brunson says the crush of COVID has reached a national crisis.

“More important than the conversation surrounding how many beds are available is how many nurses we have,” she says.

Abraham agrees.

“As the ICUs get busier and stretched thinner, care suffers,” she says. “That’s not what nurses want, or why they got into the field.”

A survey by health care staffing company Vivian in April found that 43% of nurses were considering quitting during the pandemic, including 48% of ICU nurses.

It’s not just nurses. Doctors are also considering leaving the professional. An April study published in JAMA Network Open found that 21% of all health care workers “moderately or very seriously” considered leaving the workforce, and 30% considered cutting their hours.

Beyond the ICU

As ICUs fill up, the effect multiplies throughout the entire hospital. “One thing that no one is talking about is the fact that our supply closets are wiped out,” says Brunson. “We’re trying to troubleshoot around that. We’re also still rationing PPE [personal protective equipment], after all this time.”

Every 4 hours, says Brunson, staff at her hospital huddle to determine where to send resources. “In a triage situation, there’s only so much you can do with what you have,” she explains. “We can only take care of the priority needs.”

Abraham says that often today, emergency rooms must hold critically ill patients. “Emergency care doesn’t stop for that,” she says. “The patients are still coming in. There’s less monitoring, less titration [adjusting meds], and in some cases, sending ambulances to other hospitals.”

The bottom line, according to Abraham, is that full ICUs require that hospitals bypass all their standard procedures.

“That’s never a good thing because it leads to delays in care,” she says. “Critically ill patients go to floors without specialized staff, and mistakes can happen.”

On top of it all, nurses and other personnel are burned out.

“Nurses are quitting or moving to less stressful settings,” says Brunson. “Many are becoming traveling nurses because they can make a ton of money in a short period of time and then take a break.”

Brunson says that to her mind, the most important thing is having the right nurse for the right patient. “I’m on an adult unit but had to pull in a pediatric nurse the other day,” she says. “She was a quick learn, but she’s still limited by her training.”

In spite of it all, both Abraham and Brunson hold out hope for a brighter future in the nation’s hospitals.

“I’m holding my breath, but I’m optimistic,” says Brunson. “I have hope for 3 years down the road, but we need to crank out new nurses for the system, people to get vaccinated, and a long-term strategy.”


Rebecca Abraham, registered nurse and critical care nurse; founder, Acute on Chronic LLC.

Megan Brunson, critical care nurse, Medical City Dallas Hospital; immediate past president, American Association of Critical-Care Nurses.

JAMA Network Open: “Experiences of a Health System’s Faculty, Staff, and Trainees’ Career Development, Work Culture, and Childcare Needs During the COVID-19 Pandemic.”

Vivian: “One-Year In: What’s Next for America’s Healthcare Workers.”

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