In an individual narrative published in the August issue of Health Affairs, David Scales, M.D., Ph.D., a medical sociologist and an assistant professor of medicine at Weill Cornell Medical College in New York City and a hospitalist at a community hospital there, describes challenges with understaffing that have been created or exacerbated by the COVID-19 pandemic.
Dr. Scales begins “An Understaffed Hospital Battles COVID-19” by telling the story of “Mr. L,” a patient admitted to the New York City community hospital at which Scales practices, back in March. At that time, he notes, the hospital was overwhelmed by the flood of COVID patients being admitted to the hospital, many to its ICU.
“When all the data are analyzed, it would not surprise me to find that hospitals with the least capacity for surge staffing suffered the most excess deaths,” Scales writes. “We did not run out of ventilators, although some days we came quite close. But machines alone cannot save lives.” Importantly, he notes, “A complex interconnected network of health care specialists works in synchrony, like an orchestra performing a well-rehearsed symphony, to ensure that critically ill, ventilated patients survive. Ventilators rely on well-trained and specialized nurses and respiratory therapists to function. Dialysis instruments require a qualified nurse to manage the complex array of chemicals and reagents and monitor the patient’s response. No, machines alone cannot save lives, just as musical instruments alone cannot perform a concerto.”
What’s more, Scales notes, “[I]n Mr. L’s case, the machines were not enough. Soon after intubation, his blood pressure dropped. His kidneys failed. His body shut down, organ by organ, and he passed away five days later, despite being a healthy man in his mid-sixties before contracting COVID-19. Sadly, his story is not unique.”
Speaking as both a hospitalist and a healthcare researcher, Scales states that “As patient-to-nurse ratios increase, patient safety is in jeopardy, with a number of studies showing that a patient’s risk for complications rises and their chances of leaving an ICU alive go down with these increasing ratios. Nurses are a patient’s first line of surveillance and are often the earliest to find and respond to any changes in a patient’s condition. ICUs in particular grew out of a need for more specialized nursing with higher levels of monitoring for the sickest patients, and better patient-to-nurse ratios have been associated with lower risk for pneumonias.” Meanwhile, “Data are less available for respiratory therapists, but there is reason to believe that patient-to-therapist ratios are just as vital for patient safety. Our three respiratory therapists were stretched thin covering the entire hospital, including more than thirty ventilated patients in our ICUs, another twenty patients on the regular medical floors on such high oxygen that they would normally be in ICUs, and another fifty or so patients on varying levels of oxygen. I worried that our overburdened care teams might miss details that nurses and respiratory therapists often catch (such as subtle changes in a patient’s condition, equipment problems like nearly deflated endotracheal tube cuffs, or the early signs of new infections or looming complications). Details that seem insignificant but affect how long a patient stays on the ventilator. Because each day on the ventilator increases risk for complications and death.”
A key question: “Would Mr. L have survived if we had had more nurses and respiratory therapists, if the hospital had not been overwhelmed? We will likely never know,” Scales writes. “But we do know that thinly stretched health care teams can be dangerous, and many hospitals were understaffed before the pandemic. When all the deaths are counted, what will we find among the hospitals with the highest death rates? As blacks and Latinos suffered death rates in New York at nearly twice the rate as whites or Asians, it is clear that comorbidities contribute, with social determinants of health a crucial predisposing factor. But we also need to understand whether overstretched staff became another organizational determinant of mortality in the midst of a crisis. How much of the disproportionate mortality that minorities faced can be explained because they sought care or were brought by emergency medical services to already-overwhelmed and underresourced safety-net hospitals? Disparities in resources between well-off and underresourced hospitals were assumed but tolerated before the pandemic, but the risk for complications or death between one hospital or another a few miles away was never so apparent. The stress test of the pandemic made such stark inequities impossible to ignore.”
Dr. Scale’s reflections on the situation that his New York City hospital faced this past spring is now one that the clinical and administrative leaders of countless hospitals in the Sunbelt are facing. “Ultimately, we transferred some patients to the referral hospital,” he reports, of his hospital’s situation. “At first I saw these transfers as helping us—a pressure valve to relieve the crisis at our hospital. And it did help us. But as the crisis went on, I increasingly saw it as a critical move for patients themselves—a lottery ticket to a less overwhelmed hospital with safer nursing ratios, more respiratory therapists, and, I hoped, a greater chance of survival. But such transfers came too late for Mr. L. Words from our last conversation echo in my head: ‘I trust you,’ he said. ‘Do what you need to do to save my life.’ And I wonder: Do we, as a health system, really deserve that trust? Did we do all we could?”
