Hospitals brace for COVID surge, fearing shortages, burnout

Tinny Abogado, in scrubs, outside Kaiser Permanente L.A. Medical Center. Behind her, people in masks enter the hospital.

Nov. 22, 2020 5 AM PT

Since the middle of October, doctors and nurses at Loma Linda University Medical Center had been warily watching news reports of a spike in COVID-19 patients in the Midwest. They knew that, sooner or later, their own hospital would be hard hit. They just didn’t know when.

Last week, they found out. In one 24-hour period, 15 COVID-19 patients were admitted to Loma Linda in what Dr. Michael Matus, chief of hospitalist medicine, described as “a huge rush of patients.”

“We immediately filled one ward and half of another,” Matus said. “It immediately strained the nursing staff. And then the physicians. We try to keep the physicians seeing up to 16 patients. That day, it was up to 24.... It was our biggest day in the last month.”

A new surge of COVID-19 is battering Southern California, bearing down on exhausted healthcare workers, raising anxiety levels on hospital wards and stoking fears that there might not be enough staff and supplies for the difficult weeks ahead. The coming holidays only make the situation more dire.

The recent rise in COVID-19 patients in the middle of the country has sapped the nation’s reserves of nurses and doctors, as well as masks, gloves and other protective equipment. Good news about vaccines offers hope for the future, but it’s the present that worries those who care for California’s sickest patients.

For the week ended Thursday, the most recent statistics available, the number of hospitalized COVID-19 patients rose 40% in Los Angeles County. In San Bernardino County, home to Loma Linda, the number jumped 45%; in Riverside County, it was up 34%.

“We face one of the most dangerous moments in this pandemic,” Barbara Ferrer, director of the Los Angeles County Department of Public Health, noted in a briefing Wednesday.

An exhausted Matus needs no reminder.

“Each morning, we review our overall resources and how to handle patients,” he said. “Staffing is problematic. No system is leaving trained physicians or nurses on standby.… There have been multiple days in the morning where the registry [of available nurses] is completely empty.”

Although new therapies “are giving us a fighting shot in the majority of patients,” Matus said, it is difficult seeing “the stress in everybody’s eyes. [Patients] come to the hospital short of breath. They meet me fully masked. Everybody’s just petrified.”

Dr. Anil Perumbeti, medical director for the intensive care unit at Eisenhower Health in Rancho Mirage, says the staff has taken pride in being able to work at a fast pace and high level throughout the pandemic. But there is a cost.

“There’s definitely [been] two-week periods of time where nobody makes it out of the COVID ICU, no one gets better enough to be transferred out, there are multiple deaths, there are no success stories, no one gets better,” he said. “I don’t think there’s any amount of experience that makes that OK or makes you feel like you did the best you could.”

At Keck Medicine of USC, healthcare workers had recently talked about reducing the capacity of the COVID-19 unit so there would be more space for other patients if the number of cases began to decline. Instead, it shot up again.

The Los Angeles teaching hospital is “without a doubt” seeing an upward trend in COVID-19 patients, said Dr. Neha Nanda, medical director of infection prevention. “I don’t have a crystal ball, but I anticipate in the next few weeks, it’ll continue to go up.”

Nanda said she was concerned that hospitals could soon “run short of beds” as the number of patients in the region surged.

The matter of capacity is complicated, said Carmela Coyle, president of the California Hospital Assn. She noted that, during a news briefing in early November, Gov. Gavin Newsom said the state was using only 4% of its hospital-bed capacity on COVID-19 patients. Last week, that number rose to 6%.

She said, however, that in Imperial County, for example, nearly a quarter of all hospital beds had COVID-19 patients, and in Kings County, the rate is 16%.

“With outbreaks, you can have zero [patients] today and quite a few tomorrow,” Coyle said. “I was on the phone with a [hospital] CEO. They went from seven patients yesterday to 20 COVID patients overnight.... We talk about percent of beds with COVID patients. But this is not about mattresses and pillows and bed frames.”

Dr. Alan Williamson, Eisenhower’s chief medical officer, says the pandemic underscores the trade-offs hospitals make to deliver care yet keep costs down. Health systems in the United States have moved toward a “just in time” model, so they don’t keep a lot of supplies on hand. And they’ve consolidated their buying, because gloves, masks and isolation gowns are cheaper if they give all their business to one supplier. But if that supplier runs out, there’s no backup.

“It’s a constant concern every single day as to what’s going to break down next in the supply chain,” said Williamson. “A hallmark of the pandemic is laying bare that we have tenuous supply chains.”

The Coachella Valley is a snowbird destination, and the population there can double in winter. Eisenhower is heading into its busiest season while bracing for the next surge of the virus. The hospital has already seen an increase in patients.

Tina Wallum, director of critical care units and inpatient dialysis, says the latest surge is different from earlier ones at Eisenhower. Patients are being admitted because of complications related to the virus, such as respiratory failure. But the virus has become so “endemic in the community” that the unit also has coronavirus-positive patients who are admitted for non-COVID reasons, such as congestive heart failure or sepsis. They can’t be put among the hospital’s general population for fear they’ll spread the virus.

“The entire team is emotionally fatigued from this marathon,” Wallum said. “A lot of it has to do with the fact that families are distant from their loved ones.... I have never seen anything like this in my nursing career. These patients are some of the sickest patients I’ve ever seen.”

Eisenhower has instituted virtual counseling and socially distanced debriefing sessions for nurses to address the emotional impact of caring for COVID-19 patients for so long and with no end in sight.

Wallum, who is a nurse, said the session she attended was “very helpful.” She said she realized she probably hadn’t talked enough with “people who could be helpful to me” about the hardest parts of her job, such as enforcing the no-visitors policy in the ICU, which means she must stand between dying people and their loved ones.

Family members can connect with relatives virtually, but “it’s not the same as coming in and holding someone’s hand,” Wallum said. “That’s been the most heartbreaking for me.”

Perumbeti said his hospital was prepared for the surge because “we’ve never really had a break” since the pandemic began. “The nurses feel that tremendously.”

He is one of three regularly scheduled intensivists in the Eisenhower ICU. Times like this, he said, are what he and others in the unit “have trained for our entire lives.... It’s where we like to be. We don’t want to be sitting at home when things are busy.”

Still, he said, the challenge of caring for seriously ill patients brings fatigue, and “everyone’s really feeling it.”

Tinny Abogado, a nurse at the Kaiser Permanente Los Angeles Medical Center, worries about not having enough masks to do her job safely and that her hospital is not ready for the coming surge.

“You don’t know what to expect,” she said. “It’s coming this way.... We’re not prepared at all. Besides being burned out, I’m also feeling nervous.”

Patricia Wilson is most worried about bringing the virus home. She’s 33, has been a nurse for four years, and started a job at the Riverside University Health System in the middle of the pandemic. The virus and the havoc it has wrought have taken a toll on her mental health.

Wilson said she anticipated that, with flu season arriving, and the public’s quarantine fatigue, work would be busy. With the coronavirus surging, she said, she believes she’ll be on COVID-19 units moving forward.

She has struggled with sleeping problems and anxiety. She second-guesses herself as she tries to stay healthy while keeping her patients, her husband and her 20-month-old daughter safe. She says her heart sinks and her eyes well with tears “when I see my husband come in for a good-morning kiss when I get home, but then hesitate at the very last second, as I turn my cheek to him to avoid kissing on the mouth directly.”

She sanitizes her car and her eyeglasses after every shift. She lies to people when they ask what she does. Being a nurse “once felt admirable,” she said. It “now feels like a risk. I hate this.... I feel like a pariah.”

Hospitals brace for holiday COVID surge, fearing staff shortages and burnout

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