What reaching capacity means

and more importantly, what it feels like

Let’s talk about what happens when hospitals begin to reach capacity! High bed occupancy is defined by some as reaching 85% capacity. This is significant for mortality rates increasing in the neighborhood of 9% according to a 2014 study.

But why, you ask, would being at 85% capacity mean increases in mortality?

Because capacity takes a whole lot of things into account. For example, “ghost beds”. There are hospitals that utilize semi private rooms. Due to COVID-19, these have been made private for infectious disease control purposes. But that bed still counts towards capacity.

There are also areas used for outpatient services-pre and post same surgery beds that are staffed during the day but not at night. Moving patients into these beds calls for the addition of staff to take care of them.

So—there you are. In a pandemic. Beds are tight. The ICU and the floors fill up. There are no inpatient beds. The ER begins to hold admits for extended periods of time, far beyond the normal waiting period. Meanwhile, high volumes of patients are still coming to the ER.

The ER acts as the early warning system. At some point, the ER reaches capacity, and reaches out to whoever is in charge of bed assignments for the facility, and says “HEY! we’re drowning down here, we gotta decompress, we can’t take anymore.”

Bed placement says ok, ok, let me see what I can do, and reaches out to try to expedite discharges and ICU “downgrades”. The pressure starts to build on the staff upstairs to move, move, move.

Beds are shuffled. Discharges are sped up. Bed placement says—got you some beds!

ER says cool cool cool but in the meantime we have this many more admits. We’re still getting hammered down here. We gotta do something.

Then the decision is made by an administrator to go on whatever form of diversion is available in that area.

Once one facility goes on diversion, the others in the neighboring area start taking their traffic. When one facility is busy, the others normally are too. It’s not long before everyone is on the same status. So where do the ambulances go? They have to go somewhere.

There’s a safety measure for that. The hospitals are all forced back open to traffic.

So there you are, utilizing all available resources and space to care for these sick patients. You’ve said hey we are maxed out.

The ICU patients require the largest amount of resources, so they get the highest priority to move out.

It becomes “well, who’s the sickest? Who’s the least sick? Who needs to go first and who can stay in the ER and maybe get downgraded?”

Meanwhile, the virus moves through staff, leaving staffing shortages. So now not only are the staff caring for additional patients, they’re doing it with less people.

Healthcare workers really are heroes.

The number of times I’ve heard a nurse say, “hey something’s really wrong with this guy.” Or, “bed so and so seems really anxious and not like themself, maybe he’s retaining CO2, can we check an ABG?” and caught a life threatening condition BEFORE there were any changes in labs or vital signs or X-rays is countless. I had a patient complaining of chest pain who had a normal EKG and vital signs and I took the EKG to the doc and said “I do not care what this says, this guy is having a major cardiac event RIGHT NOW and I need you to come.” And that gentleman went to the cath lab and was found to have an occluded coronary artery that would have killed him fairly quickly.

When we talk about capacity, a huge part of it is the nursing staff and their patient ratio. The doctors and their patient ratio. The more patients you have, the less time you have with each one. That additional time is CRUCIAL for diagnosis.

There is a HUGE difference between I’m having chest pain and “I felt this ripping sensation in my chest that went through to my back and it knocked me down.” Because that second one is an aortic dissection and that person does not have long to get to an OR-prompt diagnosis is CRUCIAL. It’s having the time to ask “When did the pain start? What were you doing? Did it go anywhere else? Did you feel short of breath or cold or nauseous? Oh, your dad died of a heart attack at this age?” All of those answers are going to tell you A TON of things about what’s going on.

Now I’m a dinosaur of an ER nurse. I know to bam bam bam out the important questions and what the answers are because I’ve been doing it since Frankie said relax (exaggeration, but you get the drift.)

The nurses a year in haven’t seen aortic dissections. They haven’t seen enough to go out and say “hey man can you put in a PE protocol like stat and maybe sign off on the labs to get them in the scanner?”

They know enough to say “I think something’s wrong. Hey can you maybe look at this guy?”

Which is already AMAZING.

But they need TIME to spend with that patient. That guy who had the ripping sensation in his chest that KNOCKED HIM DOWN? He said he had a tiny bit of pain. Was fine just wanted checked out. It was that extra five minutes spent digging out what actually happened that saved his life.

We need that time, we need that five minutes, and when you’re carrying a heavy load of patients it’s the question of do you give aspirin to the guy with chest pain and a huge cardiac history or spend five more minutes with a patient who has a mild complaint?

Do you run for the bed alarm cause someone’s MawMaw won’t stay in bed but will fall if left alone or check on the intoxicated guy who’s sat alarm is beeping?

That is WHY capacity is important, safe staffing ratios are important, and  decreasing this surge of COVID-19 is VITAL to ensure every patient receives the care and the time they deserve.

Because some decisions are easy. I’m gonna catch MeeMaw before she gets out of bed and THEN go medicate the back pain.

But if we keep this shit up, it’s gonna be “Do we intubate the unconscious patient requiring a jaw thrust to maintain his airway first or the diaphoretic woman breathing 50 times a minute with an SPO2 of 68% on 15/L non rebreather mask?

I’d pick #2 as long as the first isn’t vomiting but I don’t want to HAVE TO.

So please help us. Don’t make us make those kinda of decisions. We are overwhelmed and tired and scared and stressed the eff out. Help us save lives.

— the Midwestern One