Maryn McKenna has a great piece at CIDRAP News today about something that should worry all of us as we wait to see if the other shoe drops with swine flu. Our acute care health services system is so brittle it won't take much to break it:.
With the global outbreak of novel H1N1 influenza (swine flu) entering its fourth week, physicians at emergency rooms, clinics, and hospitals around the United States say they are overwhelmed with "worried well" who have as much as doubled their patient loads.All the clinicians work at medical centers that have planned and practiced for pandemics and disasters. But the crisis has exposed a weak point that their preparation could not influence: a crush of fearful patients seeking reassurance, many of them sent to emergency rooms (ERs) for tests by workplaces, schools, and busy primary care physicians.
Those who have been dealing with the onslaught say it should serve as a warning. If this flu strain or another becomes more virulent—causing more serious disease than it now does, and presumably also inspiring more panic—the healthcare system will not be able to handle the demand.
[snip]
Yet hospitals and emergency departments have been shrinking, while their patient populations have been growing. The Institute of Medicine calculated in 2006 that ER visits rose by 26% between 1992 and 2003, from 89.8 million to 114 million in a year, while 425 emergency departments and 703 hospitals closed and the number of hospital beds in use shrank by 198,000.
And last month, the American Hospital Association said that bed closures and layoffs were accelerating because of the economic crash. Half of 1,078 hospitals surveyed in March said they were seeing increased numbers of uninsured patients in their ERs, and approximately 10 hospitals per month were laying off 50 staff or more.
"My hospital has almost no surge capacity; it is running full all the time," [Dr. Edward Panacek, a professor of emergency medicine at University of California-Davis Medical Center] said. "If we had a 10% increase in the need for admissions because of flu, we would have nowhere in the hospital to put those patients. They would back up in the ER, and they would lie on gurneys for days."
Simultaneously, the public health system, which could relieve some pandemic stress by coordinating triage and testing, is experiencing sharp losses of its own. More than 11,000 jobs were eliminated in state and local health departments in 2008 due to budget cuts, according to a letter to Congress written in February by a coalition of public health organizations, and another 10,000 positions are expected to go unfilled this year. (Maryn McKenna, CIDRAP News)
The other day I asked a colleague who specializes in these things to get me some data on staffed hospital beds today versus the last pandemic (1968). As I suspected we are considerably worse off now. At the time of the 1968 pandemic the US had about 4 "beds set up and staffed" for every 1000 people. In 2007 it was only 2.7. The difference of 1.3 beds/thousand translates into about 400,000 less staffed beds today than if we had the same per capita as 1968 (even in absolute terms it is about 50,000 fewer beds). I stressed staffed beds because as nurses are fond of saying, beds don't take care of patients, nurses do. It turns out that we are even worse off than these data suggest. My informant said that of the estimated 800,000 beds listed in the American Hospital Association Guide Issue on Hospital Statistics (his source for the tables he gave me), maybe only two-thirds are actually staffed. The beds may be there in the facility, but if they are empty they aren't staffed. No hospital pays to staff an empty bed. The number of staffed beds is in reality smaller. So an apparent reserve isn't really there. Of course in a surge, it is likely hospitals would recruit back licensed nurses who today are doing non-nursing care jobs. But that would just get us back to the point where we are down 300,000 beds compared to 1968.
In addition to the worried well and the worried not-so-sick, a pandemic with effects no worse than a really bad flu season could overwhelm the ER and possibly inpatient services. Many of our health care facilities are running a t full capacity and a surge of flu cases and the worried well come on top of all the "usual" emergencies: auto accidents, heart attacks, acute asthmatic episodes, etc. They still have to be taken care of.
The question is whether our health care system and Congress will treat the swine flu episode as a wake-up call or just hit the snooze button and go back to sleep
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You know, at first blush, it sure seems like we should have more reserve capacity in the health care system for the next pandemic (or this one).
However, that extra capacity would likely increase medical costs event beyond our present high costs!
For a serous flu pandemic, where we will need 2-10x capacity, there simply is no way to keep that type of reserve level on standby.
Instead, we will have to figure out some way to train ordinary people to perform this type of care under the supervision of trained caregivers. It seems like the only answer.
You may be thinking: "This guy is a complete idiot". However, 20 years ago, if I had said that thousands of ordinary people with no medical training will have defibrilated their fellow citizens, you probably would think I was nuts. Yet that is exactly what has happened.
We probably should build high rise hotels next to hospitals but build them according to pseudo hospital standards so that the hotels can be converted to hospital beds in an emergency.
One project I have read about is a one-time-use disposable ventilator. It would cost $350 and be designed exclusively purpose of sustaining their breathing in a flu pandemic. (I have no idea how the rest of the patient care surrounding life-sustaining ventilation would be provided...i.e. sedation, etc.)
jeff: Not idiotic at all. If you go to the CDC or WHO sites there are guides to caring for people at home. It will be necessary. Of course if they need to be ventilated, that's another story..
Not every hospital is showing that surge. Mine is not. It'd be interesting to see geographically, which are and which are not... and what kind of messaging the local hospitals and DPH are doing with the public.
The one that I lust after (as a first responder) is the oxygen-powered self-regulating BVM replacement. It's to "breathing" what the AED was to "Circulation:" something that can be administered in the field by first responders or general public with minimal training.
And best of all, it's not one-time-use any more than the BVM or V-vac are.
To be clear: I'm qualified to "bag" patients, but it's (a) tiring, and (b) not something you can do in transit or while otherwise caring for patients.
That sucker is held up in the FDA approval process, but in case of a respiratory infection pandemic having them in mass production would save a lot of lives.
"...our health care system and Congress..."
And the Senate, which is dominated by reactionaries.
People really love saving money!
People will really really love having a bankrupt government nationalize health care!
Maybe "The One" can fire hospital presidents if things go wrong.
raven: Thanks for adding that. I was being imprecise and using Congress to mean both houses, but that's not a very clear usage.
Torange: I hope we have a National Health system, too. It's too bad Reagan and Bush bankrupted us, but we'll still get it.
The US Healthcare System has been downsizing for many years to become more cost effective. This effort has been heavily promoted by the US government together with commercial insurance companies and those that pay for health insurance mainly US corporations.
The result is that after some 26 years of this pressure on both not-for-profit and for-profit hosptitals there is no real surge capacity remaining within the system.
This is why even a moderate pandemic (CAR 30% CFR 2%) will result in a significant increase in deaths because when the available setup and staffed hospital beds are filled with flu patients, there will be no space available for the usual number of patients suffering from acidents, heart attacks, stroke, cancer complications, and other serious infections. Those with these usually treatable yet serious conditions will be crowded out by seriously ill flu patients.
What the lack of surge capacity means is there will not be enough fully setup and staffed hospital beds available to handle all those expected to become critically ill with non-influenza conditions when many or most of those beds are occupied with similarly ill pandemic flu patients.
GW
At least we will still be able to look down on those other countries with waiting lists for elective surgery.
In order to buttress the arguments put forth by Revere in this diairy are some outtakes from the Coming Pandemic Catastrophe written a couple of years ago. While somewhat long for a comment, I do think they will prove enlightening to those of you employed outside of the healthcare system.
The Collapse of Health Care Services
Modern health care systems throughout the developed world have adopted a centralized model for providing medical services. The well-equipped set-up and staffed hospital bed plays a key role in this delivery system. A defining characteristic of these systems is the concentration of doctors, nurses, allied health professionals, and an array of specialized high-tech equipment, supplies, and armies of non-medical personnel resulting in modern medical centers. These centers have revolutionized the care of patients in many areas of medicine and surgery. The centralized model on which they are based is highly dependent on advanced technology and has the potential to focus intense services and procedures on a small number of patients at a high cost. In the United States, there are approximately one million set-up and staffed hospital beds and 100,000 respiratory ventilators.
A set-up and staffed hospital bed includes not just an available bed but also sufficient doctors, nurses, allied health workers, medical supplies, pharmacists, drugs, lab and radiology technicians, IT operators, physical plant engineers, janitorial staff, security, and administrators to service the patient in the bed. If any one of these inputs is lost, the centralized model breaks down, becoming inefficient and in some cases ceasing to function.
During all three pandemics that occurred in the twentieth century, clinical attack rates in health professionals were as much as twice the rate seen in other groups. This single factor alone will significantly reduce the supply of set-up and staffed hospital beds since it is the people working in concert more than any other factor that make the difference. The miracle of advanced medical care seen daily in the modern hospital is entirely dependent upon having all the resources necessary available at the same time. The medical outcomes we realize today in these facilities would not be the same in patients treated in other settings, including the inadequately staffed and supplied low-tech temporary hospitals proposed by some public health officials to manage the excess of patients expected during the pandemic.
Over the past two decades, hospitals have reduced capacity, responding to economic pressure from the government and insurance companies to become more cost effective. In doing so, though, they have virtually eliminated their surge capacity, or the spare set-up and staffed hospital beds available for use in an emergency. Capacity utilization in the average hospital today is approximately seventy-five percent, and it is common for all Intensive Care Unit (ICU) beds to be full. This is a regular event in many hospitals during the routine flu season, when all the critical care beds and available ventilators in many U.S. cities are fully occupied with flu patients for many weeks each winter.
Snip
An increase in admissions to hospitals of a large magnitude would quickly absorb every available set-up and staffed bed. The US Department of Heath and Human Services Pandemic Influenza Plan published in 2005 projects a 288% increase in the need for critical care ICU beds and services. Under these circumstances, patients in need of ICU services or ventilators would be unlikely to obtain them.
Snip
One disturbing dilemma likely to evolve during the early days of a pandemic, irrespective of its severity, will be the competition for available hospital beds between critically ill non-influenza and influenza patients. At some point, many hospitals are likely to have a significant number of beds occupied by critically ill patients of both types with little hope for survival. There will be no room for new patients who are equally ill but whose chance of survival is good only if they have access to the benefits of hospitalization in a set-up and staffed bed.
This situation will present us with heart-wrenching ethical dilemmas. If the patient with the poor prognosis keeps the bed, then both patients die as a consequence of their illnesses. If the patient with the better prognosis displaces the patient with the poor prognosis, then only one person will die but the one who dies will do so because of an act of man, a choice, rather than a result of nature.
Grattan Woodson, MD
I don't understand how we can spend almost $1 TRILLION year after year on "defense" and yet not be able to defend our people against a simple flu virus.
I don't understand how we can waste 4500+ lives -- and $2 Trillion -- on an unnecessary war in Iraq and not be able to provide health care to our citizens in a flu pandemic.
I don't understand how we can commit almost $10 Trillion in tax dollars -- in TARP, loans, and guarantees --in order to bail out some of the richest people on the planet and then have to tell a young child that her mother is dead because we were promoting "efficiency" in healthcare.
I don't understand how we can commit almost $10 Trillion in tax dollars -- in TARP, loans, and guarantees --in order to bail out some of the richest people on the planet and then have to tell a young child that her mother is dead because we were promoting "efficiency" in healthcare.
Posted by: Don Williams | May 10, 2009 12:27 AM[kill]â[hide comment]
Why do you hate America?
In a real pandemic the last place you want patients to get treated at are hospitals. The system can not handle it, and thats not going to change.
Focus on what is practical, and thats treatment in public facilities (schools, stadiums) which provided antibiotics as prophylactics against bacterial pneumonia to anyone with the flu. For those very sick who can't return home, all you can do is give them a place to sleep and shelter, feed them, hydrate them, clean them and hope their immune system wins. Nurses and volunteers will be far more important than doctors or hospitals. There simply won't be enough ventilators or equipment for extraordinary efforts.
Anyone with respiratory illness should not be permitted to enter a hospital without prior screening to rule out infectious disease that could put patients and medical staff treating normal illness like heart attacks, etc at risk.
An alternative of course would be to designate certain hospitals as flu treatment centers and transfer other patients to designated flu free hospitals.
I know I sure wouldn't want to be a health care worker in this day and age. And according to FluCount.org this thing is still spreading to new countries every day. Ugh!
I was looking at the statistics of the CDC H1N1 Flu Update: U.S. Human Cases of H1N1 Flu Infection on the cdc.gov website and noticed that Wisconsin has 317 lab confirmed cases, but the neighbor state of Minnesota has only 1 confirmed case. WI(317), IL(421), MI(103), all almost beat Texas (110) and California (171) with the number of confirmed cases.
Pork Flu, These numbers are crazy. What's will Illinois? It takes at least 24 hours from a news report (or Veratech report) for a confirmed case to get on the maps. Montana has their first probable case on Sat (May 9) and is sending it to CDC in Atlanta for confirmation! How long will that take? By that time 40 other people could be infected.
Ah. That might explain some of these high numbers too.
I recall about 1990 our local nonprofit hospital, JFK Hospital in Lake Worth, Florida established their strategy for the future. The concept was that the revolution in outpatient medicine would require fewer critical care beds at the core and more satellite office space at the perimeter. I understand this wasn't done in isolation.
I wonder if the outpatient space conversion capacity has been included in any fashion in any of the calculations on pandemic response. Is it possible that this can be turned to an advantage?
War movies are much more numerous and much more exciting than pandemic movies.
@phytoslueth - This is a guess, but during this past week, some (if not all) of the state public health labs got primers that would allow them to confirm H1N1 in-house instead of sending them to CDC. CDC turnaround has gone from 24 hours to 4 days to [who knows?] as their workload has grown exponentially. If Illinois got their primers and got validated on them, they could start cranking them through on their own. If they had a backlog of several hundred that they cranked out in few days, you might see a jump in their reported cases by say... 400+ cases in 6 days. 8 on May 4, 82 on the 5th, 122 on the 6th, 204 on the 7th, 392 on the 8th and 421 on the 9th http://www.cdc.gov/h1n1flu/updates/
Looks to me like their capacity is around 200 a day, judging by the last couple of days, but maybe not, since these are all positives, and who knows how many they had to do to get that many positives. If they had a few hundred prescreened "Untypable Influenza A" specimens frozen just waiting to get the primers, their log phase could be over. If they are just taking them as they arrive, maybe not. OTOH since they have now pretty much established that H1N1 has come to Illinois (at least to parts of the state), they may back off on testing "all comers" and move to testing only people from parts of the state where they haven't demonstrated the virus, or those with severe respiratory illness. I believe that is the current CDC guidance on testing. http://www.cdc.gov/h1n1flu/specimencollection.htm
"If Illinois got their primers and got validated on them, they could start cranking them through on their own. If they had a backlog of several hundred that they cranked out in few days, you might see a jump in their reported cases by say... 400+ cases in 6 days. 8 on May 4, 82 on the 5th, 122 on the 6th, 204 on the 7th, 392 on the 8th and 421 on the 9th"
I think I'd rather see numbers reported paired with the day the sample was taken, instead of the day the PCR was run. That would give a better idea of how the spread was progressing.
And hospitals ought to start stockpiling basic supplies and PPE. Now, if they haven't already done so.
Of course I'd also like a pony....
I've been complaining and writing as long as there has been an internet. I came up with my first plan for universal healthcare 17 years ago.
One year ago, someone asked me to fill him in and give an opinion. I've been telling them when ever they ask me.
Baraq is the first person to give a "shit"
I HATE TO BE CRUDE, but he really cares. Only he will solve this mess.
The next wave may be very bad, and people had better be ready. No one can help us from that. it doesn't matter whether we have heath care or what our deduvctibles are.
We need food, water and air. Make sure you have them all or be prepared..