ICU overstrain: double the number of beds since the start of the crisis
Units for critically ill patients throughout Spain, where the pressure to save lives is strongest, have enabled up to 6,000 extra beds in almost a year of the pandemic, more than double the number before March 2020. The challenge to create them At full speed, as the number of infections increased at an exponential rate, it has been enormous. The lack of intensivists and adequately trained personnel are the main obstacles to growing at the rate of the severity of the pandemic. Also, provide them with the appropriate technology and the need to find spaces capable of housing them. Medium-sized hospitals have had to be the most flexible to multiply their ICUs, the last resistance of the health system before the collapse.
The numbers come from the data of admitted patients and the proportion they represent on the total of places that the Ministry of Health provides each day. With these parameters, on Monday there were almost 11,000 of these units (10,964 according to the mathematical calculation), when before the coronavirus pandemic there were 4,404, according to data from the ministry endorsed by the Spanish Society of Intensive, Critical and Coronary Medicine Units (Semicyuc).
The information on the first wave, between March and May, is more confusing. ICUs (or, at least, beds with a monitoring system and a respirator) were set up in all open spaces, from gyms to operating rooms. In the second wave, the process has been more controlled, in part because they had part of the makeshift beds from before the summer. If that had not been the case, the 4,732 people in intensive care for covid that this Monday’s report collects would not represent 43.16% of the critical beds, but 107% of those that were initially.
The numbers are not very exact before the summer, but focusing on the data from October, when the second wave begins to rise, it is seen that on the 9th of that month there were some 8,900 beds available (8,878 if the exact result of the account), about 2,100 less than there are currently. That is why when the daily report says that ICU occupancy drops, it must be borne in mind that it is true that the number of admitted is decreasing, but also that there are more places available.
This qualification of intensive is not uniform in time. For example, there is a significant increase (600 more beds) between October 9 and November 9 due to the rise of the second wave; In the following month they hardly prepare more, coinciding with the decline of that wave and the beginning of the subsequent one, and then the rate of creation accelerates as the indicators of the third worsen (an increase of 100 between December and January, and 1,300 between January and February).
Luis Carretero, from the Health Economics Association and manager of the Dénia Regional Hospital, in Alicante, states that in his health center the ICU beds have gone from 14 to 34 this year. “They are preparing as the incidence of covid rises, although when it has grown a lot it has been necessary to postpone non-urgent interventions,” he says. “It is a flexibility that has occurred in all centers.”
La Rioja is the community that currently has the most saturated ICUs, with almost 70% of the beds dedicated to people with covid. The manager of his health service, Alberto Lafuente, explains that before the pandemic the community had 17 ICU beds, and that they have prepared up to 109 beds in case they were needed, although at this moment they have 76 “perfectly equipped”. Lafuente affirms that one of the lessons of the pandemic is that they cannot disassemble all of them once the peak passes, and says that they will leave 43 just in case. As an example of the effort that this implies, he says that the care of the community ICUs employs 350 professionals with varied profiles, but he believes that the decrease in mortality is proof that the effort has worked.
In this continuum of taking out beds, “the first thing is to have adequate spaces”, affirms Carretero. In this sense, it indicates that intensive units have been set up in recovery rehabilitation rooms, operating rooms … that had oxygen installation, which is the basic treatment of patients with covid. But then there was the following problem: getting enough professionals, something that “costs more than the facilities,” says the doctor, since work in the ICU requires specialization. “In this we have had a very good attitude from the workers, who took advantage of the respite that the peaks of the pandemic have given to train at the hands of their colleagues.”
María Bodí Saera, coordinator of the Semicyuc Planning, Organization and Management Working Group, explains that this recycling of personnel is complicated, first, because both in medicine and in nursing there are no stoppages in intensive care specialists, and to have the Help from other professionals means affecting other services. “In nursing, specialists in the operating room and emergencies are used above all; in medicine to anesthetists, pediatric critics, emergency physicians and cardiologists ”, he says. “This pandemic has revealed that there is a lack of intensivists,” he concludes.
Francisco Marí, from the Board of Directors of the Spanish Society of Health Directors (Sedisa), gives as an example that “for 10 beds and 24-hour coverage, about 60 professionals are needed, including doctors, nurses, sanitary technicians and orderlies. The cost per day of an ICU bed can range between 900 and 1,500 euros ”.
And the third challenge remained: the effort to have the necessary technology. Carretero focuses it on two teams: the monitoring team that follows vital signs, and the respirators. The former are more numerous in hospitals and what had to be done was to change their use; the latter have been more complicated. Although with a great variety of models, an average respirator can cost between 8,000 and 10,000 euros, says the manager, and logically with that price there were no large reserves in hospitals, since it does not make sense to pay that amount to have them unemployed. They have been taken wherever possible, “and the life of use of the oldest ones has been prolonged,” says the doctor.
Bodí points out another complication. In his hospital, the Joan XXIII in Tarragona, before the covid, there were two ICUs with 14 beds, and one of them was shared with the coronary unit. Now, patients with coronavirus already occupy both rooms 100%, he says, and they also use the eight beds of the coronary unit, which has had to move, plus two floors in the hospitalization area (one for surgery generates complete and average of an internal medicine). This means transferring to other services, something that precisely Patricia Alonso Fernández, from Sedisa, points out as one of the problems, since in the last waves they are trying not to stop treating patients who do not have covid. “The impact that caring for patients with coronavirus is having on the pathologies that occupied our care until just a year ago will be difficult to estimate,” says Alonso.
In addition, although it is not clear how it has been accounted for in the Health report, many hospitals have set up intermediate spaces between a normal room with high-flow oxygen equipment, because it has been seen that there are patients who, before being intubated to receive ventilation, could be treated with these machines, which breathe in more air by a much less invasive method, explains Carretero.
All this is a great disorder, which is greater in medium hospitals like his, says Bodí, because new circuits have to be established, professionals have to go to more places, monitoring cameras have to be set up in rooms where there cannot be a visual control of the patients as it usually happens in ICUs. In addition, you have to be “continually updating” and teaching the less experienced. Add to that the stress and pressure of almost a year of pandemic. “As if not to be burned!”, Says the doctor.
Bodí believes that, taking into account that, in addition to lowering ICU admissions, beds increase, rather than a decrease in occupancy, one can still only “speak of a plateau.” “We will see in a week or 15 days,” he says. And he makes one last request. “I don’t want to hear about saving anything other than patients and professionals. This year Easter falls very early and it will be cool, so we will tend to meet indoors. If we don’t want another wave, let no one talk about saving Holy Week ”.