Nursing help keeps Fresno County from rationing care, but hospitals at COVID ‘tipping point’
A slight drop in hospitalized COVID-19 patients and the arrival of out-of-town nurses and medical teams have pulled Fresno County from the brink of potentially rationing hospital services under “crisis standards of care.”
As recently as last week, Fresno’s largest hospitals were at what Dr. Rais Vohra, Fresno County interim health officer, called “a tipping point” of considering declaring crisis standards of care because they had more patients than they had space or staff to care for.
Under crisis standards of care, hospital professionals would be put in a position of having to prioritize which groups of patients or cases for which they have resources to treat. “That’s kind of the nitty gritty,” Vohra said last week.
By Tuesday, the situation had decompressed, if only slightly.
“Currently, there is no imminent plan to move to crisis care,” said Dan Lynch, the county’s emergency medical services coordinator.
On Monday, hospitals across Fresno County were treating 390 patients with confirmed or suspected coronavirus cases, including 82 who were sick enough to require treatment in intensive-care units. That’s down from about 420 patients in the middle of last week.
Across Fresno, Kings, Madera, Mariposa, Merced and Tulare counties, 741 people were hospitalized for COVID-19 – a decrease from a peak of almost 780 patients last week.
Fresno’s largest hospital organization, Community Medical Centers, last week welcomed nearly 120 travel nurses to supplement the staffing at Community Regional Medical Center in downtown Fresno and Clovis Community Medical Center.
Additionally, Lynch said, the state of California has stepped up its assistance to Valley hospitals – including the deployment of California National Guard teams of nurses and emergency medical technicians to Community Regional and Clovis Community medical centers, Kaweah Health Medical Center in Visalia and Sierra View Medical Center in Porterville.
“These Cal Guard teams … are being used to bolster staffing in emergency departments,” Lynch said. Hospitals that have been short of staffing for their intensive-care units during the current COVID-19 surge have been holding some critically ill patients in their emergency departments until beds became open to admit them into the hospital.
“I would expect that additional beds can be added and nurse-to-patient ratios could be improved, which will provide much-needed relief for existing nursing staff,” Lynch said. “The increase in staffing will definitely prevent any of the hospitals moving to crisis care.”
Implications of crisis care
Vohra said last week that he was grateful to see more help arriving for exhausted nurses and doctors at area hospitals, “but we’re definitely not out of the woods yet.”
“We are probably going to be in this really challenging situation for the rest of the month,” Vohra said. “Fresno County hospitals are still at that tipping point” of allocating precious health care resources to patients based on their chances for recovery.
Under times of stress, “what the medical system tries to do is balance needs and resources in a way that’s rational and equitable,” Vohra said.
“But with crisis standards of care, there’s a recognition that the standard of care for every single patient may not be achievable,” he added. “Then the hospitals need to create some kind of system that still allows those resources to be distributed equitably, which may mean convening a committee to figure out beforehand which resources are going to be allocated to which patient groups just based on their prognosis.”
“Those obviously are very hard decisions, very stressful decisions for us to make and very hard conversations to have with families,” Vohra said.
Throughout the coronavirus pandemic, with surges last summer, over the winter and again over the past two months, “this is a discussion that’s been many months in the making,” Vohra said.
“It’s something we have to have a lot of conversations about so that if we do end up going there, we can do it as gracefully as possible,” he added. “But knowing that by the time we need to do it, being graceful about it is going to be a hard goal to meet.”
Guidelines issued last summer by the California Department of Public Health indicate that crisis standards represent “disaster strategies used when demand forces choices that pose a significant risk to patients but is the best that can be offered under the circumstances.”
Examples offered by the state would be “cot-based care (for some patients), severe staffing restrictions, or restrictions on use of certain medications or other resources.”
System is still under stress
The inflated numbers of hospitalizations among COVID-19 patients in Fresno County, reaching over 420 last week, compared to fewer than 50 in early July, is being fueled largely by a considerable surge in new coronavirus cases being reported each day in the county – an average of 400 to 600 new cases a day over the past two weeks.
“With our numbers of new cases being as high as they are, we know that unfortunately some of those people are going to require hospitalization as well,” Vohra said. The sickest patients, if they survive the disease, often spend days or even weeks in intensive care units before they can be discharged, he added.
“All of our Fresno County hospitals are reporting ICU levels between 125 and 150% (of capacity) with ICU patients being housed in other areas of the hospital,” Lynch said Tuesday.
The county’s largest hospitals are holding some ICU patients in their emergency rooms until they can be admitted, Lynch said, as well as between 30 to 60 less critical patients patients waiting to be admitted. “About one-third of these patients are COVID positive,” he added.
More help to relieve local hospital staff may be on the way. Last summer, and again in the winter, the U.S. Department of Defense deployed several medical teams to hospitals in Fresno and Tulare counties to assist with previous surges of hospitalizations. Lynch said federal assistance is being considered once again for hospitals in Fresno, Tulare and Kern counties.
As other parts of California see a slowdown in hospitalizations, additional planning at the state level could move more medical staff into the Valley, but no decisions have been finalized as of Tuesday, Lynch said.
The greater San Joaquin Valley, from Stockton and San Joaquin County in the north to Bakersfield and Kern county in the south, remain under a state-imposed “surge protocol” in which hospitals in the region that have available ICU beds are required to accept transfers of patients from other hospitals.
If no hospitals in the region have available ICU beds, the state’s health order requires hospitals in other parts of the state to accept those transferred patients.
This is the second week under the surge order, which was activated when hospitals in the 12-county region collectively fell to having less than 10% of their adult ICU beds available for new patients. The order will be re-evaluated Thursday.
This story was originally published September 14, 2021 at 4:33 PM.
