"We are overwhelmed," said a doctor who works at a large hospital in Central Arkansas, one of eight medical providers the Arkansas Nonprofit News Network interviewed for this story. Most asked to have their names withheld in order to speak candidly.
"We cannot possibly continue at the current rates of exponential growth in the community," the doctor said. "It's not sustainable. I believe we're looking at 10 days of wiggle room before there is nowhere to go and we're looking at those sorts of crazy scenarios where there's patients lined up in the hallway."
As of Wednesday, more than a thousand people in Arkansas were hospitalized with COVID-19 — more than double the number two months ago — and the state's intensive care units (ICUs) were 93.4% full, leaving just 75 staffed beds available statewide.
"This is like a boulder rolling down a hill," Dr. José Romero, secretary of the Arkansas Department of Health, said at a press conference on Nov. 17. "There will come a time when we cannot stop it. It will continue to escalate and it will eventually overwhelm our health care facilities."
Even as the numbers rise, Gov. Asa Hutchinson, the health department and the Arkansas Hospital Association have stressed that hospitals still have plans in place to make adjustments and add capacity as needed.
"I think there's still wiggle room in the system," said Dr. Jerrilyn Jones, the health department's preparedness medical director.
On Nov. 13, Hutchinson announced the creation of a new Winter COVID-19 Task Force that will make recommendations on hospital capacity and other issues. In press conferences Nov. 20 and Nov. 24, Hutchinson said the state has not reached a crisis point in terms of ICU occupancy. He said hospitals had experience managing high occupancy in ICUs even before the pandemic and expressed confidence they would be able to handle the increasing volume.
"The fact is, we have adequate ICU space," Hutchinson said Nov. 20. "Because the hospitals are so good about adjusting. And I haven't gotten to the point that we can say they've adjusted their way into a real problem."
However, some health care providers are beginning to sound the alarm that the system is close to a breaking point. With no end in sight to the rising case numbers, and with Thanksgiving gatherings expected to fuel more community spread, they fear what the coming weeks will bring. If the current trajectory continues, the Central Arkansas doctor said, hospitals simply won't have enough trained staff and the quality of care will suffer for COVID and non-COVID patients alike: "We will not be able to provide what we consider the standard of care. Outcomes will change. People will die that wouldn't normally die."
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"We're managing, but if the volume picks up 10%, 15%, God help us, 20%, it's not going to be manageable," Melissa Brogdon said. Brogdon, a semi-retired ICU nurse, recently finished a nine-week contract at a midsize hospital in Central Arkansas. "It felt like we're doing OK right now, but this is about as much as we can handle."
Most people who contract COVID-19 do not end up in the ICU. The ones who do reach that stage, however, "are hard to keep alive," Brogdon said. "If they get to a critical point, it takes a huge amount of attention from the nurses and the doctors and the respiratory therapists to keep them alive long enough to recover."
For hospitals, staffing is the most daunting challenge. There is no shortage of physical space, and an existing room can be converted to a critical care bed. The problem is having enough nurses, physicians and other licensed staff trained to take care of critical patients. The total number of ICU beds in the state tracked by the health department is a moving target, as the number fluctuates with available staff.
"It's not the equipment or the beds, it's the staff," Brogdon said. Without adequate numbers of highly trained staff to care for the sickest COVID patients, she said, "a larger number of them are not going to survive."
An ICU nurse at a large hospital in Central Arkansas said her unit recently had to keep several beds empty because "we don't have enough nurses to take care of the patients." Another nurse, who works at a step-down unit at a different Central Arkansas hospital, said, "We don't have the staff, and then the people that are going to work are going to be burnt out, which is going to affect the care that patients receive in a negative way." (Step-down units are an intermediate level between the ICU and general medical floor beds in a hospital.)
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Arkansas hospitals faced staffing shortages long before COVID-19, but the pandemic has exacerbated the problem. Competition for nurses has become fierce, with hospitals across the country facing potential surges. The cost of hiring traveling fill-in nurses has become exorbitant, said Bo Ryall, president and CEO of the Arkansas Hospital Association. Firms are even offering massive pay bumps to poach nurses on staff in Arkansas hospitals for contract work in other states, he said.
"The system is just not designed for a mass influx of patients," said a doctor who works in multiple hospitals in Central Arkansas. "There aren't enough nurses, there aren't enough physicians, there aren't enough respiratory therapists and physical therapists."
The doctor expressed frustration at reassuring statements from state and hospital officials about the potential to increase capacity: "That does not equal safe care. You can convert clinic spaces to hospital space, you can set up a field tent, but ultimately what you're going to have is health care providers that are seeing more patients than they can safely care for."
"What I wish that Arkansans understood," the doctor said, "is that there's going to come a point, when you come to the hospital for care, whether COVID or not, you're going to arrive in what is going to be wartime for health care providers. We will give you whatever care we can, but it won't be what it should be."
More than 300 Arkansas doctors signed an open letter sent to the governor Nov. 15 warning of "mass casualties" if the state doesn't take further action to slow the spread of the virus. A recent report from the White House Coronavirus Task Force found that " Arkansas is on the precipice of a rapid, accelerating increase in cases which will be followed with new hospital admissions." The report recommended the state consider "pausing" extracurricular school activities, limiting bar hours and limiting indoor capacity of restaurants to 25%.
Hutchinson did modestly restrict bar hours beginning Nov. 20, requiring that they close at 11 p.m. However, he has insisted that most businesses should stay open, noting the economic damage that would be inflicted by a lockdown in the absence of any new federal relief package.
"People's lives are being forfeited over money," the doctor who works at multiple hospitals said. "We feel like the government is setting us up to fail at our job. Ultimately, containing the virus is the only way to truly save lives."
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Jones, the health department's preparedness medical director, expressed confidence that the statewide health care system still has room in terms of staffed ICU capacity to handle the influx of patients. "There is not a specific number that represents a quote-unquote tipping point," she said. "Hospitals are very adept at being able to flex with respect to ICU beds."
The Arkansas Hospital Association's Ryall agreed that wiggle room remains. Over the last two months, Ryall said, hospitals across the state have added 122 ICU beds, 174 ventilators and 452 beds in negative pressure rooms designed to keep COVID patients quarantined. "Certainly they have surge plans to add even more beds as needed, as we move forward," Ryall said. "There's still capacity there, but we're concerned about it — not as much what we're seeing today, but knowing what's coming in two to three weeks."
As the number of cases has increased, the state's total number of staffed ICU beds has been around 90% occupied in recent weeks; last week it ticked up to 94%.
"I know that makes folks a little alarmed," Jones said. "Sometimes I feel like stats like this become more alarming as we are tracking them second to second." But ICU bed capacity, she said, "is extremely fluid" and can change by the hour. "You start off the shift and there's no ICU beds and then suddenly four hours later we get six beds and we can move patients upstairs," she said.
Jones pointed out that even in normal times, prior to the pandemic, some of the state's larger hospitals operated with ICUs at or near capacity.
"It's not unusual for us to be at capacity in the ICU," said Troy Wells, CEO at Baptist Health, the largest hospital system in Arkansas, with 11 facilities statewide. "The Little Rock campus is a transfer destination all over the state for the sickest patients in Arkansas, so we manage the ICU day to day. That's no different right now. We have ways of adapting day to day, and levers we can pull to slow things down or speed things up to create capacity." Baptist began hiring additional traveling nurses last summer in preparation for higher volume this fall and has added 33 ICU beds since the pandemic began, in Little Rock, North Little Rock and Fort Smith, with another 16 in Little Rock slated for January.
Jones acknowledged that the state's critical care resources are not unlimited. "I think the discomfort that many are feeling is because there are so many hospitals that are running with these margins," she said. "If all of our facilities are truly running at these very razor thin margins with no room to move, that is concerning. I'm not necessarily convinced that we are at the point where there's no room to move."
Some providers interviewed for this story expressed the concern that COVID patients stay in the ICU for a significantly longer period of time than other patients, which means that beds turn over less frequently and could create a backlog even if hospitals are efficient at managing their ICUs.
Brogdon said that she found the length of time that patients were in the ICU to be the most surprising part of working a COVID unit. "A typical critical care patient will come in and either recover or die within a couple of weeks, whereas a huge percentage of the COVID patients come to the hospital and are there for a couple of months," she said.
Jones said one possibility for increasing capacity would be identifying patients currently in the ICU who could potentially be treated in step-down beds or on the general floor. Such transfers would only be made if the patient was stable and the transfer could be done safely and without sacrificing quality of care, she said. Certain hospitals are better equipped to handle such patients outside of the ICU, she said, so the health care system could free up more space with more efficient statewide management of resources.
"I think we have room in terms of being able to drill down and say who truly needs an ICU bed," she said. "Those are some of the things we're going to look at with the task force."
Some providers told the Arkansas Nonprofit News Network that their hospitals are already being more aggressive about moving patients out of the ICU.
"We're putting sicker and sicker people on the [general] floor," the ICU nurse in the large Central Arkansas hospital said. Under normal circumstances, she said, the hospital will place some people in the ICU out of an abundance of caution, even though they may not strictly need that level of care. "We just don't have space for that precaution anymore," she said.
The nurse in the step-down unit said she is seeing a number of patients, both COVID and non-COVID, who would normally be receiving intensive care. Often, she said, patients are transferred back to the ICU when space clears up. "When we get these patients that should be in the ICU in our unit, we tend to send them back in a couple of days," she said.
The chronic shortage of staffed beds means patients are moved more frequently between departments, the nurse said. The hospital typically never moves very sick patients at night, when staffing levels are generally lower. "Within the past two weeks ... we're moving patients in the middle of the night," she said.
Hutchinson and the task force announced several policy changes on Nov. 20 aimed at helping hospitals with capacity. The governor said the Arkansas State Board of Nursing will expedite licensure and waive application fees for 1,104 nursing students expected to graduate in the coming weeks. The task force is also exploring the possibility of using the state's Trauma System to coordinate the placement and transfer of COVID-19 patients to hospitals that have the capacity to treat them.
Another new policy relaxes the health department's guidelines on when medical staff must quarantine, shortening the period before essential health care workers exposed to the virus can return to work if they test negative. The new policy also says hospitals facing extreme staffing shortages may, "as a last resort," allow asymptomatic COVID-positive health care workers to return to work, so long as they only treat COVID patients and remain segregated from other staff.
The new guidelines "will definitely help the situation," Ryall said. "We've got a significant number of health care workers who are in quarantine now at some point." As of last week, almost 400 University of Arkansas for Medical Sciences employees were quarantined due to exposure to the coronavirus or a positive test. Baptist Health had more than 200 out across the system. At Baxter Regional Medical Center, a 211-bed hospital in Mountain Home, 55 staff members were sick with COVID-19 as of Nov. 14, according to a Baxter County TV news report, including 25 nurses, forcing the hospital to delay elective surgeries that require an overnight stay.
But the idea of keeping asymptomatic COVID-positive health care workers on the job sets off alarm bells for some providers.
"To me that is an act of desperation," said the doctor who works at multiple hospitals. Even if they are not yet showing symptoms, the doctor said, health care workers should be home resting and recovering — and breaking quarantine risks exposing more people in the community to the virus.
The doctor also questioned whether it would be logistically possible to safely quarantine a COVID-positive staffer from the rest of the hospital.
"If we had enough health care workers, the governor wouldn't be willing to assume the risk of having asymptomatic COVID workers in the workplace," the doctor said.
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Many of the providers interviewed by the Arkansas Nonprofit News Network fear that stretching hospital capacity will lead to worse quality of care for patients and worse health outcomes: longer wait times, less attention from providers, less access to specialized care such as physical therapists, less communication with families and an increased chance of errors.
"It's not just for COVID patients," said the doctor who practices at multiple hospitals. "The people who come in for a heart attack are going to have a doctor who is seeing too many patients, a nurse that has too many patients. ... When you get to a sustained level of overburden, then you can never focus on anyone well."
The doctor said that the number of total beds touted by the governor paints a misleading picture. "Everything looks good on this piece of paper," the doctor said. "But if you really walked in and saw how strained the system was, the number of beds is a moot point. The number matters less than the landscape of the care being provided."
"We won't have enough health care providers to safely treat the patients," the doctor said, "and they're going to die."
"I don't believe that quality of care is suffering at this point," said Jones, who also works as an emergency medicine physician at UAMS. "We're not there. But certainly if people are not taking this more seriously and not abiding by the things we need to do to try to mitigate the spread of the disease in the community, it could get to be that way."
One of the providers' biggest concerns is that if the numbers keep rising, hospitals will have no choice but to change staffing ratios.
Typically, one ICU nurse is assigned to just one or two patients because their needs are so extensive. If that ratio increases, said Brogdon, that would mean "less time and concentration you have for your patient load." Intensive care would become less intensive and could become unsafe, she said.
At the hospital where she just completed her contract, Brogdon said, "there was a discussion among the nurse managers and the critical care nurses as to what is the next step. Are we going to accept that we're going to be taking three critical patients sometimes instead of two? Or is everybody going to work mandatory overtime every week? Because very soon we're going to have to do one or the other."
Asked about hospitals potentially changing staff ratios, Ryall said, "I do not think we're at the point where we're even thinking that way yet. If it reached [high enough] levels, that certainly would be a consideration, but those levels are way out in front of us."
For many of the providers interviewed for this story, the disconnect they feel with state officials and hospital administrators is less about the current situation and more about the days to come. For now, they said, they are managing an extremely challenging ordeal. But while officials continue to project relative calm and confidence, hospitals are reaching a tipping point, they said, and will run out of resources if community spread continues at its current pace.
"On the one hand, they're not lying," said the doctor at the large Central Arkansas hospital. "Our nursing ratios are still normal. But there's less and less wiggle room. We are used to surging, and we can handle linear growth. We can staff up and stretch and bend — that is what we do every day throughout the year. This is different."
The ideas to increase capacity presented by state officials, the doctor said, might help at the margins, but it is like "pissing on a wildfire."
"We're beyond the point where we can increase capacity," the doctor said. "There's no more. You can't grow new nurses nearly as fast as you can grow new infected patients. The only math left is to decrease the spread in the community."
This reporting is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans. Data visualization by Abby Zimmardi, courtesy of Arkansascovid.com
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