As COVID-19 spreads uncontrollably throughout Arkansas, the number of available intensive care unit beds is dwindling. On Friday, Dec. 18, at 2 p.m., Arkansas hospitals had just 37 staffed ICU beds available statewide, the lowest figure recorded since the Arkansas Department of Health began tracking the number in daily reports. By Tuesday, it was up to 51, still a precipitous drop from recent weeks: The number of open beds fluctuated between 72 and 99 from Dec. 1 to Dec. 15.
At times, some regions in the state have had only a handful of ICU beds available. A breakdown provided by the health department on Thursday, Dec. 17, showed five of the state’s seven regions had five or fewer ICU beds left. The 13-county North-Central Arkansas region had none at all.
Dr. Teresa Bau, a doctor at a midsize hospital in Central Arkansas, said her facility is feeling the strain on ICU capacity.
“There were a couple of weeks when I was at work where the only time we had an ICU bed open up was when a patient would pass,” Bau said. “And then, it was instantly snatched up. That was a really grim week for me.”
Dr. Jerrilyn Jones, the health department’s preparedness medical director, remained confident that hospitals can adapt to the situation.
“Although beds are extremely tight, I do not have any indication that the state will be unable to provide critical care to those who need it,” Jones said.
Asked what would happen if the state reaches the point of zero staffed ICU beds available statewide, Jones said, “Hospital processes and procedures will have to be adjusted to create additional ICU bed capability.”
Some medical providers have expressed concerns about critical care staff being forced to take care of too many patients because of overloaded ICUs, which could threaten the quality of care. Jones said that any changes to staffing ratios have been only temporary.
The total number of ICU beds in the state can change slightly based on available staffing and other factors. As of Tuesday at 2 p.m., around 96 percent of the state’s 1,154 ICU beds were full.
ICUs offer care for hospitals’ highest-needs patients, typically those suffering from severe illness or injury, and rely on highly trained medical providers who specialize in critical care. They have much lower patient-to-staff ratios than the general floor.
Critical care demands extensive and constant attention, said Melissa Brogdon, a semi-retired ICU nurse who finished a nine-week contract at a midsize hospital in Central Arkansas last month. “You’re basically doing everything for them and supporting every function,” she said. Many critical patients, she said, are on a ventilator, requiring management from both a nurse and a respiratory therapist.
“They’re going to have a Foley catheter, they’re going to have multiple IV lines with multiple drips going in them to support blood pressure, cause sedation, for antibiotics, fluids and electrolytes,” Brogdon said. “They are on constant measurement of their blood pressure, heart rate, oxygen, temperature, breathing rate. If the blood pressure drops, I may have to turn this drip up, but that may make their heart rate too high, so I may have to turn this one down. You have to suction their airways, you have to clean them, you have to turn them, you have to talk to them. It is a lot of care for one patient.”
Most people with COVID-19 do not wind up in the hospital at all. But those who wind up in the ICU are the sickest — those potentially in life-or-death situations. On Tuesday at 2 p.m., 353 COVID patients were in ICUs across the state, filling around 30% of the state’s ICU beds.
The biggest challenge for the state’s hospitals is not a lack of physical rooms or equipment, but having enough of the trained staff required to provide critical care. The state has long faced a shortage of critical care nurses, a problem exacerbated by the pandemic. Demand for nurses has skyrocketed as COVID cases surge across the country, forcing hospitals into a financial battle to retain staff and hire temporary traveling nurses as needed.
Jones and other state officials have stressed that hospitals have experience managing ICU capacity and are adept at adjusting and “flexing” as necessary. Some larger hospitals operated with ICUs at or near capacity even before the pandemic. Troy Wells, CEO at Baptist Health — the largest hospital system in Arkansas, with 11 facilities statewide — said that he was used to ICUs at certain hospitals hitting 100% occupancy.
“For me, being full is not unusual or scary,” said Wells on Nov. 30, appearing at a press conference with Governor Hutchinson. “Hospitals do have a lot of levers to pull and they are used to doing that.”
State officials have expressed confidence that the state’s new COVIDComm system, which went into effect Dec. 16, will help alleviate the hospital access crunch. COVIDComm builds upon the state’s existing Trauma Communications System to efficiently direct COVID patients to available beds.
Hospitals have also been ramping up capacity as part of their pandemic surge plans. Over the last several months, according to the Arkansas Hospital Association, hospitals have added at least 122 ICU beds, 174 ventilators and 452 beds in negative pressure rooms designed to keep COVID patients quarantined.
The Central Arkansas Veterans Healthcare System hospital in Little Rock has also made five ICU beds and five general floor beds available to patients who would not normally qualify for VA services, as part of an agreement with the state through the Federal Emergency Management Agency. At a press conference Tuesday, the governor said that only two of the VA beds had been utilized, which he said suggested that ICU capacity issues were still under control.
However, the governor’s number was already out of date — two additional COVID patients were admitted to the ICU that same day, said Arlo Taylor, a public affairs specialist with the Central Arkansas Veteran Health System.
More help with capacity is on the way. The governor announced at the press conference Tuesday that the state will partner with Baptist Health to provide two alternate care sites for COVID-19 patients. One of the sites, at the J.A. Gilbreath Conference Center in Little Rock, is expected to be ready in four to six weeks and will have 50 beds (but no ICU beds). The other, at Baptist’s hospital in Van Buren, will have 74 beds, including eight ICU beds. The Van Buren site is expected to take six to eight weeks to fully complete, but will have a staggered opening as beds are ready. In addition, an already planned ICU expansion will open up 16 new critical care beds at the Baptist Health Medical Center in Little Rock in January.
That still leaves the question of staffing. “It’s not a matter of beds not being there,” said Bau, the Central Arkansas doctor. “It boils down to nurses.”
The Arkansas Nonprofit News Network has interviewed a dozen doctors and nurses in recent weeks about hospital capacity issues, most of whom asked to remain anonymous so they could speak candidly. Many were skeptical that the state’s hospitals will be able to hire enough ICU nurses to meet the surging demand, and feared that strategies like bonuses often only served to poach nurses from other hospitals within Arkansas.
“There’s a tremendous competition,” one doctor who works at multiple hospitals in Central Arkansas said. “There are nurses being recruited to surrounding states for a tremendous amount of money. At this point, it’s such desperation, it’s so cutthroat. On top of that, the internal competition within the state is just creating new holes where you plug one.”
Asked at the Tuesday press conference about the need for nurses as hospitals increase capacity, Wells said, “We don't have that plan fully developed yet. We're working on that now.” He said that hospitals are actively recruiting critical care nurses.
A nurse at a large hospital in Central Arkansas said that there simply weren’t enough ICU nurses available to keep up. “Equipment doesn't make an ICU, people with the right education, training, experience and compassion make an ICU,” the nurse said. “ICU nurses are special. You cannot have just any RN take care of critically ill patients.”
Many providers expressed concern that staff will be stretched too thin if the state’s hospitals don’t have enough resources to keep up with the volume.
Typically, an ICU nurse has two patients, or even just a single patient in certain circumstances. If hospitals change staffing ratios — for example, giving three or more patients to an ICU nurse — the quality of care would suffer, providers said. That could lead to worse health outcomes for COVID and non-COVID patients alike, they said, including the possibility of an increase in deaths.
“For every person you add, the less time and concentration you have for your patient load,” Brogdon said. “There are days that a critical-care-patient load of three patients is exhausting, but safe and doable. There are times when it definitely wouldn’t be.”
Even in normal circumstances, hospitals have to make such adjustments from time to time because of unexpected surges or staffing crunches. Some providers said these adjustments are becoming more frequent and feared they could become permanent.
One nurse at a midsize hospital in Central Arkansas described a recent day in which five ICU nurses were caring for 14 patients, with four of the nurses each taking on three patients. The nurse speculated that hospital leadership would be unlikely to make an official policy change on adjusting staffing ratios, even if circumstances on the ground forced them to deviate from normal practice.
Asked whether hospitals were being forced to make more alterations to staffing ratios, Arkansas Hospital Association president and CEO Bo Ryall said, “This isn’t routinely collected in Arkansas, so we don’t have this information.”
“In a nonpandemic, nonemergency situation, [two-to-one] is a typical ratio for the sickest patients,” he said. But the ratio could safely be increased in certain circumstances, Ryall said. “Medical staffs within hospitals routinely manage their resources to provide optimal care for individual patients. Many of our skilled health care professionals can safely care for more than one or two patients.”
“I have heard of increased staffing ratios happening on occasion, but nothing sustained,” said Jones, the health department official, stressing that such scenarios were not atypical for hospitals. “I have not heard of any hospitals changing staffing ratios for a sustained period of time.”
Given the lack of ICU beds in certain regions, Jones said, patients could face longer wait times in the emergency department before a bed is assigned. “That happens on a regular basis when the hospital is full,” she said. They could also face longer-distance transfers if no ICU beds are available in the immediate area, she said.
Bau said that such transfers are happening more and more. “If one of our patients deteriorates in the hospital, and I'm out of an ICU bed, I've had to transfer as far as Missouri or Tennessee to find an ICU bed for them,” she said.
Jones said that she does not have concerns about quality of care suffering. “The processes and procedures that hospitals undergo will ensure that emergent issues can be handled safely and effectively,” she said.
Asked about a scenario in which hospitals would have to change staffing ratios in a more sustained way, Jones said, “If hospitals have done all they could to focus on caring for emergent conditions only, and, despite all efforts, there is still a need for consistent and persistent extreme staffing ratio changes, then our health care system is truly in crisis.”
In that scenario, she said, a “Crisis Standards of Care” plan would be implemented. Such a plan, she said, would be designed to help hospitals manage an emergency “when the volume of patients surpasses the available capabilities and capacity of health care providers/facilities and normal standards of care can no longer be maintained.” It would “assist health care providers in their decision making with the intention of maximizing patient survival and minimizing adverse outcomes, including worsening disparities and inequities in and through health care.”
The state’s Crisis Standards of Care plan, she said, is in development.
As of late Tuesday afternoon, the six-county Metro region, which has the highest ICU capacity in the state, was down to 13 beds available; three other regions had fewer than 10 (see chart below). These figures were pulled by the health department after its daily 2 p.m. report, and differ slightly from the daily report. The numbers can shift throughout the day as patients move in or out of the ICU or ICU patients die.
This reporting is courtesy of the Arkansas Nonprofit News Network, an independent, nonpartisan news project dedicated to producing journalism that matters to Arkansans.