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The omicron variant of COVID-19 could, like the delta variant, lead to a surge in cases and hospital admissions. And some parts of the United States are already experiencing upticks in COVID hospitalizations.
On, Monday, December 13, SciLine interviewed: Dr. Hayley B. Gershengorn, a physician and professor of pulmonary and critical care medicine at the University of Miami Health System, where she studies how patient outcomes are affected by intensive care unit (ICU) practices and staffing. She discussed: the basics of ICU care; how hospital ICUs can prepare for the possibility of another COVID-19 surge; how hospitals set priorities for allocating scarce resources (such as ventilators) during times of crisis; how staffing and ICU practices can affect patient care during the pandemic, for both COVID and non-COVID patients; and her own experiences caring for critically ill COVID-19 patients.
HAYLEY B. GERSHENGORN: Hi, everyone. My name is Hayley Gershengorn. I am a clinical professor in the division of pulmonary critical care and sleep medicine at the University of Miami Miller School of Medicine, where I also work as a medical intensivist. And what that means is that I take care of patients in our adult intensive care unit. And in terms of academic pursuits in addition to my clinical work, I’m also very interested in studying the impact of staffing and resource use in our ICUs and in particular to understand how we deploy our physicians, nurses and other clinicians to optimally care for our patients.
Interview with SciLine
What is ICU care?
HAYLEY B. GERSHENGORN: So I think it’s a bit about location, a bit about what can be provided and a bit about who we take care of in that setting. So I’ll sort of break it down that way. An ICU, or an intensive care unit, exists in many hospitals in a separate location. They were started actually during the polio epidemic as an attempt to bring people together who could then benefit from the same type of increased monitoring and increased care. And generally speaking, those are locations in the hospital where people, either following a surgery or coming in with a sort of overwhelming medical illness—an example now might be COVID, but could be a heart attack that’s really impacted their body—will be placed where they can be monitored both by technological monitors—people will have electrodes, for instance, on their chest to allow us to monitor their heart rate; we’ll monitor their blood pressure often, things like that—but more importantly have very highly trained clinicians, particularly nursing staff, who have only that patient or maybe one other patient that they’re usually responsible for, which allows them to really focus in and pay close attention to everything that’s going on with that patient. And so it’s an opportunity for us to bring those people together to sort of capitalize on good, skilled people being in the same place. It allows us to sort of care for the sickest of the sick in the hospital.
How can ICUs prepare for the possibility of another COVID-19 surge, related to the holidays and/or the omicron variant?
HAYLEY B. GERSHENGORN: I think the most important thing is for us to remain flexible, and I think what we’ve discovered over the last couple of years is no matter what we prepare, we can’t necessarily understand exactly what each surge will entail and how that will impact our operations and our patients. So in particular, I think what that means is thinking about the staff that you need—the physicians, the nurses, our other clinicians in the ICU, which include members like respiratory therapy, our clinical pharmacists, other staff members like that who are integral to taking care of patients when they’re critically ill—and think about how we can maximize their utility without burning them out. And often, what that means is thinking in advance about how we can increase the number of people present at a given time to take care of our patients, but also potentially redeploy them in ways that allow them to extend their reach. And what I mean by that is maybe have additional providers, maybe not ICU nurses, for instance, but nurses with other training areas who can be overseen by ICU nurses to try to expand the reach of the ICU nursing staff, just as an example. In addition to that, I think we’ve learned throughout this pandemic that it really isn’t about what space you have, but about what you do with that space. And so just to take the ICU as an example, we’ve learned that you can care for people in things like a cafeteria space as long as you provide good monitoring and the right clinical staff who knows how to take care of them. And so I think we need to, again, be flexible about how we can rethink what our physical structures look like—that it’s not about the number of hospital beds or ICU beds, but it’s about, how can we create spaces that will allow for care of patients in those type of environments with the clinicians that we need?
How do hospitals set priorities for allocating scarce resources during times of crisis?
HAYLEY B. GERSHENGORN: Unfortunately, I think the most important thing to point out is there’s no single answer. And that’s not because hospitals are trying to do things differently. I think it’s because it’s hard to come to that single answer. So you might find that hospital—two hospitals in the same city approach this differently. Hospitals, certainly from region to region, state to state and certainly nation to nation approach this differently. I think most will agree that the fundamental goal of any of the structures we put in place to figure out how to triage or how to give out resources that might be in short supply are aiming to do, quote-unquote, “the greatest good for the greatest number”—right?—a utilitarian goal. The problem is in defining that. And so if you look across the United States, for instance, many of our states—not all, but many—have guidance for how to allocate resources under what’s called crisis standards of care. And that is meant to encompass things like the COVID-19 pandemic, but not exclusively COVID-19, where hospitals or providers might be in a circumstance where they cannot provide the type of care that they normally do because resources may be in short supply. And most of those policies factor in something about how sick a person is in the immediate setting and how likely they are to survive with or without the resource that’s being considered. Many of the policies also consider someone’s underlying health status, so be that their age or underlying comorbidities or illnesses that they have going in to their COVID-19. For example, things like diabetes or cancer or heart failure. And then some will consider things like essential worker status, which I think as we’ve learned very clearly over the last few years by no means means health care workers exclusively, but people who perform roles in our society that are essential to allowing our society to function. And there’s some disagreement across different institutions in different states about how to do that. And as a result, and I think for good reason, there has been distinct concern by members of the health care community, as well as members of disability groups or people representing different segments of our population, that some of these policies may unintentionally bias against groups of people, which obviously is never our goal. So, for example, we know that because access to care in our country is not always the same, there are certainly groups of people who have less access to care than others, be they racial or ethnic minorities, people with lower socioeconomic status, patients with disabilities, et cetera. And we want to make sure that any systematic challenges that these folks face that put them in positions to be of less strong health going into any issue like COVID-19 are not counted against them.
How can staffing and ICU practices affect patient care during the pandemic, for both COVID and non-COVID patients?
HAYLEY B. GERSHENGORN: Staffing, in my mind, is one of the things that has the largest impact on the care we provide to patients. You know, we often think about, for very good reason, the new medication that we study and find is helpful to treat a disease. But I think we’ve always known and we’ve seen in more clear ways during COVID-19 that if you don’t have staff to deliver the—knowledgeable, educated, experienced staff to deliver the care that is necessary, you know, knowing what the right care is doesn’t matter. And so I think that’s true for anything. I think it’s certainly been true in times of increased need like with COVID-19. And so one of the ways in which institutions have managed that, which I think has been advocated for by many of our professional organizations and has worked very well in many environments, is to sort of tier our staffing; and so to allow people with more expertise, be they a physician or a nurse or any other clinical staff member who, for instance, has a lot of experience or knowledge in the intensive care unit, to work closely and sort of oversee a team of physicians or nurses, whatever is appropriate, who don’t usually work in that environment but are willing and able to assist so that whereas maybe, for example, in a standard setting, an ICU nurse may take care of two patients themselves, maybe they bring in three or four non-ICU nurses who, under the supervision of that ICU nurse, can take care of five or six or seven patients and so allow that ICU nurse to spread out. And that manner of tiered staffing has been employed in many institutions around the world. It certainly is different for us, but I think it’s been shown to be effective and is actually modeled a lot after some of the team structure we have in the intensive care unit anyway.
Can you tell us anything about your own experiences caring for critically ill COVID-19 patients?
HAYLEY B. GERSHENGORN: One of the most challenging bits of it—and I think that this is true across all aspects of health care in the setting of this disease—has been the sort of fatigue and the mental impact it’s had on clinicians and—so seeing one’s colleagues, on oneself, on our patients and their families. And so I think that’s been incredibly hard to get through. And I think that that is a day-to-day event when you’re there. And some of that has been improved dramatically by changes, for instance, in visitation policies that allow our patients’ family members better access to them; also creative technological solutions that allow us, you know, to get video conferences so that people’s families can interact with them when it’s hard for them to come visit. But I think that that’s been—that’s been one of the key takeaways for me has been the sort of burden on us and on each other. And then also, you know, this is a population, unfortunately, of folks many of whom, prior to their illness with COVID, were healthy, right? Maybe they had some underlying illnesses, but many of our population does. Diabetes or high blood pressure are pretty common in our population, and people live their lives very normally in that setting and they’re now finding themselves in the intensive care unit or even in the hospital and how hard that is for them, that this can be a long stay, when they’re going to get better; and so what that drain—how that drains on them psychologically as well as physically; and then finally, the impact on us and on them and on their families of the people who don’t do well—right?—and what that’s like. With the flip side that there’s something really amazing, I think, for me, you know, working in a medical intensive care unit at a—we call it tertiary care hospital, which are the hospitals affiliated often with academic centers, medical schools, where sort of the sickest of the sick in the community will end up, many of our patients in those units in normal times, in non-COVID times, have many underlying illnesses. And, unfortunately, even if we’re able to get them through their illness, they are—their immediate illness that landed them in the hospital—they are still struggling with whatever their chronic illnesses are. One of the bright spots of COVID-19, for me, at least, has been when we are able to really help someone who is critically ill with COVID-19 who was otherwise healthy and return them back to being a healthy person who can live another 30, 40, 50 years, that’s really inspiring.
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