More hospital strain is unsurprisingly a/w worse outcomes. As mentioned, a lot goes into the occupancy of beds suitable for mechanical ventilation: the bed/room and equipment- one MV bed is not always like another (are you in a converted unit)? but especially...STAFFING!🧵
In ideal circumstances, a sick ICU patient on a ventilator has a dedicated ICU nurse focused only on their care and a multidisciplinary team- a doctor, respiratory therapist, pharmacist, all seeing more patients but not so many that they can't give attention as needed...
Ideally, the other ICU RNs will have a good pt ratio too. When a pt needs extra attention (quite often with COVID), the bedside nurse notices changes quickly, extra nurses are on hand to help, and the doctor/others are available for immediate assistance and evaluation.
Proning is a common but staff-intensive; requires at least 4-5 staff inc respiratory therapist. In an ICU that isn't overwhelmed, this can happen relatively quickly and safely. Same w responding to emergencies (w ventilator, urgent procedures, changes to moment-to-moment meds)...
When the hospital fills up, everything is disrupted. A 'soft rationing' kicks in. Pts who might be accepted to ICU for monitoring when more beds are available- (ex: COVID on HFNC, not yet intubated) - may stay on the floor or in other units rather than the ICU...
Patients in the ED might 'board'- wait longer for an ICU bed- even if intubated- because we're waiting to move someone from the ICU to the floor, and there aren't enough people being discharged to keep it flowing. So the bar to get into ICU goes up...
If you add stretched out staff - caring for more pts than they would or using extenders (such as non-ICU trained RNs or doctors)- you provide slower, less ideal care to everyone, including the sickest patients. Acute changes take longer to notice, and
decisions to do something like proning a patient take longer to execute because you need to pull staff that are already stretched thin. With less staff, clinical practices may change too...
It takes a lot of hands-on care for a patient's basic needs, like managing incontinence. So patients get more urinary catheters, rectal tubes, etc because staff just aren't able to provide the same time & attention. That can lead to complications like urinary tract infections.
So as the strain on the hospital/staff increases, the physical number of beds isn't changing, but the staffing needs can't really ramp up to the same extent as the acuity and volume of these patients. That leads to changes in the care over time, in a more insidious manner...
Patients just slowly get different care than they would in a different situation. Rationing isn't all-or-none, it happens on a gradient. As hospitals fill up, staff slowly get overwhelmed and delays result.
The attention of a nurse, respiratory therapist, or physician is a hard resource to quantify - but when it is stretched too thin, it has serious consequences for already critically ill patients.

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More from @laxswamy

18 Nov 20
"Mechanical Ventilation Supply and Options for the COVID-19 Pandemic" in @AnnalsATS

Here are some of our key takeaways... a #COVID19 🧵to assist in planning for the next surge.…
We faced intense strain from #COVID19 in Boston, an incredibly well resourced city.

The Hawaiian islands have about 250 ICU beds & 500 ventilators for a population of about 1.4m.

Haiti, with 11m people, can provide MV to <100 people.

#COVID19 can create a crisis anywhere.
We describe contingency options for hospitals and providers to reduce mechanical ventilation demand, increase supply, create new supply in crisis situations, and address staffing needs.…
Read 12 tweets
21 Oct 20
i mean, this is gonna be great. #CHEST2020
These cases are great, and the vent sim is really top notch. here is a takeaway slide re: elevated peak pressures #CHEST2020
Love this framework! #CHEST2020
Read 7 tweets
21 Oct 20
And you thought we were done talking about burnout!

WINTER IS COMING #CHEST2020 @niven_alex @md_ritwick @susan_corbridge and Curtis Sessler!
#COVID19 'reminded me a lot of my prior deployments as a military physician' - @niven_alex

This feels more accurate than the usual military analogies - deployed _as a clinician_ #CHEST2020
Dr. Sessler highlighting this important framework: An Official Critical Care Societies Collaborative Statement-Burnout Syndrome in Critical Care Health-care Professionals: A Call for Action #CHEST2020

(I've cited it 😉, you should read it!)
Read 20 tweets
21 Oct 20
Well, a crying child slowed me down, but better late than never. Excited to see @RanaAwdish @WesElyMD @hopealuko @BrendaPun

Rana: "Wanting the patients to be comforted and having almost nothing to do that except for the medications..." #COVID19 #chest2020
'are coma and deep sedation just markers of severe ARDS?'
@WesElyMD - absolutely NOT- they are independent!
#chest2020 #COVID19
Oooh. @hopealuko - we should be careful about what is 'severe' or 'mild' #COVID19 -- listen to patients! #CHEST2020
Read 19 tweets
21 Oct 20
Now hearing from @sameepsehgal9 on VTE in #COVID19

Wide variation in incidence of VTE in COVID-ICU patients. Meta-analysis in middle -- about 30% #CHEST2020
'at least in sick ICU patients, the incidence of thrombosis in #COVID19 is probably higher than other diseases like influenza' @sameepsehgal9 #chest2020
Who clots and who doesn't with #COVID19? @sameepsehgal9 synthesizes the literature. Not too surprising overall. #chest2020
Read 14 tweets
20 Oct 20
I'm now in "How to Identify Distressed Physician Colleagues and Stop Them From Dying by Suicide"

...will tweet any highlights. #CHEST2020
this is incredibly powerful. opening with a physician with a substance use disorder... this is intense

first highlight: he noticed the gross inequity evident to him in his work and it affected him

then, personal tragedy

then, opiates for pain #CHEST2020
now detailing how he lost his professional life, became actively suicidal... unbelievable

lost a colleague to suicide...

no one talks about this (except we do at #CHEST2020)
Read 21 tweets

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