Covid-19, No Beds, Ugly Stuff

[Ado Annie, ASN, RN]

This is one of those times when I hope that no one recognizes me because I want to get real for minute.

When patients decompensate with Covid, their respiratory status deteriorates quickly. Our small hospital doesn't have a respiratory therapist, doesn't have a BiPAP, doesn't have a vent. So a transfer is necessary, but there are NO BEDS to transfer to. In the entire STATE. It may take a few hours. When we finally have a bed, the decision has to be made whether to transfer without intubating or to intubate them and transfer them with a vent. The ER doc will come to intubate, get angry that something or other is not up to his expectations, and eventually get a tube in. It can be pretty ugly. And frequently there is not much likelihood of a good outcome. I have become very discouraged by this. I know that the likelihood of a good outcome is small anyway, but it sure feels as if we have failed these patients. Perhaps Covid patients, especially with comorbidities, who are full codes shouldn't even be kept at the small hospitals, because of the potential for respiratory failure? Even so, we had a patient who was hospitalized for something completely unrelated but days later showed symptoms of Covid. And if they're not IN respiratory failure, how do you manage to get them a bed to transfer to? You can't!

I don't have answers, only questions. This has bothered me more and more. Throw telemedicine (which in general I think is a godsend) into the mix and sometimes that decision to transfer is delayed... sometimes too long. 

Thanks for your thoughts!

[TheMoonisMyLantern, ADN, LPN, RN]

Maybe the nursing staff and the ER doc who gets mad about everything could put some pressure on administration to spend some money on the equipment you guys desperately need. You guys desperately need some bi-paps and vents if you're going to be managing these patients for extended periods of time while waiting for a bed. 

That's what sucks about working at a small hospital, trying to come up with the money for something is always hell. 

[JBMmom, MSN, NP]

So sorry you're dealing with this. There is a lack of ICU beds in my whole state right now, and we are often getting transfers from pretty far due to limited capacity. It's unfortunate that in your situation some people can't pitch in as part of the team and do their part to make the situation worse not better. Just this morning we had a patient decompensate over the course of just a few hours, after having been stable on the high flow oxygen for over a week. She required emergent intubation and couldn't have waited for hours without potentially disastrous results. I don't think anyone has the answers these days, sorry you've got that particular situation and stress, you're doing the best with what you have, your patients are lucky to have you looking out for them. 

[CCU BSN RN]

I'm a little concerned about the concept of a hospital that doesn't own a ventilator or Bipap machine, to the point where I'm having trouble getting past being incredulous about that and actually wrapping my head around your issue. 

How big is your hospital? Do you have operating rooms? 

What happens when your ER doc does intubate the patient prior to transfer? Do you have to wait until EMS is at bedside to intubate so that they can be placed on the ambulance's vent? Do you just sit there and bag them until EMS shows up to transfer the patient? 

What if your patient has OSA and is on Bipap every night at home? They either bring their own machine with them or they're out of luck? 

I literally just have hundreds of questions about this logistical nightmare. 

[CampyCamp, RN]

I worked in a small rural hospital for a short period. 25 beds. No vent as such. But there was an OR and the CRNA could come in an intubate in an emergency. Periodically severe trauma patients and codes had to be stabilized before transport. 

[Ado Annie, ASN, RN]

9 hours ago, CCU BSN RN said:

I'm a little concerned about the concept of a hospital that doesn't own a ventilator or Bipap machine, to the point where I'm having trouble getting past being incredulous about that and actually wrapping my head around your issue. 

How big is your hospital? Do you have operating rooms? 

What happens when your ER doc does intubate the patient prior to transfer? Do you have to wait until EMS is at bedside to intubate so that they can be placed on the ambulance's vent? Do you just sit there and bag them until EMS shows up to transfer the patient? 

What if your patient has OSA and is on Bipap every night at home? They either bring their own machine with them or they're out of luck? 

I literally just have hundreds of questions about this logistical nightmare. 

No operating rooms as such (procedures such as scopes done in a specialty clinic with conscious sedation). Level IV ER. 

Floor census since I have been here (about 3 yrs) has ranged from 0 to 14.

Yes, we try to schedule with EMS so that an intubated patient can be placed on their vent fairly quickly. Yes, we stand there and bag them until that happens.

I haven't had a patient with a home BiPAP. We have had some that bring a CPAP. There actually is an RRT that is only here on days and doesn't do much with floor patients. 

Your questions are exactly why I'm sharing this and worrying about it. It used to be a fairly rare problem (and transfers were easier to make happen because there were beds available) but Covid has changed that.

We do physically have a ventilator now and we're going to have a brief training session for the nurses. The ER doc would be the one to set it up and start it. "It's easy"... This terrifies me. My colleagues range from terrified like me to not smart enough to be scared to confident.

 

[toomuchbaloney]

On 2/3/2021 at 10:05 AM, CCU BSN RN said:

I'm a little concerned about the concept of a hospital that doesn't own a ventilator or Bipap machine, to the point where I'm having trouble getting past being incredulous about that and actually wrapping my head around your issue. 

How big is your hospital? Do you have operating rooms? 

What happens when your ER doc does intubate the patient prior to transfer? Do you have to wait until EMS is at bedside to intubate so that they can be placed on the ambulance's vent? Do you just sit there and bag them until EMS shows up to transfer the patient? 

What if your patient has OSA and is on Bipap every night at home? They either bring their own machine with them or they're out of luck? 

I literally just have hundreds of questions about this logistical nightmare. 

Welcome to poor rural American healthcare. 

[MunoRN, RN]

As a hospital that critical access hospitals transfer their patient to, we've had the same issues earlier in the pandemic, although now we decline to accept most of these patients anyway since we aren't going to provide different care than what can be provided in a critical access hospital.

Early on in the pandemic the thinking was to put Covid patient's on vents proactively, what was called "early intubation".  We were able to wean and extubate a large portion of these patients, but that's because they didn't require a vent in the first place.  As the data came out that we were probably killing more patients than we were saving with proactive intubations, we made the criteria more stringent.

For many months after that we only intubated patients where everything else had failed, including aggressive proning, and the patient was imminently going to die without a vent.  None, not a single one, of those patient survived to discharge or was able to become non-vent-dependent.  We still intubate for issues where a vent is indicated that occur related to Covid, but not soley due to Covid.  For everyone else when it gets to the point where it seems there is no other option than a vent they get a palliative care consult, we don't offer intubation as a treatment, which is a course of treatment that can be provided in critical access hospitals.

[TheMoonisMyLantern, ADN, LPN, RN]

2 hours ago, MunoRN said:

As a hospital that critical access hospitals transfer their patient to, we've had the same issues earlier in the pandemic, although now we decline to accept most of these patients anyway since we aren't going to provide different care than what can be provided in a critical access hospital.

Early on in the pandemic the thinking was to put Covid patient's on vents proactively, what was called "early intubation".  We were able to wean and extubate a large portion of these patients, but that's because they didn't require a vent in the first place.  As the data came out that we were probably killing more patients than we were saving with proactive intubations, we made the criteria more stringent.

For many months after that we only intubated patients where everything else had failed, including aggressive proning, and the patient was imminently going to die without a vent.  None, not a single one, of those patient survived to discharge or was able to become non-vent-dependent.  We still intubate for issues where a vent is indicated that occur related to Covid, but not soley due to Covid.  For everyone else when it gets to the point where it seems there is no other option than a vent they get a palliative care consult, we don't offer intubation as a treatment, which is a course of treatment that can be provided in critical access hospitals.

Is this even the case for someone with few co-morbidities or patients that aren't advanced in age? I had read that now the thinking is to manage patients without vent support for as long as possible, but withholding it completely if COVID is the only cause for respiratory failure seems extreme.

[turtlesRcool]

On 2/4/2021 at 9:21 PM, TheMoonisMyLantern said:

Is this even the case for someone with few co-morbidities or patients that aren't advanced in age? I had read that now the thinking is to manage patients without vent support for as long as possible, but withholding it completely if COVID is the only cause for respiratory failure seems extreme.

I don't know.  What I do know is that back in the Spring, we intubated everyone who needed more than 6L/min via nasal cannula.  At my hospital, we had over 50% mortality rate with those vented patients.  The ones who came off usually had some pretty major deficits that were going to requite long term care and rehabilitation, often without a clear path back to their prior function.  We didn't know better at the time, but we probably did more harm than good.

Now we put COVID patients on regular O2, then high flow, then heated high flow (up to 60L/min), and then a few go on BiPAP.  Once they're at the point where they'd need intubation, there's virtually no chance they'll come back off.  The ones who were strong enough to come off vents in the Spring are the kind of patients who are strong enough to stay off vents now.  Once you reach the point where you can't maintain your saturation on heated high flow or BiPAP, your lungs are so damaged by COVID alone that youth and lack of co-morbidiites don't really mean much.  It's a nasty, nasty virus.

[TheMoonisMyLantern, ADN, LPN, RN]

9 hours ago, turtlesRcool said:

I don't know.  What I do know is that back in the Spring, we intubated everyone who needed more than 6L/min via nasal cannula.  At my hospital, we had over 50% mortality rate with those vented patients.  The ones who came off usually had some pretty major deficits that were going to requite long term care and rehabilitation, often without a clear path back to their prior function.  We didn't know better at the time, but we probably did more harm than good.

Now we put COVID patients on regular O2, then high flow, then heated high flow (up to 60L/min), and then a few go on BiPAP.  Once they're at the point where they'd need intubation, there's virtually no chance they'll come back off.  The ones who were strong enough to come off vents in the Spring are the kind of patients who are strong enough to stay off vents now.  Once you reach the point where you can't maintain your saturation on heated high flow or BiPAP, your lungs are so damaged by COVID alone that youth and lack of co-morbidiites don't really mean much.  It's a nasty, nasty virus.

Okay I see, that makes sense then that they would defer intubation at that point sense they have such a low chance of coming off it.

Thanks for the info! 

[marienm, RN, CCRN]

Yeah,  this doesn't answer the OP's question directly but my small ICU would do HiFlow cannula (up to about 70L) and BiPAP. Some of these patients we could wean and they went home. The others would become more and more debilitated and eventually we'd intubate. We'd transfer patients to a bigger ICU  (same hospital, different unit with more staff) when they needed to be proned on a vent. Every. Single. One. Of. Them. Died.