COVID-19 moves to LA County rationing health care as hospital crisis worsens


With intensive care units showing major increases in hospitalization through New Year’s Day, Southern California’s medical system is faced with the prospect of not being able to provide critical medical care to everyone with The probability of dying of patients increases. As they wait for help.

Already, resources are wringing to keep hospitals, the overflow of ICU patients in other parts of hospitals is not designed for them, clearing the critical care wards of patients who can survive elsewhere And in some cases keep patients on ambulance for more than eight. Hours until space is available.

But the more drenched options may be ahead as the COVID-19 boom shows no signs of slowing down, and there is little hope of the arrival of an army of additional medical professionals who expand the intensive care unit’s availability by the end of the year can do .

Many hospitals are preparing for the possibility of rationing care in the coming weeks as the number of patients exceeds their staff’s abilities to care for them. A document obtained by The Times described how to allocate resources in the event of a crisis among doctors at four hospitals recently operated by Los Angeles County.

The guidelines call for a change in mindset that is unfamiliar to many medical providers.

Instead of trying to do everything to save a patient, their goal during a crisis is to save as many patients as possible, meaning they will not receive the same level of care when their chances of survival are low They would have otherwise. Doctors will now not make all the stops to save lives, but will make a strategy about how many people are saved from dying.

“Some compromise of the standard of care is unavoidable; It is not that an entity chooses to limit the system, or local resources, that resources are not clearly available to provide regular care, ”the document reads.

LA County Health Services Director Drs. Christina Gali said in an email that the guidelines were not in force until Friday night, but that they were needed to develop which has given rise and “the worst is yet to come.”

“We have enough beds, supplies and equipment for now, but we do not have enough trained staff for the number of patients who need care. We have brought in new employees, retired and reappointed employees from other areas of the system and requested additional resources from the state. “But it is not enough to anticipate these measures to meet the ever-increasing number of patients presenting throughout the county for care.”

Across the country, it has already become harder to get hospitalized with COVID-19 symptoms than a few months ago, UC San Francisco president of the Department of Epidemiology and Biology Dr. Kirsten Bibbins-Domingo said.

This shows a potential for a lethal Catch-22 already occurring in places like China, Italy and New York – the hospitals are so crowded that people become extremely ill before being admitted, by which time , It may be too late to save them.

In the first epidemic, some less seriously ill patients in warmer areas were asked to return home rather than be admitted to a congested hospital. Some people deteriorated at home and later died. If they had been admitted earlier, as they would have been if the hospital congestion was less, they would have been more likely to survive.

In Wuhan, China, this year a steelworker told The Times how, by the time his father got a hospital bed, he was outside the ICU, and no nurses were available. His father died a week after being admitted. In April, an emergency room doctor in New York City told The Times that patients were advised to stay away from the hospital until the last minute, but then it would take three to four hours for the ambulance to arrive. In that time a patient’s condition may decline.

“When the hospital starts getting full … we change our threshold to hospitalize someone,” Bibbins-Domingo said. “So maybe last month, we could say, ‘Wow, you’re not getting enough oxygen. Let’s keep you hospitalized because we want to be more vigilant.’ And when a hospital fills up, it’s a There is a time when we say … ‘Well, we don’t wait another day and see how you do?’ ”

Symptoms can worsen so quickly that it may be too late for a person to seek help until something serious is realized, or, once it goes away, some sick patients may second-guess whether they have been hospitalized. Should come back in

“We want a system that works, anyone who is sick who should be in the hospital is able to find a place in the hospital, and if they are seriously ill, a bed is available in the ICU,” Dr. Robert Kim-Farley, medical epidemiologist and infectious-pathologist at UCLA Fielding School of Public Health.

A summer study published in the journal JAMA Internal Medicine found that patients admitted to hospitals with fewer ICU beds had a higher risk of death.

The county memo states that the shortage is not likely to be equipment such as ventilators, but rather highly trained staff, particularly respiratory therapists, ICU nurses and critical care physicians. The decision will be made by an appointed officer. For patients who receive a scarce resource, they will be given up to two days to see if it is helping, at which point they need to be reassured to determine if treatment should continue .

If the patient has not shown improvement or has worsened, the resource can be retrieved to someone else.

“The moral justification … is that in a public health emergency when there are not enough critical care resources for all, the goal of maximizing population outcomes will be jeopardized if patients who are likely to survive No, they were allowed indefinite use of scarce resources, ”the document states.

Meanwhile, patients waiting for these resources can proceed in the queue if their condition worsens and they are determined to be overdose as per the guidelines. Decisions will be made by the Triage Officer and will likely be the Chief Executive Officer if there is a dispute.

The chief medical officer of LA County’s premier public hospital warned that although the county has not yet had horrific results, it is now heading to become the epicenter of the epidemic … and if we don’t stop the spread, Our hospitals will be overwhelmed. . ”

“If you have a heart attack, if you go in a car accident, if you fall off a ladder, or have a stroke, we may not have a bed for you,” LA County Chief Medical Officer Dr. Brad Spellberg said. -USC Medical Center.

He said: “I am not going Chinese on this: we are being crushed.”

Spring surges in New York overwhelmed medical infrastructure and led to a huge increase in deaths because some people simply did not need the care they needed. Treatment of COVID-19 has progressed significantly since then, with new procedures that have reduced mortality and new drugs that are helpful to the sickest patients. Hospitals have more supplies and have better technology to increase oxygen levels in patients.

However, the autumn growth is much worse than anyone imagined in California, with many Californians deciding that they were done with social disturbances and guidelines for wearing masks, and by the authorities at large Ignoring pleas to cancel thanksgiving meetings.

If California people stopped associating with other people, the order to stay in the new state became applicable to most states in the state before midnight December 7. The state may still survive the fate of New York according to some experts. .

Dr., an epidemiologist and infectious-pathologist from UC San Francisco. George Rutherford said that if Californians are following that order, the earliest signs of a leveling in new daily affairs can be seen on Monday and the days following. “I would say we have three more weeks of pressure on hospitals,” Rutherford said. “Hopefully, some vaccines can take some pressure off nursing homes.”

Rutherford said he suspected “people are going to do the right thing.” But anything is possible. “What’s going to happen with Christmas? You saw how confident we were with thanks. ”

Chief Medical Officer of Los Angeles County, Drs. Jeffrey Gunzenhauser said he is closely watching the number of people hospitalized with COVID-19, prompting rapid growth. He said that he is waiting for the inflection point, the moment when the rate of growth begins to level.

“We have not killed it. It is still picking up fast. The number of people visiting hospitals is increasing every day. It’s not just big – it’s getting bigger fast, “he said.

Gunzenhauser said that once the county hit the inflection point, it would still be a while before the peak hit. And once it hits the peak, there will still be thousands who will continue to be hospitalized as the numbers begin to decrease.

LA County continues to report single-day coronavirus case numbers on or near daily records. On Friday, an Independent Times found that LA County reported 15,749 coronovirus cases, the second-largest single day on record; On Wednesday, 22,469 cases were reported. La County now averages 13,600 coronovirus cases over the past week, more than triple the comparable figure on Thanksgiving.

On Friday, there were 87 deaths in La County, which now totals 79 deaths a day compared to the previous week, a record and double that figure since Thanksgiving.

As of 9 am on Friday, about 70 ICU beds were available in La County, with a point-in-time daily tally recorded that actually fluctuated from hour to hour, about 100 from midnight tally the week before. A significant decline.

Arguments for the dire need for reinforcement of additional medical staff have largely gone unanswered so far, as state officials have warned, nationwide additional to actually help treat COVID-19 hospitalized patients with tsunamis Medical staff not available.

According to The Times’ county-by-county survey, California on Friday broke the record for the most coronovirus cases in a single day with 53,326, topping the previous last set, when 52,330 cases were recorded. The state now averages more than 40,000 new coronovirus cases a day in the past week, a new record and a 10-fold figure since Halloween.

The number of California hospitalized for COVID-19 has been broken for 20 days, to 16,019 by Thursday, including 3,447 people in intensive care units. COVID-19 hospitals have multiplied seven times since the end of October.

The state recorded 265 COVID-19 deaths on Friday, its fourth largest single-day rally. California now averages 226 deaths a day, also a new record, and five times the comparable figure since early November.

A doctor at LA County Public Hospital said this week that there were zero ICU beds left for patients, forcing the hospital to go into surge mode. The doctor said that the hospital is asking employees to postpone any holiday in the next six weeks. The doctor estimates that deaths will double by January and that many patients will be cared for with a staff member to treat hospitalized patients.

“In cases with a continuous rise and steep slope of the trajectory that shows no signs of bending, we inevitably deteriorate,” the doctor said. “We are afraid that California is moving toward New York’s spring conditions at this rate.”

A nurse at the Kaiser Permanente Hospital in LA County said his facility is rapidly running out of beds, as he and other employees work six days a week. Wherever possible it is possible for patients without COVID-19 to make room for the crush of coronovirus patients.

He said that we are going to get the vaccine soon, but no word is right. “It is insane and stressful with frequent changes from day to day.”

Times staff writers Meredith Blake, Luke Money and Alice Y. Su contributed to this report.

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