COVID-19’s third wave threatens to flood Colorado hospitals

When Gov. Jared Polis stood in front of a podium on Nov. 13 and asked Colorado’s hospitals to prepare for a flood of COVID-19 patients and staff shortages, it was an omen of the days to come.

Sometime that weekend, a doctor in Denver spoke to her dying patient one last time. By Monday, hospital staff in Pueblo were transferring patients to facilities in Colorado Springs and Denver. Hospitals in Mesa County ran out of intensive-care beds Wednesday. Two days later, the governor reported just three ICU beds were available throughout Weld County.

Across the Denver area, hospitals began turning ambulances away because their facilities continued to fill.

“This is absolutely insane that we are going through this for the third time, and we are burned out,” said Dr. Amy Olson, medical director of the Pulmonary Physiology Unit at National Jewish Health in Denver.

The novel coronavirus is coursing through the state at the highest rate since the pandemic began. An estimated one in 49 Coloradans are currently infected, and transmission is so uncontrolled that public health employees are struggling to keep up with the demand for testing — let alone being able to contact every infected person to find out who else could be at risk.

Cases have soared to new heights, setting records seven weeks in a row, with six times as many new infections reported in the second week of November as in the first week of October. Hospitalizations also skyrocketed, and were more than five times higher on Nov. 20 than they were on Oct. 1.

Now deaths, too, are on the rise, from about six per day in early October to more than 20 a day in mid-November.

And those facing the brunt of the third wave in Colorado are the doctors, nurses and other health care workers, who for the past eight months have toiled on the frontlines of the pandemic. They face a fiercer wave of coronavirus hospitalizations than during the early spring surge because the number of patients is growing at an unprecedented rate, their coworkers are becoming sick with COVID-19 and they must care for more patients who don’t have the new coronavirus.

And this time, they’re on their own. With cases increasing across the entire nation, there won’t be volunteers from around the country to ease the burden.

State officials have pointed to staffing, rather than beds, as the point where the system may break down. More than one-third of Colorado hospitals reported Friday that they could be short of staff in the next week, while 14% expected to run out of intensive-care beds.

The Denver Post spoke to 14 hospital workers in Colorado about their experiences in recent weeks. Some spoke on the condition of anonymity because their employers would not allow them to talk to reporters. They described the emotional toll of losing patients, their frustrations of responding to yet another surge and fears about the approaching Thanksgiving holiday.

Reality worse than predicted

The wave that hit Colorado’s hospitals this fall was like a hurricane gathering strength as it neared land, triggering weeks of warnings that became increasingly specific and dire.

When Polis made his announcement, cases had been rising for six weeks. The average number of cases each day had more than doubled in two weeks, from 1,947 at the end of October to 4,461 on Nov. 13. Health officials warned hospitals could run out of beds by mid-January, then by late December, then before Christmas.

As of Friday, 86% of intensive-care beds statewide already were in use, as were 84% of beds for general care. Statewide, 1,564 people were hospitalized with confirmed cases of COVID-19.

The Colorado Department of Public Health and Environment says there are 1,698 intensive-care beds statewide, though health care groups have given different estimates. More than half of them are in the Denver area, where all but 9% of those beds were filled Friday. In other regions, a larger percentage were available, but that could change quickly because of the small number of beds on the Eastern Plains and in the San Luis Valley.

COVID-19 basics

Symptoms of COVID-19 — including fever, cough, shortness of breath, sore throat, loss of taste and smell, and nausea — can appear between two and 14 days after exposure, the CDC says.

Public health recommendations:

— Wear masks that cover your mouth and nose

— Stay at least 6 feet from others

— Wash hands with soap and water for at least 20 seconds

More guidelines: covid19.colorado.gov

In the spring, the state ordered a shutdown because the virus was widespread in the community. The stay-at-home order flattened the curve, though cases and hospitalizations increased again, first with summer festivities, then as students returned to universities in the early fall.

In the past four weeks, new infections and hospitalizations have skyrocketed and there is once again community transmission, said Margaret Huffman, the director of Jefferson County Public Health.

The virus is so widespread it’s unclear how people are getting infected, although officials said small gatherings are contributing to the spread. This is a sign of just how much the transmission of COVID-19 is straining the state’s testing and contract-testing capabilities. The latter is the ability to locate people with the disease, identify their close contacts and ask people to isolate and quarantine.

“Now you start to see that community transmission really roll out of control,” Huffman said, adding that the virus is so ubiquitous that everyone is at risk of getting the disease.

Like with hospital staffing, the challenge in increasing testing and contact-tracing abilities mostly comes down to two things: there is a finite amount of resources and every community across the nation is competing for them.

“There is a point where you can’t buy yourself out of something and this may be one of those places,” said Theresa Anselmo, executive director of the Colorado Association of Local Public Health Officials.

“I’m seeing something I’ve never seen”

Normally, hospitals in the Denver area accept patients in need of high-level care from Montana to Oklahoma, but now they’re scrambling to find a place that can take local patients, a nurse leader at a HealthOne hospital said. National Jewish is one of the few exceptions that’s still accepting transfers from outside Colorado.

At one point, the nurse leader’s Denver-area hospital was keeping five patients who needed to be in an intensive care unit in the emergency room, which is set up to quickly treat patients and send them either home or upstairs, she said.

“I’m seeing something I’ve never seen in my career,” she said. “It’s crazy.”

Stephanie Sullivan, spokeswoman for HealthOne, said in an email that the surge has strained hospital staffing across Colorado and the mountain states. Their hospitals have offered incentives to nurses who put in extra time, and they are hiring travel nurses, she said.

An intensive care nurse who floats between HealthOne hospitals said she’s caring for four patients at a time, and often all are on ventilators. The safest thing is for each patient to have a nurse monitoring their oxygen levels and making sure they don’t pull out the tube allowing them to breathe, but that’s not possible because so many of her coworkers are out sick, she said.

Olson, the National Jewish physician, said her work requires her to perform higher-risk procedures that can send the virus into the air through tiny drops of water. Most of her colleagues who are getting sick don’t seem to be picking up the virus in those scary situations. Instead, it’s through innocuous interactions outside the hospital walls.

“It’s not like March, I don’t know that I even heard of one of us getting it in this hospital,” she said. “I feel like it’s knocking on our windows and doors. I don’t know where people have gotten it.”

Alyssa Tousignant, a registered nurse at the Rocky Mountain Regional VA Medical Center in Aurora, said increases in patients and sick colleagues have further strained a facility that couldn’t hire enough nurses before the pandemic. Normally, she cares for four patients at a time, but this week leadership announced that likely will increase to seven, she said. If that happens, she may not have time to bathe patients or even brush their teeth.

“I’m here to make sure everyone is alive, essentially,” with that many patients, she said. “That’s not why I became a nurse.”

There’s a culture of “toughing it out” in nursing, and before COVID-19 hit, most nurses only stayed home if they had a fever or were vomiting, said a nurse at Spalding Rehabilitation Hospital in Aurora. They can’t do that anymore, because a person with mild symptoms from the virus could make a patient or coworker seriously ill, she said.

“Now, if you even have the sniffles, you’re calling into work and trying to get a rapid test,” she said.

Even though her unit doesn’t treat patients with COVID-19, they’ve been affected because floating nurses are being sent to help with coronavirus patients, and aren’t available to relieve short staffing elsewhere, the Spalding nurse said. She said her unit is short-staffed almost every day.

Long hours are starting to take a toll on nurses and other staff, particularly since they didn’t completely return to normal operations after the spring wave, said state Rep. Kyle Mullica, an Adams County Democrat and emergency room nurse at Presbyterian-St. Luke’s Hospital in Denver.

“People are quick to call us heroes… but we’re normal people, too,” he said. “The best thing you can do to show your appreciation is to do everything you can to stop the spread.”

More knowledge, limited resources to fight virus

Hospitals know more about how to treat patients during this surge than they did in the spring: they’re putting fewer patients on ventilators, and the average patient goes home a few days sooner than in April. That’s allowed Denver Health to treat more total patients with the same space they had during the first wave, said Dr. Connie Savor Price, chief medical officer at Denver Health.

Hospitals do also face some strains they didn’t in the spring, when the state ordered most non-emergency medical services to stop so they could conserve protective equipment like masks, Price said. For now, state public health officials have not issued a moratorium on elective surgeries, although Polis has raised the possibility of such a measure. Instead, hospitals are postponing or canceling non-emergency procedures themselves based on their needs.

Parkview Medical Center in Pueblo canceled inpatient surgeries, and Denver Health is asking patients to reschedule procedures that require an overnight stay, if the problem isn’t likely to worsen in the near future, Price said.

“If they’re going to take up a bed or take up a nurse, we’re asking them to put that off if they can,” she said.

Mullica said that during the spring surge, patients were too afraid to come to the hospital for conditions other than COVID-19. It’s a good thing those patients are seeking care now, but it’s putting more strain on staff during the current surge, he said.

In the spring, hospitals in the worst-hit areas also could call on others for help. Dr. Josh Solomon, a critical care physician at National Jewish, traveled to New York to help with the crush of patients hitting their hospitals. Now, reinforcements aren’t likely.

Hospitals around the country are running out of space and staff, with a health system in Idaho warning it could be forced to ration care and a hospital in Reno, Nevada, moving patients into its parking garage.

“If there is a surge only in New York or in Los Angeles, they can pull from wherever,” Solomon said. “Nobody has a lot of staff where you can pull from if you need it, that’s the problem.”

Surge plans buffer wave, for now

Normally, when a hospital doesn’t have space or staff to treat all patients, they arrange a transfer to another facility. That hasn’t been possible in all cases, as some Denver-metro hospitals began turning away ambulances last week.

Colorado has three alternative care sites — St. Anthony North in Westminster, St. Mary-Corwin Medical Center in Pueblo and the Colorado Convention Center in Denver — that the governor has said will be activated as a last resort. These locations will be able to receive patients within two to four weeks after they are activated, but won’t be equipped to treat those who are seriously ill.

It’s unclear how many employees the alternative care sites will need. A spokesperson for the state Department of Public Health and Environment said in an email that it will depend on the number of patients. The workers will come from private agencies the state has contracts with and volunteer health care workers.

So far, the state has issued 461 emergency licenses to allow retired and other health care workers to reenter the field and help with the pandemic. Most of the licenses were for registered nurses and certified nursing assistants.

The state recently activated medical staffing contracts to supplement hospital staffing, although it’s unclear where those workers are coming from, other than that they are from the Denver area. The state health department declined to name the contracting agencies.

“Hospitals are currently staffed appropriately,” said the state health department spokesperson, who did not provide a name.

Medical facilities are also trying to beef up their staffing themselves by moving employees around and inviting retired nurses to come back.

“We are turning over every stone to find compassionate caregivers to care for our patients,” said Kevin Massey, a spokesman for Centura Health.

At Denver Health, there are plans to have an experienced ICU nurse oversee others who worked in different units, and “helpers” who aren’t licensed to provide medical care can run for supplies and provide other support, Price said. If the situation continues to worsen, they could shut down more services and ask those staffers to help on COVID-19 units, she said.

Kevin Stansbury, CEO of Lincoln Community Hospital in Hugo, said they don’t have an ICU and normally send their sickest patients to Denver. But they have purchased one ventilator to help out if other hospitals can’t take someone who needs to be intubated, he said.

About two weeks ago, staff at Parkview Medical Center in Pueblo began converting other parts of the hospital into COVID-19 units. Parkview officials also have spoken to the county coroner about taking bodies if the hospital reaches the point that more people die than can be stored in its morgue, which can hold about 12 bodies.

If hospitalizations increase, Parkview will cancel outpatient surgeries so that it can transform its surgery recovery unit into an ICU, said Dr. Sandeep Vijan, chief medical officer.

“After that we are at capacity, geographically, in terms of where we could put the patients,” he said.

If all those plans aren’t enough, and hospitals across the state can’t come up with enough beds and staff to treat every patient, they could be forced to resort to the crisis standards of care the state approved in the spring, said Price, the Denver Health chief medical officer.

“Then we have to start making choices we don’t want to make,” she said.

The crisis standards criteria for rationing care assign points on six measures of lung, heart, kidney and liver function. Patients with the highest scores are considered least likely to survive COVID-19, or for a year after, and are given the lowest priority if hospitals must ration resources.

Age and other chronic conditions also raise a patient’s score. A previously healthy 50-year-old would have one point added for age, while a 40-year-old with breast cancer that had spread would have six more points.

Even with clear criteria, it’s still traumatic for the health care workers to make choices about who they can’t save, Price said. The effects could echo for some time as highly skilled people decide they can’t work in medicine anymore, she said.

In April, much of the discussion focused on who would get the last ventilator, but fewer patients needed those machines than expected. If Colorado has to go to crisis standards, hospitals are more likely to have to decide who needs intensive care but has to go to a general unit, because they don’t have enough staff to safely care for everyone at that level, Price said.

“Do you add one more (patient) on and possibly compromise all?” she said.

“It’s devastating”

Doctors described feeling emotionally drained from not only the amount of death they have faced during the pandemic, but the longevity of the crisis.

The HealthOne ICU nurse said she’s frustrated by people who decide they’re tired of following precautions and will risk what they think is a mild infection. She’s seen generally healthy, middle-aged people die from the virus, and others being discharged with feeding tubes in their abdomens and tracheostomy tubes in their windpipes so they can breathe.

“That exception (to following the rules) could kill someone,” she said.

Olson, the National Jewish physician, said a patient she’d treated for about six years recently was hospitalized for COVID-19. The patient, who had an underlying lung disease, didn’t want to go on a ventilator — not that it would have helped. The patient’s lungs were so ravaged by COVID-19 that the chances of her coming off the machine and surviving “were slim,” Olson said.

With the help of another doctor, Olson used FaceTime to talk to her patient one last time, and worked with the staff to make her as comfortable as possible. The patient was anxious, because she couldn’t breathe.

By the next morning, 20 minutes after her family came to say goodbye, the patient died.

“I had a 50-year-old die the same weekend, and that’s my age,” Olson  said. “When people are dying that are your age with kids, it’s devastating.”

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