The steep rise in the number of coronavirus patients in serious condition has revived the debate on overcrowding in hospitals, and most of all the fear that plagued Israel even before the delta variant: the hospitals' so-called insufficiency to provide adequate treatment to some patients.
If forecasts of about 1,000 patients in serious condition at the beginning of September come true, hospitals will face infection rates radically different from those they've gotten used to. Many of these patients will be older people with preexisting conditions, and some will need intensive care and invasive respiratory intervention.
"Insufficiency" is hard to quantify. At the height of the third wave of the coronavirus in the winter, Israel treated about 1,200 patients in serious condition, and 51 COVID-19 patients in critical condition were hooked up to ECMO machines that support both the heart and lungs and require a large staff per patient. Even if there had been more patients back then, hospitals would still have been able to accommodate them – the question is under what conditions and price.
Israel knows how to exploit all its resources to treat people in emergency situations, but it pays for this by lowering the quality of the care, canceling treatments in other areas, postponing operations and especially by wearing down medical staff – in this case, staff who have been carrying the coronavirus burden for a year and a half. And of course some of these professionals have had to isolate, increasing the already-heavy burden on the system.
Insufficiency is measured by consequences: which procedures have been curtailed by diverting resources to patients in serious condition.
“There's a certain amount of damage when we reach 200 patients in serious condition, because most of the patients are in the internal medicine ward,” said Prof. Dror Mevorach, the head of the coronavirus ward at Hadassah University Hospital, Ein Karem, in Jerusalem. “These wards are converted into coronavirus wards at the expense of the internal medicine department, which already is limited."
In a situation where 600 patients are in serious condition, patients hospitalized in internal-medicine and other wards receive significantly poorer care; for example, because anesthesiologists are transferred to intensive care at the expense of operations, Mevorach said.
“At 800 patients the damage gets worse, and at 1,200 there's an explicit drop in the quality of treatment because of the severe shortage in intensive care beds, nurses and doctors,” he said.
Cardiologist Dr. Leon Falls of Kaplan Hospital in Rehovot, who is treating coronavirus patients, said that if “we don’t see a surprise like in Britain, then by the middle of September we'll have 1,000 to 1,200 patients in serious condition, a fifth of them on ventilators. Most of the patients will not have been vaccinated, are under 60, or are elderly who have been vaccinated,” but the hospitalization will be shorter, with a higher rate of patient turnover, Falls said.
Medical staff and department heads know the implications of a serious rise in coronavirus infections, but this time, gearing up for a spike is different because Israel is at a different starting point. Because of its vaccine campaign, Israel is carrying on with routine life, and evidence shows that the vaccines have helped some patients who are seriously ill: Their illness is less severe and their recovery is faster.
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Still, doctors say that even if the conditions of seriously ill patients are better than before, the rise in the numbers will lead to overcrowding at hospitals.
“As far as we’re concerned, the insufficiency has already begun,” said Dr. Khetam Hussein, the head of the infection control unit and the coronavirus department at the Rambam Health Care Campus in Haifa.
“Every Sunday afternoon we have 150 people in the emergency room, with people and ambulances outside. Maybe it's delayed morbidity, maybe there are other reasons. We also have a lot of trauma patients – accidents, shootings – things that we didn’t have in previous waves because of the lockdowns,” she said.
“So far at Rambam we've managed not to close internal medicine wards in order to open coronavirus wards. We took out beds here and there ... and as the numbers rise, we'll have to turn internal medicine wards into coronavirus wards.”
There's also the burnout among medical staff. “The capabilities are limited, especially when patients never stop arriving," Hussein said. "The next stage will be to postpone nonurgent operations.”
As crowding increases, quality of care drops
As Prof. Arnon Afek, the deputy director of Sheba Medical Center near Tel Aviv, puts it, “It's not mathematics. If you load up the system, especially if it lacks reserves, you reach a situation where the treatment standard drops. If a nurse treats 10 patients instead of six, the standard is lower.”
Afek agrees that the impact of the vaccine, coupled with medical staff who have now been treating COVID-19 for a year and a half, have helped. “The disease is different," he said. "It's less severe than what we saw in previous waves. In the end you need beds, doctors and nurses. We need to look at the overall system, and it's already very overloaded – it looks like winter morbidity in the middle of the summer.”
Patients in more serious condition are sent to intensive care, where there was great overcrowding in the pandemic's earlier waves. There the staff has to be large and highly trained.
“In the past few days, four coronavirus patients were transferred to us in intensive care,” said Dr. Noa Eliakim-Raz, the head of the coronavirus ward at Beilinson Hospital near Tel Aviv. “The unit has 16 beds, but the treatment of coronavirus patients requires isolation, protective gear and staff turnover – so now we have only 10 beds for the rest of the patients.”
She notes that transforming the internal medicine wards into coronavirus wards reduces the number of beds available for other patients by at least 38.
Patients in even worse condition need the ECMO machine: about 250 coronavirus patients so far, nine in the current wave. “The first patients in this wave weren't vaccinated, and slowly vaccinated patients began arriving who needed an ECMO,” said Dr. Yigal Kassif, the head of ECMO services at Sheba Medical Center and the head of the Israeli ECMO society.
“In the third wave we saw that the average age of patients connected to an ECMO was younger than in the first two waves: 40 to 50. In the third wave, we moved from ventilators to ECMO machines earlier. We decided not to drag out the borderline patients for too long and to transfer them to the machine before the damage to the lungs got very severe," he said.
"It's possible that in the fourth wave we'll treat them more correctly. I think that this time we won’t reach the same drama that we did at the beginning of the year.”
The ECMO system now has another 1,000 staff members who have undergone training, but Kassif still sees a problem. “To utilize these people we'll have to pull them out of their units and wards, which will once again lead to a shortage of staff.”