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Wednesday, March 25, 2020

By Kaiser Health News


WASHINGTON—More than half the counties in America have no intensive care beds, posing a particular danger for more than 7 million people who are age 60 and up—older patients who face the highest risk of serious illness or death from the rapid spread of COVID-19, a Kaiser Health News data analysis shows.

Intensive care units have?sophisticated equipment, such as bedside machines to monitor a patient’s heart rate and ventilators to help them breathe. Even in communities with ICU beds, the numbers vary wildly—with?some having just one bed available for thousands of senior residents, according to the analysis based on a review of data hospitals report each year to the federal government.

Consider the homes of two midsize cities: The Louisville area of Jefferson County, Kentucky, for instance, has one ICU bed for every 442 people age 60 or older, while in Santa Cruz, California, that number stands at one bed for every 2,601 residents.

Differences are vast within each state as well: San Francisco, with one bed for every 532 older residents, and Los Angeles, with 847 residents per bed, both have greater bed availability than does Santa Cruz.

Even counties that rank in the top 10% for ICU bed count still have as many as 450 older people potentially competing for each bed.

The KHN findings put in stark relief a wrenching challenge hospitals in many communities — both urban and rural—could face during the coronavirus pandemic: deciding how to ration scarce resources.

“This is just another example of geography determining access to health care,” Arthur Caplan, a bioethics professor at NYU Langone Medical Center, said when told of KHN’s findings.

Overall, 18 million people live in?counties that have hospitals but no ICU, about a quarter of them 60 or older, the analysis shows. Nearly 11 million more Americans reside in?counties with no hospital, some 2.7 million of them seniors.

Dr. Karen Joynt Maddox, a professor at Washington University School of Medicine in St. Louis, said that hospitals with larger numbers of ICU beds tend to cluster in higher-income areas where many patients have private health insurance.

“Hospital beds and ICU beds have cropped up where the economics can support them,” she said. “We lack capacity everywhere, but there are pretty big differences in terms of per capita resources.”

Doctors in rural counties are bracing for the possibility they may run out of critical care beds. Northern Light Sebasticook Valley Hospital, in central Maine, has one ventilator and 25 beds. Two of those are “special care” beds that don’t meet full requirements for intensive care but are reserved for the sickest people. Such patients are often transferred elsewhere, perhaps to the city of Bangor, by ambulance or helicopter.

But that may not be possible if COVID-19 surges across the state “because they’re going to be hit just as hard if not harder than we will be,” said Dr. Robert Schlager, chief medical officer at the hospital in rural Pittsfield. “Just like the nation, we probably don’t have enough, but we’re doing the best we can.”

Hospitals also say they can quickly devise plans to transfer cases they can’t handle to other facilities, though some patients may be too ill to risk the move.

Certainly, being in a county with few or no ICU beds may not be as dire as it seems if that county abuts another county with a more robust supply of such beds.

In Michigan, health planners have determined that rural counties with few ICU beds, such as Livingston and Ionia, in the central part of the state, would be served by major facilities in nearby Lansing or Detroit in a major crisis.

Dr. Peter Graham, executive medical director for Physicians Health Plan in Michigan, is affiliated with Sparrow Health System in Lansing. He is making no assumptions. It’s possible central Michigan could take overflow COVID-19 patients from Detroit if that’s where the disease clusters, he said. Or patients might have to be transferred hundreds of miles away.

“It’s just obvious people are going to need to move” if local facilities are overwhelmed, he said. “If we’re able to find a ventilator bed in Indianapolis, in Chicago or Minneapolis or wherever, it is go, get them there!”

Yet experts warn that even areas comparatively rich in ICU beds could be overwhelmed with patients struggling to breathe, a common symptom of seriously ill COVID-19 patients.

“No matter how you look at it, the numbers [of ICU beds] are too small,” said Dr. Atul Grover, executive vice president of the Association of American Medical Colleges. “It’s scary.”

Lenard Kaye, director of the University of Maine Center on Aging, a state with a large older population and relatively few ICU beds, agreed. “The implications are tremendous and very troubling,” he said. “Individuals are going to reach out for help in an emergency, and those beds may well not be available.”

Health workers might need to resort to “triaging and tough decisions,” Kaye said, “on who beds are allocated to.”

That concern isn’t lost on Linnea Olsen, 60, who has lung cancer and knows she is especially vulnerable to any respiratory virus.

Olsen worries about a potential shortage of ventilators and ICU beds, which could lead doctors to ration critical care. Given her fragile health, she fears she wouldn’t make the cut.

“I’m worried that cancer patients will be a low priority,” said Olsen, a mother of three adult children, who lives in Amesbury, Massachusetts.

Olsen, who was diagnosed with lung cancer almost 15 years ago, has survived far longer than most people with the disease. She is now being treated with an experimental medication — which has never been tested before in humans—in an early-stage clinical trial. It’s her fourth early clinical trial.

“I’m no longer young, but I still would argue that my life is worthwhile, and my three kids certainly want to keep me around,” she said.

She said she has “fought like hell to stay alive” and worries she won’t be given a fighting chance to survive COVID-19.

“Those of us with lung cancer are among the most vulnerable,” Olsen said, “but instead of being viewed as someone to be protected, we will be viewed as expendable. A lost cause.”

The total number of ICU beds nationally varies, depending on which source is consulted and which beds are counted. Hospitals reported 75,000 ICU beds in their most recent annual financial reports to the government, but that excludes Veterans Affairs’ facilities.