Health

Seeing the butterfly effect in hospital transfers for Covid-19 patients – STAT

Can a young man with Covid-19 pneumonia in the emergency department of an Oklahoma hospital have an effect on an elderly woman with chest pain in Connecticut?

An early-morning call from the head of my Connecticut hospital makes me think he can, and this butterfly effect is something many hospitals will be experiencing in the weeks and months ahead as Covid-19 and the Delta variant continue to surge throughout parts of the U.S.

“We’ve been getting a lot of requests from other hospitals to transfer their patients here,” my boss told me on an early morning call. As the chair of medicine for a large tertiary care hospital in Connecticut, I was used to getting requests from across New England for patients to be transferred to the higher level of care our hospital could offer. But this was different. “We’ve gotten two requests this morning,” he continued, “both from the South.”

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The butterfly effect, one of the best-known aspects of chaos theory, posits that small changes can have nonlinear impacts on complex systems. Covid-19 isn’t, by any stretch of the imagination, a small change. But it was still surprising to me that one person’s decision to forego a mask in a distant state, enabled by leaders I had no say in electing, could affect my work in Connecticut.

Even before the pandemic, hospital capacity in the U.S. (defined as the number of beds plus the staffing and resources needed to care for the patients in them) was considered to be a limited resource. Now, health care workers are seeing a troubling trend: Covid-19 patients, many from states without strict vaccine mandates or masking protocols, are overwhelming their states’ capacity to care for them, forcing patients in high-transmission states to compete with those in low-transmission states for appropriately staffed acute-care beds.

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Most regions across the U.S. have several small hospitals dealing with the bulk of the common issues that require hospitalization along with one or two tertiary or quaternary care institutions able to handle patients with more specialized needs. This regional structure ensures that patients have access to the full gamut of care. It also allows hospitals to anticipate patient load while appropriately structuring staffing and resources.

But this system was never structured to deal with a pandemic. During the first wave in the spring of 2020, the strain on the hospital system was eased somewhat by the shutdown of almost everything unrelated to Covid-19. People without Covid-like symptoms avoided health care settings and elective surgeries and other procedures were put on hold, keeping the hospital census manageable in most areas. Outpatient clinics were cancelled, leaving large swaths of the health care workforce free to help in the frontline work combating this disease.

In areas where demand due to the Covid surge exceeded hospital capacity and staffing, such as in New York City, Miami, and Seattle, the entire country jumped in to provide support. The health care workforce traveled to these sites, offering resources and staffing, as we fought a common enemy.

Things have changed dramatically since then. The U.S. health care system is now a Covid-plus system, doing all the things it was doing before the emergence of the pandemic but now for a sicker population on top of managing the surges of Covid-19. Yet hospital and ICU bed capacity remain the same, with critical shortages in staffing across the country.

What’s also changed is that we now have vaccines, making Covid-19 a mostly preventable disease.

Yet smaller hospitals — mainly in states with many unvaccinated residents — are reaching out to larger ones across the country for help, sometimes a thousand miles or more away. Multiple hospitals in Connecticut, for example, have taken out-of-state Covid patients. The hospital system I work in fielded at least 14 transfer requests from distant states just over the last week. This is a notable jump from the one to two requests per month we normally receive. Looking at the ICU capacity in the South, I worry it will trend even higher.

To be clear, I believe that every hospital that has available beds and staff should help. Overwhelmed hospitals in the South, with common regional transfer and escalation patterns disrupted, are desperately cold-calling institutions across the country searching for beds as critically ill patients wait for higher-level care.

But with limited health care resources across the country and the accessibility of effective vaccines, I realize we aren’t all in this together anymore. Much as hospitals grappled with ventilator allocation during the early days of the pandemic, those on the receiving end of today’s calls for help are left with another potentially difficult choice: reserve beds for residents in their catchment areas or accept transfers from distant states.

When issues cross state lines, federal intervention can help. The lack of reliable data around hospital capacity at the national level demonstrates that there are opportunities for a more coordinated emergency response. Whether by creating a resource with accurate data that guides the transfer process nationally or by providing incentives to make hospital electronic medical records interoperable, the government should facilitate connections between all parts of the health care system.

While nursing has been the focus of staffing shortages nationwide, access to specialized physicians has also been a barrier to care. The federal government could make it easier for providers to use existing technology to tackle capacity constraints. For instance, only 17 states currently waive physician licensure requirements for providing telehealth across state lines. Allowing all providers to provide virtual consultations can decrease the need for physical transfer of patients to get the specialized expertise needed.

What I find ironic is that states that have failed to mandate Covid-19 mitigation strategies, such as vaccines and wearing masks, are turning to states that instituted strict public health measures — and with fewer Covid-19 cases, have more available hospital capacity — to care for their patients. To encourage responsible behavior at the state level and avoid propagating a massive disruption of regional care patterns and preventable mortality, the federal government can incentivize behavioral change. President Biden’s plan to mandate vaccines for all health care facilities nationwide that accept Medicare/Medicaid funding is a strong step in that direction.

A corollary to chaos theory is that, even though no system can be completely controlled, it is possible to create conditions that will drive high performance and be mindful of catalysts that could affect them.

While public health has traditionally been regulated by states, a pandemic the scope and size of Covid-19 needs a coordinated federal approach. The U.S. has one of the most sophisticated health care systems in the world, but it is a fragile one, and a seemingly contained disruption like one person not getting vaccinated or not wearing a mask can have an impact thousands of miles away.

Suparna Dutta is a hospital medicine physician and chair of medicine at Hartford Hospital in Hartford, Conn., associate professor of medicine at the University of Connecticut School of Medicine, and an alumnus of the OpEd Project.



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