Phoenix area hospitals have started temporarily closing their doors to incoming emergency transports and hospital transfers because of overwhelming patient counts.
Between six and 10 hospitals in the region were diverting patients at various times on Monday and Tuesday, according to Banner Health, the state’s largest health care system.
Arizona hospitals are under more pressure than any time in the pandemic as the number of cases continue to surge, filling hospital beds with a record number of patients. COVID-19 patients in hospital beds, ICUs and on ventilators across Arizona are at their highest levels ever reported.
And hospitalizations show no sign of abating, hitting records nearly every day. The need for inpatient care is likely to grow as case counts escalate.
Arizona’s seven-day new-case average ranks second-highest in the nation as of Tuesday, behind only California, and public health experts expect the virus to spread further because of personal contact over the holidays.
Diversion does not apply to patients who walk into hospitals for emergency care, according to Banner. It just diverts ambulances to the next closest emergency center. Diversion status can change quickly based on capacity and patient changes.
Hospitals, which are following the state’s crisis care plan, are hoping to avoid the crisis level that involves triaging of care for patients based on factors such as their likelihood of survival.
Hospitals are “absolutely” in the worst situations they’ve been in all year, Dr. Marjorie Bessel, chief clinical officer for Banner Health, told The Arizona Republic Tuesday.
“Please help us,” she said, imploring Arizonans to act responsibly and avoid gatherings over the New Year’s holiday so that hospitals have room for COVID-19 patients and others who need urgent care.
Bessel said forecasting models predict a peak around the second or third week in January, meaning the coming weeks could be even more difficult for hospital systems statewide.
Why hospitals are diverting patients
Arizona hospitals have reported a stream of patients in the past 48 hours, causing several hospitals to go on “diversion” to restrict incoming emergency transports and hospital transfers to handle patient backlogs, Banner Health posted in a series of tweets Tuesday morning.
Six Phoenix-area hospitals closed their doors to those patients for parts of Tuesday, according to Banner. Up to 10 area hospitals were diverting patients Monday, including Banner and non-Banner hospitals.
Bessel said diversions are implemented when hospitals or emergency departments, or both, “become overwhelmed where they feel like they cannot safety take any more ambulance traffic … (so that) ambulance traffic to be diverted away from that hospital to another hospital that may have a little bit more bandwidth.”
That gives the diverting hospital some hours to decompress, with the goal of coming off diversion as fast as possible, she said.
Local hospital systems try to work together to make sure a region’s hospitals don’t all go on diversion at the same time, Bessel said. During an especially bad flu season in 2017, for example, hospitals collaborated to do “rolling diversions” where health systems took turns diverting patients for a few hours so patients could still get care and ambulance transports could stay efficient.
She said those same conversations are happening now.
Valleywise Health Medical Center has gone on and off diversion for the past few days because its hospital is at capacity, Dr. Michael White, Valleywise Health chief clinical officer, said. He expects that will continue as hospitals feel the effects of holiday gatherings.
HonorHealth has also in recent days had to implement diversion at a few hospitals, given shortages with beds and staff.
“We save that as a very, very last resort if we have no capacity at a certain hospital, but we have actually done that a couple times in the recent past just based on number of beds at a couple of our sites,” said Kim Post, HonorHealth’s executive vice president and chief operations officer.
“We do not like to do diversion, we don’t like to shut things down, because we realize we’re a lifeline to patients, not just within HonorHealth, but within the state,” she said.
Hospitals sometimes go on diversion in the winter because of higher patient counts, but Banner said it’s “unusual” for so many hospitals to be diverting patients at the same time, a challenge worsened by the “length of stay and complexity of care for COVID-19 patients” in hospitals.
Banner wrote that the situation “must be quickly and carefully addressed through balancing of patients and resources between hospitals, increasing staffing, pausing elective procedures and expediting discharges for those who no longer need hospital care.”
Hospitalizations outpacing summer peak levels
Diversions are tied to the ever-increasing number of COVID-19 patients filling up hospital beds.
Statewide, 91% of all ICU beds and 91% of all inpatient beds were in use Monday, with 59% of ICU beds and 53% of non-ICU beds occupied by COVID-19 patients, but bed capacity differs by hospital.
There were 154 ICU beds and 765 non-ICU beds available across Arizona as of Monday.
Bessel said Banner Health had a “very busy weekend post-Christmas” and into this week, with large numbers of patient visits to emergency rooms, increasing hospitalizations and seriously ill COVID-19 patients.
An added challenge is that hospital employees are becoming sick as well given the high levels of community spread, she said.
COVID-19 patients make up just under 40% of all Banner hospital patients, Bessel said. The current number of COVID-19 patients is the highest the system has seen since the pandemic began.
“We are absolutely exceeding what we experienced in the summer and yet we’re not even at the peak yet, unfortunately, because we’re going to feel the effects of the holidays here in the next couple of weeks and we’ve got stacked holidays,” Bessel said, whereas summer holidays were spread out.
White said Valleywise, the Valley’s only safety net health care system and public teaching hospital, is currently at capacity and working to add beds.
The central Arizona region of Maricopa, Pinal and Gila counties has 10% of medical/surgical beds available and 9% of ICU beds available, according to data from Maricopa County.
A record high of about 3,170 COVID-positive patients are in the central region hospitals, with 723 of the 1,131 total ICU beds filled by COVID-19 patients.
The Pima County Health Department said hospitals hit an all-time high for beds in use on Monday. Only 33 hospital beds were available in the county, a record low 2% of all beds.
For ICU beds, only nine were available, meaning 98% of ICU beds were in use countywide, even though 20 ICU beds were added in the past week and hospitals are working to add more.
The county said a record 27 COVID-19 ICU admissions took place in a single day Monday, and county hospitals reported 19 COVID-19 deaths on Dec. 25.
Phoenix’s major hospital systems stressed
Post said HonorHealth, which operates six hospitals in metro Phoenix, hit its highest-recorded COVID-19 patient count on Monday. The approximately 400 COVID-positive patients spread across the hospitals make up about half of HonorHealth’s adult inpatients.
“We’re just preparing for the continued elevation, and we have our over-capacity plans all laid out,” she said.
Post said the most challenging aspect for HonorHealth continues to be staffing. Because community spread is so high, there are many sick calls from staff, she said. And because so many states are now in a surge, it’s harder for Arizona hospital systems to compete for travel staff than it was during the summer when Arizona stood out as a hot spot.
Hospitals are running low on capacity due to the combination of many patients in few beds and the difficulty for existing doctors and nurses to care for them all.
Post said HonorHealth hospitals have overcapacity plans to prepare for 10%, 25% or 50% surges by adding spaces for patient care, assigning more patients to caregivers and doubling up rooms. So far, capacity overflow at individual hospitals has been managed by sharing the load with other hospitals in the system because all six hospitals haven’t yet been impacted at the same time, she said.
HonorHealth will “definitely” hit at least 10% overcapacity in the coming weeks, Post said.
“Probably in the next two weeks if it keeps going like this, we would definitely be in the 10%. Some of our sites would even have to move to the 25% if we continue to increase each day like we have in the last few days.”
She said triage and crisis care will depend on how well the state can balance transfers and available beds.
“I don’t see that tomorrow or in the very near future, but if our numbers keep growing significantly past our capacity, then yes,” Post said.
Dignity Health has also seen an increase in COVID-19 patients and is concerned about the weeks ahead, spokesperson Abby Friedemann wrote in an email.
“We are concerned for the health of our community and the increased staffing needs that will be required to provide care as we continue to see an increase in COVID-19 cases,” she wrote. “We continue to follow our established plans to adjust our staffing levels as quickly as possible to provide safe and effective care while adapting to changes in hospital capacity.”
Dignity Health also said it has not yet reached the indicators to start crisis care under state guidelines. Its hospitals are currently in the “surge” tier of the crisis plan and Dignity Health is focused on preventing the triage of patients, Friedemann wrote.
Bessel said she expects Banner Health hospitals to be even more busy in January. The health system is bringing in contracted labor, transferring Banner staff from Colorado, training current employees for additional duties and moving ventilators around the hospital system to where they’re needed most.
Banner Health is already operating in its crisis standards of care, which allows things like changing pediatric ICUs into adult ICUs, putting two patients in one room and streamlining electronic medical record documentation, some of which their hospitals are already doing.
Bessel said Banner hospitals have done studies and drills to prepare for triage care if it becomes necessary.
Health systems are collaborating to move around patients and do rolling diversions to balance community needs across all hospitals so that no single hospital has to triage, she said.
“It’s everybody’s desire to never get to a point where we have to triage,” she said. “It’s our absolute intent and desire to not get there and do everything we can to stretch to avoid that.”
Bessel said the public can help, especially with the upcoming New Year’s holiday, by socially distancing, avoiding groups and wearing masks.
“These things absolutely work, and if we actually were much more exquisite in paying better attention to that, we could bend the curve so that we avoid triage, don’t even get close to it,” she said. “We can bend the curve so we can get off of some of these crisis standards that we’re already doing; we can bend the curve so we don’t have to do more activities under crisis standards of care; and also just keep less people feeling ill, having a terrible illness.”
State’s surge line helps move patients
The Arizona COVID-19 surge line, a state effort since April, works to distribute patients across the state so no one facility is overloaded, patients receive appropriate care and resources remain available even as hospitals are in a surge.
Over the past six weeks, the surge line facilitated 1,645 patients, according to the Arizona Department of Health Services.
Of those transfers, 84% were for patients needing a higher level of care and 15% were for patients going from acute care to skilled nursing setting.
While patients were sent from across the state, 76% of the transfers ended up in the central Arizona/Phoenix area.
The state does not have information on how often transfers for a higher level of care are due to bed capacity, staff constraints or available medical specialties, department spokeswoman Holly Poynter wrote in an email.
Post of HonorHealth said the surge line has been important, but it does increase the burden on hospitals especially in greater Phoenix and Tucson because that’s where the medical expertise and resources are centered.
Post said HonorHealth has been “very active” in receiving patients through the surge line but that no HonorHealth patients have been transferred out of the system since the pandemic began.
Banner and Valleywise are also on the receiving end of the surge line, getting patients from across the state.
“The surge line has been one of the shining stars that we have seen throughout the pandemic,” White said, adding that it’s an essential piece of every health care system’s goal of not having any one hospital or system be overwhelmed with COVID-19 patients.
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