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A Question of Health-Care Capacity

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A Question of Health-Care Capacity

With a limited supply of personnel, New York City’s hospitals may soon face a deluge of Covid-19 patients; a simple reform could help. March 20, 2020
Covid-19
New York
Health Care

New York City’s looming coronavirus catastrophe is—as has been widely observed—a logistical question of intensive-care capacity. The city’s limited supply of hospital beds and equipment, while sufficient to deal with ordinary demands for critical care, may soon be swamped by a deluge of desperately ill people.

Of the approximately 26,000 available hospital beds in the city, about 5,000 are designated as ICU beds. These typically run at about 80 percent of capacity. Mayor Bill de Blasio and Governor Andrew Cuomo are utilizing empty hospital space, shuttered nursing homes, and possibly vacant dormitories to create room for an additional 10,200 beds—but current projections of Covid-19 transmission estimate that the city could need as many as 20,000 critical-care beds within the next four to six weeks.

Mitchell Katz, the head of New York’s Health + Hospital Corporation, the nation’s largest public-hospital network, points out that the situation is not beyond control. “Intensive care is all about staffing and equipment,” he explains, “and I can make at Health and Hospitals any bed into an intensive care bed.” As Katz explains, “What’s important about intensive care and is relevant to this disease, is being able to provide people the level of oxygen, whether it’s through a nasal cannula, which are those little prongs in your nose, a face mask, all the way to intubation and the ventilator. And I can do that in any space, as can any hospital.”

New York has nurses, though not many to spare. According to the Census Bureau, the state had about 905 nurses per 100,000 people in 2011, slightly more than the national average of 874. Assuming that New York City has roughly 100,000 nurses in total, not all trained in critical care, and given that the accepted standard-of-care, nurse-to-patient ICU staffing ratio is, at most, 1:1.5—that is, no more than three patients for every two nurses—one sees that, regardless of how many physical beds are prepared, actually caring for potentially tens of thousands of very sick people will require Herculean efforts.

Creative solutions are on offer. The city is activating its Medical Reserve Corps, which consists of 9,000 health professionals who volunteer to serve the city in case of an emergency. Only about half the MRC volunteers are medically trained; the other half includes therapists, pharmacists, and dentists, though in a pinch their help is welcome. The city issued an emergency call for more volunteers, and 1,000 nurses and doctors—retired or from private practice—answered the call on the first day. Efforts are also under way to enlist the help of medical students.

These are heroic actors. Reports indicate that medical staff are particularly susceptible to Covid-19, owing to close contact with infected people, and are being hit especially hard. Intubating sick people, even with prophylactic gear, can expose staff to high viral loads—a sobering indicator that the intensity of illness is correlated to the proximity of direct contact, and a reminder that social distancing is the best way to avoid becoming infected or infecting others.

Unfortunate missteps have been made in the deployment of medical personnel. Hundreds of doctors and nurses were ordered into two-week self-quarantine because they had potentially been exposed to infected patients, regardless of whether they showed symptoms of the disease—wasting the valuable resource of trained professionals by benching them, on the chance that they may have been exposed. At this point, it is reasonable to assume that everyone has been exposed to the novel coronavirus, and should act accordingly, self-quarantining when symptoms arise. Quarantining asymptomatic medical staff is a Catch-22—once they leave quarantine and return to work, they will surely be re-exposed, and have to go back to quarantine.

New York’s quirky licensing regulations also set it apart from other states, to the detriment of the health of New Yorkers. Most states are party to the Nurse Licensure Compact, which lets registered nurses practice freely across the country. New York is not part of that compact, and a 2018 state senate bill to join it went nowhere. Given that some states—like Wisconsin and West Virginia—have many nurses and low rates of Covid-19, it would make sense to deploy nurses where they’re most needed. It isn’t clear whether this would be possible, though, under current law.

New York’s nurse-licensing requirements are governed by the state Board of Regents, which primarily sets standards for public schools, while regulations for doctors and physician assistants are overseen by the Health Department. The Board of Regents has been criticized for its sloppy and lax oversight of nurse quality and its low frequency of taking merited disciplinary action. And unlike every other state, New York relies on nurses to self-report felony convictions. In 2016, ProPublica analyzed dozens of cases of serious criminals who were allowed to continue nursing in New York after flawed vetting failed to remove them.

Of course, most nurses and other medical personnel in New York are dedicated professionals who deserve to be lauded. Now that federal assistance is on the way to help them, with Navy hospital ships scheduled to land in New York Harbor and Army teams set to establish field hospitals, New Yorkers pray fervently that these combined resources will be enough to breast a tsunami of infection that may be bearing down on us.

Photo by Thomas Lohnes/Getty Images

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