On Tuesday, the state of California's health and human services secretary, Dr. Mark Ghaly, announced that the state's stay-at-home order would be extended indefinitely for Southern California and the San Joaquin Valley.
The order, which covers an 11-county Southern California area, took effect on Dec. 6 and was set to expire January 4, 2021. The news was not a surprise, but the extension of the stay-at-home order illustrates how the state's biggest surge is threatening to exhaust intensive care units. It also comes at a time marking the grim milestone of being the deadliest month in the U.S. since the beginning of the pandemic, as numbers continue to surge.
"We essentially are projecting that the ICU capacity is not improving in Southern California and the San Joaquin Valley, and that demand will continue to exceed capacity," Ghaly said during a Tuesday press briefing.
ICU capacity, which has been the determining threshold on whether parts of California have to adhere to a stay-at-home order or not, is at zero percent — and like Ghaly said, that does not appear to be changing any time soon. Falling below 15 percent triggered California counties to adhere to a three-week order earlier this month.
Unfortunately, what California is experiencing is on trend for much of the country, which is a shrinkage in hospital resources and ICU beds. Arizona is currently having its worst surge since July, and an estimated 56 percent of the state's ICU beds are occupied by COVID-19 patients as of December 28. Parts of Nebraska, Alabama, Tennessee, Texas and New Hampshire are facing similarly dire situations, according to the University of Minnesota's COVID-19 Hospitalization Tracking Project. An estimated 62.8 million Americans live in counties where hospitals reported ICU bed occupancy of 90 percent or more earlier this month.
But what does that mean that ICU capacity is at "zero," and what happens when ICU beds reach zilch? And how does it affect people who have non-COVID-19 emergencies?
Dr. Robert Cherry, chief medical and safety officer at UCLA Health, explained to Salon in an interview there's a difference between available ICU bed occupancy and ICU capacity.
"I know it's concerning to hear reports that there are zero intensive care unit capacity in Los Angeles and in Southern California, however it's important to know there's a difference between ICU beds and ICU capacity " Cherry said. "We have the ability to provide critical care in other locations, outside of the intensive care unit, that includes the emergency department, and recovery rooms that are often used for post-operative ICU beds."
According to California's Department of Public Health, hospitals are required to submit daily reports on the total numbers of available staffed ICU beds, including both staffed ICU beds and staffed surge beds. Staffing is critical, as there must be healthcare workers available to take care of the people occupying ICU beds.
ICU capacity is a calculation that does not include neonatal ICU beds and pediatric intensive care unit beds. It only takes into account "standardized current adult ICU capacity," meaning that the calculation of a California region's ICU capacity is meant to ensure that sufficient ICU bed capacity is available for non-COVID related patients, too.
"You want to be able to take care of both COVID-19 patients as well as other types of emergencies and planned procedures," Cherry said. The main objective, he added, is to ensure that the region's hospitals are "maximized" for both COVID-19 patients and those who aren't suffering from COVID-19. "We still need to take care of heart attacks, strokes, pregnancies and the injured," he added.
Cherry emphasized that people in Southern California should still go to the emergency room if they have an emergency, and emphasized the importance of those with chronic conditions seeking treatment when needed.
"It's actually more important than ever that people with chronic conditions take care of themselves during this pandemic," Cherry said, noting that certain chronic conditions "predispose people to more severe COVID-19" cases.
Yet there are hospitals in Los Angeles county that have already reached a breaking point, and drastically exceeded their ICU capacity. According to a report in the Los Angeles Times, some hospitals have diverted ambulances elsewhere or patients have had to wait for hours. Last weekend, according to the report, Los Angeles County-USC Medical Center reportedly had to close its doors to all ambulance traffic for half a day. Another hospital, Memorial Hospital of Gardena, had to suspend ambulance calls for four hours to buy time to move patients. In some hospitals, patients have had to be placed in gift shops and conference rooms.
Cherry said UCLA Health hasn't had to turn away patients yet, but said the situation is fluid.
"We've been fortunate, for now, not having those prolonged wait times, but of course if the surge continues on past the holidays we could be potentially impacted," Cherry said. "Space is admittedly more tight and staffing resources are more strained with increasing patients, but we do have contingency plans for these types of scenarios."
When these contingency plans are exacerbated, patients may not be able to make their own medical choices on their treatment. For example, if a patient needs extra care in an ICU, but there are no resources available, "their case will be reviewed, along with other patient cases, to determine how these resources should be shared throughout the hospital," a December 2020 community letter from Huntington Hospital stated.
Ghaly told the Los Angeles Times that all hospitals are strained, but the crisis is more pronounced for smaller hospitals right now. Last month New Mexico exceeded its ICU capacity; many of the rural hospitals had to call around to other hubs and some patients had to go on waiting lists. In California, some hospitals started rationing care, starting with a temporary ban on elective surgeries.
According to ABC News, Kaiser Permanente has already started to postpone "non-urgent" surgeries in Northern California.
"Given the impact of COVID-19 on health care systems, we have postponed elective and non-urgent surgeries and procedures that take place in our main hospital operating rooms through Jan. 4 at our Northern California facilities," officials said in a statement. "We are not postponing cancer cases or other urgent/emergent surgeries and procedures."