Nurses have no ‘wiggle room’ in ICUs amid a surge of respiratory illnesses.
Los Angeles, California – “It feels like this endless, large-volume influx that keeps coming through our emergency department, or phone calls from outside hospitals who are also bursting at the seams,” Hui-wen Sato, an intensive care unit (ICU) nurse at a Los Angeles children’s hospital, said of a recent surge of RSV cases.
RSV, or respiratory syncytial virus, is a common virus that spreads mainly through direct contact or coughing. It usually causes mild symptoms but can be dangerous for young children and elderly people.
Across the United States, children’s hospitals are seeing a surge of RSV cases that are severely straining their capacity. As in the early days of the COVID-19 pandemic, some hospitals are building overflow tents to house more beds.
Sato, who has worked as a paediatric nurse for 12 years, said she has never seen such a high number of RSV cases, telling Al Jazeera that this year feels “exceptionally overwhelming”. Before the surge, her ICU was already under pressure due to staffing shortages. Nurses in the ICU can have a maximum of two patients, and while the unit physically has 24 beds, at times they have had to limit the number of filled beds to 20 because there aren’t enough staff.
Now, with the RSV surge, Sato said it’s a struggle to keep enough “wiggle room” for severe trauma patients coming through the emergency room. In the past, respiratory illness patients made up 50 to 60 percent of those admitted, but this year she estimated they make up about 70 percent.
Low morale, mental stress and illness have pushed droves of healthcare workers to quit since the pandemic began.
“There began this real steady departure of nurses from our hospital, but we’re hearing it happen everywhere,” Sato said. “The domino effect of the pandemic, nurses leaving, a [staffing] shortage and the biological reasons why there’s such a huge RSV surge is creating this perfect storm.”
Children’s hospitals and the American Academy of Pediatrics have called on the administration of US President Joe Biden to declare an emergency over RSV. But the administration has not yet done so, telling NBC News that “public health emergencies are determined based on nationwide data, science trends, and the insight of public health experts”.
On Sunday, the country’s top infectious disease expert, Dr Anthony Fauci, told CBS that children’s hospitals in some regions were being overwhelmed: “When the nurses and the paediatric associations are saying this is really critical, it is.”
The rise of the virus this fall may be connected to the lack of contact among children who were isolated during the pandemic, experts told Al Jazeera. Daniel Rauch, the chief of paediatric hospital medicine at Tufts Medicine, said preschoolers aged two to four are typically more resilient to RSV than infants, but this year it is making them sicker than usual.
“There’s a hypothesis that the kids getting it now, particularly that preschool age group, are the kids who didn’t get it last year and the year before in the pandemic, because they were isolated, and they weren’t around other sick kids, and they weren’t sharing those viruses,” Rauch told Al Jazeera.
A decline in paediatric hospital beds over the last 20 years is contributing to the current crisis, he said. US hospitals charge for the care they deliver, and in general, hospitals are paid more for an adult in a bed than for a child in a bed, because adults are more likely to need procedures that can be billed for, while children often only need supportive care, such as being placed on a ventilator or being given oxygen if they have a respiratory illness.
“A hospital that operates on a very thin margin has to decide: Are we going to take care of kids and potentially lose money on that? Or are we going to take care of adults and make more money for it – and that will support our care of everything else we do in the hospital? That’s unfortunately very simple math for a lot of hospital administrators,” Rauch said.
“We’ve lost this capacity over the last couple decades, and it’s because we don’t pay for paediatric care like we do for adult care,” he added. “And this is what happens when you don’t value caring for children.”
One final, unexpected factor is also contributing to the bed shortage, experts say: the increasing mental health crisis among young people.
The pandemic has led to increased isolation and stress among children and teens, leading to higher rates of young people struggling with mental illnesses such as depression and substance use disorder – and those children can end up in ICUs if they attempt suicide, Rauch said.
“Five years ago, I could have handled this surge better because my beds weren’t filled with kids with behavioural health issues … There’s no psych beds for them. They’re just stuck in the hospitals,” he said. “So my capacity is actually much less than it seems, because I have all these kids with mental health issues that I can’t send anywhere else. It’s the storm of combined events that have made it very difficult to have access to inpatient care.”
While there is no vaccine for RSV, the US pharmaceutical company Pfizer has announced it will submit one for approval by the US Food and Drug Administration by the end of the year. The vaccine would be given to pregnant people who would then pass antibodies to their infants.
Janet Englund, a professor of paediatrics and an infectious disease specialist at Seattle Children’s Hospital, told Al Jazeera that her hospital was also contributing research towards the development of an RSV vaccine. “The vaccine may be available to elderly high-risk individuals by 2023 or 2024,” she said. Until then, Englund and other experts recommend wearing a mask or staying home when sick, in order to protect others and reduce strain on the healthcare system.
Sato says she constantly worries that she may admit one person too many, meaning she would have to deny a bed to an especially sick child. She also feels the moral distress of having to push her staff, “when all I want to do is support them – because as the charge nurse, I have to keep this flowing”.
She recommends that people wash their hands, postpone social gatherings if they feel sick, and wear masks.
“We’re not asking people to mask forever,” Sato said. “We’re just asking people to help the healthcare system stay afloat, and if they could just wear their masks through this winter, so that we don’t see a departure of burnt-out staff and see the whole system crumble.”