Across the state, a health care system that has largely risen to the challenge of managing more than 100 young children hospitalized with respiratory syncytial virus is facing a new stress test: a sharp increase in adult patients with the flu and COVID-19.
There could be some relief on the horizon soon. Epidemiologists hope that RSV cases in Oregon may have hit their peak this week and could decline quickly over the next month.
OHSU Hospital, 2019.
Courtesy of Oregon Health & Science University
But in the short term, there are signs the state’s overtaxed health care system could run out of staff, or beds, or both, as it faces its first full respiratory virus season with COVID, flu, and RSV all circulating at the same time.
In Southern Oregon, a small coastal hospital has declared that it is operating under crisis standards of care this week as it struggles to manage patients who need urgent surgery and cardiac care.
“The health care system in our community is constrained,” said Virginia Williams, CEO of Curry General, the Southern Oregon hospital that declared the crisis. “That would be a story in and of itself. The problem is it’s constrained everywhere.”
In Portland, the Multnomah County public health officer is reporting that all emergency department waiting rooms across the city are all full and she’s urging people to start wearing masks indoors again to cut down viral transmission and keep hospitals from being overwhelmed.
“Just put a mask back on when you’re indoors around other people,” said Dr. Jennifer Vines, stressing that her recommendation was for a “personal voluntary action,” and not a government mandate.
Coastal community hospital struggles
Curry General, an 18-bed hospital in Gold Beach, Oregon notified state officials on Wednesday that it is operating under crisis standards of care.
Curry General largely serves an older population, not children, and it made the crisis care announcement after surges of adult patients came into its emergency department and staff had difficulty finding places to transfer adults who needed a higher level of care.
In the Portland area, three hospitals announced last week they were switching to crisis operations, specifically in their pediatric intensive care units. Those hospitals have added pediatric ICU beds and increased nurse workloads to cope with a surge in very young children hospitalized due to RSV, a typical childhood virus that is causing an unusual number of hospitalizations this year.
Related: OHSU shifts to emergency mode amid rise in serious pediatric cases
Curry General is a critical access hospital that provides the lowest level of trauma care available in Oregon. The emergency department there stabilizes the sickest patients until they can be transferred elsewhere in the region, typically patients are transferred to Bay Area Hospital in Coos Bay or one of Asante’s hospitals in the Rogue Valley that provide intensive care and more specialized services.
With emergency departments and hospital beds filling up around the state, the time it takes to get patient transfer requests approved has grown “exponentially,” said Curry General CEO Virginia Williams.
The hospital is particularly concerned about patients who need cardiac care. Curry General can stabilize cardiac patients, but does not have a cardiac catheter lab, meaning it is unable to diagnose or remove blockages in arteries or perform procedures like heart surgery or placing a stent.
Williams says ideally, cardiac patients only stay at Curry General for an hour or two.
But this week, one cardiac patient at Curry General waited for 54 hours before getting a transfer to a hospital that could provide a higher level of care. Another patient waited 36 hours.
“Our holding them, every minute, it’s really dangerous,” Williams said. “It’s not good.”
A third patient with a bowel obstruction was also forced to wait much longer than normal for surgery, increasing the risk of a perforation because there were no surgeons available across the region when the patient arrived.
Curry General is not turning any patients away, though emergency department wait times have climbed to around eight hours.
Williams said she made the crisis standard of care declaration because the public “has a right to know what to expect when they go to the emergency room.”
This week, the hospital still has adequate staff to treat everyone coming in the door, but with many weeks of respiratory season ahead, staffing could become a critical problem for Curry General as well.
“We just cannot continue to burn the staff out that we have, and yet we don’t have a really good plan to backfill them,” she said.
Emergency departments full across Oregon
Dr. Alex Skog is the president of the Oregon Chapter of the American College of Emergency Physicians. He works in the emergency department at Providence Willamette Falls Medical Center.
Skog says Curry General’s decision to declare it is operating under crisis standards of care is unusual, but the pressures it is facing are not.
Since the pandemic started, the amount of time it takes smaller hospitals and rural hospitals to transfer patients who need a higher level of care has increased, in some cases drastically.
“This is another wave in what’s been a three-year long crisis,” Skog said.
He said he recently managed more than 50 patients in an emergency department with 20 beds.
“Despite the best effort and fantastic training of everyone that works in my hospital, it would be untrue to say that I can provide the same level of care to patients as I would have in 2018,” he said.
Masking, other measures, could preserve hospital capacity
In Multnomah County, health officer Dr. Jennifer Vines is stressing what people can do to reduce viral transmission.
Vines is asking people to take precautions, including getting a flu shot and a COVID shot or booster, frequent hand washing, and masking in crowded indoor spaces through Jan. 1.
Vines said she is not asking people to cancel plans for gatherings, but she does recommend masking for everyone in crowded indoor settings, including in day cares and schools.
The strain from flu and COVID-19 comes comes as children’s hospitals in the Portland area say they have successfully scaled their operations to deal with a historic surge in pediatric RSV hospitalizations.
And data from the past two weeks gives some hope that the RSV crisis may have reached its peak. The number of hospitalizations fell the week of Thanksgiving, before climbing slightly this week. The percent of RSV tests coming back positive has leveled off at around 23% after climbing rapidly in late October and early November.
OHSU’s Doernbecher Children’s hospital and Legacy’s Randall Children’s hospital have added dozens more beds for the sickest children by converting single rooms into doubles in their pediatric intensive care units. At Doernbecher, the hospital will begin adding pediatric ICU beds in other surge areas, said Dr. Carl Eriksson, a pediatric critical care specialist at OHSU.
Both hospitals are accepting transfers of children from across the state and there is no waitlist for pediatric ICU admission.
“The goal here is that we are able to provide care for every child that needs our care,” Eriksson said.
Another strain on the system right now is that parents are bringing in children who do not require hospital level care.
Related: How to treat a child with RSV safely at home — and when to call the doctor
At Randall, only about 10% of patients who are evaluated in the emergency department are admitted to the hospital.
Dr. Wendy Hasson, medical director of the pediatric intensive care unit at Randall, said it is crucially important for parents to understand that children should not be brought to the emergency department solely because they have been exposed to RSV and parents desire a test.
“Seeking care for testing alone is not an appropriate use of resources right now and is contributing to overwhelming the emergency departments and urgent cares,” said Hasson.
For any child who has general cold symptoms, knowing the name of the virus involved does not change their course of treatment Hasson said, “because the management for all these viruses is supportive care.”
Parents also do not need to bring children over 2 months old to the emergency department for fever alone.
Reasons to seek emergency care are if a child is struggling to breathe, showing signs of dehydration, or is listless and no longer interested in eating or playing.