The tension returns to the hospitals. After a spring in the front line of combat against covid-19, hospitals had moved to the rear to recover care for patients with other pathologies and reschedule the activity that was delayed. However, the boom in cases that this second wave is dragging in Spain has once again put hospital capacity on the ropes. Saturation is uneven in the country, but there are already intensive care units (ICUs) that close to – or exceed – 100% of their installed capacity and visits to the emergency room that grow 40% in a few days. In communities such as Catalonia, Andalusia or Castilla y León, among others, the increase in patients with covid-19 begins to showin their hospitals and rush contingency measures, from restricting visits to opening more plants or postponing non-urgent interventions. Unlike the first wave, however, the maxim is to maintain, as far as possible, care for covid and non-covid patients.
“It looks more and more like the first stage of the pandemic. The situation is heterogeneous in Spain, but what is happening the most is a rapid rise in cases in the ICU, with less slope than the first time, but with significant inertia. And this has led to many ICUs being over their capacity ”, summarizes Ricard Ferrer, president of the Spanish Society of Intensive, Critical Medicine and Coronary Units. According to the Ministry of Health, there are 14,539 people with covid-19 admitted to Spain, 2,031 in the ICU. This means a global occupancy of 12% of conventional beds and 22.5% of critical beds, although the ministry’s calculation is measured on the sum of the structural places and the spaces equipped with beds (operating rooms, resuscitation rooms) to respond to the pandemic.
Going to the field, the situation is more worrying. In Castilla y León there are five hospitals that have already exceeded their usual ICU capacity and have had to resort to other additional places to accommodate all their critical patients. The Ávila hospital has nine patients and it is already at 113% of its conventional installed capacity. In Palencia they had, as a base, 14 ICU places, but they have had to expand them because there are already 22 patients admitted. This community, which has a cumulative incidence of 562 cases per 100,000 inhabitants and has four confined provincial capitals, adds 1,360 admitted patients with covid-19.
For reasons of efficiency, intensive care units already tend to work with relatively full ICUs, although they have room for maneuver to open and close beds depending on the available staff and demand. “Now that margin is getting smaller and smaller,” says Ferrer. In Catalonia, ICUs have been at 80% of their conventional capacity for some time, but the Generalitat has launched an alert call because there are more and more covid patients than with other pathologies: before they were 20% of the beds occupied and now they are around 40% (296 people), according to the Government. “The proportion of covid patients rises and when that entry does not stop, the entry of non-covid must be stopped. With confinement we know that it is achieved, but if we do not want that, the only thing that can be done is to stop the surgical programming ”, says Ferrer.
An example of this is Granada, where hospital pressure has overwhelmed the operating rooms and this week the first non-urgent operations have been suspended due to the danger of saturation, which is getting closer and closer. With a cumulative incidence of 976 cases per 100,000 inhabitants, Granada has reduced surgical interventions and consultations at the Virgen de las Nieves and Clínico San Cecilio hospitals by up to 50%. “The situation is becoming critical, although it is very uneven. The covid circuits are better defined and the capacity is better. Does this mean that there will be no collapse? Not much less ”, warns Rafael Carrasco, president of the Andalusian Medical Union. Today the 50 Andalusian hospitals support 1,794 patients, 513 more than a week ago. “The UCIs work quite hard, but Granada is in a hurry”,
Catalonia has not had to suspend activity in a generalized way, but it is not far from having to do so either . “It could happen shortly. We would start with less relevant and routine pathologies ”, explains Julio Pascual, director of the healthcare and medical area at Hospital del Mar in Barcelona, who has seen income grow by 40% in just one month. “ In Vall d’Hebron we have tripled the number of patients hospitalized in conventional beds from the Pilar bridge [just over a hundred]. We are in a situation of increase, although the difference with respect to March is that it is not so abrupt ”, explains the medical deputy director of the center, María José Abadías. The doctor assures that they strive to “maintain the balance” between ordinary activity and patients with covid-19.
Unlike the first wave, when the tsunami of contagions forced to reconvert almost exclusively assistance to covid-19, hospitals have conspired to maintain ordinary activity as much as possible and prevent the waiting list from continuing to swell. “The first wave swept away all non-covid pathology, which has now come back. Now we see both and we are not neglecting any pathology due to saturation, ”says Pascual. The Bellvitge hospital has begun to operate on Saturdays to reduce its waiting lists and both this center and Vall d’Hebron have restricted the visits of companions to reduce the risk of transmission. In Catalonia, the accumulated incidence is around 430 cases per 100,000 inhabitants and the Government has warned that infections will increase in the coming days.
Given the increase in infected, hospitals in some areas, such as Navarra, which has the highest incidence in Spain (1,062 cases per 100,000) have already relied on private health to refer patients and fluff their plants. A spokesperson points out that since the end of the summer, its hospitals function as an integrated network. “At the moment, ordinary activity has not been deprogrammed, although afternoon shifts have been reinforced with productivity, but we are seeing how long this can be according to the trend and the type of infections,” he adds. According to the private employer’s association, ASPE, 21% of those admitted to Murcia with covid-19 (386 people) are in private or subsidized centers.
Even in the communities with the best indicators —within the bad—, the hospitals are “vigilant”, admits José Flores, manager of the Servizo Galego de Saúde (Sergas). In Galicia, which has 192 cases per 100,000 inhabitants, ICU admissions are around 75% of the maximum peak that has been experienced in the pandemic and the influx to the Emergency Department has risen by 10% on average in recent days. “We are concerned about the evolution,” says Pedro Rascado, coordinator of the national contingency plan for ICUs and specialist in Intensive Medicine at the Santiago hospital. In Coruña they also admit their “concern” about the increase in cases and a “significant pressure” in the emergency room. “Street diagnoses end up having an impact on the hospital and it has to be prepared. And it is complicated because we must respond to patients with covid-19 and attend to the needs of the rest ”, admits Pedro Marcos Rodríguez, pulmonologist and deputy director of Hospitalization and Emergencies of the Health Area of A Coruña and Cee. Of the 5,580 active cases in Galicia, 373 are hospitalized, 48 of them in the ICU. With almost a third of those admitted, the health area with the most pressure is that of Ourense, precisely the oldest.
Also in the Valencian Community, the admissions have increased in the last week between almost 40% in the ward and 46% in the ICUs. This Tuesday there were 735 people on the floor with covid-19, which represents 7% of the total available beds (60.2% are patients with other pathologies). In ICUs, there are 115 coronavirus patients, 20.3% of the occupation in critical care (40% suffer from other diseases). A week ago, this record of critics with coronavirus was 11.5%. Some ICUs have to start expanding spaces in the face of a future upsurge.
Madrid is still stressed
The worst stopped community is still Madrid, although after several weeks on the rise, it has stabilized. “We are on a plateau, which has allowed us to convert a covid plant into a surgical one again. Non-urgent specialties activity is recovering, ”explains a Gregorio Marañón spokesman, who rescheduled activity in September to face the rise in infections. The emergencies have dropped by 40%, but the care pressure persists in the smallest hospitals and in ICUs, whose occupation is 109% of the conventional capacity in medical ICU, yesterday there were 484 patients.
The Basque Department of Health also admits that healthcare pressure is increasing (339 admitted to the ward and 69 to the ICU), although they assure that Osakidetza has the capacity to set up 620 beds in intensive care. In Aragon, where the regional government has confined the provincial capitals, hospital pressure grows: 628 patients admitted (80 in the ICU), 204 more than at the beginning of October. There are 51 free ICU beds in the community.
However, one of the issues that most worries the hospital sector, experts agree, is the lack of personnel to deal with an increase in demand. “I am concerned about the inertia of the curve and the impact of the quarantines of the toilets. We cannot afford many quarantines and we are having them ”, admits Ferrer, who demands weekly PCR from ICU staff to avoid contagion. María José García, from Satse, warns that there has not been an adaptation of human resources: “The system is beginning to strain and we have tired professionals, who have not been able to recover physically and psychologically. We have to end job insecurity ”.