The tension returns to the hospitals. After a spring on the front lines of the fight against covid-19, hospitals moved to the rear to regain care for patients with other pathologies and to reschedule the delayed activity. However, the boom of 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 approach – or exceed – 100% of installed capacity and visits to the emergency room that grow 40% in a few days. In communities like Catalonia, Andalusia or Castile and León, among others, they are beginning to acknowledge the increase in patients with covid-19 in their hospitals and are urging contingency measures, from restricting visits to opening more factories or postponing non-urgent interventions. Unlike the first wave, however, the maxim is to maintain care for greedy and non-greedy patients as much as possible.
“It looks more and more like the first stage of the pandemic. The situation is heterogeneous in Spain, but what happens most is a rapid increase in cases in the ICU, with a lower slope than the first time, but with significant inertia. And that caused many ICUs to exceed their capacity ”, summarizes Ricard Ferrer, president of the Spanish Society of Intensive Care Medicine, Critics and Coronary Units. According to the Ministry of Health, there are 14,539 people with covid-19 hospitalized in Spain, 2,031 in the ICU. This means a global occupation of 12% of conventional beds and 22.5% of critical beds, although the ministry’s calculation is measured by the sum of structural sites and spaces equipped with beds (operating rooms, resuscitation rooms) to respond to the pandemic. .
Going to the countryside, the situation is more worrying. In Castilla y León there are five hospitals that have already exceeded the normal capacity of the ICU and had to resort to other places to accommodate all their critical patients. The Ávila hospital has nine patients and already has 113% of its conventional installed capacity. In Palencia they were based on 14 ICU vacancies, but had to expand them because 22 patients are already hospitalized. This community, which has a cumulative incidence of 562 cases per 100,000 inhabitants and has four provincial capitals confined, adds 1,360 inpatients with covid-19.
For efficiency reasons, intensive care services already tend to work with relatively crowded ICUs, although they have room for maneuver to open and close beds depending on the availability of staff and demand. “Now that margin is getting smaller,” says Ferrer. In Catalonia, ICUs have long been at 80% of their conventional capacity, but the Generalitat has issued a warning because there are more and more greedy patients than other pathologies: before 20% of beds were occupied and now 40% are there ( 296 people), according to the Government. “The proportion of greedy patients increases and when this entry does not stop, we must prevent the entry of non-greedy. With confinement we know that this is done, but if we don’t want to, the only thing we can do is to interrupt the surgical schedule ”, says Ferrer. Some hospitals in Spain, says the specialist, have already had to postpone non-urgent interventions.
An example of this is Granada, where hospital pressure overloaded the operating rooms and this week the first non-urgent operations were 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 by Virgen de las Nieves and Clinico San Cecilio by up to 50%. “The situation is becoming critical, although it is very uneven. Covered circuits are better defined and capacity is better. Does this mean that there will be no collapse? Not much less ”, warns Rafael Carrasco, president of the Medical Union of Andalusia. Today, the 50 Andalusian hospitals serve 1,794 patients, 513 more than a week ago. “ICUs work a lot, but Granada is in a hurry”, sums up Carmen de la Fuente, president of the Andalusian Society of Intensive Care and Coronary Units (Samiuc).
Catalonia did not have to suspend activity on a general basis, but neither is it far from doing so. “It could happen soon. We would start with less relevant and routine pathologies ”, explains Julio Pascual, director of the medical and health area at Hospital del Mar de Barcelona, who saw revenue grow 40% in just one month. “In Vall d’Hebron, we tripled the number of patients hospitalized in conventional beds on the Pilar bridge [algo más de un centenar]. We are in a situation of increase, although the difference in relation to March is that it is not so abrupt ”, explains the medical deputy director of the center, María José Abadías. The doctor ensures that they strive to “maintain a balance” between normal activities and patients with covid-19.
In contrast to the first wave, when the tsunami of infections forced the switch almost exclusively from assistance to covid-19, hospitals conspired to keep normal activities as much as possible and prevent the waiting list from continuing to grow. “The first wave ended all non-greedy pathology, which has now returned. Now we see the two and we have not neglected any pathology due to saturation ”, says Pascual. Bellvitge hospital started operating on Saturdays to reduce waiting lists, and both this center and Vall d’Hebron have restricted escort visits to reduce the risk of transmission. In Catalonia, the cumulative incidence is about 430 cases per 100,000 inhabitants and the government has warned that infections will increase in the coming days.
Faced with the increase in the number of infected, hospitals in some areas, such as Navarra, which has the highest incidence in Spain (1,062 cases per 100,000), already have private health to refer patients and fluff their plants. A spokesman points out that, since the end of the summer, their hospitals have operated as an integrated network. “At the moment, normal activity has not been deprogrammed, although the afternoon shifts have been boosted with productivity, but we are seeing how long this can last according to the trend and the type of infections”, he adds. According to the association of private employers, ASPE, 21% of those hired in Murcia with covid-19 (386 people) are in private or subsidized centers.
Even in communities with better indicators – among the bad ones, hospitals are “vigilant”, admits José Flores, manager of the Galician Health Service (Sergas). In Galicia, which has 192 cases per 100,000 inhabitants, ICU admissions are around 75% of the maximum pandemic peak and the influx to the emergency room has increased by an average of 10% in the past few days. “We are concerned with evolution,” says Pedro Rascado, coordinator of the national ICU contingency plan and specialist in Intensive Care Medicine at the hospital in Santiago. In Coruña they also admit “concern” about the increase in cases and “significant pressure” in the emergency room. “Street diagnoses end up impacting the hospital and it has to be prepared. And it’s complicated because we have to serve patients with covid-19 and meet the needs of others, ”admits Pedro Marcos Rodríguez, pulmonologist and deputy director of Hospitalization and Emergencies in 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 the inmates, the health zone with the greatest pressure is Ourense, which is the oldest.
Still in the Valencian Community, hospitalizations increased in the last week by 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 the ICUs, there are 115 patients with coronavirus, 20.3% of the occupation in critical care (40% suffer from other diseases). A week ago, that record of criticism with coronavirus was 11.5%. Some ICUs need to start expanding their spaces in the face of a future outbreak.
Madrid is still stressed
The worst-off community is still Madrid, although after several weeks of growth, it has stabilized. “We are on a plateau, which allowed us to convert a greedy plant to a surgical one again. The activity of non-urgent specialties is recovering ”, explains the spokesman for Gregorio Marañón, who rescheduled activities in September to face the increase in infections. The emergency room dropped 40%, but assistance pressure persists in smaller hospitals and ICUs, which occupy 109% of the conventional capacity in the medical ICU, yesterday there were 484 patients.
The Basque Health Department also admits that the pressure on health is increasing (339 inpatients in the ward and 69 in the ICU), although they assure that Osakidetza has the capacity to set up 620 beds in intensive care. In Aragon, where the regional government confined the provincial capitals, hospital pressure grows: 628 inpatients (80 in the ICU), 204 more than in the beginning of October. There are 51 free ICU beds in the community.
However, one of the issues that most concerns the hospital sector, experts agree, is the lack of personnel to deal with the increased demand. “I am concerned with the inertia of the curve and the impact of the quarantines in the bathrooms. We cannot afford many quarantines and we are having it ”, admits Ferrer, who requires weekly PCR from the ICU team to avoid contagion. María José García, from Satse, warns that there has been no adjustment of human resources: “The system is starting to wear out and we have tired professionals who have not been able to recover physically and psychologically. We have to end job insecurity ”.
With information from Sonia Vizoso, Isabel Valdés, Ferran Bono, Mikel Ormazábal Y Javier Martín-Arroyo.
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