In recent years, it has become a familiar refrain to read and hear about concerns about hospital capacity. The latest threat to hospital capacity is this year’s respiratory viral season. It is the first in which COVID-19 has co-circulated to a large extent with influenza and respiratory syncytial virus (RSV). As COVID-19 has made startlingly clear, excess hospital capacity is not robust — and even lower in pediatric hospitals — and cannot be expanded as easily as, for example, the online platform Zoom, which was expanded during the pandemic. As hospitals manage this year’s respiratory viral season, which has occupied more than three quarters of hospital beds, reviewing some of the factors that provide the context for this situation will help identify possible remedies.
Empty hospital beds mean no income
Although many hospitals are non-profit organizations, they still have to be “in the black” and generate more income than expenditure. Revenue is generated through patient care, and simply put, an empty bed can’t generate revenue (much like an empty hotel room). This is an incentive for hospitals to cut or close beds that — in normal times — are often not occupied. The shift of many procedures to the outpatient sector has also led to a reduction in demand for inpatient beds.
Added to this is the fact that hospitals simply cannot expand their capacity without taking into account the restrictions they may face from the state and local authorities that govern their operations (regardless of a hospital’s “private” status). Hospitals are licensed for a specific number of beds, and any increase in that number must be approved by the appropriate government agency. In some states, demand certification laws allow competitors to object to any capacity increase if there is no agreed “need” for it.
Even if a hospital is able to overcome these hurdles, it is subject to the speed of local development authorities and the bureaucratic network they create when new buildings are required. At the height of COVID-19, when capacity issues were paramount, UPMC, a hospital system in the Pittsburgh area (where I practice), was unable to build a new hospital due to objections from the zoning authority, and the case is now in the Pennsylvania Supreme Court.
Hospitals are also limited in their ability to convert an adult bed into a crib, the ratio of nurses to patients, and the ability to use alternative care facilities (such as tents in the emergency room parking lot) to examine patients.
Not all beds are occupied
It is also the case that a hospital bed is not really operational unless it can be staffed by a nurse. Nowadays, the supply of nurses is limited as there is a shortage of nurses all over the world. Since nurses are not immune to respiratory viruses, their daily numbers may also fluctuate, as some are invariably unable to work due to illnesses.
Solutions are difficult
There is no easy solution to this problem, and the current demand, driven by RSV, influenza, and COVID-19 at the same time — what some call a “tripledemic” — will certainly not be the last time this issue comes up. While there is no quick fix, there are several measures that I believe would help in the short and long term.
1. Burden balancing through healthcare coalitions: When there is a surplus of patients, it is important that hospitals in the same region or metropolitan area work together as a coalition and balance patients to prevent a hospital from being flooded. This is easier said than done, as hospitals could refuse to transfer patients to competing hospitals.
2. Laws to repeal the requirement certificate: There is no reason why competing hospitals should be able to determine how many beds a competing hospital wants to operate.
3. Flexibility in changing bed types, staff quotas for nurses and alternative care facilities: Much of the impetus that prompted some to declare a public health emergency for RSV was to seek this flexibility (which already exists because it is included in the COVID-19 statement). This type of flexibility should be integrated into daily operations and not only work during an official declaration of emergency.
4. Lifting limits on nurse immigration: To address the shortage of nurses, it is important to remove limits on the immigration of nurses from other countries (even though the politically powerful home health care unions invariably object).
If the US is to have a healthcare system that is able to intercept the myriad contagious and other threats it faces, while remaining able to carry out its daily operations, obstetric deliveries, psychiatric treatments, cancer screenings, and all the other vital activities that the communities that care for them depend on, it must be empowered — and approved — to do so.
Dr. Amesh Adalja is certified in emergency medicine, intensive care, infectious diseases, and internal medicine. He is a senior scientist at the Johns Hopkins Center for Health Security. Follow him on twitter: @AmeshAA