What the omicron surge is like at an ICU in Miami and how treatments are helping.

Jennifer E. Engen

Coronavirus Diaries is a series of dispatches exploring how the coronavirus is affecting people’s lives. This as-told-to essay is based on a conversation with Joseph Falise, director of nursing for critical care and progressive care at the University of Miami Hospital and Clinics. It has been transcribed, condensed, and edited for clarity by Marion Renault.

At the beginning of December, we had fewer than 10 COVID patients, which means we just need a few nurses and we make sure that those patients are well taken care of. Early in December, our predictive analysis team started telling us, “get ready.”

At first, I didn’t want to believe it. None of us did. Everybody’s so exhausted and just frustrated. Nobody wanted to see it. Nobody wanted to hear it, especially with the holidays coming.

Then, slowly but surely, we started to see the numbers go up. The number of positive cases has skyrocketed. In the state of Florida, in one day, we had 58,000 positive cases. Right now, I think our COVID census—the number of patients with the disease—is in the 50s. We expect that 20 percent of those will need ICU care. We’re preparing for that.

When COVID first started, we created ICU space, and it had to become an ICU very quickly. At our hospital, we never stopped buying and purchasing PPE—we actually rented off-site warehouses so that we could stockpile it. And never, not since day one, have we ever said we’re increasing our staffing ratios because we don’t have enough nurses. Our mantra has always been “we will spend more.” So we never really faced a shortage of staff or PPE. We were one of the lucky ones.

We’re also fortunate to have the predictive analysis team. They look at wastewater and cellphone usage, things like that, to predict what the COVID numbers will be. From the second surge on, our team has really been able to predict pretty closely how big our next surge is going to be.

Throughout the surges, we have flexed up and flexed down, as far as how many units we have open, how many beds are available. We’ve learned through six surges that there’s a pattern to this. The cases start going up in the community, then the hospitalizations go up, then the ICU admissions go up, and then the mortality goes up.

The cycle is pretty predictable at this point. The time in between surges gives us an opportunity to make sure that we’re refreshing what needs to be refreshed ahead of time: setting up equipment, replacing missing cables, checking monitors. When you’re in the middle of a surge, it’s not the time to find out that you don’t have enough equipment. We’re literally asking plant operations and facilities management people to come in and fix all of these things between peaks.

Think about it—in a patient’s room, if something goes wrong with a toilet, how do you get that fixed knowing that that’s in a COVID unit and you don’t want to bring anybody in that unit without protection? During the non-surges is when we really try and pick up all the pieces and put everything back together so that we get ready to really become a little bit of a war zone again. In those times, I really pray every day that the next surge never comes.

I think some people may not understand the amount of coordination that’s needed to, at the drop of a dime, be able to stop and say, “OK, it’s 2 o’clock in the afternoon, and four of these patients have now turned into ICU patients.” As soon as the patient starts needing critical care, there’s an enormous amount of support that’s required. Where do we find those nurses from?

In the middle of a surge like we are right now, the main priority is, on my part, to find extra agency nurses that our hospital doesn’t have. For the most part, we bring in an enormous amount of travelers, or agency contract staff, to meet demand and offset where we’re losing nurses.

Because regular, organizationally based staff nurses are leaving in droves for agency compensation packages three and four times what we can pay them. That’s what’s happening all over the country, even within our own state. We have nurses from our organization who are quitting, finding an agency job, and literally going 50 miles away to work. Some of them are just going across the street. Every hospital has seen this. Every hospital is having nurses that are quitting and going to work for a travel agency.

And for the nurses who stuck it out with us, we’re asking a lot of them. We’re asking them to do more work. We’re asking them to watch over the people who are just temporary and who come to our hospital not knowing anything about our protocols or our practices or our background work. Somebody comes in making three times what you’re making, and all they had to do was travel a little bit to go do it. There’s a tendency for that to look a little bit unfair. But as much as there’s a little bit of resistance to having them there, we would never survive without travel nurses.

And their assignments can be unfair, too. It’s all based on demand, so they go to where the hot spots are. They’re unsafe. They’re so under-resourced and understaffed. When they come back, travel nurses tell me stories about how they were asked to take four ICU patients on a regular basis, how the CEO worked from home for the entire pandemic, how there was no senior leadership that ever rounded on the floors. There was no concern for their well-being. There was no PPE. These are all things that I have heard.

We have also seen nurses who were ready to retire, who have just said, “I’m done.” I say, “I thought you had a couple more years,” and they say, “It’s just not worth it.” There’s a few on my staff alone that have done that. I have seen a couple of people who have completely left nursing.

I would say, as I talk to the nurses that work in the COVID unit right now, I sense more optimism. In the first and second surges, we saw so much death and dying and suffering. It was really, really, really heartbreaking.

This time, patients just aren’t as sick. The general mindset now is we’re going to treat their symptoms till they get past it. We’re going to give them remdesivir. We’re going to give them IV steroids. We’re going to give them IV antibiotics. We’re going to monitor them. Then we’re going to send them home. Now, whether or not that changes, we won’t know until it actually happens, but for right now, the majority of the patients that we have are not in danger of dying.

As much as omicron has just completely annihilated the population, we have better practices in place now. We’ve learned from our mistakes. We’ve learned from our past experience. We have better supplies. As somebody who has led that charge, that response, from the beginning, I can tell you that we’re much better prepared.


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