It has become a familiar refrain to read and hear about hospital capacity concerns the past several years. The latest threat to hospital capacity is the year’s respiratory virus season which is the first in which COVID-19 has co-circulated at high levels with influenza and respiratory syncytial virus (RSV). As COVID-19 has made strikingly clear, excess hospital capacity is not robust — and even lower with pediatric hospitals — and cannot be expanded during a sustained surge as easily as, for instance, the online platform Zoom expanded during the pandemic. As hospitals trudge through this year’s respiratory virus season, in which over three-quarters of hospital beds are occupied, revisiting some of the factors that set the context for this situation helps to identify possible paths to its remedy.
Empty hospital beds mean no revenue
Although many hospitals are not-for-profit entities that doesn’t remove the need for them to operate “in the black,” taking in more revenue than expense. Revenue is generated by patient care and, simply put, an empty bed cannot earn revenue (akin to an empty hotel room). This incentivizes hospitals to cut or close beds that — during ordinary times — are often unoccupied. The shift of many procedures to the outpatient setting also has decreased demand for inpatient beds.
Regulatory constraints
Coupled with the above is the fact that hospitals simply can’t expand capacity without consideration for constraints they might face from state and local governments that govern their operation (irrespective of a hospital’s “private” status). Hospitals are licensed for a certain number of beds and any augmentation of that number must be agreed to by the relevant government authority. In some states, via certificate of need laws, competitors have the ability to object to any increase in capacity if there is not an agreed upon “need” for it.
Even if a hospital is able to clear those hurdles, it is then subject to the glacial pace of local zoning boards and the bureaucratic web they weave if new construction is needed. During the height of COVID-19 when capacity concerns were paramount, UPMC, a hospital system in the Pittsburgh area (where I practice), was unable to build a new hospital due to zoning board objections and the case is now with the Pennsylvania Supreme Court.
Hospitals are also constrained in their ability to “convert” an adult bed into a pediatric bed, nurse-to-patient ratios and the ability to use alternative care sites (such as tents in the emergency department parking lot) to screen patients.
Not all beds are staffed
It is also the case that a hospital bed is not really operational unless it is able to be staffed by a nurse. In the current era, the supply of nurses is constrained as worldwide nursing shortages abound. Additionally, as nurses are not impervious to respiratory viruses, their daily numbers may fluctuate as some are invariably unable to work due to illness.
Solutions are difficult
There is no easy solution to this problem and the current demand driven by RSV, influenza and COVID-19 simultaneously — what some are calling a “tripledemic” — will certainly not be the last time this issue arises. Despite no quick fix, there are several actions that I believe would help in the near and longer term.
1. Load-balancing via health care coalitions: In a patient surge event it is important for hospitals in the same region or metropolitan area to work as a coalition and load-balance patients to prevent any one hospital from becoming inundated. This is easier said than done, as hospitals may oppose transferring patients to competitor hospitals.
2. Repeal Certificate of Need Laws: There is no reason that competitor hospitals should be able to stipulate how many beds a competitor hospital wants to operate.
3. Allow flexibility in conversion of bed types, nurse staffing ratios, and alternative care sites: Much of the impetus that drove some to advocate a public health emergency be declared for RSV was to seek this flexibility (which already does exist because it is covered by the COVID-19 declaration). This type of flexibility should be something that is built into everyday operations and not something only operable during an official emergency declaration.
4. Lift caps on the immigration of nurses: To solve the nursing workforce shortage, it is important to lift caps on the immigration of nurses from other countries (even when politically powerful domestic nursing unions invariably object).
If the U.S. is to have a health care system that is able to absorb the myriad infectious and other threats they face while still continuing to be able to perform their day-to-day surgeries, obstetric deliveries, psychiatric care, cancer screenings and all the other vital activities the communities they deliver care to depend upon, they must be empowered — and permitted — to have the capacity to do so.
Dr. Amesh Adalja is board certified in emergency medicine, critical care medicine, infectious disease and internal medicine. He is a senior scholar at the Johns Hopkins Center for Health Security. Follow him on Twitter: @AmeshAA