Last week’s nationwide nurses strike, and another strike this week by medical technicians, come as no surprise given the massive health crisis brought on by the coronavirus pandemic. Medical workers are collapsing beneath the strain.
According to data reported by the Ministry of Health last week, four of the country’s largest hospitals are already exceeding their bed capacities. Worst among them is Hadassah Ein Kerem in Jerusalem, operating at 120% of its overall bed capacity and, in its Coronavirus ward, at 152% of capacity.
Part of the explanation, emerging in Knesset hearings on August 3rd, is that hospitals added just 19 beds since February and instead shifted beds in other units to newly-opened Coronavirus units.
This is unacceptable but not unexpected. Anyone familiar with scenes of patients in beds lining hospital corridors during the high demand winter season knows that Israel doesn’t have enough hospital beds in the best of times. This means that hospitals and staff have been overwhelmed, potentially compromising both patient and staff safety well before the novel Coronavirus infected tens of thousands of Israelis, hospitalized more than 700 (300 in serious condition, of whom nearly 100 are breathing with the aid of mechanical ventilators), and placed more than 3,000 healthcare workers in isolation.
Healthcare experts estimate that hospitals in which patients fill an average of more than 80-85% of its beds are generally less likely to be able to provide high quality and safe care during periodic patient surges. Among OECD countries, the average bed capacity is about 75%. In Israel, that rate, as reported by the Taub Center last year, is 94%. With just 2.2 hospital beds per 1,000 population, Israel has almost 40% fewer beds than the OECD average (of 3.6 per 1,000 population). Last year Haaretz reported that these rates were the worst in 20 years.
The shortages extend beyond beds in internal medicine departments, however. With fewer than 250 ICU beds nationwide, Israel is at the bottom among OECD countries, as pointed out in a 2019 Israel Health Policy Journal. This means that there haven’t been enough beds in ICUs to meet the demand for mechanical ventilation even before COVID-19 pneumonias. And, again, before COVID-19, many hospitals met the demand for mechanical ventilation by placing intubated patients in internal medicine departments where they are monitored not only by fewer staff, but by staff whose training is not equivalent to that of ICU teams.
Staffing matters. Here again, Israel falls short. According to the OECD, the number of active physicians in Israel has been declining since at least 2000 and is today about 12% below the average in OECD countries. At the same time, Israel employs 42% fewer nurses per 1,000 patients.
How do these rates translate into care quality as the number of COVID-19 patients surges? And what do these rates mean for the staff that Minister of Health Yuli Edelstein righty called “angels in white” on a recent visit to a hospital Coronavirus ward?
Until data about Israel’s situation are available, reports from other countries suggest that we have a problem. According to reporting from the New York Times, patients with COVID-19 were three times more likely to die in under-resourced than in wealthier New York City hospitals during the March through May COVID surge. In the wealthy Manhattan hospitals, there are typically about 5 beds per 1,000 residents. However, in the city boroughs with high COVID-19 death rates the average number of beds per 1,000 residents before the pandemic looks a lot like Israel’s: 1.8 in Queens, 2.2 in Brooklyn, 2.4 in the Bronx.
We learned from the New York experience, however, that simply adding beds merely spreads staff among more and more patients, inevitably compromising care quality. For example, best practice ICU staffing (in Israel and internationally) is one nurse for every two patients. While numbers are currently not available in Israel, in New York City during the COVID surge, one nurse cared for three to four patients in the better resourced Manhattan hospitals.
In the underfunded hospitals in Queens, Brooklyn and the Bronx, however, one nurse cared for seven to nine patients. With less time for monitoring, particularly of patients on ventilators who need constant attention, the Times reported that many people died unnecessarily – an outcome that also contributes to the emotional trauma healthcare workers from around the world increasingly report from hospitals that have been overwhelmed with COVID patients.
Even before COVID hit Israeli hospitals, the healthcare system was underfunded, under-bedded, and understaffed. The price can be detected in overflowing wards, in chronically overworked staff, and in the quality and safety of care that patients receive. There are many ways to gauge quality of care. One international measure is the number of patients who are injured or sickened as a result of their hospital stay. The Ministry of Health reports that more than 4,000 patients die every year from infections they got while hospitalized. As patients with COVID-19 surge, it’s not unreasonable to expect this – and other indicators of quality – to get worse.
It’s not safe and it’s not fair to assume that even highly trained and dedicated healthcare workers can compensate for systemic failures – for the lack of beds or for shortages of sufficient and appropriately trained staff. Until we begin making the needed repairs to the healthcare system as a whole, the least that those of us who are not “angels in white” can do is to work very hard to stop the spread of the pandemic.