America's hospitals are in bad shape right now — overwhelmed and understaffed — just as the omicron variant of the coronavirus takes hold across the country and Americans begin traveling and socializing for the holidays.
The Centers for Disease Control and Prevention released new figures late Monday showing that the omicron variant now accounts for 73.2% of new coronavirus cases in the U.S.
That's a sixfold increase from the previous week, when the CDC estimated 12.6% of cases were caused by omicron.
This news comes at a time when many US. hospitals are depleted by an exodus of health care workers who have quit or taken other jobs and are already buckling under the strain of caring for COVID-19 patients across the Northeast, Midwest and Southwest.
"It's bad news for COVID patients and it's bad news for everybody else who needs hospital-level care," says Dr. Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security.
At this point in the pandemic, hospitals know how to prepare for the worst-case scenario — whether that's stockpiling equipment or opening up field hospitals — but many no longer have the requisite manpower to muster the same all-hands-on-deck response as they did during previous surges.
"When it comes to the workforce, it's fair to say we're facing a national emergency," says Rick Pollack, president of the American Hospital Association.
How hard will an omicron-driven surge hit U.S. hospitals?
Omicron is on track to send new infections soaring quickly in the U.S., as it already has in Europe and the U.K., but it's unclear just how bad an omicron-driven surge will be for hospitals. The latest models project a wide range of scenarios — from a small bump in hospitalizations to an inpatient surge that's even bigger than those hospitals faced last winter.
But while models are helpful, most experts warn there's no time to wait to see how omicron affects U.S communities. Omicron cases are doubling at such a fast pace that "if we wait for signals in increasing hospitalizations, we're probably too late by a substantial amount," says Marm Kilpatrick, an infectious disease researcher at University of California, Santa Cruz.
Omicron did not hit South Africa's hospitals as hard as earlier variants like delta, but a recent study on omicron in the U.K. concludes there's no evidence yet that omicron has a different level of severity compared with delta.
Kilpatrick says the impact in the U.S. could look very different than in South Africa, given how many Americans are vulnerable to the virus — either because they are completely unvaccinated, haven't gotten the booster or are generally older and more susceptible because of chronic illness. And, even if omicron turns out to cause less severe illness than earlier strains did, hospitals could still be overwhelmed because a small fraction of patients ending up with severe illness could still add up to a huge number.
"I'm quite concerned," says Kilpatrick.
New research shows that when hospitals become overburdened, the consequences are dire: Patients are more likely to die.
One study found nearly 1 in 4 COVID-19 deaths was "potentially attributable to hospitals strained by surging caseload." Another showed that COVID-19 surges were associated with higher mortality among other kinds of patients, too.
"Staffing gets stretched to a point where you just can't really effectively provide critical care" says Dr. John Hick, an expert on hospital response to medical disasters. "Stuff gets missed. Patients die because of small errors."
Facing a 'perfect storm,' with few options to add capacity
The arrival of omicron in the U.S. comes at a time when many states are already reporting that hospital ICUs are full and emergency rooms are overloaded.
Currently, about one in every five ICU beds in the U.S. is occupied by a COVID-19 patient. In some states, it's much higher than that.
"I do feel like we are looking at a perfect storm, potentially," says Dr. Stanley Martin, director of infectious diseases for Geisinger, one of Pennsylvania's largest health systems.
Geisinger's hospitals are running at over 100% capacity and patients who need ICU level care can't always find a bed quickly — or at all, says Martin. "We've had patients who we've had to take care of in the hallways."
In Minnesota, hospital CEOs recently took out a newspaper ad warning the public that "access to care is being seriously threatened by COVID."
"We've never seen these kinds of sustained volumes — half my [emergency] department's usually waiting for an inpatient bed that doesn't exist," says Hick, who's also an emergency physician at Hennepin Healthcare in Minneapolis.
When hospitals get packed, there are not many ways to create more capacity — let alone to prepare for another wave of patients, he says: "It's a pretty bare-looking cupboard ... for the next few months, it's going to be kind of gutting it out in the trenches here."
Not every region of the country is dealing with the same onslaught of COVID-19 patients, yet many hospitals are still at or exceeding capacity because of how the pandemic has disrupted health care for so many months.
"We are bursting at the seams," says Dr. Amy Compton-Phillips, chief of clinical operations at Providence, which has hospitals up and down the West Coast.
Hospitals are also affected by capacity problems in other parts of the health system. For example, about 20% of patients at Providence's hospitals are ready to be discharged, Compton-Phillips explains, but there's nowhere to send them — in large part because nursing homes and long-term-care facilities are also short-staffed and don't have room to absorb new patients, she says.
Meanwhile, other patients are coming to hospitals for long-delayed surgeries or showing up sicker because of chronic health problems that went unmanaged during the pandemic.
"We're doing a lot very, very rapidly to make sure that we have capacity when the next wave comes, but none of it's easy," says Compton-Phillips.
Could some hospitals return to rationing care?
With omicron moving so quickly, the time needed to shore up U.S. hospital capacity is rapidly disappearing.
Even large hospital chains don't have many options for preparing, other than moving equipment around and pleading with the public to get vaccinated and take precautions, says Dr. Dan Roth, chief clinical officer of Trinity Health.
"You can make more masks quickly, you can't make more nurses," says Roth. "We could open up a new unit, or a new field hospital, but we wouldn't be able to staff it as easily [as last year]."
Given the uncertain outlook, Dr. Toner of Johns Hopkins says state leaders and hospitals need to decide now how will they respond to what could be an even worse surge than last winter's and with a health care workforce that is even more exhausted and depleted.
"There's no magic bullet," says Toner. "The only way to adapt at this point would be to not do other things."
In hard-hit states like Ohio and Rhode Island, hospitals are already needing to cancel procedures that aren't considered emergencies or even delaying care for some types of emergencies because of a shortage of staffed beds. The federal government has also sent in members of the military to support hospitals in some states that are currently dealing with a surge.
It's possible a wave of omicron-driven illness across the country could force hospitals to take drastic steps and start rationing who gets care altogether.
States like Idaho and Alaska already reached that point earlier in the pandemic when they activated "crisis standards of care," directing hospitals to prioritize certain patients over others based on their chance of survival. For example, this can mean that certain patients are not given dialysis or an ICU bed, even though they would benefit from the treatment.
Even if states don't activate "crisis standards," clinicians have already faced harrowing situations when patient demand soared — and they expect to face them again.
"Politically, it's very hard for state health departments and governors to acknowledge that those are the choices that we're getting down to," says Dr. Hick of Hennepin. "But if we can't make that choice, I don't know how we really engage in conversation about limiting resources on a broader scale."
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