The people caring for Alaska’s most vulnerable patients say a new flood of COVID-19 cases is stressing the state’s already compromised intensive-care system at levels they’ve never seen before.
Alaska’s ICU system is maxed out — too many patients and not enough staffed beds, medical professionals from the state’s top doctor to floor nurses said this week.
Summer is normally a busy time for hospitals, as tourists, vehicle wrecks and outdoor recreation crank up patient numbers, or rural residents put off medical care to pull in salmon for the winter at fish camp.
But right now, Anchorage critical care units are experiencing prolonged capacity issues exacerbated by increasingly short staffing and a new challenge: the ongoing COVID-19 surge driven by the highly infectious delta variant that’s triggering a wave of severe illness in younger, sometimes otherwise healthy people, nearly all unvaccinated, who need time-consuming levels of care.
Statewide, more than five times as many people are hospitalized with the virus now — 132 as of Monday — as there were in early July. COVID-related deaths are rising, too. One infectious disease doctor had three patients die in the space of a week recently -- one every day for three days.
As of Tuesday, there were just a handful of ICU beds available across the city, according to a municipal dashboard. A statewide hospital dashboard showed Anchorage’s three ICUs closed or near capacity.
Nurses face constant pressure to work extra shifts. High-level managers are handling bedside patient care. Some critical care patients end up in beds outside the ICU, increasing their mortality risk. Some critical care nurses are seeing COVID-19 deaths in patients younger than they are.
““It’s relentless. There’s no let up,” said Jacque Quantrille, director of critical care nursing at Alaska Native Medical Center. “When you walk in the door and you come to work there is no down time. Cold coffee, cold pizza, barely a lunch break. The level of illness for these patients, we’re seeing them far sicker for far longer. They’re requiring more resources.”
Seattle hospitals are so full it’s preventing Alaska hospitals in Southeast from transferring patients there, providers here say. The national COVID-19 surge makes it harder to get traveling, fill-in nurses to Alaska.
The ICU crunch comes with another new challenge here: few restrictions in place at the municipal or state level to try to stall the spread of the virus.
Last year, state and municipal officials enacted strict COVID-19 mandates such as travel restrictions and, in Anchorage, a mask mandate and capacity restrictions, to safeguard the state’s fragile hospital capacity.
Now Gov. Mike Dunleavy and Anchorage Mayor Dave Bronson say the decision to wear masks, much less get vaccinated, is up to individual Alaskans.
Hospital officials say they don’t see a quick end to capacity problems without a change in behavior like broad vaccination or masking.
A system under stress
The sickest people in Alaska’s hospital system end up in Anchorage’s three big hospitals — Providence Alaska Medical Center, Alaska Regional Hospital and the Alaska Native Medical Center — in ICU beds reserved for acutely ill people who need special equipment like ventilators or close monitoring from doctors and nurses trained in critical care.
Anchorage, with just over 60 of the state’s 120 ICU beds, often sees patients transferred for higher levels of care from rural communities around the state.
This week, COVID-positive patients made up almost a third of patients in Anchorage ICUs. Their cases are complicated and time-consuming, doctors and nurses say. They are intubated, on ventilators. They may get pneumonia. Often they need dialysis because the respiratory distress caused by the virus deprives their kidneys of oxygen. Blood clots can compromise their limbs.
Transferring patients from one hospital to higher levels of care elsewhere is currently significantly delayed statewide because no one has space, according to Dr. Ryan Webb, a hospitalist who sees patients at Providence.
Webb said he’s treating more people in their 30s or 40s than ever — all very sick COVID-19 patients, all but one unvaccinated.
He said hospitals are doing a good job coordinating to make sure patients get the care they need.
“But the system itself is under a great deal more stress than I’ve ever seen before,” Webb said. “What I see is a very stressed ICU system statewide. And the way that manifests is we are getting more frequent calls from outlying hospitals that are facing the same pressures we are in terms of increasing number of very ill patients.”
View from the floor
Marcy Merrill, an RN in the Providence intensive-care unit, looked at her phone on her day off Monday to see a message from work.
“I have already received today a text from one of my managers … we are two nurses short for day shift and at least two nurses short for night shift,” Merrill said. “That’s just today. I get a message like this every single day.”
The hospital is offering bonuses and crisis pay. She stayed home.
The former hospital administrator says she loves her job and cares about her patients. But there just aren’t enough nurses for the sicker-than-ever patients she’s seeing. A day off is essential.
The ICU has been at short staffing levels every time she’s worked lately, Merrill said. That means she’s expecting to not get any breaks on her next night shift in the ICU later this week.
“I’m gonna have to suck it up because I’m not coming in on my day off to help either,” she said. “We’re not upset at our fellow nurses at all. There’s no problem with our fellow nurses. It’s the same for us. We know it’s going to be hard.”
The hospital holds COVID-19 patients in a designated area with negative pressure rooms. Nurses don and doff respirators, gowns, hair and shoe covers to enter those rooms, a time-consuming process. IV poles hung with various fluids and medications sit outside the rooms, so the nurse inside a room with a patient doesn’t have to run out, removing all that gear, just to change out a bag when alarms sound.
Merrill’s biggest fear as a nurse is one of her patients -- say, a COVID-19 patient held “proned” on their stomach to help them breathe, their eyes taped shut, a feeding tube up their nose -- comes out of sedation and realizes they can’t move.
“Imagine a moment when each one of us is in with one patient and there’s nobody out there and you have two or three pumps going off. And some of those pumps are life-saving,” she said. “Imagine that going off and you wake up.”
Longer waits for care
The ongoing ICU crisis prompting hospitals to scramble to make room for patients trickles down.
Without enough space in the ICU, critically ill patients are sometimes housed in already crowded emergency rooms, leading to lengthy ER waits for others.
“The heart attacks are waiting longer. The strokes are waiting longer. The kiddo with the laceration on their hand is waiting longer,” said Dr. Anne Zink, the state’s chief medical officer, who also works emergency department shifts at Mat-Su Regional Medical Center.
Anchorage hospitals are busy, but so are those in other parts of the state. Zink, working a weekend shift, said the hospital had three patients referred from the Yukon-Kuskokwim Delta Regional Hospital in Bethel.
“I have never had a referral from Bethel in Mat-Su,” she said. “Ever.”
Usually, Bethel hospital managers who need to transfer a patient for ICU-level care reach out first to Alaska Native Medical Center, then the other Anchorage-area hospitals, according to a spokesperson for Yukon-Kuskokwim Health Corp., the tribal health organization that operates the hospital. If those hospitals are at capacity, the hospital looks to other critical care units in the state and then, if needed, beyond Alaska to Seattle.
“Transfer capacity at ANMC and Anchorage hospitals for our critically-ill patients has been off and on for about 10 days,” YKHC spokesperson Tiffany Zukolsky wrote in an email Monday. “Ultimately this delays our ability to get patients to facilities that can offer the next-level of care they need. To date, we’ve not had to transfer COVID critical patients, but patients needing higher levels of care for other issues.”
Zink, in turn, transferred five patients to a hospital in Seattle, two of them ICU patients who needed respiratory treatment not available here. Normally the hospital transfers maybe one patient a month to Seattle.
“So, it’s hard. It’s heartbreaking,” she said. “Every patient that you see, you’re struggling to figure out what resources are available or not available.”
Full beds, new strategies
Hospital officials described an organized but constant chaos in Anchorage ICUs this week.
Providence had 29 staffed ICU beds this week including a “crash” bed reserved for emergencies, according to nurse supervisors. As of Tuesday, there were patients in nearly every bed including eight COVID-19 patients. At most, the ICU has one or two beds open at any given time.
The patients are almost entirely intubated and unconscious but the floor is busy, said Kate Pojedinec, an RN who serves as the clinical manager of the ICU.
“We’d like to have a little more breathing room,” Pojedinec said. Operating so close to capacity for long puts pressure on moving people out of ICU, but also can compromise the floor’s ability to take patients from other facilities or from Providence’s ER or other parts of the hospital.
Alaska Regional Hospital has 14 ICU beds, with three COVID-19 patients on ventilators, according to chief medical officer Dr. Tim Ballard, who said the hospital is managing the high patient loads but “barely treading water” in doing so. Regional recently used its ambulance bay to isolate people with COVID-19 symptoms who came to the ER.
“We’ve been busy just like everywhere else,” Ballard said. “Essentially every day at some point our facility has no availability and our staff make it work every day. It’s sort of a cycle of admissions versus discharges.”
There are 22 beds in the Alaska Native Medical Center critical care unit. As of Tuesday, six of held COVID-positive patients, according to Quantrille. All the beds were full. The hospital has an 8-bed unit that can convert to critical care. They are full too.
The hospital is using anesthesia and emergency staff to help treat critical care patients, said Quantrille, who herself is temporarily filling in as an emergency department director.
She’s also occasionally working with patients again for the first time in six or seven years, filling in behind her nurses. She keeps scrubs in her office.
Over the weekend, the hospital held a critical care patient in emergency for nearly two days, Quantrille said.
“I want to share the level of intensity that we’re suffering,” she said.