Health centers hold their breath in the face of the rise of the sixth wave of the covid. Hospital admissions and admission to intensive care (ICU) due to the coronavirus have almost tripled in the last month – there are 6,667 people hospitalized, 1,306 in the ICU – and health workers are watching with “concern” the coming weeks. Although the mass vaccination of the population – about 80% of Spaniards have completed the vaccination schedule – is working as a retaining wall to prevent collapse and hospital occupancy levels remain below those registered in other months of 2021, Health centers are already experiencing saturation and the short-term scenario is bleak: professionals predict more pressure on hospitals and primary care due to the expansion of the omicron variant, the effects of social interaction after Christmas and confluence of the coronavirus with the influenza virus.
They paint clubs for the health system: the healthcare pressure is intensifying and uncertainty looms over the immediate future. To begin with, because epidemiological indicators do not accompany, warns Álvaro Castellanos, president of the Spanish Society of Intensive Care Medicine: “Everything is on the rise and taking into account that the restrictions are not important, the forecast is that everything will continue to increase”, ditch . Nor does the foreseeable rise of social gatherings at Christmas parties, a breeding ground for the spread of the virus, or the threat of the omicron variant help. The European Center for Disease Control and Prevention (ECDC) has already set off all the alarms and urged hospitals to prepare for a foreseeable explosion of cases. “It is foreseeable that the omicron will cause more hospitalizations and deaths than those already contemplated in the forecasts that have only taken into account the delta,” reads the risk report published by the European health agency.
The hospital situation in Spain is not yet the one experienced in other waves. At this point, last year, with an incidence of 207 cases per 100,000 inhabitants, there were more than 11,300 patients admitted, about 2,000 in the ICU; This Friday, however, the infection rate was more than double, 511 cases per 100,000 inhabitants, and hospitalizations were 41% less: 6,667 admitted, according to data from the latest report from the Ministry of Health. But this wave is still on the rise and the situation is uneven among the communities: in fact, there are half a dozen communities with a hospital occupancy similar to or higher than the peak of their fifth wave – all below 8% – and there are also several, such as the Basque Country, Asturias or the Valencian Community, among others, whose ICU occupation is at the level of the peak of the previous wave.
For their part, in health centers, although the care burden has increased and they are still installed in a permanent saturation, they do not reach the collapse of the fifth wave: for example, in Aragon, explained last Wednesday a spokeswoman for the Ministry of Health. Health, some 4,300 case contacts are being followed up from primary care, but last summer this figure reached 18,500 and in October 2020, 24,300.
However, pressure is growing at all levels of care, and health workers are already experiencing overload. Jesús Díez Manglano, president of the Spanish Society of Internal Medicine and an internist at the Royo Villanova Hospital in Zaragoza, exemplifies: “The number of cases in my hospital has quadrupled in the last 15 days. It is not a collapse situation, but it is worrying. ” Pere Domingo, covid coordinator of the Sant Pau Hospital in Barcelona, agrees: “Last Friday [por el día 10]As things looked bad, some interventions were suspended, but in the end, the weekend was calmer than expected. We have 25 patients with covid in the ward and a dozen in the ICU [llegaron a tener 450 y un centenar, respectivamente, en la primera ola]. If this doesn’t get worse, we can put up with it. The problem is if this is a harbinger of what is going to happen ”.
Nine communities are already over 15% occupancy of ICUs with covid patients. There are even several that exceed 20%: the most “worrying”, in the opinion of Castellanos, is Catalonia, where a quarter of its critical beds are already full of patients infected by coronavirus (338 people). María José Abadías, assistant director of the Vall d’Hebron, the largest hospital in Catalonia, points out that hospitalization “is growing slowly” and the situation is still under control: last week they had about twenty patients in critical condition, many fewer than the 220 who came to attend simultaneously in the first wave. Also Sonia García de San José, assistant manager of the Hospital Gregorio Marañón in Madrid, points out that the situation in her center is under control, but they are “expectant”: “We see an increase in pressure in the emergency room, with about 600 patients a day, among 50 and 80 more than usual. And the percentage of positive covid tests went from 7% to 26% in one week. But the pictures we see are lighter, ”he explains. They have not yet had to alter the surgical schedule or enable new covid plants.
The most common patient profiles in this sixth wave, both in the ICU and in the ward, agree the experts consulted, are two: unvaccinated and elderly people with risk pathologies (immunosuppressed or with chronic ailments) who have completed the vaccination schedule a long time ago. Puncture protection in this group declines over the months, Castellano points out: “Now we see that 60% are vaccinated: the virus affects more immunosuppressed people and the protective effect of the vaccine declines.”
The intensivist points out that the average age of those admitted to the ICU is between 60 and 63 years. In the plant, adds Díez Manglano, there are also people, especially between 50 and 70 years old: “There are elderly people with the complete vaccination schedule or the three doses and also people 15 years younger than these and who are not vaccinated or have the incomplete guideline ”. The internist insists that, even though there are vaccinated people who are admitted, hospitals are “on a contained rise thanks to vaccines”: “Any vaccine helps prevent the disease, but it is not 100% effective. In older people, just as the whole body ages, so does the immune system: it generates fewer antibodies and less response to the vaccine ”. Even so, Díez Manglano specifies, “these vaccinated people who are entering arrive with less serious conditions than those who entered a year ago.”
Contingency plans have not yet been widely deployed in health centers, but some hospitals have already had to take action. At the San Jorge de Huesca Hospital, for example, more specific beds have already been opened for patients with covid, and in Vigo non-urgent operations have begun to be reprogrammed. In the Basque Country they have increased ICU places at the end of November and have limited the surgical programming. Also at the Valdecilla Hospital in Santander a new covid ICU has been opened and two operating rooms have been closed this week. In Navarra, where the global hospital occupancy is around 79% (due to covid, non-covid and recovery of ordinary activity), the fifth floor of the University Hospital of Navarra has already been converted to provide differentiated care to patients with coronavirus. Home care has been reinforced and some non-urgent operations have been deprogrammed.
Saturated primary care
For its part, primary care also denounces the saturation of health centers, which are assuming the care of their conventional patients, the vaccination campaign and the detection and monitoring of positives and their contacts. The president of the Galician Association of Family and Community Medicine, Susana Aldecoa, warns: “In Ourense, primary care is overloaded as never before in this pandemic.” Primary care personnel are also experiencing infections again because, Aldecoa points out, the triage circuits of patients have been “relaxed”, and now they enter the consultations without going through a prior control of symptoms.
María Fernández, a doctor in Madrid and spokesperson for the Spanish Society of Family and Community Medicine, is also shown in this line: “Hospitals are still calm and tense because we are the anteroom, but we are already drowning.” The doctor warns that the consultations are overflowing with face-to-face and telephone visits, the nurses cannot cope and the bureaucracy is eating them up: “We are tired, without support, without reinforcements. We are always behind the pandemic, there is no proactivity ”, he laments.
From end to end of the country, the diagnosis is repeated in primary care. A doctor from a health center in Mallorca who prefers to remain anonymous, assures that they do not get to everything: “Now we are joined by the suspicion of covid with people who come for other pathologies and bring a list of reasons for late consultation. This is crazy, ”he laments. And, in addition, there is a lack of professionals: “In my center, for example, today there are three colleagues missing and I have 30 patients cited, plus the emergencies that come from my quota, plus the patients of my colleagues, who we have to attend to. because they don’t replace them ”, he exemplifies. They can’t take it anymore, he insists: “We are tired, burned out and we feel abandoned. You no longer have the fear of the first waves, but psychologically and physically we are exhausted ”.
Short-term uncertainty
Faced with the coming weeks, health centers are waiting. The uncertainty of the role that some epidemiological variables will have prevents them from predicting what will happen, the experts consulted admit. Clara Prats, researcher in Computational Biology at the Polytechnic University of Catalonia (UPC), warns, for example, that “the evolution of ICU occupation in Catalonia is going through the upper range of the estimated values and that is worrying”. Physics, an expert in projections of the pandemic, looks uneasily at the omicron variant: “If it were a wave of the delta variant, between third doses and some lesser measure, it could be well controlled. But what we see with the omicron variant, which seems up to two or three times more transmittable than the delta, is a change of scenery from one day to the next. It’s like, all of a sudden, you hit a switch. It would have to lower the severity a lot to compensate for the collapse that this high transmission can generate ”.
Neither would an eventual convergence of the covid wave with a flu epidemic have a minor effect. Last year, there were hardly any cases of this seasonal virus, but now some are beginning to be seen, says Abadías: “The covid already lets in other viruses: we have already admitted some patients with the flu and we have already had a lot of pressure at the level of the Pediatric ICU due to respiratory syncytial virus [el microorganismo causante de la mayoría de las bronquiolitis en los más pequeños]”. Professionals urge to maintain individual protection measures to combat covid-19 and other respiratory viruses, but also accelerate vaccination against coronavirus in children and the third doses in risk groups to cut transmission and avoid income.
However, in a scenario of more saturation, experts agree that health centers now have more elasticity than at the beginning of the pandemic to adapt their resources to the needs of the moment. They can assemble and disassemble beds in a few hours. Also enable entire plants and activate devices with agility. But they warn that another saturation will take its toll on the population, which will once again see non-covid care postponed to respond to the pandemic, and also on professionals: health workers are “more prepared,” Domingo points out, but “more tired.” Especially seeing the one that is coming over them, he admits: “We are between fear and boredom.”
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