January 8, 2021

The next big shortage in Covid-19 care? Oxygen.

Daily Briefing

    As a surge of Covid-19 patients increases demand for oxygen, hospitals in areas of California, Texas, and elsewhere are tackling major fault lines in the supply chain and equipment necessary to deliver the gas to patients.

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    'It's been nuts, absolutely nuts'

    While oxygen itself isn't in short supply, the "crush" of patients requiring supplemental oxygen as part of their treatment for Covid-19 "has stressed the infrastructure for delivering the gas to hospitals and their patients," according to Kaiser Health News. These stress points include not just weaknesses in the oxygen supply chain, but also with hospital piping and equipment that was not designed to meet this level of demand.

    For instance, in terms of the supply chain, demand for oxygen put pressure on access to the portable cylinders that contain oxygen; the concentrator devices that pull oxygen from the air; nasal cannulas, the tubes needed to give patients oxygen; and even in some cases, the sheer quantity of oxygen that hospitals need delivered.

    "It's been nuts, absolutely nuts," Esteban Trejo, general manager of the El Paso, Texas-based industrial and medical gas distributer Syoxsa, said. Trejo, whose company's clients include several temporary hospitals established to care for Covid-19 patients, said he was fielding midnight calls as far back as November 2020 from customers worried about oxygen supplies—and, when Syoxsa's usual supplier fell through, the company was hauling oxygen from Houston, necessitating a 10-hour plus drive each way.

    Hospitals' oxygen infrastructure threatens to buckle under demand

    Perhaps even more troublesome is the strain such high demand for oxygen is placing on hospital's infrastructure, KHN reports.

    According to KHN, oxygen is frequently stored in liquid form at very low temperatures—around minus 300 degrees Fahrenheit, "about as cold as the surface of Neptune"—to save space. However, as hospitals have had to convert massive amounts of liquid oxygen to gas to care for the surge of Covid-19 patients, some are seeing ice form over the equipment designed to make that liquid-to-gas conversion. And as hospitals have to pull increasing amounts of liquid oxygen from the storage tanks, the frigid liquid can soak further into the vaporizing coils where it is converted to a gas form.

    And that's an issue, Rich Branson, a respiratory therapist at the University of Cincinnati and editor-in-chief of Respiratory Care, said. He explained that while some ice formation is normal, an excessive amount of ice can cause the device valves to freeze in place—essentially freezing the system to a stop. "You can completely—literally, completely—shut down an entire hospital supply if that happens," Branson said.

    Further, according to Robert Karcher—VP of contract services for Acurity, a group purchasing organization that contracts with hospitals—the ice can also restrict airflow in the piping that delivers oxygen to patient rooms. And while hospitals can address the issue by using backup vaporizers (if they have them), hosing down iced-over vaporizers, or shifting patients to cylinder-stored oxygen, those alternatives can further strain oxygen-cylinder supply and medical gas suppliers.

    Overall, the Army Corps of Engineers has surveyed 11 hospitals in and around Los Angeles for issues related to frozen oxygen piping—a mix of older hospitals and smaller facilities experiencing high demand amid the Covid-19 surge, according to Corps spokesperson Mike Petersen.

    And the issues are particularly severe for hospitals that have had to reconfigure regular hospital rooms into ICU rooms; since ICU pipes are typically larger than those elsewhere in the hospital, the pipes for converted rooms are sometimes too narrow to deliver the necessary amount of oxygen.

    As a result, hospitals are once again relying on oxygen cylinders, Cathy Chidester, director of the L.A. County Emergency Medical Services Agency, said—but vendors are facing challenges meeting demand. In fact, since even smaller oxygen cylinders and oxygen concentrators are in short supply, patients who would otherwise be sent home with mobile oxygen units are forced to remain hospitalized—and use a bed that could be otherwise open for someone else, KHN reports.

    Similarly, hospitals in Fresno County are also "scrambling for oxygen-making machines," as they try to discharge Covid-19 patients who would otherwise remain hospitalized to make room for a continual influx of new patients, the Los Angeles Times reports. And while hospitals in Fresno County said they can still adequately supply patients with oxygen—thanks in part to aid from American Ambulance, which has oxygen-generating machinery and refill tanks—there are concerns that hospitals in the area could face the same infrastructure challenges as hospitals in L.A. county.

    "We're trying to do as much as we can to track down the supplies that will be needed just to prepare ourselves for an even larger number of patient volumes in the weeks to come," Rais Vohra, Fresno County interim health officer, said.

    'We've never reached capacity before—until now'

    These issues aren't just limited to Los Angeles and El Paso, KHN reports. Physicians in the Navajo Nation as early as December 2020 said they needed more oxygen and oxygen-delivery supplies for patients in the hospital and at home. "We've never reached capacity before—until now," Loretta Christensen, CMO for the Navajo Area Indian Health Service, said in December.

    According to Christensen, the facilities are older and aren't designed to care for such large numbers of severely ill patients. The hospitals quickly realized that as they put more patients on high-flow oxygen, their oxygen flow was weakening—an issue stemming from the hospitals' insufficient oxygen-delivery systems.

    And while some hospitals have since bolstered their reserves, such as one hospital that put in new filters to optimize oxygen flow, medical facilities in the nation are always "on edge" due to limited supplies, KHN reports. For instance, Tséhootsooí Medical Center has occasionally had to keep patients in the hospital who would otherwise be sent home with oxygen cylinders and transfer incoming patients elsewhere.

    "Honestly, we worry about supply a lot out here because—and I call it extreme rurality—you just can't get something tomorrow," Christensen said. "It's not like being in an urban area where you can say, 'Oh, I need this right now'" (Bichell/Weber, Kaiser Health News, 1/7; Lin/Money, Los Angeles Times, 1/6).

    Learn more: How Covid-19 will impact the supply chain

    supply chain

    Covid-19 has revealed critical shortcomings in the health care supply chain. Shortages of personal protective equipment (PPE), ventilators, and other vital supplies have hindered the U.S. health care system‘s response to this crisis, and additional waves of shortages are likely in coming months.

    Read our take to learn three requirements for a more resilient, transparent supply chain in light of Covid-19.

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