Why some hospitals have to scramble for oxygen to treat Covid-19 patients

As Covid-19 cases began spiking last month, Mara Bryant and her hospital staff had to scramble to ensure enough oxygen was available.

As the number of patients at Adventist Health White Memorial Hospital in Los Angeles reached 200 a day, the facility quickly began using six times its normal amount of oxygen. To cope, a 6,000-gallon tank was added as a back up to the usual 9,000-gallon tank, but finding that extra tank took two weeks. And once it was in place, it had to be refilled every day or two.

“When you’re talking about Covid, running out of oxygen would be your worst nightmare,” said Bryant, the operations executive at Adventist Health, which also runs a hospital in nearby Glendale, California. “You need a high flow of oxygen to try to help people breathe as they fight the virus. But that’s a very heavy use. Our problem was that we were consuming oxygen so fast, we started to get pressure fluctuations in our system. You don’t want to see that. Oxygen needs to flow regularly to be safe for patients.”

The issue does not appear to have emerged in a widespread way outside of California. But if other hospitals were to face similarly overwhelming demand for oxygen, they could run into the same challenges. Normally, between 15% and 20% of hospital patients might require respiratory support such as oxygen, but that percentage has ballooned amid the pandemic, according to Devin Hugie, an independent consultant, who was formerly a facilities and operations executive at CHOC Children’s Hospital in Orange, Ca.

Although oxygen itself appears not to have been in short supply, other factors — notably, surging demand, but also aging infrastructure and a run on spare oxygen storage tanks — have created crisis upon crisis for many hospitals in and around Los Angeles that were already struggling to combat the pandemic.

“This all depends on some variables – the size of the hospital system and number of patients they’re trying to serve,” said Hugie. “Not all facilities are having a problem. But we’re talking about a pandemic. I wouldn’t say what’s happened in California is a fluke.”

Some Los Angeles area hospitals caring for Covid-19 patients, for instance, have been plagued by freezing pipes. The hospital plumbing that takes liquid oxygen from on-site storage tanks can freeze when too much oxygen is forced through the hospital piping. This is because oxygen is very cold as it moves from a liquid to a gaseous phase, and a sudden increase in volume will cause a system to ice up.

Think of it this way:  The liquid oxygen is pumped through a ¼-inch pipe designed for distribution to 25 faucets. But if you turn on 50 faucets, the pipe is unable to handle the sudden increase in volume. When this happens, the temperature will fall. And if it falls too far too fast, the mechanism designed to regulate the pipeline pressure will no longer function properly.

“Typically, when you design a medical gas system, you’re not designing for all 100% of the outlets in the facility,” said Chad Beebe, deputy executive director at the American Society of Healthcare Engineering. “Now, you have an increased number of beds with patients needing ventilators and more oxygen flowing at a higher rate… It’s the kind of problem that can creep up on hospitals.”

A spokesperson for AirGas, one of the major oxygen suppliers whose customers includes Adventist Health, wrote us that the company has seen an increased demand for bulk liquid medical oxygen from hospitals. This is especially true in areas facing higher rates of Covid-19 cases and hospitalizations, although she declined to specify which areas of the country.

The supply of oxygen in the southern California area appears to be sufficient at this point, according to Rich Gottwald, who heads the Compressed Gas Association, which represents companies that supply medical gas to hospitals. “The problem is that many hospitals are trying to put too much oxygen through systems that can’t handle it,” he told us.

Another factor that contributed to the scramble to supply oxygen in southern California is a shortage of oxygen cylinders, the portable tanks that are also used by hospital emergency rooms and patients at home. Like the propane tanks used for outdoor grills, an empty tank must be returned to the hardware store and swapped for a fresh canister.

But overwhelmed by the pandemic, some Los Angeles-area hospitals did not return all their empty cylinders to suppliers, which caused shortages. Meanwhile, a lack of cylinders has emerged elsewhere in recent weeks, notably among emergency medical services units, according to one hospital executive.

“The smaller portable tanks do not last very long — a few hours — and need to be exchanged. These are in limited supply, which is why EMS is having so much difficulty with keeping their supplies adequate,” said Lewis Nelson, who chairs the Department of Emergency Medicine at Rutgers New Jersey Medical School and University Hospital in Newark, N.J. He added that his hospital has not encountered the problem.

For his part, Gottwald believes that the issue in Southern California is plateauing. At the same time, the number of new cases in the U.S. has been falling. As of Feb. 3, more than 26.5 million Covid-19 cases were confirmed. But an especially big spike in the number of cases in other large metropolitan areas, such as what was seen in Los Angeles, could create more widespread problems.

The possibility exists if only because more contagious Covid-19 variants have sparked concerns about the potential for upticks in the number of cases nationwide. So far, federal health officials have confirmed 546 cases attributed to variants, largely involving a strain first documented in the U.K.

“I’ve been in this line of work for 30 years and folks went through some level of motion to prepare, but I don’t think any of us in the industry had any idea what a pandemic really meant and the demands on our facilities and our systems,” Edmund Lydon, senior director for facilities and support services at Beverly and Addison Gilbert Hospitals in Massachusetts. “Unfortunately, there’s just so much pressure you can push through a pipe.”