As Covid-19 cases spike all over the country, many healthcare systems are in desperate straits. States that proudly saw thousands of their nurses fly out this spring to “frontline” hotspots like New York City, Seattle, New Orleans, and Boston are now starved for resources themselves. With the latest stage of the pandemic coursing through 48 states, the frontlines are often in smaller cities and rural states that tend to lack the amenities common at metropolitian hospitals. Local and state health care systems are struggling to treat patients amid dire shortages of staff, beds, and equipment.
Under the strain of the present surge, healthcare systems are assigning non-Covid patients to beds in convention centers, hospitals are canceling elective surgeries, ICU nurses are working 60-hour weeks, and nurses who sped to New York in April are now working overtime to treat Covid patients in their hometowns. Areas that are especially overwhelmed, such as El Paso, store their dead in mobile cooling units staffed by jail inmates, and airlift non-Covid patients to hospitals in cities that for the present have escaped the new surge. In addition to seeking aid from National Guard medics, the American Hospital Association’s vice president of quality and patient safety, Nancy Fosterome, told Stat News that some hospitals are even turning to local dentists, Red Cross volunteers, and people with basic health experience to help with tasks that require less training.
In North Dakota, the weight of the Covid caseload—currently the worst in the country and, per capita, one of the worst in the world—has effectively broken the state’s contact tracing system. Kailee Lingang, a University of North Dakota nursing student now helping with contact tracing in the state, told the Washington Post that “Test and trace went by the wayside. Even if we had enough staff to call up everyone’s workplace and contact, there are so many new infections that it wouldn’t be as effective. At this point, the government has given up on following the virus’s path through the state. All we can do is notify people, as quickly as we can, that they have the virus.”
In Indiana, the state and local healthcare systems are sputtering in the wake of a 60% increase in hospitalizations. One doctor in the state, Timothy Mullinder, told MedPage Today that patients “who need to go to the ICU have been stuck in the ER for 24 hours because there are no beds available. Post-operative patients are stuck in the PACU recovery area well over 24 hours because there are no beds available.”
With the entire state out of staffed hospital beds, Iowa’s healthcare system is also overwhelmed. Whitney Neville, an Iowa nurse, told the Atlantic on November 13, “Last Monday we had 25 patients waiting in the emergency department. They had been admitted but there was no one to take care of them.” The strain on the system, combined with the state’s relaxed social distancing policies, prompted one infectious disease doctor to speak in near-apocalyptic tones: “The wave hasn’t even crashed down on us yet. It keeps rising and rising, and we’re all running on fear. The health-care system in Iowa is going to collapse, no question.” The problem, however, extends well beyond North Dakota, Texas, and Iowa. A November 17 Atlantic article found that 22% of all US hospitals are facing staffing shortages, and added, “More than 35 percent of hospitals in Arkansas, Missouri, North Dakota, New Mexico, Oklahoma, South Carolina, Virginia, and Wisconsin are anticipating a staffing shortage this week.”
At the center of the system, nurses and other healthcare workers are working as many shifts as they can, while doing their best to attend to waves of incoming patients. The latest surge, however, has driven a growing number of nurses to express their frustration with incoherent policies and public intransigence on the matter of masking, social distancing, and incredulity over the very existence of the virus. Michelle Cavanaugh, a nurse at the Nebraska Medicine Medical Center, spoke for many when she told a Utah reporter, “We’re seeing the worst of the worst and these patients are dying, and you go home at the end of the night and you drive by bars and you drive by restaurants and they’re packed full and people aren’t wearing masks. I wish that I could get people to see COVID through my eyes.”
Nurses in North Dakota came out against a new policy that allows healthcare workers with asymptomatic SARS-CoV-2 infections to continue working at hospitals and nursing homes.
The policy was issued Monday by North Dakota Gov. Doug Burgum, who announced an amended order that allowed coronavirus-positive health workers to work in the COVID unit of a licensed healthcare facility as long as they remain asymptomatic and additional precautions recommended by the CDC and the North Dakota Department of Health are taken.
In a statement released Wednesday, the North Dakota Nurses Association objected to allowing nurses with the virus to continue working, emphasizing that a choice to work while infected should be up to individual nurses, not their employers.
The group also said all other public health measures to reduce the demand on the healthcare system should be implemented first, including a statewide mask mandate, which North Dakota does not have.
Neither the North Dakota Medical Association nor the North Dakota Hospital Association reacted publicly to the new policy as of press time.
On Wednesday, the North Dakota Department of Health announced a record number of active COVID-19 cases. “At this point, every county in our state is at high risk level,” said Tessa Johnson, MSN, RN, president of the North Dakota Nurses Association. “The governor has put this policy out and still, no masks are required. It feels like a slap in the face to nurses right now.”
“We really feel like if we’re going to make a big change, it needs to start with that,” Johnson told MedPage Today. “The governor has very much left it open to individual cities and counties, and some have chosen to have a mask mandate, but there’s no teeth behind it.”
On paper, the new policy appears to have protections built in for patients and co-workers, but that’s not the case in the real world, Johnson said.
“It’s not as simple as just putting a COVID-positive patient and staff member together,” she said. “There are shared spaces in hospitals, nursing homes, and clinics to be concerned about — bathrooms, break rooms, hallways, elevators.”
And in rural areas of the state, small facilities are connected to one another, Johnson pointed out. “You may have a long-term care facility, an ER, and a hospital all attached to each other, and the same RN may care for all those patients. How’s that going to work? No one has answers and there’s a lot of fear surrounding that question.”
When the governor’s statement was issued on Monday, the association reached out to nurses throughout the state and received immediate feedback. “A point they emphasized was make sure that, even with this order, nurses and their employers must have a choice: you cannot mandate any nurses to do this,” Johnson said.
The message the policy sends to the community is troubling, too, she noted: “We are a very ethical, trusted profession and people look to us for guidance. In this whole time, we’ve been saying wear your mask, socially distance, and stay home if you are in close contact. So how can we continue to be credible sources and tell people to stay home if we’re not?”
What’s happening in North Dakota may be due in part to the changing shape of COVID-19 patterns throughout the country, observed Cheryl Peterson, MSN, RN, vice president of the American Nurses Association, the national professional nursing organization based in Silver Spring, Maryland.
Early in the pandemic, nurses could move from one COVID-19 hotspot to another to help, but that’s no longer the case, she noted. “Because of how widespread the disease is circulating, there’s no place for that now,” she said.
“There’s no give in the system now to get more resources to these hospitals, and I think that is going to play out,” Peterson told MedPage Today. “We see it now in North Dakota,” she said. It wouldn’t surprise her if similar policies spread to other states “as we move higher up the spike or further into the pandemic,” she added.
“The piece we want to really focus on is that hospitals recognize it is up to the nurse as to whether or not they are interested in working when they are COVID-positive,” Peterson said.
“The CDC guidance says they have to be willing to work. It’s up to them whether they’re going to work and if they say, yes, they’ve made a decision. If they say no, that, too, is a decision and it must be respected by the facility and there should be no retaliation.”
By Judy George, MedPage Today
The ever-present nursing shortage is becoming dire during the pandemic. COVID-19 cases are surging in rural places across the Mountain States and Midwest, and when it hits health care workers, ready reinforcements aren’t easy to find.
In Montana, pandemic-induced staffing shortages have shuttered a clinic in the state’s capital, led a northwestern regional hospital to ask employees exposed to COVID-19 to continue to work and emptied a health department 400 miles to the east.
“Just one more person out and we wouldn’t be able to keep the surgeries going,” said Dr. Shelly Harkins, chief medical officer of St. Peter’s Health in Helena, a city of roughly 32,000 where cases continue to spread. “When the virus is just all around you, it’s almost impossible to not be deemed a contact at some point. One case can take out a whole team of people in a blink of an eye.”
In North Dakota, where cases per resident are growing faster than any other state, hospitals may once again curtail elective surgeries and possibly seek government aid to hire more nurses if the situation gets worse, North Dakota Hospital Association President Tim Blasl said.
“How long can we run at this rate with the workforce that we have?” Blasl said. “You can have all the licensed beds you want, but if you don’t have anybody to staff those beds, it doesn’t do you any good.”
The northern Rocky Mountains, Great Plains and Upper Midwest are seeing the highest surge of COVID-19 cases in the nation, as some residents have ignored recommendations for curtailing the virus, such as wearing masks and avoiding large gatherings. Montana, Idaho, Utah, Wyoming, North Dakota, South Dakota, Nebraska, Iowa and Wisconsin have recently ranked among the top 10 U.S. states in confirmed cases per 100,000 residents over a seven-day period, according to an analysis by The New York Times.
Such coronavirus infections — and the quarantines that occur because of them — are exacerbating the health care worker shortage that existed in these states well before the pandemic. Unlike in the nation’s metropolitan hubs, these outbreaks are scattered across hundreds of miles. And even in these states’ biggest cities, the ranks of medical professionals are in short supply. Specialists and registered nurses are sometimes harder to track down than ventilators, N95 masks or hospital beds. Without enough care providers, patients may not be able to get the medical attention they need.
Hospitals have asked staffers to cover extra shifts and learn new skills to cover the shortage. They have brought in temporary workers from other parts of the country and transferred some patients to less-crowded hospitals. But, at St. Peter’s Health, if the hospital’s one kidney doctor gets sick or is told to quarantine, Harkins doesn’t expect to find a backup.
“We make a point to not have excessive staff because we have an obligation to keep the cost of health care down for a community — we just don’t have a lot of slack in our rope,” Harkins said. “What we don’t account for is a mass exodus of staff for 14 days.”
Some hospitals are already at patient capacity or are nearly there. That’s not just because of the growing number of COVID-19 patients. Elective surgeries have resumed, and medical emergencies don’t pause for a pandemic.
Some Montana hospitals formed agreements with local affiliates early in the pandemic to share staff if one came up short. But now that the disease is spreading fast — and widely — the hope is that their needs don’t peak all at once.
Montana state officials keep a list of primarily in-state volunteer workers ready to travel to towns with shortages of contact tracers, nurses and more. But during a press conference on Oct. 15, Democratic Gov. Steve Bullock said the state had exhausted that database, and its nationwide request for National Guard medical staffing hadn’t brought in new workers.
“If you are a registered nurse, licensed practical nurse, paramedic, EMT, CNA or contact tracer, and are able to join our workforce, please do consider joining our team,” Bullock said.
This month, Kalispell Regional Medical Center in northwestern Montana even stopped quarantining COVID-exposed staff who remain asymptomatic, a change allowed by Centers for Disease Control and Prevention guidelines for health facilities facing staffing shortages.
“That’s very telling for what staffing is going through right now,” said Andrea Lueck, a registered nurse at the center. “We’re so tight that employees are called off of quarantine.”
Financial pressure early in the pandemic led the hospital to furlough staff, but it had to bring most of them back to work because it needs those bodies more than ever. The regional hub is based in Flathead County, which has recorded the state’s second-highest number of active COVID-19 cases.
Mellody Sharpton, a hospital spokesperson, said hospital workers who are exposed to someone infected with the virus are tested within three to five days and monitored for symptoms. The hospital is also pulling in new workers, with 25 traveling health professionals on hand and another 25 temporary ones on the way.
But Sharpton said the best way to conserve the hospital’s workforce is to stop the disease surge in the community.
Earlier in the pandemic, Central Montana Medical Center in Lewistown, a town of fewer than 6,000, experienced an exodus of part-time workers or those close to retirement who decided their jobs weren’t worth the risk. The facility recently secured two traveling workers, but both backed out because they couldn’t find housing. And, so far, roughly 40 of the hospital’s 322 employees have missed work for reasons connected to COVID-19.
“We’re at a critical staffing shortage and have been since the beginning of COVID,” said Joanie Slaybaugh, Central Montana Medical Center’s director of human resources. “We’re small enough, everybody feels an obligation to protect themselves and to protect each other. But it doesn’t take much to take out our staff.”
Roosevelt County, where roughly 11,000 live on the northeastern edge of Montana, had one of the nation’s highest rates of new cases as of Oct. 15. But by the end of the month, the county health department will lose half of its registered nurses as one person is about to retire and another was hired through a grant that’s ending. That leaves only one registered nurse aside from its director, Patty Presser. The health department already had to close earlier during the pandemic because of COVID exposure and not enough staffers to cover the gap. Now, if Presser can’t find nurse replacements in time, she hopes volunteers will step in, though she added they typically stay for only a few weeks.
“I need someone to do immunizations for my community, and you don’t become an immunization nurse in 14 days,” Presser said. “We don’t have the workforce here to deal with this virus, not even right now, and then I’m going to have my best two people go.”
Back in Helena, Harkins said St. Peter’s Health had to close a specialty outpatient clinic that treats chronic diseases for two weeks at the end of September because the entire staff had to quarantine.
Now the hospital is considering having doctors take turns spending a week working from home, so that if another wave of quarantines hits in the hospital, at least one untainted person can be brought back to work. But that won’t help for some specialties, like the hospital’s sole kidney doctor.
Every time Harkins’ phone rings, she said, she takes a breath and hopes it’s not another case that will force a whole division to close.
“Because I think immediately of the hundreds of people that need that service and won’t have it for 14 days,” she said.
Published courtesy of KHN (Kaiser Health News), a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Mountain States editor Matt Volz contributed to this story.