A few weeks ago, a woman gave birth at Hereford Regional Medical Center, a critical access hospital in the Texas Panhandle.
Or, rather, the woman gave birth in the parking lot at Hereford Regional Medical Center after driving over an hour to get there, according to Jeff Barnhart, the hospital’s chief executive.
Barnhart said he’s heard it all over the years: patients giving birth at rest stops and in ambulances and in the car on the side of the road. The hospital’s patients come from a 1,600-square-mile area in the Texas Panhandle, and some of them just don’t make it in time.
But now, even patients who do make it to the hospital have another variable to contend with: critical staffing shortages and exploding COVID-19 case counts. There are days when Hereford Regional doesn’t have enough nurses to operate the labor and delivery unit, forcing it to divert patients 50 miles northeast, to Amarillo.
“We give them a medical exam and see if there’s time to get them in an ambulance to another hospital that can take them,” he said. “But sometimes, that baby’s coming and there’s just not time.”
Those patients give birth in the emergency room, an increasingly common occurrence as rural hospitals limit or cease labor and delivery services due to insufficient staffing.
Nationally, the health care system is facing an unprecedented labor shortage as nurses retire, resign, burn out or leave staff positions for more lucrative travel nursing contracts. Rural hospitals, many of which already operate with a shoestring staff, are especially hard hit.
Declining populations and cuts to Medicaid and Medicare funding have made Texas the national leader in rural hospital closings, with some 26 closures — permanent or temporary — of rural facilities in the last decade. Two-thirds of the state’s 157 rural hospitals are public, which means less flexibility in salary negotiations. Administrators also say it’s often difficult to recruit medical personnel to smaller towns in remote counties.
Struggling to survive, the remaining hospitals in Texas’ rural communities have had to cut back services. And when that happens, labor and delivery is often the first to go.
Only 40% of Texas’ rural hospitals still have a labor and delivery unit, according to the Texas Organization of Rural and Community Hospitals, leaving whole swaths of the state without access to nearby obstetrics care.
“If we’ve got nurses to cover a day, of course, we’re going to try to take care of everything that we can here,” Barnhart said. “But it’s just a scheduling crisis, and whenever we can’t make it work, we just let the hospitals in Amarillo know so they can expect it.”
Cuts to services
Adrian Billings has been delivering babies at Big Bend Regional Medical Center for 15 years, serving patients across a 2,000-square-mile area in West Texas. The hospital delivers about 200 babies a year, he said, with pregnant patients sometimes driving over 100 miles to give birth.
But in recent months, for the first time since he’s worked there, the hospital has limited the hours the labor and delivery unit is open. Over the holidays, the unit shut down entirely for two weeks. For a while, it was only open Monday through Thursday morning.
“When that happens, essentially, it’s a maternity care desert Thursday morning through Monday morning out here,” he said.
He said the hospital tried to schedule inductions during the week as much as possible, but childbirth can be hard to predict. If a patient goes into labor during the off hours, they either give birth in the emergency room or are sent 60 miles away to Fort Stockton.
A spokesperson for Big Bend Regional said in an email that the hospital recently hired additional nurses who will soon allow it to resume full-time maternity care. But many rural hospitals say they simply aren’t able to keep up in today’s ultracompetitive labor market.
“We only have six doctors at our hospital,” said Jennifer Liedtke, the director of the labor and delivery unit at Rolling Plains Memorial Hospital in Sweetwater, about 40 miles west of Abilene. “When you’re talking about a census of 20-plus patients, we’re carrying a full load trying to get everyone seen. … It’s rough.”
Rolling Plains typically tries to have three labor and delivery nurses scheduled for each shift. But recently, Liedtke said the team is scraping by with one nurse and a shift supervisor who can step in as needed. Her nurses often get pulled into other units when there are no deliveries.
“There’s not a patient back there today, so both of [the nurses] are working the COVID unit right now,” she said. “So if we do have a patient come, they have to go shower and change into all new scrubs and stuff before that patient will have to come back.”
Many of the longtime nurses at Rolling Plains retired during the pandemic, Liedtke said, and it’s been difficult to find replacements. On Monday, all five of the hospital’s ICU beds were occupied, according to state health numbers.
“We’re trying to recruit right out of school right now, but a lot of the young nurses are going into travel nurse positions,” said Liedtke, who is also a family physician and OB-GYN. “They can sign big, big contracts … and that’s just not something we’re going to be able to match.”
Liedtke said it’s especially difficult to recruit nurses to work in the obstetrics unit of a rural hospital. At a larger facility, there might be different nurses dedicated to labor and delivery, the nursery, and postpartum care. But at Rolling Plains Memorial, one nurse has to handle all those roles.
Labor and delivery is a major investment for rural hospitals, requiring specialized nurses and a recommended 2-to-1 nurse-to-patient ratio during delivery. It’s rarely a money-making enterprise for these hospitals, particularly if they’re serving uninsured or Medicaid patients.g
John Henderson, president of the Texas Organization of Rural and Community Hospitals, said struggling hospitals often see labor and delivery as an easy target for cuts. But he worries that these short-term closures and limited services will create a ripple effect that will ultimately leave rural hospitals worse off.
“You’ve compounded the problem by forcing people to leave the community when they need care,” he said.
If patients give birth at a hospital in a larger city, he worries they may be less likely to return to the local hospital for future medical care.
“It won’t just be obstetrics,” he said. “They’ll probably end up seeing a pediatrician [at the larger hospital], and the next time they have a sprained ankle, that’s where they’re going.”
Transferring to larger hospitals
Many rural hospitals have already shaved down their services as much as possible, asking nurses to do double duty or transferring patients to larger hospitals for more specialized care.
Fewer than half of the state’s rural hospitals perform surgeries or have specialists such as cardiologists on staff, and many don’t have an intensive care unit. In normal times, it’s enough. But these days, there’s a logjam of patients who are waiting for a higher level of critical care than some of these hospitals can give on a long-term basis.
In the tiny Southeast Texas town of Anahuac, the local hospital is feeling the effects of soaring COVID-19 hospitalizations in Houston, an hour east.
“All of Houston’s medical center [complex of several hospitals] is in code red, meaning everyone is at capacity,” said William Kiefer, CEO of Chambers Health, which runs Anahuac’s hospital, OmniPoint Health. “And so the downstream effect of that is that we have two patients … who require transfer. We’ve had them for days. They’re not going anywhere.”
Rural hospitals say they can usually find beds in larger hospitals for patients who need to give birth, but even that’s become more tenuous as omicron and staffing shortages rage.
Teresa Baker, an OB/GYN with Texas Tech University Health Sciences Center in Amarillo, said she can always tell when there’s been an interruption in service somewhere else in the Panhandle. Suddenly patients are coming from farther away, later in the labor process, and often arriving via ambulance.
“We’re happy to take them,” Baker said. “The hospitals are doing a very selfless thing by shipping those patients, because they know they can’t handle them without the right staffing. The altruism is apparent.”
But hospitals in Amarillo are being walloped by the omicron variant just like everywhere else. During a recent shift, Baker said, seven out of 10 of their laboring patients were positive for COVID-19.
“We just assume everybody’s positive,” she said. “If the baby is born at full term and is healthy, then we can keep the mom and baby together, and the dad, because we can isolate them in the room.”
But many of the babies the hospital delivers have to go to the neonatal intensive care unit for additional care, which becomes much more difficult if the mother has tested positive for COVID-19.
“That’s what makes your heart bleed,” Baker said, “because these moms don’t even get to see their babies or nurse their babies because they’re positive. And it’s just a terrible situation.”
She said for the first time during the pandemic, the hospital has had to figure out issues like how to discharge babies from the NICU to COVID-positive parents.
“I said, what are they going to do, just meet her at the back door with her baby?” she recalls asking the nurse. “Because she can’t come into the hospital unless she absolutely needs to.”
Vaccine misinformation impacts staff, patients
Hospitals around the state are also contending with vaccine hesitancy among staff and patients. That’s just another challenge that’s hitting rural hospitals harder than better-resourced urban facilities.
For a time, Liedtke worried the labor and delivery unit at Rolling Plains Memorial might have to shut down, thanks to a federal vaccine mandate for health care workers that is tied up in the courts.
“To be very clear, I would love to see everyone vaccinated,” she said. “But from a staffing perspective, we were probably going to lose half of our [obstetrics] nurses.”
Other hospitals report similar concerns, saying they’re aware of large percentages of their nurses and hospital staff who would resign if they were required to get a vaccine.
OB/GYN doctors and nurses are also struggling to communicate vaccine information to their pregnant patients, many of whom are wary about a perceived lack of information about the effects of the vaccine on pregnancies.
“It’s so emotional for these moms, and I know they’re trying to make the best decision they can for their babies,” said Baker. “We just have to meet them where they are and just keep revisiting it.”
Baker said she tries to remind patients that the risks associated with getting very sick from COVID-19 outweigh any potential risks from the vaccine.
Holly Dunn, a maternal fetal medicine specialist in Abilene, has seen an uptick in patients needing specialized care because they develop COVID-19 symptoms during pregnancy.
“It’s more common now for my patients to have COVID or have had COVID than not,” she said.
She said it’s her unvaccinated patients who are developing serious pregnancy complications and fetal development issues, and even experiencing stillbirths. She’s implored her patients to get vaccinated for themselves and their children, and tells them about her own experience: She recently had a healthy baby after getting vaccinated.
“So I practice what I preach,” she said. “That gives me some street cred with my patients. If we can convince even one patient, it’s a victory.”
One in five individuals avoided healthcare during lockdown in the COVID-19 pandemic, often for potentially urgent symptoms, according to a new study publishing November 23rd in PLOS Medicine by Silvan Licher of Erasmus University Medical Center Rotterdam, the Netherlands, and colleagues.
During the COVID-19 pandemic, consultations in both primary and specialist care declined compared to pre-pandemic levels. It is unclear to what extent healthcare avoidance by the general population contributed to these declines. In the new study, researchers sent out a paper questionnaire to 8,732 participants of the Rotterdam Study, a cohort study designed to investigate chronic diseases in mid to late-life, covering several COVID-19 related topics, including healthcare avoidance. 73% of participants responded between April and July 2020 and the final population for the study was 5,656 individuals residing in the same district in Rotterdam, the Netherlands.
About one in five (20.2%) of participants reported having avoided healthcare during the pandemic. Of those, 414 participants (36.3% of avoiders) reported symptoms that potentially warranted urgent medical attention, including limb weakness (13.6%), palpitations (10.8%) and chest pain (10.2%). However, there was no data available on the severity of symptoms. Groups most likely to have avoided healthcare included females (adjusted odds ratio (OR) 1.58, 95% confidence interval (CI) 1.38-1.82), those with poor self-appreciated health (per level decrease 2.00, 95% CI 1.80‑2.22), and those with high levels of depression (per point increase 1.13, 95% CI 1.11-1.14) and anxiety (per point increase 1.16, 95% CI 1.14-1.18). Lower educational level, older age, unemployment, smoking and concern about contracting COVID-19 were also associated with healthcare avoidance.
“Findings of our study suggest that healthcare avoidance during COVID-19 may be prevalent amongst those who are in greater need of it in the population, such as older individuals, those with low perceived health and those who report symptoms of poor mental health,” the authors say. “These findings call for population-wide campaigns urging individuals who are most prone to avoid healthcare to reach out to their primary care physician or medical specialist to report both alarming and seemingly insignificant symptoms.”
“One in five avoided healthcare during COVID-19 lockdown, often with alarming symptoms like chest pain or limb weakness,” Licher adds. “Vulnerable citizens were mainly affected, emphasising the urgent need for targeted public education.”
Vaccinated health care workers who experienced breakthrough COVID-19 infections during the winter of 2020–21 had lower viral loads than their similarly infected but unvaccinated co-workers, according to a new UCLA study.
The findings, published this week in the peer-reviewed journal Open Forum Infectious Diseases, show that infected workers who were fully or even partially vaccinated with either of the two mRNA vaccines authorized for use in U.S. had less of the virus in their test samples and were therefore less likely to “shed” — or orally or nasally expel — viral particles.
While the research was conducted prior to the recent delta variant surge, the findings are consistent with current data showing that those who are vaccinated are less likely to spread the virus, said the study’s lead author, Dr. Paul Adamson, an assistant professor of infectious diseases at the David Geffen School of Medicine at UCLA.
“These findings should be reassuring for the general public because lower amounts of virus might translate to decreased transmissibility,” Adamson said. “This is another benefit of the vaccines and yet another reason to get vaccinated against COVID-19.”
For the study, the researchers analyzed 43,516 COVID-19 tests administered to approximately 11,930 UCLA health care workers between Dec. 16, 2020 — roughly the time the two-dose Pfizer–BioNTech and Moderna mRNA vaccines became available at UCLA — and March 31, 2021. During the course of the study, 880 individuals tested positive for infection.
The research team examined these workers’ vaccination status at the time of their infections to see who had received either of the mRNA vaccines and who had not been vaccinated. They also specifically measured cycle threshold, or CT, values from the COVID-19 tests of infected individuals. These CT values have an inverse relationship to the amount of virus one has: The lower the CT value, the higher the viral load, and vice versa.
Of the 880 total COVID-19 infections, 616 (70%) occurred among unvaccinated employees, while 264 (30%) occurred among those who had received at least one vaccine dose. The researchers then examined CT values for each infected employee, broken down into vaccination status and time categories:
Unvaccinated
Less than 12 days after the first dose of a two-dose vaccine
12 or more days after the first dose, but before the second dose
Less than seven days after the second dose
Seven days or more after the second dose
The lowest CT values, corresponding with the highest amount of the virus, were seen in the samples from unvaccinated employees. The amount of virus in the samples decreased with each of vaccination category, with employees who had received both mRNA vaccine doses carrying the lowest amounts of the virus.
The researchers noted that recent data suggest that viral loads of the delta variant — which became the dominant strain in Los Angeles County in May 2021, after the study period had ended — are similar in both vaccinated and unvaccinated people. But data also indicate that vaccinated individuals experience a more rapid decline in delta variant viral loads and clear the virus faster than unvaccinated people, which also helps to reduce viral transmission.
“SARS-CoV-2 viral loads are known to be a critical driver of transmission,” the researchers wrote. “Thus, our findings, using real-world data, suggest that COVID-19 vaccination might translate into decreased transmissibility of SARS-CoV-2 infections.”
The researchers said the study may have some limitations. For instance, they may not have captured variables such as age, infection onset and severity of symptoms, and collection and testing methods, which might have had an impact on CT values. In addition, the number of people with mild or asymptomatic infection may have been undercounted, possibly affecting the overall lower CT values across all categories.
Additional study authors are Dr. Michael Pfeffer, Dr. Valerie Arboleda, Omai Garner, Dr. Annabelle de St. Maurice, Benjamin von Bredow, Dr. Jonathan Flint, Leonid Kruglyak, and Dr. Judith Currier.
This study was supported by the National Institutes of Health.
The Department of Health and Human Services (HHS) has awarded the largest field strength in history for its health workforce loan repayment and scholarship programs thanks to a new $1.5 billion investment, including $1 billion in supplemental American Rescue Plan (ARP) funding and other mandatory and annual appropriations. More than 22,700 primary care clinicians now serve in the nation’s underserved tribal, rural and urban communities, including nearly 20,000 National Health Service Corps (NHSC) members, more than 2,500 Nurse Corps nurses, and approximately 250 awardees under a new program, the Substance Use Disorder Treatment and Recovery Loan Repayment Program. The U.S. Department of Health and Human Services’ (HHS) Health Resources and Services Administration (HRSA) oversees these critical programs.
“Thanks to the American Rescue Plan, we now have a record number of doctors, dentists, nurses and behavioral health providers treating more than 23.6 million patients in underserved communities,” said Health and Human Services Secretary Xavier Becerra. This demonstrates the Biden-Harris Administration’s commitment to advance health equity and ensure access to critical care across the country. We will continue to invest in our health workforce to make life-saving support within everyone’s reach.”
During the pandemic, thousands of NHSC and Nurse Corps health care providers have served in community health centers and hospitals across the country, caring for COVID-19 patients, supporting the mental health of their communities, administering COVID-19 tests and lifesaving treatments, and putting shots in arms.
Connecting Skilled Providers with Communities in Need
HRSA’s workforce programs directly improve the nation’s health equity by connecting skilled, committed providers with communities in need of care. National Health Service Corps, Nurse Corps, and Substance Use Disorder Treatment and Recovery Loan Repayment Program members work in disciplines urgently needed in underserved tribal, rural and urban communities.
“Today’s awards, which represent a more than 27 percent increase in scholarship and loan repayment awards, support current and future providers who are committed to working in vulnerable communities,” said HRSA Acting Administrator Diana Espinosa. “These awards also provide critical support for health care sites that need to recruit and retain clinicians to meet increasing demand.”
Today’s field strength includes more than 11,900 members working in behavioral health disciplines, including psychiatrists, substance use disorder (SUD) counselors and psychiatric nurse practitioners.
Nurses represent the largest proportion of the field strength, numbering more than 8,000 across all scholarship and loan repayment programs. National Health Service Corps nurse practitioners make up its largest discipline at approximately 5,400 and fill a critical need for primary care where shortages exist throughout the country.
Currently, one-third of HRSA’s health workforce serves in a rural community where health care access may be especially limited or require patients to travel long distances to receive treatment.
More than half of all National Health Service Corps members serve in a community health center where patients are seen regardless of their ability to pay.
Providing Treatment and Care to Patients with Substance Use Disorders
Through dedicated funding for substance use disorder (SUD) professionals, HRSA is now supporting more than 4,500 providers treating opioid and other substance use disorder (SUD) issues in hard-hit communities. The Substance Use Disorder Treatment and Recovery Loan Repayment Program was launched in FY 2021 to create loan repayment opportunities for several new disciplines that support HHS’ comprehensive response to the opioid crisis, including clinical support staff and allied health professionals. In addition, this year’s NHSC awards include 1,500 substance use disorder (SUD) clinicians at approved treatment sites through the NHSC’s Substance Use Disorder and Rural Community loan repayment programs.
Investing in the Future Health Workforce
Through scholarship programs, HRSA is investing in the next generation of providers committed to working in communities most in need. The American Rescue Plan supplemental funding announced today allowed HRSA to award almost 1,200 scholarships — a four-fold increase — in the National Health Service Corps and nearly doubled the number of Nurse Corps scholarship awards to 544. In addition, new awards to 136 nurse faculty are supporting training for the future nursing workforce. This year’s scholarship recipients join 2,500 current National Health Service Corps medical, dental, and health professions students and residents and approximately 900 current Nurse Corps scholars preparing to serve in high-need communities across the country.
HRSA also recently awarded approximately $28.4 million in ARP funding to create new accredited teaching health center primary care residency programs in rural and underserved communities. To further support the expansion of primary care, the Administration plans to continue awarding the full $330 million in ARP funding for Teaching Health Center Graduate Medical Education in the coming months. This additional funding will support the expansion of the primary care physician and dental workforce in underserved communities through community-based primary care residency programs in family medicine, internal medicine, pediatrics, internal medicine-pediatrics, psychiatry, obstetrics and gynecology, general dentistry, pediatric dentistry, or geriatrics. They are based in the communities they serve, with 80 percent located in community-based health centers, such as Health Center Program-funded health centers, Health Center Program look-alikes, rural health clinics, community mental health centers and tribal health centers.
Opportunities Now Open for Loan Repayment Programs
American Rescue Plan funding has made it possible for the National Health Service Corps to make a historic number of awards to all eligible applicants. Additional American Rescue Plan-funded awards are planned, with the next application cycles for the National Health Service Corps and Nurse Corpsloan repayment programs now accepting applications.
The National Health Service Corps helps medical, dental, and behavioral health clinicians pay off their student loan debt through scholarship and loan repayment programs in exchange for working in a Health Professional Shortage Area (HPSA). Nurse Corps participants commit to providing care in facilities with a critical shortage of nurses or as nurse faculty and help reduce the nursing shortage issues experienced across the nation. The Substance Use Disorder Treatment and Recovery Loan Repayment Program makes awards to clinicians, allied health professionals, and support staff who provide substance use disorder (SUD) treatment and recovery services to patients at treatment facilities located in a Mental Health Professional Shortage Area or in a county (or a municipality, if not contained within any county) with a threshold drug overdose death rate defined in statute.
Today’s funding announcement is directly responsive to the recommendations in the final report – PDFof the Presidential COVID-19 Health Equity Task Force.
Insulin is as essential as water for many people with diabetes. Of the more than 30 million Americans with diabetes, approximately 7.4 million rely on insulin to manage their condition. But it is one of the most costly drugs on the market, and the COVID-19 pandemic has intensified the already rampant problem of insulin hoarding or rationing.
Not only is diabetes associated with an increased risk of severe COVID-19 infection, but COVID-19 is also associated with both an increase in new diabetes diagnoses and a worsening of preexisting diabetes complications. By September 2021, death rates for people with diabetes were 50% higher than before the pandemic, a net increase of more than twice the overall death rate of the general population.
I am a pharmacist who studies ways to improve clinical, economic and quality-of-life outcomes in vulnerable populations. My recent study on how insulin prescription rates have changed because of the pandemic underscores the challenges that people with diabetes face in accessing care.
Managing diabetes during a pandemic
Although insulin is a vital component of diabetes management, the pandemic has led many patients to forgo the prescriptions they need.
My recent study looked at the insulin prescription claims of 285,343 people in the U.S. between January 2019 and October 2020. In the first week of 2019, there was an average of 17,037 new and existing insulin prescriptions picked up by patients per week. This number increased by 11 claims each week leading up to the pandemic.
By the first week of the pandemic in March 2020, however, insulin prescriptions decreased significantly by an average of around 396 prescriptions. Prescriptions continued to decrease an average of around 55 per week as the pandemic progressed through to October 2020. This decline may result from a combination of health insurance loss owing to unemployment, restricted access to clinicians and pharmacies and rationing or stockpiling of medications by both pharmacists and patients.
And the effects of the pandemic on diabetes go beyond just insulin prescriptions. Diabetes management involves visits with a variety of health care providers and routine testing. But diabetes patients in the U.S. had a significant drop in usage of health care services in 2020 compared with 2019, because of clinic closures and reduced capacities, health insurance loss and transportation difficulties. Patients are left in a bind, risking potentially life-threatening complications from missing needed diabetes care as well as risking exposure to COVID-19 if they need emergency care for those complications.
Ongoing effects of care delays
As COVID-19 overwhelmed health care systems, people with chronic conditions like diabetes have experienced significant disruptions in routine and emergency medical care. By the end of June 2020, an estimated 41% of U.S. adults had delayed or avoided medical care.
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Even now, with hospitals crowded with unvaccinated COVID-19 patients, nearly 1 in 5 American households had to delay care for serious illnesses in the past few months. These care delays have the potential to worsen chronic conditions and contribute to excess deaths directly and indirectly caused by COVID-19.
The full effect that the COVID-19 pandemic continues to have on diabetes management and care, however, has yet to be fully understood. More research on how the pandemic has affected people with diabetes is needed to ensure that these patients receive the care that they need.
