POST 190, August 21, 2021. CORONAVIRUS. “We’re looking, in essence, at running two systems — a COVID system and a non-COVID system of care”…“Emergency medical technicians (EMTs) and certified paramedics can now care for patients in Mississippi hospitals and emergency rooms under a new health office order issued by the Mississippi State Department of Health on Wednesday.”

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“At many Valley hospitals this week, patients are stacking up in emergency rooms waiting for other patients to be discharged from inpatient beds.

At Kaweah Health in Visalia, CEO Gary Herbst said this week the hospital was under enough strain to force leaders to declare a “code triage” or “internal disaster” on Monday, when about 160 patients overflowed the emergency department.

“It really reached what we could consider to be a crisis situation,” Herbst said. More than 60 of those waiting in the emergency rooms needed to be admitted to the hospital, he said, but the hospital’s beds were already full with other patients and there was no place to admit those waiting until others could be discharged.

Kaweah Health leaders called other hospitals in central California in hopes of finding one to which patients could be transferred to ease the strain in Visalia. “Unbeknown to us, all of them had also declared internal disasters,” Herbst said. “Literally there was not a hospital in the Central Valley that was capable of accepting a transfer.”” (M)

“Nursing shortages have long vexed hospitals. But in the year and a half since its ferocious debut in the United States, the coronavirus pandemic has stretched the nation’s nurses as never before, testing their skills and stamina as desperately ill patients with a poorly understood malady flooded emergency rooms. They remained steadfast amid a calamitous shortage of personal protective equipment; spurred by a sense of duty, they flocked from across the country to the newest hot zones, sometimes working as volunteers. More than 1,200 of them have died from the virus.

Now, as the highly contagious Delta variant pummels the United States, bedside nurses, the workhorse of a well-oiled hospital, are depleted and traumatized, their ranks thinned by early retirements or career shifts that traded the emergency room for less stressful nursing jobs at schools, summer camps and private doctor’s offices…

Across the country, the shortages are complicating efforts to treat hospitalized coronavirus patients, leading to longer emergency room waiting times and rushed or inadequate care as health workers struggle to treat patients who often require exacting, round-the-clock attention, according to interviews with hospital executives, state health officials and medical workers who have spent the past 17 months in the trenches.

The staffing shortages have a hospital-wide domino effect. When hospitals lack nurses to treat those who need less intensive care, emergency rooms and I.C.U.s are unable to move out patients, creating a traffic jam that limits their ability to admit new ones. One in five I.C.U.s are at least 95 percent capacity, according to an analysis by The New York Times, a level experts say makes it difficult to maintain standards of care for the very sick.

“When hospitals are understaffed, people die,” said Patrica Pittman, director of the Health Workforce Research Center at George Washington University.” (A)

“With hospitals in the U.S. again running out of ICU bed space, administrators are dealing with a shortage of nurses, scrambling to fill shifts and offering high wages to those who can help. The problem comes as the crushing workload of the coronavirus pandemic, coupled with external and on-the-job pressures, have led some nurses to simply step down altogether….

Last year, when the first wave of COVID-19 patients threatened U.S. hospitals, some sounded the alarm about a looming staffing shortage.

“Recent analyses have raised concerns about whether the United States has enough hospital capacity for a surge of patients needing care for COVID-19 infections,” reads a March 2020 blog post authored by the University of California-San Francisco’s Joanne Spetz and published by Health Affairs. “But even if we can double or triple the number of intensive care unit beds, we don’t have enough nurses to staff them.”…

During earlier waves, hospitals also sent some nurses into COVID-19 wards to help out even if they were trained for other specialties. But Stimpfel says asking a neonatal nurse to work in the ICU with a COVID-19 patient – a high-risk environment involving possible exposure to a potentially deadly contagion – was a big ask.

“Not all nurses are trained in critical care,” she says. “There are different specialties that nurses are prepared for, and you can’t prepare a nurse to take care of these intensely ill patients, and do that overnight. That was still such a leap for them to be put into that sort of situation.”

Meanwhile, colleges and nursing schools are urged to expand capacity to graduate more caregivers, with experts saying the more trained hands working in a COVID-19 ward, the better. In a recent speech to graduates, McCauley, the Emory nursing school dean, says she compared the class to soldiers on the front lines of a battle: “I said, ‘In ways, you remind me of my colleagues when I graduated: nurses that were serving in the Vietnam War.”

The new nurses “are walking into a workforce where everyone is exhausted,” McCauley says. “These new graduates can hold up that workforce just with their youth, their enthusiasm. They’re willing to go the extra mile.”

Still, McCauley acknowledges that in battling a virus that’s mutated to become more contagious, youthful enthusiasm isn’t a substitute for the “wisdom and professionalism” that comes with experience. And, she says, treating COVID-19 patients who got sick because they chose not to get vaccinated – and may have spread the virus to other people – can be disheartening…

But it could take years before staffing levels get to a better place.

“There are some experts that could probably model it better than I can, but I would say it’s going to be at least six to 10 more years before we get over this,” Stimpfel says. “And that’s because of factors that were already in play before COVID.” (B)

“The rapidly escalating surge in COVID-19 infections across the U.S. has caused a shortage of nurses and other front-line staff in virus hot spots that can no longer keep up with the flood of unvaccinated patients and are losing workers to burnout and lucrative out-of-state temporary gigs.

Florida, Louisiana, Arkansas and Oregon all have more people hospitalized with COVID-19 than at any other point in the pandemic, and nursing staffs are badly strained.

In Florida, virus cases have filled so many hospital beds that ambulance services and fire departments are straining to respond to emergencies. Some patients wait inside ambulances for up to an hour before hospitals in St. Petersburg, Florida, can admit them — a process that usually takes about 15 minutes, Pinellas County Administrator Barry Burton said.

One person who suffered a heart attack was bounced from six hospitals before finding an emergency room in New Orleans that could take him in, said Joe Kanter, Louisiana’s chief public health officer.

“It’s a real dire situation,” Kanter said. “There’s just not enough qualified staff in the state right now to care for all these patients.”..

Miami’s Jackson Memorial Health System, Florida’s largest medical provider, has been losing nurses to staffing agencies, other hospitals and pandemic burnout, Executive Vice President Julie Staub said. The hospital’s CEO says nurses are being lured away to jobs in other states at double and triple the salary.

Staub said system hospitals have started paying retention bonuses to nurses who agree to stay for a set period. To cover shortages, nurses who agree to work extra are getting the typical time-and-a-half for overtime plus $500 per additional 12-hour shift. Even with that, the hospital sometimes still has to turn to agencies to fill openings.

“You are seeing folks chase the dollars,” Staub said. “If they have the flexibility to pick up and go somewhere else and live for a week, months, whatever and make more money, it is a very enticing thing to do. I think every health care system is facing that.”  (C)

“Under typical circumstances, an I.C.U. nurse might care for two patients.

But Covid patients can require more attention and tend to stay in the I.C.U. longer — a median of seven days instead of about four.

The virus’s rampage through the body can take unexpected turns, throwing a relatively stable patient into an urgent crisis with little warning. This and other complications sometimes lead I.C.U.s to dedicate individual nurses to certain Covid patients.

To help, hospitals can draw staff members from other parts of the hospital, who may lack specialized skills, or bring in short-term travel staffers. Where that’s not possible, or not enough, it can affect the number of patients cared for by each nurse.

“We’ve been swamped,” said Judy Carver, an intensive care unit nurse at Martin Luther King, Jr. Community Hospital in Los Angeles. “We were having to take three patients. It was really heavy, super heavy.”

In California, Gov. Gavin Newsom temporarily altered the rules to allow one I.C.U. nurse to care for three patients instead of the previous maximum of two. In some hospitals, the ratios have gone even higher.

Covid patients are often rolled onto their stomachs, called “proning,” which has been shown to increase oxygen flow. Turning someone over carefully can take several people, and some hospitals have created “proning teams.”

Once patients are face-down, even simple tasks such as bathing them become more challenging — and require more time than nurses might need for a non-proned patient.

The prone position can help patients breathe, but it requires more staff attention.

Proned patients must be watched carefully and moved regularly, so sores do not develop on their faces.

Many Covid patients are on ventilators, which need to be finely adjusted; some are on continuous dialysis machines; and all must be watched for blood clots, which present a greater risk with Covid patients.”” (D)

“States with low vaccination rates have been hit hard: Louisiana is approaching a “major failure” of its health system, Gov. John Bel Edwards said last week.  Oklahoma is sending patients out of state, KFOR reported. Tennessee is rolling out the National Guard to fill staff shortages in hospitals. And Alabama has no ICU beds available left, according to a hospital chief.” (E)

“Multiple studies have reported a link between short nurse staffing and higher rates of hospital-acquired infections. A 2020 study on sepsis, published in the American Journal of Infection Control, found that each “additional patient per nurse is associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission.” Hospital-acquired infections kill 98,000 Americans annually; bed sores in particular pose a threat, as they can lead to sepsis unless they are prevented and cared for with proper nursing.” (F)

“Emergency medical technicians (EMTs) and certified paramedics can now care for patients in Mississippi hospitals and emergency rooms under a new health office order issued by the Mississippi State Department of Health on Wednesday.

In an effort to assist with staffing shortages in the state’s hospitals, EMTs, certified paramedics and advanced emergency medical technicians can help care for patients, acting under medical direction, while not on duty with a licensed Emergency Medical Services agency. Jim Craig, Senior Deputy and Director of Health Protection for the Mississippi State Department of Health, announced the new orders during a press conference.

“That’s going to be a real benefit in the requests that we receive from a lot of hospitals, to allow EMTs and medics to extend some of the services into the hospital setting,” Craig said. “It is another tool in the toolbox to help us try to make health care resources available in the state of Mississippi.”” (G)

“Regulatory authority is among steps the state has taken to help address staffing needs, Governor Bill Lee signing Executive Order 83 last week. The order extends previous orders which allows for trained National Guard personnel to assist in tending to the sick, testing, logistics, and other areas where help may be needed. The order also allows for out-of-state licensed professionals to assist, a move the governor’s office also made during last year’s peak. One lever they don’t anticipate needing to pull is for alternate care sites which had previously been built in Memphis and Nashville but have since been deconstructed.” (H)

“Georgia’s health agency will more than double the number of temporary hospital staff to help cope with the current surge in COVID-19 patients, Gov. Brian Kemp announced Monday.

The Department of Community Health (DCH) will commit $125 million in addition to $500 million the state already is spending to increase state-supported hospital staff at 68 hospitals across Georgia from 1,300 to 2,800, Kemp said.

Specifically, 170 of the new staff will go to rural hospitals, the governor told reporters during a news conference at the state Capitol.

Commissioner of Community Health Caylee Noggle and her team have also identified 450 beds in nine regional coordinating hospitals that will be soon be available for the new staff being deployed to treat patients.

Kemp said his decision to increase hospital staff was based on input during the last week from hospital CEOs.

“Virtually every hospital’s most pressing issue was a lack of qualified staff to treat the patients coming thru their doors, nurses, respiratory therapists, ICU personnel, just to name a few,” he said.

The additional hospital staff will be provided through a continuation of the state’s no-bid contract with a private Alpharetta-based staffing firm, Jackson Healthcare, and a subsidiary. Georgia Health News reported recently that the contract, which began with the first wave of COVID-19 in Georgia last year, had brought Jackson $434 million as of July 23.” (I)

“Missouri will spend $15 million to provide temporary staffing for hospitals operating under the stress of treating thousands of COVID-19 patients, Gov. Mike Parson said Wednesday.

Parson also announced a $15 million program to establish five to eight monoclonal antibody infusion stations to operate for 30 days throughout the state. Monoclonal antibodies are proteins to help fight off COVID-19 and reduce the risk of severe disease and hospitalization. It’s typically administered to high-risk patients after diagnosis. The state estimates 2,000 patients will be treated by the project.

Both programs will be funded through the state’s portion of the federal Coronavirus Aid, Relief and Economic Security (CARES) Act.

“We know our hospital capacity is limited due to staffing shortages, not a lack of bed capacity,” Parson said during a Wednesday news conference. “Every critical- and acute-care licensed hospital will have access to this program. Staffing allocations depend on the number of licensed beds per hospital. It is our hope this program will decrease hospital capacity strain caused by staffing shortages and decrease the need for future alternative care sites.”…

Robert Knodell, the acting director of the department of health and senior services, said medical staff from outside Missouri will be brought in by a vendor once a contract is finished.

“The state has entered into discussions with potential contractors across the country that have traveling medical professionals that move around the country into surge situations or severe events, whether it’s an infectious disease, hurricane or other extreme event,” Knodell said. “We have been assured those individuals will be available if contracted by the state and our local health care partners.”

Parson said ongoing communication with health care systems in Springfield and around the state will help meet medical needs caused by the pandemic.

“I think all of the resources we have put in there – infusion centers, ambulance resources, respiratory guidelines that were waved to get people in to help – from the state level, it still comes down to what they need,” Parson said. “They’re going to have to work with these companies because they won’t just send 200 people. Hospitals will have to say what they need and it will be determined whether that’s available. But I think we can distribute this around the state of Missouri. There’s going to be an opportunity for hospitals in both rural or urban to take advantage of this program.”” (J)

“The surge of COVID-19 cases and hospitalizations is putting a strain on Hawaiʻi’s healthcare staff. The head of the Hawaiʻi Nurses’ Association says two Oʻahu hospitals “are in crisis mode as far as staffing goes.”…

He said some intensive care unit nurses are working 16 hours straight, two days in a row…

Johnson said the health system now has close to 100 COVID-19 patients. To address the surge in patients, Johnson said they have closed down elective surgery and are deploying available nurses from surgical services to the emergency department.

Through the Federal Emergency Management Agency, Johnson said the health system “ordered” 140 nurses and respiratory therapists. She said they’ve also requested about 60 from a mainland agency.

But Ross said relying on travel nurses, who do not require benefits, is part of the problem. Usually, there is a contractual agreement that says Queen’s cannot have more than 30 travel nurses at a time — COVID-19 changed that.

Hawaiʻi Pacific Health said it too has made arrangements for additional staff and travel nurses for its hospitals, and is working with the Healthcare Association for additional staffing aid through FEMA.” (K)

“We’re looking, in essence, at running two systems — a COVID system and a non-COVID system of care,” said Jonathan Lewin, president and CEO of Emory Healthcare. “We’ve had to redeploy perioperative services staff to provide front-line testing, and redeploy people at the front desk to be temperature screeners. And, there are patients who depend on us for care for heart attacks, transplants, and brain surgery — and we need to be able to take care of them while flexing up our COVID care.” (K)

(A) ‘Nursing Is in Crisis’: Staff Shortages Put Patients at Risk, By Andrew Jacobs, https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta.html

(B) Strapped by Shortage and Hit With Departures, Nurse Corps Swamped by Another COVID Wave, By Joseph P. Williams, https://www.usnews.com/news/health-news/articles/2021-08-19/fourth-covid-wave-swamps-stressed-nurse-corps

(C) Hospitals Face A Shortage Of Nurses As COVID Cases Soar, THE ASSOCIATED PRESS, https://www.npr.org/2021/08/10/1026577164/hospitals-face-a-shortage-of-nurses-as-covid-cases-soar

(D) See How Covid-19 Has Tested the Limits of Hospitals and Staff, By John Keefe, Yuliya Parshina-Kottas and Sheri Fink, https://www.nytimes.com/interactive/2021/02/23/us/covid-hospital-icu.html

(E) “States with low vaccination rates have been hit hard: Louisiana is approaching a “major failure” of its health system, Gov. John Bel Edwards said last week.  Oklahoma is sending patients out of state, KFOR reported. Tennessee is rolling out the National Guard to fill staff shortages in hospitals. And Alabama has no ICU beds available left, according to a hospital chief.” (D)

(F) Hospitals Already Had a Nurse Staffing Crisis. Then Covid-19 Came Along., by Matthew Cunningham-Cook, https://theintercept.com/2021/06/25/hospitals-nurse-staffing-shortage/

(G) Miss. EMS providers authorized to care for patients in Eds, by Blake Alsup, https://www.ems1.com/hospital/articles/miss-ems-providers-authorized-to-care-for-patients-in-eds-CcHYMRsnDP9QCKKW/

(H) Tennessee faces hospital staffing issues as COVID cases soar, available ICU beds dwindle,by Adrian Mojica, https://fox17.com/news/local/tennessee-faces-hospital-staffing-issues-as-covid-cases-soar-available-icu-beds-dwindle-pandemic-delta-coronavirus-united-states-vaccine-mississippi

(I) Georgia governor beefing up hospital staffing amid COVID-19 surge, by Dave Williams, https://www.onlineathens.com/story/news/2021/08/16/georgia-gov-kemp-beefing-up-hospital-staffing-amid-covid-19-surge/8158026002/

(J) Missouri spending $30 million for temporary hospital staffing, COVID-19 antibody infusion centers, by Joe Mueller, https://www.washingtonexaminer.com/politics/missouri-spending-30-million-for-temporary-hospital-staffing-covid-19-antibody-infusion-centers

(K) Two Hawaiʻi Hospitals in ‘Crisis’ Staffing Mode as COVID-19 Patients Surge,  By Catherine Cruz, Sophia McCullough, https://www.hawaiipublicradio.org/the-conversation/2021-08-11/hawaii-hospitals-crisis-staffing-covid-19-patients-queens-hph-straub

(L) How Can Hospitals Overcome Staffing and Supply Shortages Amid COVID-19 Surges?, By Stephanie Miceli, https://www.nationalacademies.org/news/2020/08/how-can-hospitals-overcome-staffing-and-supply-shortages-amid-covid-19-surges

(M) Fresno-area hospitals face ‘internal disaster’ as COVID cases, staff exposures mount, BY TIM SHEEHAN, https://www.fresnobee.com/news/coronavirus/article253587074.html