For a nation grappling with the devastating effects of the COVID-19 crisis, a lot of the dialogue about how hospitals were handling the pandemic for months focused on hardware such as ventilators and personal protective equipment for hospital staff.
But behind the scenes, the biggest challenge facing hospitals in Texas as some ICUs began to surge with coronavirus patients was a shortage of people, not equipment. Keeping medical facilities fully staffed with experienced nurses, technicians and other essential personnel—and keeping them healthy enough to work through an extended crisis period—has been a tough job for hospital leaders.
And some of the unique factors of this pandemic—the length of time it continues to go on, the unpredictability of needs in any particular place at any given moment and the financial strain that shutting down elective procedures in states like Texas has put on hospitals—have made it an even more difficult burden to manage, administrators and staffing experts say.
“It has been a challenge,” said Kelli Nations, chief nurse executive for HCA Houston Healthcare and HCA’s Gulf Coast Division. “We really saw a surge here in Houston; at one time we had over 1,000 COVID-19 patients.” While that number has dropped to about half, the ongoing care is incredibly demanding, she says. “So while our numbers may be lower now, we still do have a really high acuity. Our patients are still very sick.”
Nations oversees about 7,000 nurses and 10,000 employees over a network of 16 hospitals, outpatient surgery centers, diagnostic imaging centers and other facilities. Nations says that the size of the HCA network has been invaluable for keeping hospitals facing COVID-19 surges staffed, with hospitals able to draw staff from other Gulf Coast-area hospitals or even farther away.
“We had nurses from Kansas City and nurses from our Denver market,” she said. “They came down and helped us. We have moved staff from multiple hospitals and they have jumped in to help when we had a critical-care need at one hospital or a med-surge need at another hospital. We’ve definitely been sharing resources here in the Houston area.”
In addition to the challenge of outfitting staff with the proper PPE and reconfiguring visitation protocols as hospitals across the country have done, Texas hospital administrators said they have spent a lot of time shifting staff among departments in order to utilize expertise going unused during elective-procedure shutdowns or cross-training nurses to fill ICU needs.
Brian Becker, MD, chief medical officer at Ascension Providence in Waco, said that in July, his hospital faced its second surge of COVID-19 patients, many of them in need of critical care. With nearly 50 patients and only a 30-bed ICU, Becker said it wasn’t equipment that needed the most attention.
“Where we were really struggling was with the nursing-staff side, that was difficult,” he said. “These were critical patients who required a great deal of care and oftentimes one-to-one care. We were having to pull additional staff from across the hospital.”
He points out that ICU nurses are not always interchangeable with, say, medical-surgical nurses in terms of their skillsets. “And so, we had to pull nurses from our acute care units, from anesthesia, from our post-anesthesia care unit and from our ORs in order to adequately staff those areas.”
In March, he says, Ascension Providence began training all in-house nurses to give them a comfort level to work in the ICU. “Almost all the nurses at our hospital now have been trained so that they can step into that role,” he said.
Dr. Becker says that the staff worked longer shifts and at one point had to rely on outside staffing resources but made it through the crisis until hospitalizations for COVID-19 began to drop. He credits the hospital’s ability to keep from being overwhelmed to a three-tiered plan and with cooperation between Ascension Providence and Baylor Scott & White Hillcrest, the other major Waco hospital.
“We’re having regular conversations, weekly conversations, in conjunction with the health department here,” Dr. Becker said. “We have been having these conversations since February looking at how we manage resources for our community.”
Part of those plans included creating an alternate care site in case Waco hospitals were overwhelmed. Luckily, Dr. Becker said, that site has not yet been needed.
Who Fills the Staffing Holes?
Given those circumstances, those in the business of helping hospitals remain fully staffed have been busy in recent months while also facing their own set of hurdles.
Sherry Kolb, RN, began working in 2002 to create a go-between for South Carolina hospitals and the staffing agencies it was dealing with. Today, she’s president of the company that was originally funded by a Duke Endowment grant, Qualivis.
As president of the company, Kolb works with 21 state hospital associations, including the Texas Hospital Association, to provide supplemental staffing for hospitals.
Kolb says that when COVID-19 began snowballing in the U.S. in March, the capabilities of hospitals, their staff morale and ability to adapt were tested. “This is something that we, in our lifetimes, have never dealt with. It’s a reminder for hospitals and hospital leaders to think a little differently and maybe a little more aggressively about contingency plans.”
Kolb says that before COVID-19, the overall demand for ICU RNs was about 14% nationwide. Today, that figure is 35% of staffing demand for Qualivis, which she says has changed the market in favor of those RNs who are willing to travel to and work where they’re most needed.
“I’ll be quite honest,” Kolb said, “what we hear from a hospital is, ‘We needed them yesterday.’” Because the pandemic crisis is so widespread, it’s not the same as emergency staffing needs after, say, a hurricane, a medical personnel strike, or other localized situation.
“So now Texas hospitals are not just competing with other Texas hospitals for nurses. They’re not just competing with Oklahoma, they’re not just competing with Arkansas. They are competing with other states that are surging. And so, supply and demand follow,” Kolb said.
That means more aggressive pay bill rates and more security for even short-term assignments; it is not uncommon for traveling nurses to expect a minimum of 48 hours a week at a given assignment. States have created emergency licensing for nurses to speed up the process and hospitals are waiving some credential requirements to get ICU nurses through the door. Many nurses, Kolb said, are still choosing to stay away from COVID-19 hot zones to protect their health or their family’s health. But those that are willing to take those risks are being rewarded.
“We’re paying the nurses more to take these assignments. So, the nurses are really driving the market right now,” Kolb said, “They have their choice of pay package, location and contract.”
Even when the nurses come from other parts of the same hospital network, as with HCA Healthcare, essential medical staff are being incentivized for their mobility.
“This is a big inconvenience for them to spend three weeks away from their family,” said HCA’s Nations. “They are incentivized from the bonus structure and we pay for all their travel and all their meals. We welcome them with open arms and have gift baskets when they arrive.” HCA also provides temporary housing for traveling staff members.
“We really roll out the red carpet for them,” Nations said.
Wellness and Mental Health
Hospital administrators across Texas agree that in addition to supplemental staffing and strategies to keep ICUs fully staffed, a strategy for making sure nurses and other staff on hand are taken care of, physically and mentally, is just as important.
From peer-to-peer groups to wellness apps to services that allow nurses and other staff to call a professional after potentially traumatizing workplace incidents, many programs are in place to help.
But it’s unclear yet, as the pandemic continues to evolve, how effective these services will be long-term and how many are using them.
Ann Marie Warren, Ph.D, Research Center Director at Baylor Scott & White Research Institute, has a team of researchers working on two separate studies on the psychological impact of COVID-19. One of those studies focuses on a large group of non-medical essential workers, health care workers and people in the general population. A second study is more focused on health care workers, many drawn from the Baylor Scott & White community.
While it’s too early to draw conclusions from either study as they continue to collect and analyze data, Warren says that she’s been closely following studies published from other countries that began dealing with COVID-19 earlier, and that her team is especially interested in resiliency and coping.
“As important as it is to understand how people are being affected in a negative way, we really need to understand what’s working for them,” Warren said. “What coping strategies work?”
In order to understand how best to deal with issues that providers face—including anxiety, depression and PTSD from working on the frontlines of a pandemic—there is a great deal of interest in finding the right kind of interventions to keep staffers healthy.
But those solutions are not easy, she said. “People in health care need things that are easily accessible, quick to use, and don’t take a lot of time because frankly, they don’t have a whole lot of time to spare. We have to give people tools and techniques at their fingertips. Care takers in ICUs don’t typically have an hour for meditation. Is there a way we can make meditation very brief, and still be equally effective?”
In July, the Texas Hospital Association released its own list of strategies to support health care workers, which included items such as provide emotional support, promote mindfulness and connect with expert help.
“We recognize the physical and emotional toll that responding to COVID-19 has on direct care providers. We created a short, easy to read document that lays out strategies for prioritizing mental wellness and managing stress,” said Aisha Ainsworth, director of advocacy communications at the Texas Hospital Association.
In addition to this, THA is also encouraging Texans to thank and support the frontline workers in their community.
As staffing challenges continue, and hospitals increase their efforts to look out for their staff amid an ongoing crisis, Nations says that everyone is getting an education as they go on how to manage all of these components.
“We sure have learned a lot,” Nations said. “They’re going to write about us in the history books one of these days, that’s for sure.”