Why hospital ERs are filled beyond capacity

Cases are down, but staff vacancies are way up

THE CORONAVIRUS PANDEMIC, which has afflicted more than 68 million people and caused more than 850,000 deaths in the United States, continues to serve as a giant stress test for the nation’s healthcare system.

After the mortgage loan crisis of 2008, financial institutions used stress tests to help identify weaknesses and determine whether institutions had sufficient capital to weather future financial storms. In a similar way, the COVID-19 pandemic is testing the nation’s healthcare system. It has revealed both great strengths and weaknesses. Among the strengths:

• Healthcare systems, care providers, and staff are truly committed to their patients and to the communities they serve.
• The pandemic accelerated the discovery of effective new treatments for severe COVID symptoms.
• Telemedicine became a widely used tool for diagnosing and treating patients, while reducing the need for face-to-face interactions.
• The pandemic forced close collaboration between governmental, medical, and business leaders to contain the disease and protect communities.
• Pharmaceutical companies proved they could deliver safe, effective vaccines within a year of the disease’s outbreak.

But the two-year-old pandemic also is revealing major challenges.

Hospital emergency rooms are now filled beyond capacity, and not because more people are requiring emergency medical care (at Southcoast Health’s three hospitals, Charlton Memorial, St. Luke’s and Tobey, the number of cases being treated in the emergency department is down approximately 20 percent in 2021 compared to the number of cases before the pandemic in 2019). Rather, it is due in part to the cascading effect of large numbers of nurses, medical technicians, and support staff leaving community hospitals in more vulnerable communities like New Bedford, Fall River, and Wareham — that have suffered disproportionately during the pandemic. Systemwide, Southcoast Health is facing a 28 percent position vacancy rate for emergency department nurses and a 33 percent vacancy rate for emergency department technicians, who are critical to a patient’s care team.

Southcoast Health’s experience is not unique. These challenges are mirrored at many other hospitals across the Commonwealth and nationwide. Some nurses are leaving hospital service for less demanding practice with more predictable hours. Others are lured to better-paying jobs at big city teaching hospitals, where relatively fewer patients are on Medicare and Medicaid. Those public programs pay less than private insurers, and at Southcoast’s three hospitals, where nearly 75 percent of patients are on Medicare or Medicaid, that disparity is reflected in the healthcare system’s financial health. And with hospitals across the country facing similar nursing shortages, private staffing agencies recruit nurses for temporary assignments elsewhere at wages two or three times higher than they were being paid at a local community hospital, along with a signing bonus and housing and travel stipends.

That, in turn, can be discouraging to longtime, loyal nurses who each day put their own health at risk caring for desperately ill patients. Many patients admitted with severe illness are unvaccinated for COVID-19 or have delayed seeking care throughout the pandemic, coming in with more severe illness or injury than usual.

As our healthcare system continues to navigate these challenging times, it is no wonder that many veteran nurses have chosen to retire, leaving behind the stress and long hours that the pandemic has forced on hospital workers. Southcoast’s three hospitals combined are short 200 full-time-equivalent nursing positions.

It is not just hospitals and health systems bearing the burden during this years-long crisis. Nurses and medical support workers have also been quitting jobs at nursing homes and other post-acute care facilities, which are left unable to accept additional patients. This significant decrease in post-acute and long-term care options leaves some patients — especially elderly patients — with nowhere to go when they no longer need hospital care.

And so, hospital beds are increasingly filled with medical “boarders” who are waiting for a safe place to recuperate. That affects emergency rooms, where patients awaiting hospital admissions take up beds needed for emergency cases, where hallways are lined with gurneys, and where physicians sometimes are seeing patients in the lobby. The same is true for people undergoing a psychiatric crisis and who need care and supervision. They too are often being “boarded” in emergency rooms because of a statewide acute shortage of behavioral health specialists and inpatient beds for behavioral healthcare patients.

The result is often emergency room wait times of many hours for less seriously ill or injured patients. That increases anxiety for worried loved ones as staff must continuously prioritize and treat an exceptionally high volume of patients waiting based on need. It is yet another reason that nurses and technicians are leaving the profession.

This nursing shortage demands a range of policy changes to begin to solve it.

• We need to provide our nurses with greater personal and professional support through peer training programs and options for self-care, like learning meditation techniques and taking time to grieve a patient who has died.
• We must establish state and federal government-backed tuition loan forgiveness programs — similar to those available for physicians who agree to work in public service jobs, the military, or on reservation lands — so that nurses are not forced by unaffordable loan payments to leave their home communities for higher-paying work.
• We need more qualified nursing faculty to teach future generations of nurses.
• Healthcare needs to recruit future nurses among idealistic young people. Elementary students aren’t too young to hear the joys of making a difference in their communities.
• We must find a way to ensure that hospitals serving low-income communities can afford to hire and retain nurses; socioeconomic differences must not condemn some communities to staff shortages that affect the availability and quality of care.
• We need more skilled-nursing facilities to care for patients who no longer need to be in the hospital but who are not ready to go home.
• We must strengthen our community health programs, bringing churches, schools and other non-profits together to promote basic wellness.

These are significant challenges, but when all is said and done, the COVID-19 pandemic will have afforded us an opportunity to build a stronger, more equitable healthcare system that is ready for the next public health crisis. That is how progress happens.