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‘There aren’t enough of us to fill that need’: As hospitals fill, staffing becomes biggest challenge

By Catharine Richert, Minnesota Public Radio News

As the coronavirus pandemic continues its deadly rampage through Minnesota, hospitals around the state are dangerously full, stretching medical staff as they try to care for as many patients as possible.

For weeks, public health officials have warned that, while additional space and supplies to treat COVID-19 patients are available, staff is not. That leaves individual hospitals and health care systems to an exhausting, daily game of staffing chess to keep up with the demand for care, as more and more COVID-19 patients flood the state’s intensive care units and hospital floors.

Not only are more people than ever seriously ill with the virus, but hospitals are simultaneously trying to keep up with patients suffering from strokes, heart attacks and other serious injuries.

At this critical juncture, this logistical gymnastics is necessary, but it also threatens to burn out the system’s already limited staff, said Kelley Anaas, an intensive care nurse at Abbott Northwestern in Minneapolis.

“What’s new, and we’ve been seeing the clouds gathering the horizon for a while, is how many people are going to need us and how there aren’t enough of us to fill that need,” said Anaas, who has been taking care of COVID-19 patients since the start of the pandemic.

“That’s what’s scaring nurses most of all right now. We want to be there to help, there’s only so much we can do as one person.”

Unabated community spread of the virus in all corners of the state is contributing to the staffing and space crunch: More and more medical staff are having to stay home from work, because they have the virus, have been exposed to the virus or are taking care of someone at home who’s experienced either.

As of late last week, within Mayo Clinic’s health care system in the Midwest, roughly 2,000 staff members were either out because they have the virus or home with someone who has it — or are limited in the work they can do, because they’ve been exposed to the virus and are in some level of quarantine.

The state does have a coordinated care center that’s helping hospitals manage their surge capacity — helping them find beds if they need to transfer patients, and shifting staff to respond to large influxes of patients at any given time.

But while Minnesota has extra beds, space and supplies on hand to expand the physical capacity of its health care system, there isn’t an abundance of extra workers that the state or hospitals can bring in to help care for patients in those beds and using those supplies.

Traveling nurses and other typically available health care workers are in high demand nationwide, as entire regions of the country are experiencing simultaneous coronavirus surges.

This perfect storm of staffing challenges has left hospitals around the state with imperfect solutions that all carry risks to patients and workers: Staff are being asked to take on more patients or new responsibilities, and some are working in COVID-19 wards after being exposed to the virus — an approach that’s been given the Centers for Disease Control and Prevention’s blessing in the crisis, but that contradicts best practices in normal times.

Hospitals are once again delaying elective procedures to free up staff — unlike earlier this spring, on the basis of need, rather than mandate — creating potential health risks for patients who would benefit from timelier treatment.

But even if all these puzzle pieces — beds, space and supplies — fall into place, some health care providers said they’re already having to make difficult decisions about how they treat patients, because they don’t have space or staff to treat everyone at once.

Lean staffing model makes spike overwhelming

Across Minnesota hospitals, changes are being made to meet patient demand across the board, from the front lines of intensive care units to outpatient services.

From her perch in Abbott’s ICU, Anaas sees the large volume of patients colliding with hospitals’ typically lean but efficient staffing model.

In the last few weeks, as COVID-19 cases have started to climb, Anaas said the volume of patients in her department has become overwhelming.

“What we’re running into is that these COVID patients, when they get really sick, what they require is one-to-one nursing care,” she said.

Those patients, she said, have very specific, constant needs and tend to stay in the ICU for longer than other patients. When they are on ventilators, for instance, they often need to be rolled onto their stomachs, into the prone position, to get more oxygen. They need constant monitoring.

“It requires so much manpower and monitoring by the nursing staff,” she said. “When we’re doing that for 15 COVID patients, that’s 15 COVID nurses right there. It’s almost like we’re doubling our need just based on how sick these patients are.”

Anaas said that means nurses who normally would be giving one-on-one care to other critically ill ICU patients are taking care of several at a time. She said it’s a manageable strategy for now, but it’s not ideal for vulnerable patients — and she fears its potentially unsustainable.

One strategy hospitals have put in place to meet the new demand is to bring in workers from other parts of the hospital to help in the ICU and COVID-19 wards.

Finding available help from skilled nurses in other parts of the hospital has been hard, Anaas said, because most elective procedures and surgeries continue, so nurses are needed in their own departments.

Meanwhile, hospitals around the state are following different quarantine guidelines for exposed workers to keep staffing levels high — in some cases, asking people with low-risk COVID-19 exposures to come to work while they await test results.

That’s an approach Abbott Northwestern has begun to take. Just a few weeks ago, Anaas’ son was tested for the virus. And while she waited for his results, which turned out to be negative, Anaas continued to come to work. State Health Department guidance for people awaiting COVID-19 test results is to quarantine, stay home and monitor any symptoms.

In a statement, Conny Bergerson, a spokesperson for Allina Health, which operates Abbott Northwestern, said that the approach is helping the hospital maintain its highest levels of staffing and care.

“[Asymptomatic] employees who have been exposed are able to continue working, pending results of their COVID-19 test,” she said. “This strategy follows CDC guidance and is in alignment with other healthcare systems in the state and nation.”

Still, Anaas worries.

She said she’s not sure this is safe for her patients who aren’t being hospitalized for COVID-19 — or for her colleagues.

“The nature of our work is that we are working physically close to each other all day long,” she said. “To go into work and potentially infect my co-workers and take them out of commission is that part that worries me.”

Adjusting approach to meet the need

Across the state line in North Dakota, nurses are fighting back against a state order that allows nurses who have tested positive for COVID-19 but are asymptomatic to come back to work in COVID-19 wards.

In Minnesota, that isn’t the case. But hospitals are tweaking the Centers for Disease Control and Prevention’s recommendation that people quarantine for 14 days after a COVID-19 exposure to allow employees to return to work earlier — and to align staffing levels with the demand for care.

At Hennepin Healthcare in Minneapolis, spokesperson Christine Hill said the hospital is asking staff who have been exposed to the virus to return to work before the end of their quarantine if they work in areas experiencing a staffing crisis.

“Nurses at Hennepin Healthcare have developed a process to test staff at seven days after a high-risk exposure,” Hill said. “Only if the test is negative can they return to work, adhering strictly to required precautions.” She said the process allows staff to return to work early, but doesn’t require it. The move is a voluntary one, she said.

At Mayo Clinic in Rochester, Dr. Conor Loftus, a gastroenterologist helping lead the hospital’s COVID-19 staffing response, said the hospital is dialing back some elective procedures to redeploy staff to other departments where labor is in high demand.

For instance, anesthesiologists who would typically be caring for people in surgery are now helping to care for people in the ICU, he said. The health care system is capitalizing on having sites throughout the Midwest, in Florida and Arizona.

“Being a large and broad enterprise is a real asset. We’re sharing resources across the entire organization,” he said. “Arizona had a surge in the summertime, and Florida was surging, to a degree, as well. We were able to help Arizona and Florida. Now, our amazing colleagues in Arizona and Florida are calling me up, asking how they can help.”

Ryannon Frederick, Mayo’s chief nursing officer, said that since the pandemic began, the system has been focusing on rehiring retired nurses, tapping nursing students to take on lower-level responsibilities and hiring traveling nurses to fill expected staffing gaps.

And at the same time, they’re retraining some other staff — for instance, training desk staff to administer nasal swab COVID-19 tests, a task that’s typically been done by nursing staff.

“We can shift that precious nursing resource, who is really trained at assessment and intervention, to some of the higher acuity needs that we have,” she said.

Slow, mass casualty event

At one large metro-area hospital, beds in and out of the ICU are perpetually full, said the chair of medicine there. The doctor asked not to be named because she isn’t authorized to speak on behalf of her employer.

It’s a far cry from what the hospital experienced at the start of the pandemic, the doctor said, after Gov. Tim Walz signed an executive order putting elective procedures on hold around the state.

While the strategy came at a financial cost to hospitals, forced to delay high-dollar procedures — and at a health risk to patients, some of whom could have benefitted from earlier treatment, the order freed up staff and space in other parts of the system to help treat that first wave of COVID-19 patients.

Now, she said, even if a bed is physically available, if there aren’t enough nurses or doctors to staff it, it’s effectively unusable.

That has meant that she can’t always admit patients from other parts of the state who need to be transferred to her hospital, for its ability to provide a higher level of care.

“Some of the [hospitals] I’ve been talking to will say, ‘You’re the eighth person I’ve talked to. Please, do you have any bed?’” she said. “And I have to say no. Because I’m at my limit of patient care.”

Inside her hospital, the doctor said some patients with slightly less-acute cases of COVID-19 who would have been admitted to the ICU at the start of the pandemic are now being treated in other parts of the hospital. Emergency room patients who need to be admitted now stay in the ER for hours, and sometimes overnight, until there’s enough staff in the hospital wing to care for them.

The staffing crunch has had an impact beyond the hospital’s COVID-19 ward, too, she said. For instance, people coming in with illnesses like a mini-stroke or diabetes — patients who would have typically been admitted for an overnight stay — are being sent home and asked to come back the next day for treatment in an outpatient setting.

The doctor said she worries that patients’ conditions will worsen in that short period of time — and she worries they might not return for additional treatment at all, especially if they have a job they can’t miss, transportation challenges or are homeless.

“That’s concerning. It’s not ideal. That’s not what we usually do,” she said. “We don’t have the space, so we have to go to the next lower level of care. That bumps up against our ethics.”

She said she and her colleagues are already having to make difficult decisions about who they can and can’t admit to the hospital right away because staff is at capacity and space is full.

“It’s not a comfortable position to be in when you’ve taken the Hippocratic oath, because you pledge to do the most good for the most people, to do no harm,” said the doctor. “But then you’re being asked, ‘Here are 10 people. You can only pick seven,’” because that’s all the patients the hospital has space to care for.

The doctor said that when the pandemic is over, she worries more people will have died, not just from COVID-19, but from not being treated promptly for other conditions.

“It does feel like a slow, mass casualty event,” she said.