HOSPITAL CARE - As frontline health care workers prepare for the next coronavirus wave to hit California, almost everyone involved in the battle agrees on one thing: What happened during the last peak surge was as easy to explain as it was grim.
COVID cases overran the state’s health care system, which wasn’t equipped to handle the load. Ambulances circled facilities for hours, looking for a place to safely deliver their patients. Medical staffs frayed, working multiple shifts with no days off. Nurses in particular began leaving the industry, worn out, frustrated and emotionally drained.
These scenes played out against the backdrop of last January, the virus’s deadliest month in California, when nearly 15,000 people lost their lives to COVID. There were 6,411 deaths in Los Angeles County alone. The surge in cases overwhelmed hospitals’ collective ability to respond.
“The health care system underwent a stress test with COVID last winter, and we failed,” says Dr. Jeanne Noble, director of COVID response for the emergency department at the University of California, San Francisco, Medical Center. “We failed in many ways.”
But those on the front lines suggest not much has changed since that last statewide emergency. And, says Noble, if California plunges into another viral surge in the coming months, the same hospitals that were overwhelmed a year ago will again find themselves stretched to the breaking point.
In interviews with doctors, nurses, hospital administrators and advocacy groups, a clear picture emerges: Hospitals trying to turn a profit will find a way to keep most of their beds occupied most of the time, and they’ll use the lowest staffing levels possible. In normal times, that formula rankles employees but makes money. During a crisis, it implodes.
COVID cases in California requiring hospitalization have jumped
15% since the beginning of December.
“I do not feel we are prepared for another winter surge,” says Jill Leon, a registered nurse who works with COVID patients at Kaiser Permanente Walnut Creek Medical Center. “We are very short-staffed versus what our levels were even two years ago — and we’re short-staffed everywhere, not just with nurses. We are in constant critical need.”
It’s not yet clear what the demand for hospital care will look like in California. Researchers say the omicron strain of the virus is more transmissible than previous mutations, including delta. But vaccination and booster efforts, which were not in place a year ago, could suppress the number of people whose cases become so severe they need medical intervention.
Still, most health officials are expecting heavy traffic at hospitals. COVID cases in the state requiring hospitalization have jumped 15% since the beginning of December, and Santa Clara County Public Health Officer Dr. Sara Cody said she expects a “deluge of omicron,” adding, “What I see is perhaps one of the most challenging moments that we’ve had yet in the pandemic.”
“We worry about a strain on the hospital care system,” Los Angeles County Public Health Director Barbara Ferrer said recently. “We have a really noted staffing shortage issue at many of our hospitals.”
All sides are in lockstep on that fact, but not on the reasons why. To many nurses, physician assistants and technicians who have been in the COVID battle for the better part of two years, their employers’ staffing and equipment issues reflect conscious choices, not circumstances beyond their control. They say that suboptimal staffing has been occurring for years, since long before the pandemic hit.
Beyond that, many hospitals have already proved they aren’t likely to be ready for a large-scale emergency. As Capital & Main reported last year, poor planning contributed to many systems being plunged almost immediately into crisis mode, and governmental response — at the state, local and federal level — was mostly reactive, with much of the help coming long after hospitals were depleted of space, staff and supplies.
“We have fewer staff and more patients than we did a year ago.”
~ Kiyomi Burchill, vice president for policy, California Hospital Association
Some of the government interventions did little to actually improve conditions. In 2020, Gov. Gavin Newsom relaxed staffing ratios for hospitals in such critical areas as intensive care, telemetry, emergency and surgery. That brought many facilities into state compliance in the midst of a pandemic, and even critics of the move conceded that it was impossible for hospitals to be fully prepared for a COVID emergency that scaled up with frightening speed. But for the nurses, Newsom’s decision simply meant they would have to care for more patients with the same amount of time, resources and energy — and no additional staff.
Advocates for the hospital industry point to research showing that nearly one in five health care workers has quit since the pandemic began, and argue that it has exacerbated a workforce crisis that, for many reasons, has been building since long before COVID. “We have fewer staff and more patients than we did a year ago,” says Kiyomi Burchill, vice president for policy at the California Hospital Association.
Health workers say they know why that’s happening: Hospitals haven’t done enough to keep them safe, and they don’t hire enough workers to adequately care for patients or prevent rampant employee burnout. During the pressurized months of COVID, it led employees to leave in droves.
“This is a time in history when a lot of nurses are retiring early,” says Semanu Mawugbe, a registered nurse at Kaiser Panorama City Medical Center. “Some have died from COVID after caring for patients. Some have changed jobs and left the profession because the pressure has been so heavy. We need nurses who are simply not here.”
At Paradise Valley Hospital in National City, health care workers voted to unionize “right in the middle of the pandemic,” says nurse Rochielle Jocson, who was one of the organizers of the union drive. “We were incredibly short-staffed. We were reusing PPE [personal protective equipment] because of shortages. It was crazy. Nurses needed representation. We’ve been giving everything we’ve got for the better part of two years — and a long time before that, too.”
One factor that compromises California hospitals is the number of them that
rely significantly on “travel nurses” to round out staff.
Among hospital employees, suspicion of the companies’ bottom-line operating model runs deep. Several worker organizations recently joined a petition urging the U.S. Occupational Safety and Health Administration to adopt a permanent standard at health care workplaces with respect to COVID, an implicit criticism of the hospitals’ failure to do so. The petition asks OSHA to ensure safe working conditions for hospital employees “by mandating optimal PPE and other protections,” according to a news release.
But the larger issue is structural. “The fundamental problem is, we have a for-profit health system in this country,” says UCSF’s Noble. “We are not set up to run at 50% capacity or even 75% capacity. That is not a money-making proposition. Hospitals make money when they are close to full. So there is pressure to take as many transfers (from other hospitals) as possible. There is pressure to schedule as many surgeries as possible.”
Being nearly full, of course, means that a sudden patient increase of any kind — the result of a virus, say, or a rush of drug-related hospitalizations — can be a tipping point. The fact that hospitals can almost see another COVID surge coming does not mean those facilities are well prepared to handle it.
In the time since last winter, many hospitals have learned how to repurpose other areas of their buildings to add patient space or bedspace, or to create makeshift extensions of ICUs. Because of that, says Burchill of the hospital association, those issues are less urgent than the questions surrounding staffing. The room to house additional patients means nothing if there aren’t enough health workers to care for them.
One factor that compromises California hospitals is the number of them that rely significantly on “travel nurses” — those who move around the country on short-term assignments — to round out staff at different hospitals. Noble says that roughly 20% of UCSF’s nursing staff are travelers, meaning the hospital is bidding against medical companies across the U.S. to hire out of the same talent pool during peak crisis periods. Travel nurses can earn huge bonuses by going to COVID hotspots.
For years, hospitals in the state have moved toward a lowest-cost approach to health care, reducing bed count, trimming staff, running at near capacity and increasing profit by asking the remaining employees to do more with less. It has left the system vulnerable to the kind of challenge that a disease like COVID can mount — and it will be again this winter, if a new wave of hospitalizations hits.
As Noble puts it, “We’re pretty overwhelmed right now. So yes, any surge will overwhelm us.”
(Mark Kreidler is a California-based writer and broadcaster, and the author of three books, including Four Days to Glory. This article was published in Cpital & Main.)