Colorado faces the possibility of running out of hospital beds by the end of December, and while the current COVID-19 surge would be the final push over the edge, nurses say the crisis has roots that go back years.
If current trends continue, more than 2,200 people are expected to be hospitalized with COVID-19 by Jan. 1, taking up every available hospital bed in the state, and possibly going over capacity. Gov. Jared Polis has called for hospitals to find space for 300 to 500 more beds, but it’s not clear who will care for the patients in them, if facilities do find enough room.
In the current wave, the shortage is in skilled people, not equipment or even physical beds. Even though fewer people are hospitalized with the virus than at last’s December peak, more people are coming into hospitals with other conditions, and there are fewer nurses and other frontline staff to care for them.
Pandemic-induced burnout is one reason some have left health care, but nurses say it piled on top of their existing concerns: that they were being asked to do more, without sufficient support and with largely stagnant pay. Frontline staff from four Colorado hospitals, owned by three different companies, described to The Denver Post a workforce problem that had been building for years before COVID-19 made it a crisis.
While COVID-19 hasn’t directly affected all units, nurses are dealing with the same stressors in their personal lives as everyone else, on top of long-term frustrations over pay and limited opportunities to get ahead, said Nicole Alexander, a labor and delivery nurse at a Front Range hospital.
“COVID is probably the straw that broke the camel’s back,” she said.
Intensive care units have been hit hardest in recent weeks, with 72 beds available as of Thursday. COVID-19 hospitalizations are increasing in Colorado at the same time that people who put off care during earlier phases of the pandemic are finally coming in — often sicker than they might have been if they’d gotten care last year.
Taylor Rasmussen, an intensive care nurse at UCHealth University of Colorado Hospital in Aurora, said that in normal times, each nurse would be responsible for one or two patients in the ICU. Because of the surge in patients and the loss of nurses to other jobs, they’re trying to balance four or five, she said. Her unit primarily treats people who have had lung or heart surgeries, including transplants.
Patients in her unit are on multiple medications to support their blood pressure and other basic functions, and most are on ventilators, Rasmussen said. The most seriously ill patients should have near-constant monitoring, which isn’t possible with current staffing levels, she said.
“We haven’t had normal patient ratios in a year-and-a-half,” she said. “It’s essentially a triage situation every day when we go to work.”
Dan Weaver, spokesman for UCHealth, said intensive-care nurses aren’t asked to care for more than two patients, unless some of the patients only need a lower level of care. The system has “labor pool” offices to assign staff to support nurses in busy units, either by helping with less-specialized medical care or doing tasks like errands, he said.
“Incentive pay may be available for many of these individuals and shifts to help recognize our employees’ dedication and work,” he said.
Diverting ambulances from full ERs
It’s not only intensive-care units that are overtaxed. With no one to staff available hospital beds, patients are backing up in emergency rooms, said Dr. Ramnik Dhaliwal, president of the Colorado chapter of the American College of Emergency Physicians and assistant medical director at Sky Ridge Medical Center in Lone Tree. He said he wasn’t speaking on behalf of Sky Ridge, and noted that emergency departments are struggling statewide.
Colorado’s emergency rooms spent 4,198 hours on “divert” status in October, meaning that ambulances were instructed to take patients to another hospital if they could do so safely, according to data from the Colorado Department of Public Health and Environment. That’s 31 times the number of hours they were on divert in January.
Diverting can be useful when a hospital is seeing a short-term rush — say, when victims from multiple accidents happen to arrive at the same. But when many hospitals are backed up and diverting at the same time, it stops being a way to manage the flow of patients. Ambulances still have to take patients somewhere.
When patients can’t move from the emergency department to an ordinary floor, the room where they’re staying isn’t available for the next patient coming in the door, Dhaliwal said. That translates into long waits for patients and more staff time spent checking on people in the waiting room, he said.
“Patients spend hours in triage,” he said.
HealthOne, which owns Sky Ridge, said its hospitals have increased incentive pay and brought in traveling nurses to help out. In 2021, it also has hired 5,315 people across the system, including 2,100 registered nurses, spokeswoman Stephanie Sullivan said.
“There is no question that the ongoing increase in patient activity has put a strain on staffing across Colorado, the region and the entire nation, but we are grateful that our hospitals have been able to meet the needs of our patients,” she said.
Nurses “exhausted,” considering leaving
As of January and February, just over half of Colorado nurses said they had felt “exhausted” in the previous two weeks, according to a survey from the American Nurses Foundation. About 18% of those surveyed said they planned to leave their jobs in the next six months, with more than half citing low staffing as one of their reasons. It isn’t clear how many actually quit, though.
Hospitals nationwide are having a similar problem, with 96% of managers and executives overseeing nurses saying that retaining staff was a challenge in an August report by the American Organization of Nurse Leadership. That’s roughly double the percentage that considered staffing a top challenge in July 2020.
The recent resurgence in COVID-19 is one factor that’s making their jobs harder, nurses say.
The Colorado Hospital Association estimated about 15% to 20% of hospitalizations were for COVID-19 in the first week of November, which is lower than at the pandemic’s peak late last year. But the difference is that non-COVID hospitalizations haven’t fallen as they did then — with a bigger overall number of people hospitalized, the virus will account for a smaller percentage, said Cara Welch, spokeswoman for the association.
As of Wednesday, 38% of hospitals reported they could be short-staffed in the next week, meaning 62% say they’re doing fine — a number Colleen Casper, executive director of the Colorado Nurses Association, said she doesn’t believe. The public needs better data on staffing levels, she said.
Hospitals report whether they are short-staffed based on whether they’re having to exceed the staffing levels they set internally, said Julie Lonborg, the Colorado Hospital Association’s senior vice president of communications. Colorado law doesn’t limit the number of patients each nurse can care for, though staffing levels must be high enough to keep patients safe.
On Tuesday, Colorado acknowledged that staffing was a pervasive problem by activating that portion of its “crisis standards of care.” The standards provide a guide for stretching resources and legal cover for hospitals if they have to use practices that wouldn’t normally be considered good care, like having staff work in units outside their expertise.
The hospital association is talking with the state about how to limit time-consuming inspections during the surge, to ease the burden on frontline employees, Lonborg said. They’re also looking into whether there’s a way to direct federal money to hospitals that can’t afford to hire traveling nurses, who often earn three or four times more the normal hourly wage, she said.
The state could do more to recruit nurses in less-stressed parts of the state to help out in overwhelmed areas, but the steps with the biggest impact have to come from hospitals, Casper said. They need to pay nurses more, give them more say about their working conditions and do more to hold onto experienced staff who can oversee and mentor new graduates, she said.
“They’re not acknowledging that they played a role in the staffing shortages,” she said.
Frustration with pay
Dhaliwal, the president of the emergency physicians group, said salaries for nurses and other providers had “stagnated” before the pandemic. That made it harder to hire and keep staff, contributing to a “vicious cycle” as hospitals filled up and workloads increased, he said.
“Colorado’s a great place to live, but we pay poorly,” he said.
Colorado ranks near the middle on nurses’ hourly wages and nursing publications typically list it as a good place to work, but the relatively high cost of living can cause difficulties for those who have families, Lonborg said. Also, nurses may not always think about other benefits that employers offer, like covering much of the cost of health insurance, she said.
“Are there places that pay more? Sure. Are there places that pay less? Yes,” she said.
Hospitals aren’t the only sector struggling to keep employees, Lonborg said. People are increasingly walking away from jobs across the board in what’s become known as the “Great Resignation.” Some nurses decided they were done dealing with difficult patients and families, she said.
And about 2.8% of people working in Colorado hospitals decided not to comply with the state’s vaccine mandate, according to data from the state health department, though it’s not clear how many of them were frontline care staff. Some hospitals promptly dismissed unvaccinated employees who didn’t get an exemption, though others have kept trying to persuade them.
At the same time, nursing schools have reported a record number of applicants, which suggests people still consider it a desirable profession, Lonborg said.
While the rise in applicants may be a positive sign, nursing schools can’t produce new graduates fast enough to fill the demand.
The number of nurses in teaching positions declined during the pandemic, according to NPR, and the number of sites where nurses can get practical experience hasn’t kept up with the flood of applicants. While nursing programs accepted more applicants in 2020 by having larger classes or stretching other resources, more than 80,000 qualified applicants didn’t find a slot, according to the American Association of Colleges of Nursing.
“No bad guy to point at”
A charge nurse who works in a step-down unit in a Denver-area hospital, who spoke to The Post on condition of anonymity to protect her job, said the hospital where she works has been “chipping away” at support staff for years, though the process accelerated at the start of the pandemic. When elective surgeries stopped in spring 2020, her hospital laid off clerical staff and some certified nursing assistants, who do tasks like checking patients’ vital signs and responding to call lights, she said.
“Most nurses I know don’t take a lunch break… and then they stay after (their shifts) to do paperwork,” she said. “Sometimes you have patients that need to be fed, and no one has time to feed them.”
Charge nurses oversee the bedside nurses on their units and are responsible for paperwork and some direct care. The nurse at the step-down unit, which treats patients until they’re stable enough to go to a rehabilitation facility to recover from their illness or surgery, said almost all of the nurses working under her are recent graduates, though they typically have one or two traveling nurses plugging gaps. New nurses need more oversight, and without clerical support, tasks like managing supplies and fielding calls from patients’ families fall on the charge nurse, she said.
“I’m one person, and I’m trying to do the job of three people,” she said.
Some, though not all, hospitals tried to keep their operations as lean as possible before the pandemic, given the uncertainty around whether the state would pass laws that would increase costs or lower revenues, Lonborg said. Health care also had shifted, with fewer procedures provided in hospitals, so they may have cut staff or moved them to outpatient centers, she said.
The charge nurse said hospitals and the state could take a few steps to help keep nurses, including offering them bonuses to stay and putting a mask mandate back in place long enough to get COVID-19 under control. They could also take small steps, like reducing the amount of paperwork required and getting rid of the expectation that someone will meet with patients every day to talk about their treatment plan, she said.
Hospital administrators are doing the best they can, and some are even filling in as nonclinical support, the charge nurse said. But it isn’t enough to address the level of need now, she said.
“All they’ve got available is Band-Aids, and we’ve got a massive bullet hole,” she said. “I think the thing that makes it harder is there’s no bad guy to point at.”
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