Some California hospitals are running out of ICU nurses. What else can Gavin Newsom do?
Every bed in the intensive care unit where Amy Arlund works is full.
On her overnight nursing shift, she says she has to care for two dying patients at once with almost no help. The surge in COVID-19 cases has maxed out capacity throughout the hospital, forcing medical staff to treat some patients in a tent out in the cold.
“It looks like a war zone,” said Arlund, who works at Kaiser Permanente’s Fresno Medical Center. “A lot of us have been working full time, double time, overtime… We just cannot keep up this pace, and there is no relief coming our way.”
The situation at her hospital in the heart of the Central Valley illustrates a deadly problem facing the state: a shortage of intensive care unit doctors and nurses.
“The biggest scarcity right now is the workforce,” said Anthony Wright, director of consumer advocacy group Health Access. “We see it as a health access issue for everybody. Even if you’re not at risk of dying of COVID, you’re at risk if you can’t get the care you need because the hospitals are overrun.”
Across the state, intensive care units are filling up. In the Sacramento region, less than 15% of beds are available. In Southern California, capacity has fallen below 2%. The Central Valley’s available ICU capacity dropped to zero over the weekend, but has since crept up to 1.6%.
Nationally, the death rate is rising as hospitals overflow, Senate Health Committee Chair Richard Pan said.
“Because hospitals are so full and the personnel are so stretched, they’re not able to pay as close attention to each patient,” said Pan, D-Sacramento. “Before, we were worried about ventilators. Now, it’s staff.”
Gov. Gavin Newsom and California lawmakers face pressure to address the shortage.
On Friday, Newsom’s Department of Public Health rolled out an expedited process for hospitals to increase the number of patients nurses can treat at one time, which nurses say puts patients in grave danger.
His administration is hiring temporary staff to help, but the state faces increased competition for available medical workers as the entire country battles the latest surge.
This week, Newsom announced that asymptomatic health care workers exposed to the coronavirus can return to work after just a week of quarantining, instead of the previously recommended two weeks.
Meanwhile, patients continue to pour in. The state projects that the number of COVID-19 patients in California hospitals will more than double in a month.
“I’m not sure that there’s much that the Legislature can do,” Assembly Health Committee Chair Jim Wood said. “We can’t create new nurses out of thin air.”
More patients per nurse
As patients flood emergency rooms, the California Hospital Association has been pushing for a blanket waiver from the state’s nurse staffing ratio laws, which limit the number of patients nurses can treat at one time.
On Friday, the Newsom administration rolled out an “expedited waiver process” for hospitals, making it easier for them to increase the number of patients ICU nurses can treat at once from two to three.
Hospitals need the waivers to meet the surge of patients, California Hospital Association President Carmela Coyle said. The ratios have been forcing some hospitals to delay bringing patients into their ICUs and emergency rooms, she said.
“We need that flexibility to be able to stretch our nursing capacity,” she said.
The California Nurses Association adamantly opposes changes to the ratio rules and are staging protests at hospitals across the state. On Monday, nurses protested the changes outside a Los Angeles area hospital Newsom was visiting to watch the first medical workers in California receive COVID-19 vaccines.
“What we shouldn’t be doing right now is further causing harm to our patients by giving them substandard care,” said Stephanie Roberson, the nurses union’s top lobbyist. “We know that ratios save lives.”
Arlund, who serves on the union’s board of directors, says she’s already stretched to the breaking point. If her hospital gets a waiver from the ratio requirements, she says the results will be dire.
“The fewer nurses you have, and the more patients each nurse has during this pandemic, the more people die,” she said.
Pan described the staffing ratio issue as “tough.” If people don’t get care because hospitals can’t admit them, they could die. But they could also die if they are treated at a hospital where nurses are overstretched and can’t pay adequate attention to their patients, he said.
Wood said waiving the ratios is not an appealing option, but may be necessary.
‘Right now there’s a nationwide shortage of nurses,” the Santa Rosa Democrat said. “I don’t know what else you do.”
Adding ICU capacity
Newsom said last week that the state is trying to hire 815 medical workers, mostly to work in ICUs. As of Tuesday, about 300 of those contract workers had been deployed in California.
The state is also training more nurses to work in ICUs through a two-day program Newsom described as a “very effective, focused training to speed up opportunities to bring nurses into the ICU to help patients.”
As of Friday, about 195 registered nurses had enrolled in the online course, Health and Human Services spokesman Rodger Butler said.
Health and Human Services Secretary Dr. Mark Ghaly acknowledged training an ICU nurse takes years, not days, and said the program is intended just to help nurses who may be pulled into the ICU in an emergency.
That will likely be necessary as hospitals run out of fully-trained staff, Coyle said.
First, Coyle said hospitals will likely call on post-acute care nurses, who typically work closely with ICU nurses to care for patients that have just come out of surgery. Hospitals might also create teams of nurses from other parts of the hospital led by ICU nurses in an effort to stretch capacity.
Pan said bringing nurses and doctors from other parts of the hospital into ICUs will reduce quality of care. He used himself as an example. As a pediatrician, he does have some emergency training from medical school and his residency, but his skills have gotten rusty and aren’t up to ICU standards.
“It’s been a while since I ran a ventilator,” Pan said. “I’m probably better than nobody, but I’m not able to perform at the same standard, and the death rate will be higher.”
Pre-existing shortages
Most hospitals run close to capacity in a normal year, Pan said, and hospitals typically try to maintain only a bare minimum number of beds to save costs. Most winters, hospitals have to shuffle patients among ICUs, emergency rooms and other parts of the hospital to ensure the sickest people get adequate care.
California, in particular, has one of the lowest numbers of hospital beds compared to its population, according to data from the Kaiser Family Foundation.
“Having an empty hospital bed means that’s just money going down the drain,” Pan said. “You don’t want to have a lot of excess people standing around. These doctors and nurses are expensive.”
In March, many people stopped going to the doctor or to hospitals for non-COVID-19 issues and preventative care. That meant the health care industry suffered financially, and caused hospitals to even lay off some staff, said Wright, the director of Health Access.
“It was a weird irony where in the middle of the pandemic, you would think the issue would be hospitals and providers being overrun,” Wright said. “It actually created a financial stress on the health system not because there were too many patients, but too few.”
If that happens again, it could make the industry’s longer term staffing problems worse. It could also result in more non-COVID-19 health problems if people let manageable issues fester without treatment, especially if hospitals have to start canceling scheduled surgeries, which cover a wide range of non-emergency but serious issues, Wright said.
The nurses union has criticized the hospitals for laying off staff earlier in the pandemic, and argues that hospitals haven’t done enough to hire nurses to prepare for the winter surge.
“The shortage was already there before the pandemic, and the pandemic just exacerbated staffing shortages we were seeing for years,” Arlund said.
Earlier in the pandemic, Arlund says her team was able to rely on operating and recovery room staff and space because the hospital stopped non-emergency surgeries. But now that scheduled surgeries have resumed, those staff and rooms are no longer available. She thinks hospitals should stop elective surgeries again to meet this new surge so that ICU nurses aren’t stretched so thin.
Wright said cutting back on scheduled surgeries could be dangerous.
“There’s lots of situations where care delayed can mean care denied, or care delayed can mean a more intrusive and expensive intervention,” he said. “The obvious examples are a cancer that metastasizes.”
Delayed care could also be a problem for people who have co-morbidities like diabetes. If they can’t or don’t get care because of the winter surge, Wright said they will be more vulnerable to COVID-19.
The current surge is crashing over hospitals so quickly, there’s little time for policymakers to step in and help. The state could run out of capacity before the Legislature returns to Sacramento in January, and even then, there’s little lawmakers would be able to do, Pan said.
In the meantime, Pan said the governor has done one of the most effective things he can: shutting down parts of the state’s economy in an effort to slow viral transmission.
“We can manufacture more beds and ventilators, but it’s the people. There’s no law or magic wand to increase the number of skilled people to do this,” Pan said. “The best thing we can do to help them out is to do everything we can to stop the virus.”
This story was originally published December 16, 2020 at 5:00 AM with the headline "Some California hospitals are running out of ICU nurses. What else can Gavin Newsom do?."