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Overcrowded ERs, Nursing Shortages Hammer Hospitals

Since the onset of the coronavirus pandemic in 2020, hospital emergency rooms have been buffeted by a rising tide in patient volume, fueled in large part by COVID-19 cases, most recently the omicron variant.

Virus Outbreak New York
Emergency medical responders wheel an elderly patient into the emergency room at Brooklyn Hospital Center, Sunday, April 5, 2020, in New York. The hospital has been on the frontlines of the battle to treat high numbers of coronavirus patients during the viral pandemic. (AP Photo/Kathy Willens)
Kathy Willens/AP
(TNS) — Alesha Holley had terrible abdominal pain. On the recommendation of her doctor, she took herself to the emergency room.

Holley would have to wait an excruciating 24 hours before the medical staff at UPMC deemed that she needed surgery and would have to be admitted.

Her experience in September was nothing short of nightmarish, she said.

“My gallbladder was bad was going to rupture. I was in a lot of pain,” said Holley of Boiling Springs. “It’s horrific to try and go get help in an emergency room right now. It’s a horrific experience especially if you are in a lot of pain.”

Nancy Campbell had a similar experience.

She rushed her adult daughter to an ER in Allentown after she fell off a curb, injuring both her ankles.

They arrived at the emergency department at Lehigh Valley Health Cedar Crest at 11:40 p.m. Her daughter was not seen by a doctor until 9 a.m. It would be another hour before she was prescribed pain medication for what turned out to be a triple fracture on one ankle and severe sprain on the other.

Campbell recalls the exasperation — indeed, the shared exasperation among the 80 or so other people waiting for emergency care that night.

“It is a tragedy. It is a disgrace that these hospitals make so much money,” Campbell told PennLive this week from her Lehigh Valley home. “It’s not just them. I‘m sure the same can be said for most hospitals in the region. I think it boils down to a severe nursing shortage.”

In fact, Holley’s and Campbell’s experiences are not uncommon these days.

Since the onset of the coronavirus pandemic in 2020, hospital emergency rooms have been buffeted by a rising tide in patient volume, fueled in large part by COVID-19 cases, in particular most recently, the fast-spreading omicron variant.

Hospitals across the Commonwealth — and the nation — are facing a triple threat posed by the rising cases of respiratory viruses surging across the country: so-called RSV infections impacting children, the flu and COVID-19.

“(T)he volume of patients seeking care at some of our urgent care locations is more than double or triple that of previous years,” said Ryan Coyle, a spokesman for WellSpan Health, which operates eight hospitals in central Pennsylvania.

The health system, he said, takes proactive steps to address the sharp uptick in patient volumes, including adjusting staffing levels to best serve patients.

“When necessary, this includes temporarily consolidating locations in regions where there may be overlapping coverage so that we may best utilize available resources,” Coyle said.

Hospitals say all patients who enter their emergency departments are triaged and receive priority based on severity and urgency for care.

“That’s an innovation that has come about in the last couple of years,” said Dr. Craig Skurcenski, vice president of Emergency Medicine at UPMC in Central Pa., which counts Carlisle Area Hospital in its network.

“Emergency departments are learning how to care for patients in different ways and honestly in different locations. They are initiating care in that space. We used to call it the front house. It’s being called the triage area. We are actually seeing these patients early on in their visit with an advance practice provider or physician or they are being seen by a nurse.”

In recent months, hospitals across the region have had to adopt strategies to meet the demands on emergency departments. These include diverting patients with non-threatening conditions by ambulance to a different hospital, a strategy employed after ambulance crews complained that excessively long ER wait times were hampering the ability of crews to respond to the next emergency.

Patients who are waiting to be seen may not always realize that they are on the ER medical staff’s radar.

Holley went into the emergency room at UPMC Carlisle at precisely 3:20 p.m., she recalls. She wasn’t called until 7:30 p.m. for blood work, and then sent back out to the waiting room. She was eventually moved to a triage area and around 5:30 a.m., moved to another room.

“I was there for 24 hours until they moved me upstairs,” she recalls. “No one explained anything to me. They said they were going to triage me and were going to get me back as soon as possible. That was the last I heard until they took me back for blood work.”

But that triage and incremental care is exactly what Skurcenski describes as ER protocol these days.

In the early hours in an ER, a person waiting is typically evaluated, undergoes lab work, and is sent to imaging departments for CAT scans or MRIs or x-rays.

“We have learned that when space is full and patients need care, we need to bring care to the patients,” Skurcenski said. “It’s about accelerating the use of whatever space is available.”

Optics remain a major challenge for hospitals, though. In a crowded waiting room, the order in which patients are seen does not necessarily come down to who came in first — but who is the sickest or who has the highest probability of getting sicker who gets moved to the top of the list.

Skurcenski said it would be a rare circumstance for someone to sit in the ER waiting area unattended for an extended period of time.

“We want to identify those patients who are having chest pain or signs of a stroke immediately,” he said.

Among the confluence of factors nothing has affected the skyrocketing ER wait times more than the chronic shortage of nursing staff.

Perusal of most social media platforms yields any number of posts from people frustrated with long ER wait times.

PennLive this week put up a Facebook post canvassing readers for their experiences at emergency rooms. There were some bright spots, with stories of people being tended shortly after arrival, but the vast majority of more than 1,100 commenters shared anger-filled recollections about their experiences.

Wrote one commenter: “Went to UPMC Harrisburg Hospital ER last Tuesday with a very high fever. The place was packed. We were seen by a doc after 12 hours. Others waited 20 hours. Staff was great. The ER is a mess and should be avoided at all cost. Was then in an ER hallway and then an ER room for over two days before getting a room upstairs.”

Another commenter wrote: “8 hours with a kidney stone…not fun. They did give me meds for nausea and pain but I sat in the waiting room just to be told I definitely had a large kidney stone that required a surgical procedure to remove and I should just go home and call my urologist.”

These are prevailing narratives across the state, said Chris Chamberlain, head of the emergency management team for the Hospital and Healthsystem Association of Pennsylvania.

“We know it’s stating the obvious but hospitals across Pennsylvania are feeling the strain of workforce challenges,” he said. “There were challenges with a workforce getting older, people retiring but then the pandemic made it worse. As of late, we are seeing particularly in hospitals that provide care to children there’s been a pretty significant seasonal viral illness issue with RSV with more children needing in-patient care combined with covid and influenza. Right now the conversation is very active.”

Few members of the health care sector have born the brunt of the pandemic as much as nurses. In the height of surging COVID-19 cases, the nation witnessed the bravery of nurses as they worked under duress and in danger of their health to provide care to a seemingly endless stream of sick and dying patients.

The pandemic has taken a toll on the nursing industry, with thousands of nurses having left or about to leave their vocation, suffering from burn out, emotional duress and fatigue.

“Nurses are the people with patients 24-7. They are the frontline professional staff,” said Mary Ellen Smith Glasgow, dean and professor at the Duquesne University School of Nursing.

“Many times they are not getting meal breaks or bathroom breaks. They are running around. Even the amount of respect a nurse gets is an issue. I don’t think people understand the intellectual rigor required for the role. You are having all this and covid comes and you are working with many people suffering and dying. You have a lot of emotional stress.”

The nursing workforce shortage continues in an unstable and potentially dangerous trend, experts say.

A report earlier this year by McKinsey & Company, a health care consortium, found that over the past two years nurses increasingly report planning to leave the workforce at higher rates compared with the past decade. In the latest McKinsey survey, 29 percent of responding RNs in the U.S. indicated they were likely to leave their current role in direct patient care, with many respondents noting their intent to leave the workforce entirely.

The picture is grim, looking just two years out.

McKinsey estimates that as many as 450,000 nurses in direct patient care could leave the workforce. That amounts to a 10 to 20 percent gap.

“Hospitals did the best they could under the circumstances but it was like you went to war,” Smith Glasgow said. “It was like nothing we had ever seen. No one thought about the mental health of nurses. Everyone was trying to survive. It has taken a great toll.”

Smith Glasgow said the nursing sector has several strategies that in the long term can address and remedy the exodus of nurses such as scholarships or recruiting from new demographic groups — those in mid-career in other fields or those seeking employment after an early retirement.

“We need to get people into nursing and we have to get faculty to teach them,” Smith Glasgow said.

Strategies that foster retention will also be key, she added.

“We need to do basic things like making sure nurses get bathroom breaks and a chance to eat lunch,” Smith Glasgow said. “We need to have a culture of real respect for nurses. Historically we talk about the physician but people come to the hospital, other than for surgery, they come for nursing care. That’s why they are there. We really need to look at the amount of respect and value the nurse brings to the institution.”

The Pennsylvania Department of Health does not track emergency room wait times. But it enforces regulatory requirements that hospitals be adequately staffed and equipped to meet the needs of patients requiring emergency services.

Maggi Barton, the department’s deputy press secretary, noted the Wolf Administration has made investments in the healthcare industry through programs like recruitment and retention grants, nurse loan forgiveness.

The health department, like most health care systems, encourages people to consider seeking care from a primary physician or urgent care center rather than the ER whenever possible.

“We are trying to get the message out that if you need us, we are here and we want you to come because we are ready,” Skurcenski said. “For people who are not in a critical stage, we are going to care for you in the best way we can. We are going to bring care to you in a pattern and in a rotation that may not meet traditional expectations and, the third piece is to make sure that if it’s not the emergency department that you need, that you utilize more appropriate care options for you.”

A week out from her experience, Campbell’s anger over her experience in the ER has eased — but not her concern for others in far worse condition than her daughter who may be short changed by inadequate hospital staffing.

“I know that most of the professionals up there want to do the right thing and want to take care of patients,” she said. “I know their frustration. It’s interpreted by people like me that they were being mean. I realize in hindsight that is their frustration. I don’t understand how anyone who runs an ER can look at the pitiful few staff they have available and think this is sufficient.”

Coyle provided one silver lining — at least as it pertains to Well Span Health. The health system may be seeing an increase in patients at the ER, but they don’t necessarily end up as admissions.

“We often see an increase following major holidays like Thanksgiving, Christmas and New Year’s when families gather and respiratory viruses can spread easily,” he said. “While our urgent care locations and emergency departments are currently seeing an increased number of patients, we have not been experiencing a steep rise in hospitalizations similar to the previous surges of COVID-19.”

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