It’s four in the morning and you awaken with crushing chest pain. Your family calls 911 and paramedics arrive and diagnose a cardiac event. They inform you that they need to transport you forty-five minutes away because your two local hospitals have closed over the last several months. Even when you arrive at the hospital, there is massive overcrowding and they inform you that there are no ICU beds open for you in that fifty percent of the beds in the cardiac unit are “browned out” due to lack of staff. This nightmare is an all too familiar post pandemic reality about the delivery of health care in our country. This is not the expectation that the public expects in the delivery of health care in one of the richest nations in the world that has been at the cutting edge of health care innovation of the last century.
What has led to this post-pandemic nightmare is multifactored. The pandemic changed how health care professionals are both valued and how they see themselves. During the height of the pandemic they were heroes that were endangering their lives to help the community. But now things look different.
Around 7,000 nurses on strike in New York City nursing strike is emblematic of the dire situation. Nurses, who are essential to the critical functioning of all hospitals, are entitled not only to more equitable compensation and benefits, but ultimately safer staffing ratios in all patient care settings. What’s ironic is that the strike will force these very health care systems to replace employed nurses with temporary nurses from staffing agencies, further compounding their financial woes, and ultimately, their bottom lines. Until we invest in people and their value in healthcare, we won’t be able to see light at the end of the tunnel.
Everyday we read about hospitals throughout the country losing millions if not billions of dollars per year. Hospitals are closing urgent care centers, obstetric, pediatric and other services to try to survive. One of the major factors that has triggered this crisis is the lack of staff. Post-pandemic hospital staffing has massively decreased with a rise in temporary locum staffing dependency. Hospitals and clinicians no longer have regular staff that can build professional and patient relationships; instead, they are dependent on locum staff with short term contracts to provide such services. Those locum providers are at all levels of the professional ladder from physicians, mid-level providers, nurse, respiratory therapists, and radiology technologists. This staffing model has led to many issues both professionally and financially.
On the professional level this massive short fall of staff and dependency on temporary staff has created a critical issue in the realm of patient care. Hospitals and clinics have shut down services in all vital patient services. It is not uncommon to hear that health care systems have shut down Pediatrics, Psychiatry, Obstetrics, and ICU. Other healthcare systems have gone to the point of closing down entire hospitals because of staffing issues. Another important factor is the crisis is that outpatient services have reduced hours and days. It is obvious that this reduction of services has greatly affected access to health care. Individuals have loss the ability to get timely appointments, x-rays, and tests. In many communities, it is the underserved that have payed the greatest price in terms of getting timely care.
Hospitals have had to also close down operating rooms due to staffing thus delaying both elective and emergent services. Critically ill patients boarded in the emergency department have also spent long hours or days waiting for inpatient beds due to lack of trained staff even when bed become available. Even when they may be ready for hospital discharge patients have long waits to find rehab and skilled nursing facilities because they have also been affected by short staffing. This inability to transfer patients to appropriate facilities only adds to the short fall of inpatient beds.
During the pandemic, it was not uncommon for older providers with health issues to retire than to go into work. Individuals that did go to work worked long hours and had increased levels of stress. Post pandemic, many of these individuals were not financially rewarded: they saw COVID-19 relief money go to upgrade facilities, build new buildings, and other non-employee rewards. This obviously changed the relationship between the bedside providers and hospital leadership.
Adding to this breakdown for many were the city and state vaccine mandates. Many believed that they had worked hard with limited resources and experience against COVID-19 and now the appreciation is losing your job over your own ability to make health care decisions. Another major issue is the shortfall of individuals who wish to be health care providers. Many individuals and families observed how hard healthcare workers were required to work and to work while other professions and jobs could work from home.
One of the most important aspects in the shift was the introduction of massive numbers of temporary workers during the pandemic which continues today. Temporary workers (typically known as Locums) are a major contribution to staffing issues. As regular hospital staff learn about the financial rewards that locum providers receive, it only leads to more individuals questioning, “why do I still work here?”.
Locum providers may be receiving two to three times the hourly rate of pay, and in some cases, free housing, rental cars and meal allowances. This is not a good model for worker satisfaction where an individual works through the pandemic with all its stress and is now training an individual who will make many folds their salary with additional perks who has no loyalty to the facility. In some areas of the country locum health workers may be from the hospital down to the street. Employees from hospital A go to hospital B then hospital C without having to travel.
Also integral to this discussion is the high pre-pandemic levels of burnout and attrition among providers that further devastated the supply of available healthcare providers leading into the pandemic. Addressing this issue is integral for the ongoing supply of providers throughout the U.S.
The widespread use of locums also affects the way and quality of the care provided. In the complex environment of health care delivery over the last few decades, we have learned that the best care is provided by individuals who work as teams caring for specific issues or problems. Prime examples of this are operating rooms and ICUs. Here, providers know the individual expertise and skills of each provider and protocols and guidelines needed to care for specific conditions. You can easily see how this would generate the best care. With short term locum providers, use of this system collapses into a world where individuals do not know the guidelines, location of supplies, the needs of individual providers and what each individual brings to the table. What also suffers is the ability to run through simulations and learning scenarios because staff is temporary. Many of us will see a rise in complications and poor outcomes in the next few years because of the breakdown in the healthcare team.
The massive financial drain imposed by staff shortages and use of locums has led to many health care facilities reaching the point of financial instability. Daily reports of massive quarterly losses by both internationally known and local hospitals where billions of dollars are being lost in an industry which was already working on a slim margin will lead to many additional facility closure. This has affected not only rural hospitals with slim operating margins, but larger urban healthcare facilities as well. The loss of such important services in hospitals and associated outpatient facilities will impact care for our communities for future generations.
So, if all of the hospital and healthcare facility close, where will we get our care? The answer is bleak. If we are hit with another pandemic where will the care be delivered, where will the beds be? This critical financial issue is also going to affect other industries. Medical technology companies cannot sell cutting edge ventilators, monitors and imaging devices to facilities that have no cash flow. Aging medical infrastructure cannot be repaired, upgraded or replaced in this financial environment.
As a backdrop to this evolving crisis, we wonder why is this not a major news story. Why are our local and national leaders addressing this issue?
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Contributor: Robert Glatter and Peter Papadakos