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A new national survey of hospitals conducted last month paints a bleak picture of the ability to balance routine patient care against surges of COVID-19 patients, the extent of their staff shortages, and the potential impact of the pandemic on their financial stability.
The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) surveyed 320 hospitals in 45 states and the District of Columbia. The survey was conducted February 22-26.
While the time frame reflects the situation that hospitals were in during the latest surge of COVID-19 disease, the responses of hospital administrators indicated that it would take some time for their institutions to recover from the ravages of the pandemic.
The same may be true for patients with diseases other than COVID-19. Hospital administrators reported that many patients had delayed or forgone routine care as a result of the pandemic, including “preventive and urgent care for serious conditions such as heart attacks or strokes.”
As a result, they said, the health status of some patients had worsened. “Administrators predicted that widespread delayed care could result in higher hospitalization rates and the need for more complex hospital care in the future,” the OIG report said.
These observations track with recent studies of excess mortality published in the Journal of the American Medical Association and the Morbidity and Mortality Weekly Report of the Centers for Disease Control and Prevention (CDC).
The CDC reported that, from late January to early October 2020, the United States had 299,000 more deaths than the typical number during the same period in previous years. While about 198,000 of these deaths were attributed to COVID-19, it’s unknown how many of the other deaths were the result of conditions not related to the coronavirus.
The hospitals surveyed by OIG reported difficulties in integrating COVID-19 care into normal operations, mainly because of concerns about infection control. As hospitals resumed elective surgeries after the early months of pandemic, the report said, they found it hard to keep COVID-19 patients separated from noninfected ones.
Hospitals also found it difficult to discharge COVID-19 patients after their acute stage of illness, so many of them stayed in the hospital longer than necessary, the report states. One barrier to discharging these patients, OIG noted, was that some post-acute care facilities, such as nursing homes and rehab facilities, “were either unwilling or unable to accept patients because the facilities were concerned about potential COVID-19 infections.”
These delays in patient discharges affected available bed space throughout hospitals. Longer stays created bottlenecks in ICUs and emergency departments. One hospital noted that 13 of its 17 ED rooms had been recently occupied by COVID-19 patients waiting to be admitted.
Turnover Leads to Staffing Shortages
A higher-than-normal turnover among medical staffs led to concerning staffing shortages at some institutions, the report shows. Turnover was especially high among nurses. One Texas hospital in a high-poverty area, operating at 100% ICU occupancy, said its annual average for nurse turnover increased from 2% prior to the pandemic to 20% in 2020.
Hospitals also reported losing other types of staff in the past year, including respiratory therapists, certified nursing assistants, phlebotomists, and laboratory technicians.
Much of the turnover was attributed to the stress and burnout caused by caring for COVID-19 patients. Hospitals also cited competition for healthcare workers and the opportunity to earn more money by joining a staffing agency. “Hospitals that lost nurses reported that they often experienced increasing staff costs from the higher hourly rates charged by staffing agencies,” the report states.
The staffing shortages forced some hospitals to increase their staff-to-patient ratios from 1 to 6 to 1 to 12. “Reduced staff-to-patient ratios can lead to mistakes when less attention is given to each patient,” the report said. One hospital network, for example, had seen an increase in central line infections that it attributed to inadequate staff and staff fatigue.
This patient safety finding is supported by a study just published in the Journal of Hospital Medicine, which shows that deaths of patients hospitalized with COVID-19 were higher in hospitals that had been hit with the largest surges of patients during the pandemic.
Rural and Underserved Areas
The pandemic has slammed rural hospitals especially hard, the OIG report noted. It has exacerbated the challenges these facilities face in terms of staff recruitment and retention, bed capacity, lack of access to specialists, and financial strain.
Such hospitals aren’t part of systems that can shift around staff as needed; if a single physician falls ill, they may be in trouble. Telehealth services are also not too effective in rural areas, where many people lack internet access.
During the pandemic, the report noted, the lack of available beds at many larger hospitals prevented rural hospitals from transferring patients. Many rural hospitals lack ICUs; when COVID-19 patients needed to be transferred to a hospital with an ICU, some rural facilities had to send them to hospitals in other states.
Healthcare disparities in poorer communities are also a challenge. “Administrators from hospitals in communities with higher social vulnerability reported deep concern about worse outcomes for many of their patients,” the report states. “Hospitals also reported clinical challenges in treating patients with certain comorbidities that disproportionately affect people of color, such as heart and lung ailments and chronic illnesses such as diabetes, and that patients with these comorbidities are at higher risk of severe illness from COVID-19. These patients may enter hospitals at a more severe stage of illness, and require a higher level of care.”
Hospitals have taken the lead in vaccinating their staffs and patients against COVID-19, and some facilities have operated mass vaccination sites. While the facilities were glad to be involved in these efforts, hospital administrators said that vaccinations had worsened existing clinical staff shortages and hospital financial woes, because staff members had to be diverted from patient care to administer shots.
In addition, they said, the required administrative work was time-consuming; state and local rules on eligibility were confusing; and vaccine supplies were inconsistent. The vaccine hesitancy among some staff members was also noted, with some hospitals saying a third of their staffs had declined to be vaccinated.
Shortages of personal protective equipment (PPE) are no longer as extreme as they were early in the pandemic, but some hospitals still lacked dependable supply chains for PPE, especially gloves and N95 masks, the report states.
Hospitals were finding it difficult to identify reputable vendors, and the delivery of PPE was inconsistent. Some hospitals had received poor-quality PPE, and others had paid inflated prices. One administrator said his hospital was now paying $8-$9 for a mask that used to cost $1.
Big Financial Impact
The responding hospitals reported that in the past year, their operational costs had increased dramatically while their revenues had declined, threatening their financial stability in many cases. Facilities in underserved areas and those with under- and uninsured populations were in an especially bad predicament.
The high costs were associated with staffing, PPE, and COVID-19 patient care, testing, and vaccinations, the report said. The revenue decline started last spring with the temporary suspension of elective surgeries in many states.
The number of non–COVID-related services that hospital provided was still lower than it was before the pandemic. Because of patients’ fear of COVID-19, there were fewer admissions and elective procedures than in the past.
According to a recent report by Kaufman Hall, a hospital consulting firm, nearly 40% of hospitals could lose money this year, even if the vaccine rollout goes smoothly and COVID-19 hospitalizations decline, Fierce Healthcare reported.
On the other hand, some of the largest healthcare systems in the country posted steep profit increases for 2020 because of sicker-than-usual patients and a higher percentage of privately insured patients, noted an article in Modern Healthcare.