The COVID-19 pandemic has seen crisis standards of care created and implemented in emergency departments across the United States, from waiting rooms converted into treatment spaces to patients back-transferred from urban hospitals with oxygen shortages to rural centers. While some of these documents have been successful, others have been problematic.

A paper published in NAM Perspectives last summer on crisis standards of care and COVID-19 noted that the authors were unable to share specific details some colleagues relayed as some of these clinicians suffered “professional retribution for raising these issues or being willing to have open and honest discussion of the tactics that were implemented.”¹ It cited improvements needed in the areas of equity and allocation of resources; graduated changes across the care continuum in staffing, dialysis, and respiratory support; and prior crisis standards-of-care work and its contributions during COVID-19.

In the emergency department at the University of Florida Health Jacksonville, instituting crisis standards of care has meant treating patients in waiting rooms with vertical beds as well as forming a Hospital Incident Command Center (HIC) that opened in February 2020 and has remained open since, according to Kelly Gray-Eurom, MD, a professor and assistant dean for quality and safety. 

“During the initial phases of the first surge, the HIC’s team met via Zoom every day at 9 a.m.,” she says. “The team was large and multidisciplinary so communications and planning could be robust.” These team members included all members of the hospital’s C-suite, the dean, medical disaster officer (an emergency physician), patient safety officer, nursing leaders from all areas of the hospital, pharmacy, supply chain, infection prevention and control, media relations as well as representatives from housekeeping and laundry. 

The State of Alaska had a crisis standards-of-care document in development years before the COVID-19 pandemic, but it wasn’t approved until March 2020 when it looked increasingly clear they may need it, according to Anne Zink, MD, chief medical officer for the state and an emergency physician at Mat-Su Regional Medical Center in Palmer, Alaska. The state convened a group of clinicians to adopt a document close to The Minnesota Framework but with edits to adjust for things such as the fact that Alaska does not have a burn unit. The state updated the document last August and is currently in the process of updating it again. But, as helpful as that document has been, it was by no means a panacea. “Those documents cover what happens when you run into things,” Dr. Zink says. “They do not address what happens when you run out of people.” 

Nursing Shortages 

Kelly Gray-Eurom, MD

Even prior to the COVID-19 pandemic, the United States was projected to run short of RNs.² Baby boomers created more demand for health care, and the national move toward health care reform in recent years has meant nursing schools nationwide have had to expand capacity, according to the American Association of Colleges of Nursing. Nearly two years into the pandemic, hospitals across the United States have felt that shortage acutely, particularly in the dwindling numbers of nurses available to staff emergency departments. 

According to a recent American Nurses Foundation survey, 21 percent of 9,572 nurses surveyed last fall said they intended to leave their position, with another 29 percent saying they were considering leaving.3 Of those wanting to leave, 47 percent cited the negative effects of work on their health and well-being, and 41 percent cited insufficient staffing. 

“I’d be lying if I tell you we’re doing good,” says Maureen Ramos, MSN, RN, speaking of the exhaustion and burnout nurses are still facing during the pandemic. Ramos is director of nursing in the emergency department at Ben Taub Hospital, part of the Harris Health System in Houston. “I think for the past almost two years now, it’s been hard. These clinicians have burdens they carry from their home life, and they’re expected to be 100 percent all of the time they’re here. I’m in awe of the fact that they come in here 100 percent.” 

The pandemic combined with nursing shortages has meant longer hours, higher nurse-to-patient ratios, and protocols that have had to be fluid to accommodate things like personal protective equipment shortages and pivoting on best practices based on the latest information. Another nursing challenge is that the pandemic has made it very lucrative for experienced emergency nurses to get contracts to work through outside staffing agencies. Those working for traveling nurse agencies can make as much as $150–$200/hour, which can be up to five times the amount emergency department nurses make when they are on staff at a hospital. On top of this, some traveling nurses are provided with food, lodging, and bonuses. 

“It has been a challenge to keep very experienced emergency department nurses because everyone’s just competing for the same exact manpower I want for my team,” Ramos says. 

Not only is Ben Taub Hospital competing with traveling nurse agencies, it is also competing with the many health care institutions in the Houston area. Recruiters from these health care facilities have reached out to the hospital’s staff directly in an attempt to lure them away, and administrators at Ben Taub have had to develop strategies to retain their staff, including tuition reimbursement and big retention bonuses as well as sometimes matching inflated pay for a limited time period.

The same thing has been happening at University of Florida Health Jacksonville. “Our CEO, CNO, and CFO have been very impactful, adding increased salaries and bonuses for staff across the house but especially the COVID units or other hard-to-staff areas,” says Dr. Gray-Eurom, adding that the large increase in salary expense is not sustainable at a safety-net hospital, so it is difficult to know what the future will bring. 

Visibility  

Maureen Ramos, MSN, RN

Another pitfall when it comes to crisis standards of care is that they don’t necessarily make sure clinicians have visibility on everyone in emergency departments across the state who need help. 

“They’re really good for a single facility deciding who goes on dialysis,” Dr. Zink says. “But from a state perspective, if you don’t have awareness that a patient in a rural community needs dialysis because that clinician was told there’s no bed availability, then we don’t know that person’s out there and we can’t try to solve that problem.”

Scrambling to find creative solutions saved lives. In Alaska, they offloaded overcrowded urban hospitals facing oxygen shortages by back-transferring patients to rural centers. The hospital where Dr. Zink practices, an hour outside of Anchorage, rarely receives patients from other hospitals, but during the pandemic when it had availability, it became commonplace to accept patients from hospitals around the state—and sometimes from hospitals hundreds of miles away. They had to set up different processes for accepting patients, and the state ended up purchasing dialysis machines for their hospital and others. “In consultation with nephrology, we were able to expand the number of hospitals that had dialysis capacity during our surge,” says Dr. Zink, adding that the state brought in 477 additional health care workers, from nurses to respiratory therapists, from around the United States to help them expand capacity.  They also juggled patients, when necessary, transferring more stable patients who required less oxygen back to smaller hospitals as well as locating outpatient dialysis for patients who needed it. 

In another change during the pandemic in Alaska, the state now has a website with a dashboard showing the availability of beds at each of the 26 hospitals in the state. Whether it’s ICU beds, med/surg beds, or psychiatric beds, every emergency physician in the state can see what’s available and where instead of calling around.

Burnout

Anne Zink, MD, FACEP 0

With repeated surges comes burnout. One of the biggest challenges to emergency departments is that the tools traditionally applied to crisis standards of care do not take into account the length of time the pandemic has dragged on, the many months hospital systems have been overwhelmed, and the inevitable fatigue for health care workers. 

“You can’t just have people be in emergency or crisis mode for three months straight. As humans, we need to sleep, we need to care for each other. It’s impossible to be in that crisis response full time,” Dr. Zink says. “This is where hospitals have had to lean into systems changes to make sure they’re able to get the care they need.”

Dr. Gray-Eurom says her hospital’s Center for Healthy Minds and Practice saw a surge in use throughout the pandemic. Across all types of employees, she says, there were increases in burnout, relationship challenges, and other stress-related factors. The center provides free, confidential, and unlimited behavioral therapy to all employees as well as develops and maintains a peer-support counseling network to widen the available safety net to employees experiencing acute adversity.

With the most recent surge in Alaska, Dr. Zink says she is hopeful her team has improved the ways they think about caring for everyone in the state, including the transfer of patients, as well as improved their understanding and awareness of statewide resources. 

“I do think that the hospitals, emergency medicine physicians, and the subspecialists like hospitalist groups have a much better understanding of each other’s capabilities, capacities, limitations, and their willingness to work together to solve problems,” she says. “I think this is helpful and will extend long past the pandemic.” 

References

1. Hick J. L., D Hanfling, M. K. Wynia,et al. 2020. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. NAM Perspectives. Discussion paper. National Academy of Medicine. Washington, DC.
2. Nursing shortage. American Association of Colleges of Nursing website. Accessed Dec. 22, 2021.
3. Mental health and wellness survey 3. ANA Enterprise website. Accessed Dec. 22, 2021.