Dr. Jaime Moreno, head of emergency medicine at Mount Sinai Hospital, was making the rounds Tuesday when he tried to take a quick mid-afternoon break.
“I haven’t had the chance to sit down yet today,” he said, microwaving a container of beef and vegetables brought from home. “I don’t get a lunch, so I’m going to take my lunch right now.”
Within minutes. a voice came over the hospital’s public address system: “Code Yellow, Code Yellow, trauma in the emergency room.” A teenager, gunshot wound to the hip. Lunchtime over, Moreno jumped up and hurried to help.
At the three-year anniversary of the coronavirus shutting down Illinois, the pandemic has ebbed, but Chicago area hospitals are struggling to cope with the vastly altered health care world the plague left behind.
“COVID has changed many things,” said Moreno. “We’re still reeling from it.”
While the public might be trying to forget COVID, that is not a luxury the medical community can indulge in.
Dr. Ngozi Ezike, who headed up the state COVID response as director of the Illinois Department of Public Health for two years, said while we’re familiar with mass casualty events overwhelming a single hospital or city, COVID is a nationwide mass casualty event — more than a million dead.
”It was an incredible strain on the system,” she said. “No one living has seen an overwhelming of all hospitals in the entire country at the same time, for a prolonged period of time, literally months at a stretch for each surge. This was unprecedented, and not something any system could fully plan for, prepare for, or endure.”
“The landscape has changed so completely,” said Kristin Ramsey, senior vice president quality/chief nurse executive at Northwestern Medicine. “Health care providers in all fields are walking away.”
‘Unprecedented’ staff shortage driven by burnout
Exodus of staff is the No. 1 problem cited by hospital administrators in Chicago and nationwide.
“A lot of burnout,” said Moreno. Mount Sinai, almost always 10% understaffed, is even lower on “bad days,” with 30%, even 40% fewer personnel on hand than necessary.
“Unprecedented,” he said. “People are stressed out. A lot of nurses have stepped away, leaving a lot of holes. Not just in my hospital but hospitals around the country.”
Last year, a U.S. Health and Human Service study found 19% of U.S. hospitals have “critical staffing shortages” — the worst state being Vermont, where more than half the hospitals were in desperate need of medical personnel. Illinois is well down the list, in 42nd place, at just under 8%.
But the situation has significantly deteriorated in the past year. One survey found one-fourth of U.S. hospitals have at least 100 open nursing positions.
“There was a massive amount of burnout which lead to the mass resignation which has led to the workforce shortage which has caused skyrocketing health care workforce labor costs,” said Ezike, who left the Illinois Department of Public Health in June to become CEO of Sinai Chicago, which includes Mount Sinai Hospital, 1500 S. Fairfield Ave., and Holy Cross Hospital, 2701 W. 68th St., and Schwab Rehabilitation Hospital, 1401 S. California Ave.
The prime driver is overwork. Add to it social pressure.
Health care became political battlefield
“We went through the phase where health care workers were applauded as heroes,” said Paul Casey, senior vice president and chief medical officer at Rush University Medical Center. “People clapping on balconies and banging pots. Then they were villainized, such an emotional roller coaster that a lot of people began to question, is this still right for them?”
“It doesn’t feel good anymore,” said Susan Swatt, executive director of the American Nurses Association of Illinois. “To be honest, that’s what I’m hearing from nurses.”
In addition to the physical and emotional demands of providing care during an unpredictable plague, not to forget the risk and experience of contracting COVID themselves, often multiple times — Moreno has had it twice — health care workers are facing the threat of rising violence from the people they are trying to care for.
At Mount Sinai, an emergency room nurse, eight months pregnant, was punched in the face by an angry patient. Anxiety ratcheted up last October when two nurses at the maternity ward in a Dallas hospital were shot and killed by a jealous boyfriend.
Moreno says he connected COVID isolation with the rise of violence, inside and outside of hospitals. Skyrocketing substance abuse is also a factor.
“The lack of social gathering, the inability to do things normally, had an impact,” he said. “We saw so much violence, even within the hospital. The nature of aggression toward hospital staff has increased over the past two years.”
Usually mental illness was the root cause of patient violence, but after COVID, a new factor came into play: politics. Suddenly, sound medical practices became political flashpoints.
“According to where you lived, you either believed that masks were necessary or you didn’t believe that masks were necessary,” said Swatt. “Nurses were on the front line, the first people these frustrated individuals were dealing with, and we took the brunt of it.”
“The violence is ridiculous,” she continued. “It’s more common than people realize. There’s a lot of fear. Nurses are spat on because they told people to put on masks. Nurses are slapped. A lot of emotional and verbal abuse.”
Ramsey used a term once more generally applied to soldiers when referring to medical personnel and the “post-traumatic stress they’re dealing with, related to COVID.”
This was a problem pre-COVID. In 2018 the U.S. Bureau of Labor Statistics reported that nearly three-quarters of all nonfatal workplace injuries caused by violence were experienced by medical workers.
“We decided as a society that it’s OK to just not be kind,” Swatt said. “You can say whatever you want to say whenever you want to say it. Nurses are already dealing with people who are emotional overwrought. Everyone’s emotions are on high, and now we’ve got this permission to do whatever we want.”
“COVID really took away people’s social graces and tolerance and kindness for each other,” said Ramsey. “We’ve lost empathy as humans toward each other. There’s no way that would not spill into the hospital environment.”
Impact felt on emergency medicine, nursing
Because of this, emergency medicine has taken a nosedive as a career choice. The National Resident Matching Program reports applications to emergency medicine training programs has fallen 26% since 2021.
“Emergency department physician used to be one of the most coveted residency positions,” said Ezike, noting that during the recent residency match hundreds of positions went begging, “it was just unbelievable the number of emergency medicine spots that did not get filled.”
Northwestern is down hundreds of nurses. One administrator estimated the statewide gap is 15,000, but that’s an old figure. The truth is even worse: Nobody knows.
“We do not have accurate data in Illinois,” said Swatt. “The shortage is across the board. It was present prior to the pandemic and only became worse.”
Hospitals fear one of the most long-lasting effects of COVID is the rise of travel nursing. With hospitals desperate for staff, they started paying premiums for any help they could get from anywhere. Nurses who once spent decades at one hospital now move around the country, doubling or tripling their salaries, or more.
“It really is problematic,” said Moreno. “Nurses have the luxury of going wherever they want to go, looking for an amount of dollars, and you can’t blame them. Not only does it create holes, but causes stress on hospital systems paying premiums to staff nurses.”
The concern is that a focus on patients is being replaced by a focus on money.
”It’s created this mercenary workforce where people who before had been committed to this mission of caring for people, have turned into more professionals for hire,” said Ezike. “It’s a paradigm shift, born out of burnout.”
“We nearly broke the system,” said Ramsey. “You see hospitals that haven’t been able to recover because of staffing shortages and the financial implications.”
In 2019, before the pandemic, less than 5% of hospital labor costs were for travel nurses. That octupled, to 38.6%, according to the American Hospital Association. While travel nurses account for less than a quarter of the nursing hours, they represent 40% of the labor expense.
Administrators also worry there is a falloff in quality of care. A hospital is a vastly complex environment, each with its own procedures and processes. There can be a long learning curve; it is not designed to have nurses constantly cycling through new institutions, learning how to do things.
“Policies and procedures, electronic medical records, data entry,” said Moreno. “A nurse new to the system might not know the system as well, how to read an order, find a medicine. There are many, many different ways that can impact on a daily basis. It affects patient care.”
This turmoil on the staffing level radiates upward, as managers struggle to staff their sprawling, 24-hour operations.
“Managing on the other side of COVID has been the hardest thing as a leader I have ever faced,” Ramsey said.
What we learned from COVID
Now, the push is to try to learn the many lessons of COVID.
“Mask-wearing is one,” said Ezike. “I hope that continues. Hand-washing is another. I see that more than I did pre-pandemic. People are carrying hand sanitizer with them.”
“The peril of misinformation,” said Casey. “In 2019, we never considered how political interference could play such a role where we would have to be convincing folks that masking and hand-washing are the most effective ways to prevent the spread of disease. How important it is to follow evidence-based medicine.”
Over the past year, the financial rewards of travel nursing have begun to moderate.
“The wages being provided at height of pandemic are now coming back down to level of what the market can afford,” said Christina Wagener, chief nursing officer at Sinai Health.
Meanwhile, hospitals are working harder to attract and keep staff.
Sinai Health is reaching out to retirees and to nurses overseas, while improving pay, benefits, scheduling flexibility and job opportunities.
“There are opportunities for travel nurse to come back to their home,” said Wagener. “More than ever their homes are calling them back.”
“What we’re struggling with right now is when a new person comes into the organization, how to meet their needs by showing a continual path of growth and development,” said NU’s Ramsey. “How do you keep them engaged, how do you keep them invested in your mission instead of seeking another dollar down the street?”
The undermining of trust in society as a whole and medicine in particular must be combatted.
“Just the understanding of how critical key trusted messengers are — doctors, community members, religious leaders,” Ezike said. “You have to use trusted messengers to get messages out. The mistrust of public health leaders is a new phenomenon. I pray we’ll be able to go back to a time when we trusted our scientists, our physicians.”
Amid surge in telehealth, things just easier in person
Just as Zoom conferences took off during COVID, so did telemedicine. First as a way to avoid infectious hospital settings, now as a strategum to cover staff shortages.
”Across the country a trickle of telehealth all of a sudden exploded, and has been sustained. About 20% of our visits are telehealth,” said Casey. “That will only continue.”
“Telemedicine gives the opportunity to stretch scarce resources,” said Ezike, adding that it is particularly effective with mental health care.
“We have to be creative how we provide care, “ said Ramsey, who is already looking to the next health care development.
“Partnering with robots,” she said. “External kinds of monitoring. We can scream all day long, ‘We want more nurses at the bedside!’ If there aren’t nurses, we have to find different ways to provide high quality, safe care. All hospitals are doing that right now.
Casey said that while he expects half of medical visits to be via telehealth, “certain things must be done in person.”
Such as tending to that teen who showed up at Mount Sinai Tuesday afternoon, shot in the hip. After he’s bandaged, ER staff head to the next case. Moreno lingers. The issue is raised: Who tells the teen’s mom her day is about to get more complicated?
“I’ll call her,” said Moreno, writing the mom’s name and phone number on his left glove. The wounded boy later hands the doctor his phone, which has a dead battery.
“Can you charge it?” the teen asks.
Moreno takes the phone to a desk in the emergency department to find a charger.
