This article was originally published by Oregon Public Broadcasting.
Registered nurse Chris Kish’s recent 12-hour Saturday shift in the emergency department started like they all do.
At 6.30 a.m. he swipes his Oregon Health & Science University badge, walks through the ambulance entrance doors, and heads into the back. He puts on a mask and safety goggles, grabs a stethoscope and then takes a minute to clear his head before his shift starts.
Usually, the department’s 32 rooms are already full. Most mornings, patients also fill the stretchers that have been set up in the halls. One of those beds is right next to the extremely busy emergency department elevator.
There are a dozen or more patients already in the waiting room: sick people who have been waiting overnight to be seen, or admitted to the hospital.
When Kish gets there each morning, he said, he’s often “feeling this incredible powerlessness of ‘here we go again. It’s another bad day starting off this way. We’re going to have to try and do the impossible.’”
That means trying to take care of all of the patients who’ve been stuck in the emergency department overnight, or for days at time, because the rest of the hospital is full, while simultaneously taking care of each new trauma patient who comes in the door.
The pressure builds as the shift grinds on. Ambulances arrive, even though the drivers know the emergency department here is full. There aren’t any other hospitals to take many of these patients.
Paramedics call hospitals “red” when they go on divert status, a request that ambulances take less critical patients elsewhere, if possible.
“It’s not uncommon at all any more for every hospital to be red, almost throughout the state right now,” Kish says.
But this time it’s not COVID-19 that’s swamping Oregon’s hospitals, it’s too few nurses to serve too many patients. In some cases, there were beds available on other floors, just not enough nurses to cover patients there. In part, that’s because the federal money helping hospitals pay for travel nurses to swell their ranks is now gone. And, in part, it’s because there are so many patients.
In response to the overload, some of the busiest hospitals across the state have formally reduced their standards of care and requested emergency funding from the state Legislature.
“Said simply, there are not enough health care workers in Oregon,” reads a July letter from the Oregon Association of Hospitals and Health Systems to Gov. Kate Brown.
In theory, nurse to patient ratios, one of the core standards that protect patient safety, have not changed. By law in Oregon, those ratios are set in each hospital by an internal staffing committee and are very hard to alter.
In practice, OPB interviewed several nurses who said they are caring for more patients at one time than their role allows. Kish — who said he was speaking only for himself — and two other nurses spoke to OPB on the record. Others spoke anonymously, for fear of repercussions at work.
“My colleagues and myself are afraid that we or anyone we love will need the hospital right now,” said one OHSU nurse who asked that their name be withheld. “We’re drowning.”
Nurses who spoke to OPB for this story worried that it’s only a matter of time before they make a mistake because they are so overwhelmed and worn out by being asked to supervise too many patients at once.
Overcrowded emergency departments
Back in the OHSU emergency department, the waiting room fills up throughout the day. By evening, there might be 30 or 40 people there, waiting for care that providers are required by law to give.
On days when Kish is working triage, his job is to make sure that every person is seen within five minutes of when they arrive. That’s especially critical at OHSU, one of just two Level 1 trauma hospitals in the state — responsible for treating some of the most complex and life-threatening injuries.
Sometimes, a patient is sick enough to need immediate treatment, but there isn’t any room or hallway bed available. So Kish and the triage team might bring the patient back briefly into a private room, start an antibiotic or some fluids or narcotic painkillers, and then send them back to sit in the crowded waiting room, with a portable monitor to track their vital signs.
“We’ve given people blood transfusions in our waiting room because we don’t have any other safe spot to do that,” Kish said. “It takes away the little bit of dignity that they have. They hate it. We hate it.”
It’s a scene straight out of the darkest days of the pandemic, when hospitals were overwhelmed by COVID-19 patients during the delta and omicron waves. Though this time it’s not COVID-19 driving a surge of patients to the hospital, it’s the steady demand for long delayed health care.
According to Kish, OHSU usually has more space — and beds — available on the floors upstairs during his shifts. There is physical space to set up more beds in the research hospital’s four intensive care units and on the medical-surgical floors.
But those units are short staffed too, often down a dozen or more nurses, Kish said.
The staffing problems are driven by a lot of unpredictable factors — nurses calling out sick, for example. But records suggest it’s also a result of changes in the labor market and OHSU’s latest budget, adopted in July. Facing a $77 million dollar shortfall, administrators are trying to limit the amount the hospital is spending on short term contract labor, much of which has been going to travel nurses for the past two and a half years.
Dr. Renee Edwards, the chief medical officer at OHSU, says trying to accurately forecast the number of travel nurses the hospital will need to serve the number of patients seeking care in a given month has been extraordinarily difficult.
“Our goal is to hit it just right so we are paying for the nurses we need, while managing our financial situation and not committing to more contracts than we need,” she said.
It would help free up beds if the hospital could discharge medically stable patients more quickly. Instead, every day, dozens of patients who are ready to be discharged can’t leave the hospital, because there’s no space in the skilled nursing and rehabilitation facilities that would normally take them. There’s a labor shortage there too.
Mistakes might be made
A good emergency room nurse knows how to recognize when a patient is starting to go downhill fast, said Kish, who has seven years of experience in his field. But with so many patients in the waiting room these days, Kish worries he won’t see the signs.
“What scares me is that we’re going to miss that change in condition,” he said. “We’re going to have a patient that has to wait a little bit too long to get their initial assessment and that might cost them their life.”
A spokesperson for OHSU said the hospital has added a new shift in the emergency department for a physician, available from noon to 2 a.m., to help with triage.
Kish also worries about the quality of health care he’s delivering to the patients who wind up stuck in the private rooms in the emergency department while waiting for a bed to open up elsewhere in the hospital. Kish is confident in his skills as a critical care emergency nurse — he can save you from dying in a crisis — but he’s not used to managing medications and chronic conditions, and the emergency department isn’t set up to provide that kind of care.
“At some level, we’re failing our patients especially when I’m having to switch hats and be an inpatient nurse,” Kish said. “Things may not happen on time. They may not happen at all.”
Hospitals on the brink, statewide
All summer long, OHSU has struggled with a surge in demand for health care and staff shortages that have pushed parts of the hospital to the brink of failure. The hospital operated under contingency standards of care for much of June.
At the end of that month, Michael Whitaker, the director of adult critical care, sent a series of emails detailing the severity of the situation. The hospital, he said, was dealing with an increase in demand for care, a “rapidly declining financial trajectory,” and staffing shortages “in nearly all departments.”
In the emergency department, Whitaker wrote, people were being treated in equipment closets and being housed in the ambulances that brought them, due to lack of physical space.
“Most of you have been to our ED and you know how compact it is, so the risks to patients was great in these situations,” Whittaker wrote.
And though it holds prominence as the state’s premier research hospital, OHSU’s problems are not unique. Facing serious staffing shortages and overcrowded emergency departments, at least three of Oregon’s other major health systems have taken official steps to lower the standard of patient care over the summer.
Salem Health is currently in contingency standards of care, due to staffing challenges, and has been since January. Legacy Health implemented contingency standards of nursing at its hospitals on July 18. St. Charles briefly declared crisis standards of care in July in an effort to circumvent its nurse staffing plans. A spokeswoman declined to clarify what standards the health system is currently using.
Spokespeople from Kaiser Permanente, PeaceHealth, and Samaritan Health Services, which collectively serve patients throughout western Oregon, all said they have not shifted to contingency standards of care, but noted they are dealing with high patient volumes and have been canceling some elective surgeries.
Asante, which serves patients in southern Oregon, did not respond to OPB’s request for information about their current care standards.
Health system leaders have said that the primary purpose of the reduced standards of care is to cut red tape for nurses and reduce the amount of documentation they have to complete for each patient.
And they stress that contingency standards of care do not indicate the type of full blown resource crisis that many feared early in the pandemic, where intensive care resources are in short supply and may need to be triaged — in effect forcing hospitals to choose which patients live or die.
Some nurses disagree that the new standards are merely a matter of reduced documentation. They say they are being pressured to take on more patients than they can handle. And they say hospitals are skirting their legal responsibilities, among them to provide nurses lunch breaks, and to get input from a committee that includes nurses before changing staffing plans.
“We are experiencing what a failed health care system looks like,” said Matt Calzia, with the Oregon Nurses Association. “We’re three years into a pandemic and we’re worse prepared now for anything to go wrong.”
Where have all the nurses gone?
Data is hard to come by, but this is the picture that emerges when you talk to nurses and hospital administrators:
Burned out by the pandemic and their working conditions, nurses are leaving the bedside, particularly high stress units like the emergency department and the ICU. They’re trading those jobs for less emotionally taxing telehealth positions and for short-term traveling contracts that pay better. They are cutting back hours. Older nurses are retiring faster than they can be replaced. Younger nurses are considering leaving the profession.
Though they are seeking new jobs, Oregon nurses do not appear to be letting their licenses expire, according to data reviewed by the Oregon Center for Nursing. It found that about 95 percent of nurses in Oregon continue to renew their licenses on time.
As federal pandemic aid ended this spring, hospitals lost funding to help cover the cost of temporary traveling workers, which can run more than $1 million a month for a large health system.
Traveling worker costs are driving hospitals to post their worst financial performance since the pandemic began. Hospitals in Oregon lost a collective $103 million in the first quarter of this year. Labor costs are up 20 percent over a year ago, according to the Oregon Association of Hospitals and Health Systems.
Sarah Mittelman is a charge nurse who works part time in the emergency department at the Unity Center for Behavioral Health, Portland’s psychiatric hospital. She’s responsible for managing operations and patient flow in the emergency department. Mittelman says this summer, she sometimes has just half the staff she needs to appropriately care for the patients there.
“They tell us ‘we’re going to let you do less,’” she said. “‘You can do less charting, but we’re going to give you more patients’ — and we’re already struggling to see and take care of the patients that we have. It doesn’t help me.”
Mittelman says Unity, like OHSU, is dealing with “boarders,” patients who wind up stuck in the emergency department while they wait for an inpatient bed to open up for them. And there are no beds, or private rooms, in the Unity psychiatric emergency department. Instead, it has a large common area, with recliners for patients to sit in.
In July, one patient waited in a recliner for five days before he was able to get an inpatient bed, Mittelman recalled. She feels tired and hopeless. And she said the standard of care is “slipping.”
“I don’t hear any positive stories about our patients anymore,” she said. “I just see them coming back.”
Like Kish at OHSU, Mittelman worries that something preventable will happen that will lead her to lose her nursing license.
Some of the patients at Unity try to hurt themselves, with their own body parts if nothing else is available. Mittelman said her nurses are forced to focus on the highest risk patients.
Mittelman has given up on trying to eat lunch, and carries a cup with a mix of coffee and a Costco-brand protein shake, which is what she consumes during her 12-hour shifts. She said that prompted an email from her managers, telling her it’s required by law that she take a break.
“I know that’s the law,” she said. “Help me. Why do I choose between my patients and the safety of my unit and a break?”
Every day, the Legacy Health system is treating about 100 more patients than it was a year ago, enough to fill a small hospital, according to Michael Avery, the chief operating officer at Legacy Health. One reason this has happened is that patients are staying in the hospital about 30 percent longer, according to Avery. Patients with chronic conditions are showing up sicker. And without beds available in long term care, they’re staying in the hospital even after they’re ready to go.
Avery said it was “possible” that a Unity patient had waited for five days for a bed, but did not confirm it.
Avery said Unity is still meeting its goal of about 70 percent of patients discharged from the emergency department with a care plan within 24 hours. And that while nurse staffing has been “not ideal” at Unity and Legacy’s other hospitals, he said Legacy has not fallen below its minimum standards during the current crisis. Unity has hired about 20 additional travel nurses over the summer.
“I think the larger community feels that the pandemic has started to recede and that things are on an upward trend everywhere and that is not the case in health care,” Avery said.
Legacy declined to say what the minimum staffing standard is at the Unity Center.
Some modest help could be on the way. The Oregon Health Authority and the Department of Human Services have requested $40 million in emergency funding from the state Legislature.
If granted as written, $14.9 million from the state would pay for temporary staff at nursing homes and rehabilitation centers, to help move people out of hospitals and free up beds. And $6.9 million would help cover a portion of the costs of temporary contract nurses. That would pay for just 50 additional nurses statewide, according to the Capitol Chronicle.
The nurses who spoke with OPB remain skeptical that their working conditions or the staffing crisis will improve.
The situation has become a snake eating its own tail. The working conditions drive staff to leave, driving the hospitals to try to backfill with travel nurses and to push the nurses who remain even harder, which drives staff to leave.
“A lot of us in the emergency department specifically feel like our hospital leadership has abandoned us,” Kish, the nurse from OSHU, said.
He said that after the delta wave, nurses told hospital leaders they needed to provide staff nurses with immediate financial incentives to keep them from leaving and taking traveling contracts. Instead, he said, managers bring pizza to the emergency department on days that are particularly hard. Last year, OHSU mailed all of its employees a thank you card and a small lapel pin with the hospital’s four colors on it.
Edwards, OHSU’s chief medical officer, said the pins were dreamed up in the spring of 2021, in a moment of optimism, before anyone knew the delta wave still lay ahead. She is aware that particular attempt at a thank you fell flat.
“And I’m sorry that it left people with that feeling,” she said, “because that was certainly not the intent.”
She said that when the pandemic started, OHSU created a wellness team, including psychologists, to support the staff. A year ago, OHSU gave its nurses a $1,000 stipend. She says any larger pay bonuses have to be negotiated through the nurses’ union.
No easy way out
Edwards herself does not see an easy way out of the current crisis.
Oregon has the second fewest hospital beds per capita of any state in the nation, 1.6 beds per 1,000 people. That may have been enough to meet the state’s needs before the pandemic, but with COVID-19 becoming a baseline problem we all have to live with, and people sicker after everything they’ve been through, it may no longer be enough, she said.
As for the workforce crisis, Edwards says OHSU is working on increasing its class sizes and graduating 30 percent more clinicians by 2030. That might help in the long term.
In the short term, Edwards wants the public to understand two things. First, it’s getting harder to deliver the care you expect. If you’re headed to an emergency department in Oregon, understand that if you’re not the sickest person in the room, you may have a long wait.
And second, the nurses and doctors that may appear to be ignoring you are working as hard as they can.
“What they’re living through, the effort they’ve put forward, and the care that they’re delivering on a daily basis can’t be emphasized enough,” she said.
Matt Calzia, with the Oregon Nurses’ Association, said there’s a larger cultural problem. He said nurses, who make up the largest part of the workforce, have long been forced by administrators to absorb whatever extra work needs to be done in a hospital, whether it relates to their clinical training or not.
“There is too much for a registered nurse in a hospital to get done in a 12-hour shift,” he said.
Hospitals need to hire more nurses, he said, but they also need to hire additional support staff to fill in around them and take away some of their non-clinical responsibilities — like the way it has become common for doctors to work with scribes.
“Hospital administration has not looked at the last three years and what’s happened to the nursing profession and changed their behaviors,” Calzia said. “They just continue it: ‘The nurses can do more, they can take it.’ The fatigue is demonstrating that’s not true.”
According to OHSU officials, 31 emergency department staff in total have transferred or resigned in the last 18 months. Just two weeks ago, another of Kish’s colleagues left; one more position the hospital now needs to fill.
This story was originally published by Oregon Public Broadcasting.