Even in parts of the United States where COVID-19 isn't overwhelming the health system, patients are showing up to Emergency Rooms (ER) sicker than they were before the pandemic, their diseases more advanced and in need of more complicated care, reports National Public Radio.
It’s a stark contrast to where emergency departments were at the start of the coronavirus pandemic. Except for initial hot spots like New York City, many ERs across the US were often eerily empty in the spring of 2020. Terrified of contracting COVID-19, sick people with other illnesses tried to avoid hospitals. Visits to emergency departments dropped to half their normal levels.
But now, they’re overflowing. Even in parts of the country where COVID-19 isn't overwhelming the health system, patients are arriving at the ER sicker than they were before the pandemic, their diseases more advanced and in need of more complicated care.
Months of treatment delays have exacerbated chronic conditions and worsened symptoms. The severity of illness varies, and includes abdominal pain, respiratory problems, blood clots, heart conditions and suicide attempts, among others.
But there's nowhere to put them all. Emergency departments are ideally meant to be brief ports in a storm, with patients staying just long enough to be sent home with instructions to follow up with their doctor or being sufficiently stabilised to be transferred “upstairs” to inpatient units or the ICU.
Except now, those long-term care floors are full too, with a mix of COVID-19 and non-COVID-19 patients. That means people coming to the ER are being warehoused for hours, even days, forcing ER staff to perform long-term care roles they weren't trained for.
At Sparrow Hospital ER in Lansing, Michigan, ER space is a valuable commodity: a separate section of the hospital was turned into an overflow unit. Stretchers stack up in halls. The hospital has even brought in a row of reclining chairs, lined up against a wall for patients who aren't sick enough for a stretcher but are too sick for the waiting room. Some patients in the recliners are hooked up to IVs, others talk to doctors on wheeled stools.
Outside the ER is Sparrow's ambulance bay. Seventy to 100 ambulances pull in daily. “It’s a lot,” Dusang says, “the highest I've ever seen.”
About three times a week, the ER arrives at a point where it can’t take any more patients. Then it alerts ambulances to divert patients to other hospitals, risky, because Sparrow is one of the only hospitals in this part of the state equipped for severe traumas.
Even patients arriving by ambulance are not guaranteed a room. One nurse is running triage here, screening for those who absolutely need a bed and those who can go in the waiting area. Lately they’ve been pulling out patients who are already in the ER’s rooms when others arrive who are more critically ill.
This isn't just happening at Sparrow. ‘We hear this from around the country,” says Dr Lisa Moreno, president of the American Academy of Emergency Medicine (AAEM). "Everyone is seeing this same phenomenon.”
Although the number of ER visits returned to pre-coronavirus levels this past summer, admission rates, from the ER to the hospital’s inpatient floors, are still almost 20% higher, according to analysis by the Epic Health Research Network, which pulls data from more than 120 million patients countrywide.
“We’re seeing more acute cases than we were pre-pandemic," says Caleb Cox, a data scientist at Epic, tells NPR.
Less acute cases, like people suffering from health issues like rashes or conjunctivitis, still aren't going to the ER as much as they used to. Instead, they opt for an urgent care centre or their primary care doctor, Cox adds. Meanwhile, there has been an increase in people coming to the ER with more serious conditions, like strokes and heart attacks.
“Even though we’re seeing the overall volumes return to normal over the summer here, the more acute conditions are still higher than pre-pandemic normals, while the lower-acuity conditions are below pre-pandemic normals,” Cox says.
Moreno, the AAEM’s president, works at an emergency department in New Orleans. She says the level of illness, as well as the inability to admit patients quickly and move them to beds upstairs, has created a level of chaos in the ER she describes as “not even humane”.
At the beginning of a recent shift, she heard a patient crying and found a man with paraplegia who’d recently had surgery for colon cancer. His large post-operative wound was sealed with a device called a wound vac, which pulls fluid from the wound into a drainage tube attached to a portable vacuum pump. But the wound vac had malfunctioned, which was why he had come to the ER. Staff were so busy that by the time he had come in, the fluid from his wound was leaking everywhere.
“When I went in, the bed was covered,” she recalls. “He was lying in a puddle of secretions from this wound. And he was crying. He said, ‘I’m paralysed — I can’t move to get away from these secretions, and I’m going to end up getting an infection, or an ulcer. I've been lying in this for eight or nine hours’.”
The nurse in charge of his care simply hadn’t had time to help this patient yet.
“This is not humane care,” Moreno says. “This is horrible care.”
But it’s what can happen when emergency department staffers don’t have the resources they need to deal with the onslaught of competing demands.
“All of the nurses and doctors had the highest level of intent to do the right thing for the person,” Moreno says. “But because of the high acuity of … a large number of patients, the staffing ratio of nurse to patient, even the staffing ratio of doctor to patient, this guy did not get the care he deserved to get, just as a human being.”
This unintended neglect is extreme and not the experience of the vast majority of patients who arrive at ERs right now. But the problem is not new. Even before the pandemic, ER overcrowding had been a “widespread problem and a source of patient harm … reflective of not just individual department performance or even individual hospital performance, but of health system dysfunction throughout the United States”, according to a recent commentary in The New England Journal of Medicine.
“ED crowding is not an issue of inconvenience,” the authors wrote. “There is incontrovertible evidence that ED crowding leads to significant patient harm, including morbidity and mortality related to consequential delays of treatment for both high- and low-acuity patients.”
And it’s burning out an already overwhelmed staff. Burnout feeds staffing shortages, and vice versa, in a vicious cycle
Every morning, Dusang wakes up and checks her Sparrow email with one hope: that she won’t see yet another nurse resignation letter in her inbox. But despite her best efforts to support her staffers, check on them regularly, talk to them and make them feel seen, heard and appreciated, she cannot stop them from quitting. And they’re leaving too fast to replace, either to take higher-paying gigs as travel nurses, to try a less-stressful type of nursing or to simply walk away from the profession entirely.
Midway through the afternoon shift at Sparrow, a nurse breaks down sobbing. A fellow nurse, Amy Harvey, pulls her into a corner and reminds her to take deep breaths.
“Everybody has a breaking point,” Harvey says. “It just depends on the day and the situation. … Mine could be in three days. Something comes in that just hits home for some reason, and I need a minute to take a deep breath.”
To help fill the staffing gaps, Sparrow’s ER has hired about 20 “baby nurses”, a term for brand-new nurses. The hospital waived its previous requirement for working in the ER — at least one year of nursing experience elsewhere — and many of these new nurses are fresh out of nursing school. They’ve begun their careers by diving into the deep end, even though they’re still training.
At 4pm, the emergency department is the busiest it’s been all day. The patients waiting in the halls seem especially vulnerable, silently witnessing the controlled chaos around them. One woman is sleeping or unconscious on a stretcher, naked from the waist down. Someone has thrown a sheet over her, so she’s partially covered, but part of her hips and legs are bare, and open sores are visible on her calves.
Dusang faces a new crisis: the overnight shift is even more short-staffed than usual. “Can we get two inpatient nurses?" she asks, hoping to borrow two nurses from one of the hospital floors upstairs. “Already tried,” replies nurse Troy Latunski.
Without more staff, it’s going to be hard to care for new patients who come in overnight — from car crashes, seizures or other emergencies.
But Latunski has a plan. He’ll go home now, snatch a few hours of sleep and return at 11pm to work the overnight shift in the ER’s overflow unit. That means he will be largely caring for eight patients alone, on just a few short hours of sleep. But right now, that is their only, and best, option.
“OK,” Dusang says. “Go home. Get some sleep. Thank you,” she adds, shooting Latunski a grateful smile. And then she pivots, because another nurse is already approaching her with an urgent question. It’s on to the next crisis.
See more from MedicalBrief archives:
Millions of cancelled operations due to COVID and high death risk – UK study
Minimum nurse-to-patient ratios cut mortality risk by up to 11% — Australia study
Reducing US hospital readmission not increasing death rates
Fewer registered nurses linked to increased mortality risk in wards