Worker stress, patient risk rise in emergency rooms overwhelmed by omicron

As COVID-19 cases increase fivefold in Pima County, the burden for the hospitals is not only exploding, it’s shifting — to emergency departments.

“It’s not the severity of omicron, it’s the raw number of cases that it’s generating,” said Dr. Joe Gerald, a researcher and associate professor with the UA’s Zuckerman College of Public Health. “Omicron is more in our emergency departments. It’s shifted the focus of where the crisis is unfolding.”

The available data doesn’t show what’s really going on.

COVID-19 data collected by the Arizona Department of Health Services, for example, doesn’t include so-called “holds,” which are beds set up in emergency departments for those waiting for a spot elsewhere in the hospital. During pandemic surges, additional emergency department beds are sometimes set up in hallways.

Data on these beds, which changes quickly as patients are moved or check out, is not something hospitals are required to provide to the state. However, it’s still of vital importance, said Will Humble, executive director of the Arizona Public Health Association and former state health director.

Often, he said, these beds are basically converted to monitored intensive care beds.

“So,” Humble said, “what looks like 94% occupancy (in a hospital) could actually be well over 100%.”

A national study published last week by Harvard researcher Dr. Jeremy Faust explores how that is happening not only in Arizona, but in California, Washington and Wisconsin: these states appear to have more hospitalized patients than recorded beds.

And this stress comes at a time when hospitals are trying to cope with low staffing, an increase in workers getting sick with COVID-19 and many reports of low morale after two years of coping with the pandemic.

Late-January peak expected

Arizona’s seven-day rolling average of daily coronavirus cases has quintupled in the past two weeks, rising from nearly 3,000 in late December to over 16,000 on Wednesday, according to Johns Hopkins University data.

It’s the steepest rise in cases since the pandemic began, said Dr. Joshua LaBaer, executive director of the Arizona State University’s Biodesign Institute, and the biggest related concern is the stress that is putting on health care systems.

The numbers are overwhelming emergency departments, where beds are now set up in hallways to accommodate booming patient loads, he said during a news conference last week.

Gerald, of the UA, predicts omicron transmission will peak here in late January, with “very large numbers of hospitalizations continuing into February.”

New cases were being diagnosed at a rate of 731 cases per 100,000 residents as of early January, a report published by Gerald shows.

“Our health care workers are just burning out,” he said, adding that their jobs are “more like battlefield work now.”

Situation called ‘unsustainable’

In a letter first drafted in December and then updated last week, 1,258 Arizona doctors, nurses, allied health care workers and public health professionals called for Gov. Doug Ducey, other elected officials and health leaders to make changes immediately to reduce the spread of the omicron variant.

The letter outlined several interventions that can be taken now to have a crucial impact, before the hospitals get any worse, including statewide vaccine and mask mandates, and a temporary but comprehensive prohibition on large gatherings.

“Arizona’s healthcare system is in crisis. Since this letter was originally drafted on December 20th, 2021, the situation in our hospitals has only become more dire as a result of the COVID-19 pandemic running unmitigated throughout the state with combined Delta and Omicron surges,” the letter reads.

“Continued inaction by our hospital leaders and lawmakers will be viewed by the healthcare community as an informed decision to ignore the health and safety of the communities you serve and an attack on those sacrificing their health and safety to care for their community.”

The letter cites a recent report from the American Medical Association, which estimates an average of 1 in 5 physicians and 2 in 5 nurses intend to leave practice in the next two years.

The worst effects, the letter said, are more patient deaths and severe, enduring health care worker shortages.

Dr. Bradley Dreifuss, a Tucson emergency medicine physician who co-authored the letter with other doctors and public health professionals, said Friday that they have received little response.

“Both Pima and Maricopa County staffers indicated that they would make sure that the Supervisors saw the letter,” Dreifuss wrote in response to questions from the Arizona Daily Star.

“Dr. (Richard) Carmona was responsive and has offered to meet with our group, as we bring the voice of the healthcare workforce to the the forefront.”

Carmona is the senior public health adviser to Ducey.

Otherwise, Dreifuss said they have been disappointed to hear that the state is “not planning any further mitigation measures.”

“Our community members are going to need to stand up/speak out to indicate that our communities expect the stewards of our health systems to take action and safeguard the health and well-being of our community members,” Dreifuss wrote.

Ducey’s press aide, C.J. Karamargin, did not respond to requests for information about the governor’s response or plan.

‘Many, many more deaths’

Registered nurses with Tucson’s St. Mary’s and St. Joseph’s hospitals called for change last week, saying conditions in their hospitals are unsafe for patients and unworkable for staff.

“The United States is not experiencing a nursing shortage, just nurses not wanting to work under unsafe conditions or risk losing our licenses,” said Mellissa Fatula, a registered nurse at St. Mary’s Hospital for the last seven years, most recently in the medical surgery unit.

Many are waiting in the hospital’s emergency department for several days, she said.

“We can’t suddenly close the door of our emergency department and turn people away,” she said, “and it continues to create these very, very scary and dangerous situations for our patients.”

Fatula said as a member of the National Nurses Union, she has requested, along with union colleagues, that Tenet Healthcare Corporation invest to hire more workers, provide enough personal protective gear — which she said ran extremely low during previous surges and was locked away from staffers — and create a more open work environment overall.

“If we don’t have these things in place we’re just going to see not only many, many more cases but many, many more deaths,” she said. In her unit, they are supposed to have a maximum ratio of four patients per nurse but right now there are as many as seven patients per nurse, she said.

“That’s something I’ve never seen before in my career.”

‘Shocking for us’

It’s hard to say how many deaths occur because of medical error “but we know from aggregate data and research that medical errors are important (to study) as a cause of death,” Gerald said.

Studies have shown that there is higher COVID-19 mortality in health care facilities that are overwhelmed, he said, and “people who would otherwise have survived, don’t.”

Fatula said she and her colleagues have tried to talk to administrators at both hospitals about their concerns but were shut down.

“This was the first time we were met with this sudden closed-door policy,” she said. “It was very shocking for us.”

Tenet responded to the Arizona Daily Star through email provided by spokesperson Taja Vivens and said adequate PPE supplies are being provided and protocols are in place to protect both patients and staffers.

“The hospital has and continues to operate with an open-door policy and employees are free to approach their supervisors with feedback. However, there have been a few instances where very large groups of 20-30 employees have approached administrative offices to ‘March on the Boss’ and we have handled that appropriately,” the email read.

“We are disappointed with recent irresponsible comments made by those with their own agendas as these comments do not honor or represent the hard work being done by our staff to care for the community every day.”

Tenet also reported it is continuing to make “aggressive efforts to increase staffing to help supplement and support our core nursing staff including proactively compensating our team with millions of dollars in market-leading retention and new employee referral incentives.”

‘Difficult month’

Brian Sinotte, market CEO for Northwest Healthcare, said their emergency rooms are busier than during last year’s peak and that, as the world begins its third year of the pandemic, “it’s clear that we are running an ultra-marathon, not a sprint.”

“While many are COVID patients, we are also seeing an increased number of patients with other medical conditions,” Sinotte wrote in an email to the Arizona Daily Star.

“Many people were reluctant to keep routine doctor visits and medical screening appointments early in the pandemic, and we are now seeing patients come into our ERs with more acute needs. More of these patients need inpatient care and treatment, so it is keeping all of our hospital departments incredibly busy, not just our emergency room.”

He said they are “hopeful that the end is in sight.”

“We need your help — get vaccinated,” he wrote, “and if you haven’t received your booster, get it scheduled today.”

At Tucson Medical Center, statistics show emergency department arrivals from April through December 2012 were 32% higher than those months the year before. And during the first few weeks of 2022, there has been an increase of about 22% over the last few weeks of December.

The pressure of COVID has created health care system gaps, with experienced professionals leaving the industry due to burnout, PTSD and other reasons, TMC spokesperson Angela Pittenger wrote in response to questions from the Arizona Daily Star.

Emergency department capacity is limited when patients are waiting there on “hold” and being cared for by the ICU team. TMC is not seeing a huge spike in COVID-19 hospitalizations, she wrote, but the need for acute and critical care for all admissions is high.

As at Northwest Healthcare, patients at TMC are arriving sicker — with other conditions — than in pre-pandemic times because they have been waiting to get care.

It didn’t have to be like this

Gerald said the stress on the health care system is spreading out and lasting longer. The overall occupancy in Arizona hospitals has been more than 2,000 patients for 146 consecutive days, compared to summer 2020, when high occupancy lasted 57 days and winter 2021, when it lasted 98 days.

As of Jan. 6, 29% of the the state’s 8,769 general ward beds were being used by patients with COVID-19, which was a 12% increase from the week before.

Mask mandates are “urgently needed to reduce transmission, blunt the worst of the Omicron wave, and relieve overwhelmed hospitals,” he wrote in a recent report.

Gerald predicts hospitals will see occupancy increase 25% in general services and 35% in intensive care services.

It didn’t have to be like this, he said.

“If we had acted quickly and reasonably in early December, we could have flattened the curve a bit and helped each other out,” Gerald said. “The biggest bang for your buck is early on in the growth period.”