The viral outbreak has not yet reached that crisis point in Texas. But as the state prepares for a peak that may still be weeks away, hospitals are already grappling with how to deploy and protect their most important resource: their staff.
“The problem, of course, is not just where’s the greatest patient demand, but also the physicians are at significant risk for getting COVID themselves,” said David Fleeger, a colorectal surgeon in Austin and the president of the Texas Medical Association. “That’s a significant impact on the workforce.”
With nonessential medical procedures canceled and patients skipping routine doctors’ visits, many health care providers can be reassigned to the wings of the hospitals that need them most, likely the emergency rooms and intensive care units that will tend to the sickest coronavirus patients. But staffing shortages could prove insurmountable should large numbers of clinicians fall ill with the virus, and the risks are only higher amid a nationwide shortage of the personal protective equipment needed to keep them from contracting it. A nurse at HCA Houston Healthcare Northwest is fighting for his life after caring for patients without a proper mask, the Houston Chronicle reported this week.
“Staffing is a serious concern,” said Carrie Williams, a spokeswoman for the Texas Hospital Association. “We have to be able to keep doctors, nurses and other frontline workers safe, otherwise we could have beds with no one to take care of them.”
Hoping to boost the number of clinicians on the front lines, Gov. Greg Abbott has loosened or waived a number of state licensing requirements. Abbott issued an executive order welcoming out-of-state physicians to Texas with fast-tracked licensing and another to help retired nurses to return to the workforce and student nurses enter it early. A state portal soliciting volunteers has so far drawn just over 500 names, but the vast majority of those — roughly 370 — were not health care workers who can work directly with patients, according to a spokesman for the Texas Department of Emergency Management. Just four out-of-state clinicians have signed up on the site.
Even before the current crisis, Texas faced a shortage of nurses; a state agency estimates a deficit of tens of thousands of registered nurses. And hospitals are rarely staffed for “a full census” of patients, explained Serena Bumpus, director of practice for the Texas Nurses Association.
A robust nursing staff will be particularly crucial to fight this virus: When patients are critical, nurses typically tend to just one or two at a time.
“When you think about the influx in number of nurses required if every one of those patients was a 1-to-1 or 2-to-1 ratio, it’s next to impossible to be able to manage that with the current staffing that most of our hospitals have across the state,” Bumpus said.
With elective procedures canceled, many hospitals are drawing up surge plans, cross-training nurses to staff other areas of the hospitals or corralling them into “float pools” to direct them where they are most needed. Not every nurse is comfortable with or qualified for every position, but many have training they can call on for critical care. In some hospitals, nonessential personnel like clerical staff or volunteers are being sent home and clinicians are filling their roles, an effort to minimize the number of people who are in hospitals.
“That’s what some of our facilities are working on right now: What can we do with these extra hands?” Bumpus said. “How do we maximize the use of our workforce knowing that not everybody is going to be utilized in the normal operating way?”
A nurse who works in a Williamson County hospital said colleagues whose work has slowed — nurses in the operating room, for example — have all been told to cross-train through the intensive care unit.
“The expectation is that this is going to get bad,” said the nurse, who asked to remain anonymous because she fears retaliation from her employer. “When that happens, we will need additional staff.”
Likely the busiest wings of the hospital will be the ICU and the ER, where sickest patients are tended to. The new virus causes breathing issues, so perhaps the busiest group will be pulmonologists and “intensivists” used to running ventilators and caring for patients with lung problems — “and there aren’t enough of them,” Fleeger said.
Fleeger said an influx of patients will require “a cascade of: Everyone needs to step up one level.”
For the sickest patients, that will likely mean bringing in anesthesiologists and emergency room doctors who are comfortable with intubations, ventilators and IV drips. Other doctors will tend to patients in less severe condition. The majority of Texas physicians are specialists, and many of their calendars are emptying as patients stay home and non-urgent procedures are canceled. They can be reassigned to roles they’re comfortable performing, Fleeger said.
“I’m not going to run a ventilator — I haven’t done one since I was a resident 35 years ago,” Fleeger said. “But I can make rounds on someone in the hospital who has COVID-19 and has a nasal cannula. I can write the notes for the other doctors.”
And, he said, there will be a role for older, retired doctors “who we don’t want to put in harm’s way” — staffing screening call centers, for example.
“We would hope that things wouldn’t get so serious that we had true shortages,” Fleeger said. “It’s just something that we’re going to have to face if and when we get there — doctors will be taking care of larger numbers of patients than they normally do. It’s something we’ll do if we need to.”
Some doctors have already moved into new roles in anticipation of a crush of COVID-19 patients.
Dermatologist Brent Kelly typically spends days seeing patients with pimples, analyzing biopsies and helping his University of Texas Medical Branch colleagues identify mysterious rashes. But watching news coverage of the chaos in Italian hospitals, as some doctors fell ill and others scrambled into unfamiliar roles, Kelly started to think about running a ventilator and intubating patients — procedures he hadn’t done in years. He wanted to shake the rust off. So he reached out to the team directing his hospital’s coronavirus response.
“Wherever you guys need me, I can do it,” he told them. For the past several weeks, he’s been staffing the hospital’s screening clinic, studying a hospital-distributed curriculum on caring for respiratory ailments, completing hospital rounds on coronavirus patients, learning how to properly put on and take off the personal protective equipment that shields him from the deadly virus.
For outpatient physicians who do not work in hospitals, the primary task right now is to keep patients with mild symptoms of the new virus or unrelated ailments out of the hospital, to preserve scarce time and protective equipment. But those doctors are also preparing for the possibility that they might be called in to staff hospitals facing shortages, said Alison Days, a pediatrician and president of the El Paso Medical Society.
“If they call us and say they’re starting to come out sick, or they just don’t have enough hands for the number of people that are coming in, there would be a call to outpatient doctors,” Days said. Outpatient doctors in her area are informally discussing who might need to step in first. “All of us are prepared to consider that.”
Shift work, already a defining feature of life for hospital workers, will become even more essential as workforces navigate the spread of infection within their ranks. In the Panhandle’s Moore County, hospital executive Jeff Turner said he has created three teams — A, B and C — to ensure the hospital has two weeks of continuous surgical coverage even if clinicians fall ill. The split will allow him to bench one team for two weeks should a member fall ill.
Still, even as they plan, hospital administrators and clinicians know there are some circumstances it is impossible to be ready for.
“It’s a lot of, ‘I don’t know,’” Kelly said.“It’s frightening to think about, but I think it’s possible that if things get really bad, the clinicians that aren’t intensivists might have to step up like they did in Italy. I’m hoping that it doesn’t get to that stage here,” he said. “I think we all could do it. It may be that a lot of us are going to have to do it.”
Disclosure: The Texas Medical Association, the Texas Hospital Association and the University of Texas Medical Branch have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.