Hospital staff and bed shortages as winter brings greater need

Dec. 26—For health care systems across New Hampshire, this winter could be a Code Blue — time for all available workers to quickly come together to save lives.

According to administrators, manager-physicians and health care advocates around the state, hospital beds and staff are in unprecedented short supply as winter brings a triple threat from COVID, the flu and RSV — a common respiratory virus that spiked this fall that can be dangerous for children and seniors.

Hospitals around New Hampshire report they are running at, near or above 100% capacity, depending on the day of the week, and medical patients are frequently boarding in emergency rooms waiting for an available bed.

"You're running the ins and outs of the hospital on an hour-to-hour basis," said Dr. Greg Baxter, president of Elliot Health System, which includes the Elliot Hospital in Manchester plus urgent care centers. They have treated record numbers of children this year, recently because of RSV.

"We've been able to get treatment for everyone in need," Baxter said. "Sometimes we bring inpatient resources to the ER, to patients wherever they are." Staff are stepping up to take extra shifts as necessary, and long hours are a way of life.

"It's a brittle system right now. It's really one in, one out at this point," Baxter said.

What's the outlook for this season — with a virus trifecta and staff shortages on top of ordinary medical and surgery needs?

"There's a high likelihood that the demands will be at least as high as they are now," Baxter said. Elliot Hospital has been operating between 90% and 105% capacity, sometimes higher, for several months.

"RSV is behind us to a great degree. COVID has been ticking up, but it's manageable," he said. "Influenza is the wild card."

Heading into winter, Concord Regional Health Care's three hospitals in Concord, Franklin and Laconia have been running at "virtual 100% capacity" for two months, said Dr. Chris Fore, the system's chief quality officer.

Staffing shortages and the inability to hire more LNAs, techs and nurses have capped patient beds at 50 in Laconia, even though there's physical room to add more.

"In Concord in particular, we've been routinely holding a couple of patients in the ER all the time," he said. The wait typically lasts a few days.

Space, workforce woes

Three winter viruses rotating and spiking without warning have exacerbated capacity and workforce shortages. Hospitals report that RSV has slowed, COVID is rising slowly, and no one knows what the flu will do, after two years of uncharacteristically low numbers. Demand for services remains high.

"It's cardiac, respiratory, neurological. You name it we're seeing it," Fore said.

The severity and immediacy of medical needs, the increased length of stay in hospitals, and the inability to move fragile elders to long-term care and rehabilitation centers are creating complex challenges.

"There are no options to convert additional space because we don't have staff," Fore said.

Some days Concord Hospital is unable to accept patient transfers from smaller, rural hospitals because of the lack of available beds. In some cases, patients are waiting in smaller hospitals that are not designed to serve their specific needs.

"Everyone is doing whatever they can. We always find some way to provide care that's needed," Fore said.

But with lack of beds, insufficient staff to add more, and the expenses of traveling nurses who are paid at least two to three times what full-time staff nurses receive, hospital operations have become a precarious balance that sometimes pass the tipping point.

"The workforce challenges and salary expenses are unprecedented," he said. "For health care, it's going to be a rough winter."

The crisis for hospitals and health care has been brewing long before COVID. The pandemic caused an exodus of health professionals, with many retiring or leaving because of burnout. According to some New Hampshire hospital administrators, the omnibus bill that just passed the Senate does not contain emergency relief or ongoing support for health care, which was available during the pandemic when federal funds were used to dispatch emergency health care teams to states including New Hampshire.

Although capacity and financial resilience can vary between hospitals, most of New Hampshire facilities are not-for-profit enterprises with tight bottom lines. Hiring traveling nurses when staff can't be found becomes a fiscal drain they can't endure forever.

"In terms of acuity, capacity, (patient) needs and the challenges of workforce and placing patients in long term care, it's as bad as it ever was during COVID and probably worse," said Fore, speaking about the pressures on hospitals. When it comes to patient transfers, "there are times when no one can accept patients. Patient demand is inelastic. You can't cancel flights."

Long-term care crunchNew Hampshire's nursing home staffing shortage is currently the second-worst in the country, said Brendan Williams, president of the New Hampshire Health Care Association, which represents nursing homes and assisted living facilities statewide. Based on the most recent data reported to the federal government, New Hampshire's average nursing home occupancy is 77% compared to 89% pre-pandemic.

Beds are offline in many New Hampshire nursing homes, but facilities are not closing completely, Williams said.

It's a Catch-22. "If you can't improve occupancy, you can't add staff. If you can't add staff, you can't improve occupancy," said Williams, who believes the only long-term solution is for New Hampshire to invest in health care, and in training and retaining workers.

On Dec. 22, Hillsborough County Nursing Home had a wait list of roughly 140 people with 60 beds vacant because of insufficient staff, according to administrator David Ross. Kathryn Kindopp, who heads Maplewood Nursing Home of Cheshire County, a county-run center, reported a wait list of 119, with 100 beds staffed and filled and 50 offline.

"There are combining factors, workforce shortages and lack of post-acute care options at the root of the current capacity crisis facing the health care sector," Dr. Jonathan Huntington, chief medical officer at Dartmouth Hitchcock Medical Center in Lebanon, wrote in an email. "While acutely felt in our region this is a national crisis that needs thoughtful and immediate attention."

According to Huntington, inpatient volume remains high and often runs at or above capacity at DHMC, which is the state's only Level I and II pediatric trauma center. The number and acuity of DHMC's emergency room patients exceeds pre-pandemic levels, and there are more requests for transfers from outside hospitals seeking advanced treatment, complex procedures and specialty care for patients. At the same time, patients are staying longer at Dartmouth-Hitchcock because of a lack of step-down options.

As a result of ongoing capacity challenges, DHMC has had to limit some surgeries and procedures that require inpatient admission.

"We prioritize cases according to urgency and severity. When clinically appropriate, and based on bed availability, we coordinate patient transfers to other Dartmouth Health system members from our ED," Huntington wrote.

Transfers delayedDr. Barry Gendron, chief medical officer at Huggins Hospital in Wolfeboro, stated by email that the hospital's inpatient census rose significantly in recent weeks and staff are prioritizing beds for patients in the community. Emergency room patients are cared for by emergency and hospital physicians while waiting for a bed at Huggins or another facility. The intensive care unit has been at or near capacity, he said.

"We are working with other hospitals across the state to make sure patients get the care they need," said Monika O'Clair, Hugglins Hospital's vice president of strategy. "This includes working with each other in creative ways. In one example we accepted a patient from another facility in order to open a bed at that facility for patients with more acute needs."

Many smaller hospitals, including Speare in Plymouth, continue to rely on traveling nurses to maintain full occupancy, which is financially dicey. Here, too, patients wait longer to transfer, and those in the emergency room spend more time in limbo, waiting for a vacant hospital bed.

"Many elective surgeries do not need a bed. They get discharged the same day," Michelle McEwen, president and CEO of Speare Hospital, explained by email. "For the larger cases, we assess each day whether we think we will have an available bed to accommodate them."

If illness spikes in Speare's service area, which includes Waterville Valley and much of Grafton County, and more beds are needed, McEwen said some post-operative space will be converted into an additional six-bed unit — a strategy used last year during COVID.

"This will affect our surgical capacity, which means at that point we may need to significantly curtail elective surgeries," she said.

At this point, the Concord hospital system is hopeful.

"We're seeing staffing get a little better," said Fore. The central New Hampshire health care network consists of approximately 4,000 full-time employees. Roughly seven openings are filled every two weeks.

"Universally, nurses and doctors are pretty frustrated" by the staff shortage and the simultaneous pressure to cover more shifts and care for needy patients. Fore said.

But patients shouldn't postpone going to the hospital or seeking medical care.

"Number one, if you need to receive care, don't delay it," Fore said. "If you do need to receive services, please bring a little grace and patience."

Silver Linings is a continuing Union Leader/Sunday News report focusing on the issues of New Hampshire's aging population and seeking out solutions. Union Leader reporter Roberta Baker would like to hear from readers about issues related to aging. She can be reached at rbaker@unionleader.com or (603) 206-1514. See more at www.unionleader.com/aging. This series is funded through a grant from the Endowment for Health.