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BALTIMORE — As COVID-19 hospitalizations climb into uncharted territory, fueled by the highly contagious omicron variant, Maryland’s medical work force is increasingly diminished by illness and exposure, burnout and turnover.
Gov. Larry Hogan has responded with pleas for people to get vaccinated and boosted and wear masks to spare the hospitals. The state opened several testing sites near hospitals so people would stop flooding emergency rooms with nonemergencies.
Hogan’s also sending Maryland National Guard troops to hospitals to perform nonmedical tasks and relaxing guardrails on licenses for medical workers, particularly nurses.
Some criticized the Republican governor’s moves as insufficient, while a few worried about patient safety. And while others welcome the efforts and flexibility, some fear there just won’t be relief through the surge.
“I’ve said it to myself, and had leadership conversations about it, there is no backup cavalry,” said Nicole Beeson, senior vice president and chief nursing officer at the University of Maryland St. Joseph Medical Center in Towson. “So how do we do the best we can with the resources we have? We make decisions every single day, leveraging those resources.”
Beeson said hospital officials meet every four hours to redeploy staff among departments, they teach people new jobs and they find new corners for beds. They prioritize patients for CT scans and high-flow oxygen. They even ration the most basic of duties, like hand-holding for the sick and scared.
On any given day, 30% of the hospital’s positions may be vacant because workers left or are in quarantine. At the same time, St. Joe’s inpatient volume is up 400% from Thanksgiving. Those left working are “deeply committed, but exhausted,” she said.
Leslie Simmons, LifeBridge Health’s chief operating officer and executive vice president, said leaders at Sinai Hospital and other system facilities are redeploying administrative staff to restock carts, deliver supplies and do other nonclinical tasks.
They hope Hogan’s orders will provide relief by allowing some nurses who’ve retired, recently moved to Maryland, just graduated or couldn’t get their licenses renewed to work.
“Our health care workers are caring for COVID-19 patients with the same level of compassion as they have from the outset, and they are exhausted,” Simmons said. “Additional resources, such as retirees or new graduates, can be helpful in supporting our teams, when we get them in place.”
Andy Owen, spokesman for the Maryland Department of Health said a workforce survey is underway to better understand and address staffing levels.
“Health care staffing is one of our top priorities right now,” he said.
U.S. Bureau of Labor Statistics data show that the health care and social assistance workforce dropped significantly in Maryland during the pandemic and has not recovered. There were 386,400 people working in those areas in February 2020. That dropped by 14% within two months. By November 2021, the latest month for which figures are available, the workforce remained down by about 4% — amounting to thousands of people.
The Maryland Hospital Association has said that just over 107,000 people worked directly for hospitals before the pandemic, but has no current estimate.
Bob Atlas, the association’s president and CEO, said he was thankful for Hogan’s orders, including sending guard troops and waiving license requirements.
Hogan’s actions didn’t just speed things up, but became critical after a recent cyberattack on the health department systems crippled the state’s ability to grant professional licenses and renewals, among other tasks.
“And yet, if the governor’s prediction comes true — that we may see up to 5,000 people in hospitals with COVID in just a few weeks — our health care system will have to stretch even further to handle the load,” Atlas said. “We will continue to work with our state partners to make certain that personnel and other critical resources, including funding, are available to meet the demand.”
Maryland hospitals exceeded 3,000 COVID-related hospitalizations Monday, four times the number on Dec. 1. As of Friday, the 12 hospitals in the University of Maryland Medical System were caring for a total of 810 COVID positive inpatients, spokesman Michael Schwartzberg said. That’s almost exactly twice as high as the system’s previous peak.
Though the dominant omicron variant appears less dangerous, it is more contagious than earlier variants. So even if the percentage of people hospitalized is smaller, it still amounts to a lot of people, said Matthew Frieman, professor in the University of Maryland School of Medicine’s department of microbiology and immunology.
“We are seeing a disconnect between cases and hospitalizations in the immediate time frame, at least in percentages. But a large number of cases are in the hospitals now, pushing the system to the edge,” said Frieman, a longtime coronavirus researcher. “When we layer on staff that are out because they are positive, it is very hard to keep the health system functioning normally.”
Frieman said he expects even more infections in the next several weeks, and hospitalizations won’t ease until several weeks after cases start to go down.
“We need to be steadfast in our masking and distancing as much as possible, while keeping sick kids and adults out of schools and businesses to limit spread,” he said.
While he declared a state of emergency Tuesday, Hogan declined to impose a statewide mask mandate. Despite instituting one in the past, he called the measure unenforceable.
Officials at MedChi, the Maryland State Medical Society, the hospital association, the Health Facilities Association of Maryland and others urged a mandate in a Dec. 24 letter.
“We would urge your COVID task force to review the rapidly changing recent data and consider returning to science-based requirements for masking,” read the letter addressed to state Health Secretary Dennis R. Schrader. “As previously curtailed activities increase, it seems important to try all measures to minimize the effects of the coronavirus pandemic.”
MedChi CEO Gene Ransom said he still supports an indoor mask mandate, though he feels Hogan took other “good steps.”
He plans to ask the Maryland legislature for longer-term fixes, such as doctor and nurse school loan forgiveness, to address worker shortages that the pandemic has worsened.
“Nationally, across the board, in all sectors, people just aren’t going back to work,” he said. “This burnout issue is real; if you’re changing your practice and busting your butt, it wears on you. There’s frustration among some physicians about some patients not taking this seriously. For anyone who’s been in the eye of the storm for 18 months, it gets old.”
Ransom and others said the state should take proactive steps to not just plug holes during emergencies but make Maryland a destination of choice for health care workers.
Increased protections for laborers, better wages and benefits are some areas where Maryland can improve, said Donta Marshall, vice president for long-term care at the Maryland and Washington, D.C., division of the 1199SEIU health care workers union.
Marshall said members have suffered over the last two years, with some contracting the virus on the job and suffering from serious illness as a result, including long-haul COVID. Others brought the virus home and spread it to loved ones. But the work never stopped.
“Governor Hogan’s emergency order fails to do what’s necessary to address the real need,” Marshall said. " ... The real solutions to the staffing crisis include robust hazard pay and paid leave in the short term, and in the long term, strict oversight of health care facilities, as well as funding for family-sustaining wages, benefits, and career-advancing training for all.”
Meanwhile, some of Hogan’s directives, such as allowing graduate nurses to work before receiving their licenses, and allowing providers to work outside the scope of their licenses, may not be universally celebrated among health care workers. Some experts noted the need to balance patient safety with the the needs of the public health emergency.
Michael Greenberger, director of the University of Maryland Center for Health and Homeland Security, said Hogan should be tapping the broad powers given to him during the emergency.
Hogan has met some resistance to previous mandates, with some claiming the government was infringing on their individual rights. But the U.S. Supreme Court has upheld governors’ powers, Greenberger said, making “the wind at the back of governors in this regard.”
Greenberger said Hogan is correct about mask mandates being tough to enforce, though that doesn’t mean he shouldn’t impose one.
“It could and should be done,” he said. “That’s where you’re stepping on the political ideology of the governor. He is a Republican, and is also thinking about running for president, and a mask mandate is a step too far for him.” Asked last month on “Fox News Sunday” about a 2024 campaign, Hogan said he’s “going to be governor until January of ‘23 and then I’m going to take a look at what the options are.”
The other measures could help, Greenberger said, like mobilizing the guard and easing license requirements.
“It is relaxed, but not so relaxed that people should be worried they’ll be treated poorly,” he said. “It does ease the burden on care providers.”
Jane Kirschling, dean of the University of Maryland School of Nursing, agreed. She said no recent graduates or nurses experienced in a specific unit would be called on to perform duties they were not prepared for. They would be supervised and trained.
At Hogan’s request, the school has allowed students to graduate slightly early for four semesters to get more nurses on the front lines. The school also started a program where students earn clinical training hours in specific hospital programs where they later go work. That reduces orientation time and gives hospital units a pipeline of prepared nurses, Kirschling said.
“But I don’t think hospitals will change dramatically what they do with new graduates,” she said. “They will still be structured and supervised.”
Kirschling said that as state systems recover from the cyberattack, the state orders will help get new nurses on the job without the license paperwork. It also will free up “competent and capable” retired and out-of-state nurses.
So far, those measures aren’t being felt much at nursing facilities and rehabilitation centers, which in recent years relieved hospitals by taking patients not ready to go home.
“We have a considerably smaller workforce in health care than we did,” said Joseph DeMattos Jr., president and CEO of the Health Facilities Association of Maryland, about nursing facilities.
“It’s not just physicians and nurses, but those in food service, housekeeping and maintenance,” he said. “We’re thankful for the guard deployment of about 100 guardsmen are coming. They will really make a difference, but they are not going to do any medical work.”
DeMattos said workers are fatigued and many are getting infected and exposed to COVID-19. Up to 16% of the workforce, or several thousand people, is absent on a given day, he said.
The industry also faces competition for workers with nonmedical businesses, such as retailers, that are paying more, said Regina Figueroa, chief operating officer for National Lutheran Community and Services, which operates four sites in Maryland and Virginia and a home health care company.
“We’re pulling from the same pool of nurses, certified nursing assistants and therapists as the hospitals and the same pool of maintenance and dietary workers as Target and Chick-fil-A,” Figueroa said.
The state could help, she said, by creating a portal to identify nurses without licenses and doing outreach to locate them.
“We appreciate the orders, but if it’s five or 5,000 people, the next step is getting a system in place to find them,” Figueroa said. “If they are out there.”