Viruses, 'patient boarding', staffing shortages create gridlock in Arizona ERs, doctors say

Arizona hospitals, facing a higher-than-usual level of patients with respiratory viruses, are gridlocked because of a backlog of patients in emergency rooms, a statewide physician group says.

In some cases, patients are spending days getting care in the emergency department because of a lack of staffed hospital beds, said Dr. Nicholas Vasquez, a Phoenix-area emergency room physician and spokesperson for the Arizona College of Emergency Physicians.

The problem is not just an issue with the "triple threat" of flu, COVID-19 and RSV — respiratory syncytial virus — that's elevating emergency room volumes, though that's certainly a big factor, Vasquez said.

Compounding the respiratory viruses that are circulating, Arizona and hospitals across the country have inadequate staffing because of both a nursing shortage and health care worker burnout, Vasquez said.

Further exacerbating a strain on hospitals, health care workers across the country say there's an ongoing mental health crisis caused by long-term impacts of the COVID-19 pandemic. Patients in a mental health crisis will often go to an emergency room to get help.

"To really understand an emergency department, I think it's best to think of it as a filter. It will filter whatever society's problems are, and it will show up as our patients," Vasquez said.

Staff for post-hospital placements such as nursing homes is also in short supply, meaning patients who are hospitalized are spending longer than needed waiting for a place to go. That creates a backlog that leads to longer emergency department waits before hospital beds open up and more patients being treated and held in emergency rooms rather than in hospital beds.

Holding patients in emergency departments for hours or days is often referred to as "patient boarding," and it has ripple effects across the entire health care system, including causing longer emergency department waiting room times, Vasquez said.

"Boarding looks like a patient who sits in a bed or a hallway in the emergency department," Vasquez said. "We have more than ample evidence the longer they board, the worse their health is. ... Across the state, when ER docs go to work today, the vast majority of them will walk in to patients who have been boarding in the ER for 10, 15, 20 hours, sometimes days, and that's a real challenge to communities, to hospitals and staff."

Emergency department volumes at Valleywise Health Medical Center in Central Phoenix are about 30% higher than they were at this time last year, chief medical officer Dr. Michael White said.

Valleywise Health is the public health system for Maricopa County.

As of Monday, five inpatient psychiatric units within Valleywise Health were closed because of staffing shortages. Such shortages affect what hospital officials refer to as "throughput" — getting patients from the emergency department to a hospital bed and then ensuring they are safely discharged home or to a post-hospital facility.

"It's a multipronged problem," White said.

The gridlock is not only happening in Arizona. The American College of Emergency Physicians and several other major medical organizations, including the American Academy of Family Physicians, the National Alliance on Mental Illness and the American Medical Association on Nov. 7 wrote a letter to President Joe Biden that calls patient boarding "its own public health emergency" and one that has pushed emergency departments to a "breaking point." The letter implores Biden to make patient boarding a "major priority."

The letter was written as respiratory viruses swept across parts of the U.S., overwhelming hospitals with a surge in patients that is now being felt in Arizona, which historically gets hit by seasonal respiratory viruses later than most other parts of the country.

"We are asking both locally and federally for stakeholders to sit down and talk together about reducing the impact of boarding," Vasquez said. "It is a common problem. ER boarding reflects hospital crowding. As hospitals have a harder and harder time retaining nursing staff, boarding has gone up."

In a Sept. 30 research letter published in the journal JAMA Network Open, authors from Yale University and the University of Michigan say that "harms associated with emergency department boarding and crowding, long-standing before the pandemic, may have been further entrenched." The letter says that The Joint Commission, a health care accrediting organization, identifies emergency department boarding as a patient safety risk that should not exceed four hours.

"Downstream harms include increased medical errors, compromises to patient privacy, and increased mortality," the authors write.

'Another moment of overstretched capacity'

While an unusually early and vicious spate of RSV cases, primarily in young children and infants, appears to have peaked in Arizona, cases remain higher than usual for this time of year.

Flu also arrived earlier than usual and is on a continued upswing. Cases of flu in Arizona as of Dec. 3 were 13 times higher than the five-year average for this time in the flu season and 24 times higher than cases reported at this time last season, according to the most recent data released Wednesday. Hospitalizations for flu are high throughout the country.

"The past several years have certainly not been easy, and we now face yet another surge of illness, another moment of overstretched capacity, and really one of tragic and often preventable sadness," CDC Director Dr. Rochelle Walensky said during a Dec. 5 telephone briefing. "Hospitalizations for flu continue to be the highest we have seen at this time of year in a decade, demonstrating the significantly earlier flu season we are experiencing."

Pima County on Dec. 1 issued a public health advisory warning about increased transmission of viral respiratory diseases, including COVID-19. Officials with the Maricopa County Department of Public Health on Friday said they want to notify the public about increased transmission of respiratory viruses so that county residents can take preventive steps to keep the problem from getting worse.

COVID-19 and flu cases are on the rise in Arizona's most populated county, and flu is "widespread," which is the highest category of flu spread. The Centers for Disease Control and Prevention as of Thursday is recommending residents of 14 of Arizona's 15 counties, including Maricopa, wear face masks when indoors in public due to COVID-19 levels.

Two pediatric flu deaths have been reported in Arizona so far this season — one in Pinal County and one in Cochise County, which had not reported a pediatric flu death since 2010. Nationally, 14 pediatric flu deaths have been reported since Oct. 1, officials with the CDC say.

“Respiratory viruses can cause severe disease, especially in infants, young children, and older adults,” Dr. Nick Staab, medical epidemiologist at the Maricopa County health department, said in a statement. “It is concerning to see so many cases before many holiday gatherings and travel have even happened. We are already seeing a strain on our healthcare systems.”

In an interview Friday, Staab said that there are anecdotal reports of high volumes of people seeking care in local emergency departments and urgent cares.

"We know from CDC data that our COVID hospitalizations are increasing, and just as during previous surges in COVID, we know that our health care systems can only take so much before their resources are strained, particularly health care workers. We know that's where we have fewer resources than we need."

Staab said patients should expect longer waits when they are accessing health care, though he said county officials have not heard that there's any change in the level of care being provided by any local health care systems.

"We can prevent individuals from seeking health care with all these infections through vaccination," Staab said. "Vaccination will decrease the severity of any breakthrough infections, and they will prevent infections. So if we can get people to be vaccinated, especially ahead of the next holiday gathering, we believe that we can make a critical step here in decreasing the strain on our systems."

Both the flu and COVID-19 vaccines are now authorized for anyone 6 months and older.

Asked about gridlock in emergency departments this week, officials with Banner Health, which is Arizona's largest health system, told The Arizona Republic that patients entering Banner emergency departments "are seen and triaged in a timely manner."

The most severely ill are treated first, while less ill patients may wait longer, Banner officials said in a written statement.

"Sometimes, admitted patients wait in the ER for patient room availability," the statement says. "These wait times fluctuate depending on factors such as how busy the hospital is and staffing. If you are experiencing severe illness, do not hesitate to visit an ER. We see every patient and provide the care they need."

Banner officials also said that a decline in RSV cases has resulted in a 24% reduction in pediatric hospitalizations and a 30% drop in emergency department visits over the past few days.

"Flu cases remain high, and we don’t know if/when they will peak. COVID cases are increasing, but ICU COVID cases are in the minority," the Phoenix-based nonprofit health system said in its statement. "We encourage the public to get a flu shot and the latest COVID booster whenever eligible."

Just 12% of eligible Arizonans have received the updated COVID-19 booster

During a visit to Phoenix on Thursday, U.S. Department of Health and Human Services Secretary Xavier Becerra said one of the best ways to avoid overloaded emergency departments is for more people to get the updated, bivalent COVID-19 vaccine booster.

"The winter months are when we see the most infection, whether it's flu, RSV or COVID. This is when we are in the danger zone. That's why I am here today," Becerra said. "You get vaxxed, chances are you stay healthy. If you stay healthy, you don't take up a really precious bed in the hospital. It's all about helping each other. It's not about just thinking about yourself."

Becerra visited with staff and patients at the South Mountain Post Acute skilled nursing facility in Phoenix, which on Thursday held a COVID-19 vaccine clinic. About 90 staff and residents received the updated booster. The facility has both long-term and short-term patients, and about 60% of them have the updated bivalent booster, while about 30% of staff are up to date, leaders with the facility said.

Uptake of the bivalent booster, which became available in September, remains low across the country and Arizona is lower than the national average.

As of Wednesday just 12% of Arizonans ages five and older had received an updated bivalent COVID-19 vaccine booster, which is lower than the national average of 13.5%. Among the more vulnerable over 65 population, 31% of Arizonans had received the updated bivalent vaccine, compared with the national average of 34.2%.

"Everywhere I've gone and I've gone pretty much throughout the country, most people who aren't vaccinated will say it's not that they are against it or they believe it's going to make them ill. ... It's that no one has really connected with them that they trust," Becerra said.

"At this stage, it's all about getting it done in the trenches. The big victories are gone. Now it's slow progress. We need to know what works because the successes won't be in the thousands anymore. It's all about getting 10, 20, 50 people vaccinated in a day."

Getting staff and residents of nursing homes vaccinated with the updated COVID-19 booster is one of the critical pieces in helping hospitals avoid problems with overwhelmed emergency departments, said Dave Voepel, executive director of the Arizona Health Care Association, which represents long-term care facilities.

People in skilled nursing facilities are more likely to be older and have compromised immune systems and spend longer stays in the hospital if they get sick.

But another part of the problem is that like hospitals, skilled nursing facilities are facing staffing shortages, which means people are sometimes spending longer than they need to in the hospital waiting for a bed in a skilled nursing facility.

"The staffing has been depleted so much. ... Part of the issue is that we can't really help in some cases because we have such low staffing," Voepel said. "We hurt people if we can't staff appropriately, and that's the struggle."

Reach health care reporter Stephanie Innes at Stephanie.Innes@gannett.com or at 602-444-8369. Follow her on Twitter @stephanieinnes.

This article originally appeared on Arizona Republic: Viruses, staff shortages create gridlock in Arizona hospitals