The coronavirus pandemic is placing enormous staffing pressure on hospitals and health systems, who must manage a surge in patients while ensuring their staffs are healthy and rested for the next shift.
Kaufman Hall Senior Vice President Therese Fitzpatrick, Ph.D., RN, FAAN, explores the strategies hospitals can use to prepare their organizations for the surge, from recruiting recently retired physicians and nurses to redeploying current staff to help cope with expected waves of patients.
This interview was conducted on March 23, 2020.
Q: How would you characterize the current hospital staffing situation?
A: We’re hearing from organizations that are concerned about clinicians who have been exposed. They’re currently figuring out how to isolate those individuals for a couple of weeks. The greatest concern is building depth into the medical staff. It’s also important to help prepare physicians who may not have cared for patients in an emergency department (ED) or intensive care unit (ICU) setting for many years. For instance, if a physician’s specialty is in gynecology, organizations need to provide preceptors to help these physicians become comfortable in their new roles.
In states that have significantly slowed down or stopped elective procedures, that means there are anesthesiologists and surgeons who could be deployed into new roles. Many organizations are developing staffing matrices to understand what resources they have, where they can and should be deployed, and how to schedule staff to avoid burnout and ensure there’s sufficient back-up if clinicians do need to be isolated.
Q: How would you characterize the current state of preparedness?
A: All organizations that are accredited by the Joint Commission or the DNV GL are required to have a very robust emergency plan, and do drills multiple times throughout the year. From a preparedness perspective, whether you’re a large academic medical center in an urban setting or a small critical access hospital in a rural setting, all organizations are required to do this. We’ve got a good basis for that activity.
However, this particular situation is adding complexity to those plans. Hospitals can start to organize this by the type of professionals that are needed within an organization. The first area that organizations are looking at right now is their medical staff. It’s usually the responsibility of the boards and governing councils to privilege and credential physicians and advanced practitioners, whether they’re physician assistants or advanced practice nurses (APNs). We’re beginning to see now how organizations can modify those credential procedures around two things: getting physicians and APNs into the hospital in a more expeditious way, and addressing how they credential physicians across specialties.
If there’s a requirement that physicians in the ED be board-certified in emergency medicine, we may need to deploy internists or surgeons to help treat patients in the ED.
Many organizations are now looking at their rosters of recently retired physicians and practitioners, or individuals with emeritus status, and contacting them to determine if they’re willing to be deployed in this growing emergency.
Medical staff offices are going through those lists, and presenting them to the presidents of the medical staff or the chief medical officers. Medical staff leaders can then reach out to those physicians to determine their ability to join the roster. Those credentials can be fast-tracked through the system. In larger systems, each hospital’s board might have its own responsibility for credentialing under normal circumstances. We’re now seeing the systems take responsibility for credentialing under these emerging circumstances.
Q: How can organizations organize their current staffing needs into an actionable plan?
A: We’re beginning to see organizations utilize a cohort staffing plan. For example, in nursing, you’d look at your entire nursing staff and, depending on the size of the organization, divide them into two to four cohorts. Each cohort is scheduled in a such a way to be able to relieve another cohort. For instance, if you have three cohorts, cohorts one and two are busy at work, and cohort three is at home resting, so they can come in to rotate the staff.
Organizations also need to look at all of the licensed personnel in a nursing department, whether they’re frontline caregivers or support staff—including educators, clinical nurse specialists, quality assurance staff, and nurse managers. Organizations can develop triggers based on patient acuity and volume to determine when they need to bring in another tier. Specifically, the staff nurses might be able to manage the volume to, say, point X. When an organization hits that point, it triggers the deployment of the second tier, which might be educators, nurses in clinics, or nurses in physician offices. A third tier might be nursing leaders.
In some instances, organizations might be suspending work rules. Under normal situations, an organization might not permit a nurse to work more than three consecutive 12-hour shifts. Right now, though, they might need to add another 12-hour shift to ensure they have coverage.
Q: How can organizations help caregivers manage their stress levels and workloads?
A: Obviously, organizations are going to have staff that get burned out or get sick themselves. We’re seeing organizations making sure that their staff is utilizing the time before they’re slammed with patients for sufficient rest and time with their families. Organizations might tell staff to go home, and that they’re temporarily exempting them from email.
We’re also hearing organizations talk about making sure there are sufficient services available for staff. For instance, in faith-based organizations, this might mean making the hospital chaplain’s counseling staff is available to physicians, nurses, and front-line caregivers. While it hasn’t happened in the U.S. yet, we’re seeing in other countries that staff are having to make very difficult triage decisions. We need to be able to provide psychological support to our caregivers right now.
Q: How should organizations engage agencies and other vendors to ramp up staffing?
A: Many organizations have established partnerships, whether it’s with locum tenens or staffing companies for nurses. They’re having conversations with them and identifying resources. This is a situation where you’re not going to want to wait to prepare for a staffing need on the night shift tonight. You’re going to need to preplan that and figure out how to get individuals trained up on electronic medical records and oriented to the organization.
Some states are also allowing nurses and staff to work in adjacent states. That will have a significant positive impact. In addition, many states are postponing their renewal deadlines. For instance, in Illinois, the state is automatically renewing expiring licenses for medical professionals—which were initially required to be renewed in May—through September.
Q: What are some of the other issues that hospitals should be thinking through right now in terms of staffing?
A: Because so many schools are closed, there’s a massive need for daycare for the children of staff, and many hospitals are bringing daycare on site.
Another issue is that the current group of operating room (OR) nurses nationwide tends to be roughly 8-10 years older than the rest of the nursing workforce. Organization are worried about a large wave of retirement in general, but specifically in the operating room. There has been growing action to see how to organizations might able to keep nurses that are close to retirement engaged in the workforce.
We’re also helping clients better understand their demand patterns within their individual department to see if there is a need for atypical shifts. So instead of working three long 12-hour shifts, places like ORs, EDs, or surgical units might lend themselves to some 8-hour shifts. This is the opportunity to deploy some of those creative solutions.
There are also ways to redeploy sitters, who are often at a nursing assistant or a care technician level. Sitters usually sit at the bedside and monitor a single patient, who could be on suicide precautions, or might be disoriented, or may be a potential fall risk. In a disaster, you have to very quickly triage patients who are in the hospital. There are a whole set of activities on the back end to free beds up. Not everyone who is going to be discharged is ready to go home. Organizations have teams that are trying to figure out where to send patients, and if they have home health nurses in place to assist once they get home. Provided they’re not monitoring actively suicidal or homicidal patients, sitters can assist with those efforts.