Hospitals across the United States are overwhelmed. The combination of a swarm of respiratory illnesses -- RSV, coronavirus and the flu -- staffing shortages and nursing home closures has sparked the state of distress visited upon the already overburdened health care system. And experts believe the problem will deteriorate further in coming months. More than a half-million people in the health care and social services sectors quit their positions in September -- evidence, in part, of burnout associated with the coronavirus pandemic -- and the American Medical Association says 1 in 5 doctors plan on leaving the field within two years.
"This is not just an issue. This is a crisis," said Anne Klibanski, president and CEO of Mass General Brigham in Boston. "We are caring for patients in the hallways of our emergency departments. There is a huge capacity crisis, and it's becoming more and more impossible to take care of patients correctly and provide the best care that we all need to be providing."
Along with a shortage of beds, Klibanski said her hospital system is extremely short-staffed. The fast-paced and anxiety-inducing environment of an emergency room is a deterrent for many health-care workers.
"Many people don't want to work in hospitals," Klibanski said. "There are other [less stressful] settings where they can work."
The staffing shortages extend beyond physicians and nurses, and include technicians, respiratory therapists and other hard-to-fill jobs, Klibanski said.
The shortages have hit the health-care system like a tsunami, according to Thomas Balcezak, chief medical officer at Yale New Haven Health Hospital. He said physicians, nurses and support staff have experienced a shift in how the public treats them compared with 2020.
"When covid first hit, there would be all of these parades past our hospital where people would call health-care workers heroes," Balcezak said. "Now, we're seeing nurses who show up in scrubs try to sign up for apartments being turned down because [management companies] don't want people living there who work in health care."
Since the start of the pandemic, health-care workers have faced increasing violence, said Christopher Kang, president of the American College of Emergency Physicians.
According to the American Hospital Association, 44% of nurses reported physical violence, and 68% said they experienced verbal abuse since the pandemic began.
In October, two health-care workers were shot dead at Methodist Dallas Medical Center. Groups such as the Texas Nurses Association say hospitals remain among the most dangerous place to work.
"I've seen nurses and physicians be the victims of both physical and verbal violence," Kang said. "It shouldn't be a surprise when they leave a field where they are no longer respected."
And the workload is daunting: Kang has witnessed physicians having to evaluate patients in waiting rooms in the emergency ward. Patients who need to be admitted will sometimes be forced to linger in the ER because of insufficient nursing staff to move them to the inpatient floors.
"It's unfortunate because it's an uncomfortable situation in terms of privacy as well as perception," Kang said.
Some hospitals have set up overflow tents and activated transfer agreements with nearby facilities to manage the surge in patients.
In October, Johns Hopkins Children's Center, which was running at capacity, reopened covid triage tents that were initially used to manage the Baltimore hospital's overflow at the height of the pandemic.
In the Northeast, Boston Children's Hospital announced this month it would postpone elective surgeries.
Colorado hospitals activated transfer protocols this month to help manage the overflow. The Colorado Hospital Association said the activation was because of "flu, covid-19, and respiratory syncytial virus (RSV) cases, which are challenging hospital capacity, especially for the pediatric population."
Data show that overcrowding in hospitals leads to worse health outcomes. An analysis published in the Journal of Patient Safety found that longer waiting times in the emergency room were associated with a greater chance of medical errors.
But unlike pediatric hospitals, where capacity issues stem from an explosion of RSV cases and other childhood respiratory illnesses, older patients and those requiring long-term care face a different problem: They do not have any place to go once they have been discharged.
"Many patients will come into the hospital from a nursing home for care of some sort, and then when it's time to discharge them, they can't go back because there isn't a bed available," said Kathleen Parrinello, chief operating officer at Strong Memorial Hospital in Rochester, N.Y. "And then we can't get patients into our emergency department because our beds are filled with more nursing home patients than we've ever had."
The hospital bottleneck is only going to get worse. During the pandemic, 327 nursing homes were shut down nationwide, causing 12,775 residents to be displaced, and more were projected to close this year.
Parrinello said nursing home bed availability in her region has gone from 4,500 to 3,000 because of facility closures. But most of the capacity issues can be attributed to existing nursing homes not being able to manage their capacity. "They don't have the staff to keep the beds open and take in those patients," Parrinello said.
Out of the roughly 1 million hospital beds in the United States, more than 700,000 are registered with the Centers for Medicare and Medicaid Services. Seventy-eight percent of hospital beds registered with CMS are filled with patients, and 4% of those are filled with covid patients, according to data from the Department of Health and Human Services.
And the number of occupied beds is expected to increase as the United States heads into the late fall and winter as coronavirus season collides with an earlier onset of flu cases.
Influenza cases continue to rise, with the latest data from the CDC finding that there have been 23,000 hospitalizations and 1,300 deaths from flu so far this season.
Nearly 146 million doses of flu vaccine have been administered. And 31 million people ages 5 and up have received the updated coronavirus booster vaccine. But vaccines are not enough alone to fix the crumbling emergency room infrastructure.
Earlier this month, the American College of Emergency Physicians and 35 other health care associations sent a letter to President Joe Biden urging the administration to address ER staffing shortages and burnout. "Shift work, scheduling, risk of exposure to infectious-disease, and violence in the emergency department can all affect the mental health and well-being of the physicians and nurses," they wrote.
Many of these long-standing issues were exacerbated by the pandemic, and the assumption was when the coronavirus surges subsided, things would return to normal. But Klibanski of Mass General Brigham said "there is no more normal."
"Everything has changed, and now all those issues at the forefront are only getting more exacerbated over time," Klibanski said.