COVID, delta variant & burnout fueling crisis. 68% of Florida hospitals expect to hit critical staff shortage

Florida hospitals are near a breaking point as COVID-19 patients fill intensive care units and spill into other units while stretched-thin staff struggle to keep burnout at bay.

By next week, 68% of hospitals expect to reach a critical staffing shortage, according to an Aug. 9 survey conducted twice weekly by the Florida Hospital Association.

The figure climbed 8 percentage points from four days earlier on Aug. 5, which signals how rapidly the situation is deteriorating as the delta variant continues its sweep across the hard-hit state.

Florida consistently has been the top one or two states with the highest number of new cases. Hospitalizations hit 15,840 on Friday and are climbing, according to the U.S. Department of Health and Human Services.

Willa Fuller, executive director of the Orlando-based Florida Nurses Association, said the pandemic has exacerbated the ongoing nursing shortage. But now more hospital nurses may be nearing wits' end and quit because of the delta variant.

“They get all the praise about being brave health care heroes, but they are not bulletproof,” Fuller said. “Now that this (delta variant) has hit, they are already fatigued. So now you are looking at people fatigued on top of fatigue.”

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Hospitals don’t really want their communities to know how dire the situation is with their staffing needs, Fuller said.

“They want people to feel safe,” she said. “Aside from painting a rosy picture, there is the liability issue to say if there is a staffing shortage.”

Dr. Sam Atallah, a colorectal surgeon in the Orlando area, said hospitals in his region can no longer handle patients with medical needs other than COVID-19. He declined to identify the hospitals.

“This is the point of crisis we are at right now in the Orlando area,” he said. “Hospitals had to reallocate our nursing staff and other resources to accommodate the COVID patients.”

Hospitals nationwide and in Florida are contending with a workforce shortage that started well before the pandemic and accelerated in the last 18 months because of it, said Savannah Kelly, spokeswoman for the state hospital association.

“As hospitals are experiencing increased hospitalizations due to the delta variant, staffing is an acute challenge,” she said in email.

Hospitals have turned to contract agencies to bring in traveling nurses, and in some cases larger systems can reassign staff on a temporary basis, Kelly said.

“The (FHA) has been working with state officials to make it easier for out-of-state health professionals to enter the state to practice,” she said. “Out-of-state staff still need to apply for a Florida license in order to practice.”

Atallah, the Orlando-area surgeon, isn’t confident that will be enough.

“This has to be on the radar at the government level,” he said, but he declined to say if he thinks the state or federal government should step in to help.

Setting up field hospitals requires resources and staffing that hospitals can’t spare, he said.

All of this comes as workforce stress is boosting burnout.

“We cannot keep going at this full throttle much longer,” Atallah said.

Florida hospitals at 145% capacity

Hospitals are required because of COVID-19 to report staffing and capacity details to the U.S. Department of Health and Human Services on a daily basis.

The state hospital association uses the HHS data to release frequent updates that show how hospitals are functioning.

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Florida hospitals on Tuesday were at running at 145% capacity compared to the previous COVID-19 peak on July 23, 2020.

The data shows 85% of beds were in use by all patients and 90% of intensive care unit beds were occupied, according to the state hospital association. Nearly 33% of all patients in hospitals have the virus.

When the hospital association surveyed members about a critical shortfall of staff, defining what that means was left to each system, said Kelly, the spokeswoman.

“A critical shortage would most likely be defined as a situation where supply of staff cannot meet up with increasing demand,” she said.

How hospitals are coping

Dozens of Florida hospitals have stopped elective surgeries to conserve beds and other resources that include personnel.

Hospitals are making those decisions on their own, in contrast with spring 2020 when Gov. Ron DeSantis ordered a stop to manage supply of personal protective equipment.

Other ways of addressing staff shortages include paying top-dollar for traveling nurses through contract agencies, paying overtime to existing staff and reassigning nurses to keep patient care ratios in line with care models.

During the pandemic last year, hospitals worked together to share the supply of traveling nurses, but that may not be the case now, said Fuller of the nurses’ association.

“Now a lot of our nurses are going to other states and nurses in other states are coming here,” Fuller said.

For nurses willing to take on stints as traveling nurses, pay boosts are far above their usual hospital salaries. Fuller has heard nurses say they have paid off their student loans that way. 

She said one drawback of using traveling nurses is getting them up to speed.

“Agency nurses are experienced, but it’s a new environment so you come in and re-orient,” she said. “It might slow down the care a little bit.”

Dr. David Lindner, medical director of the COVID-19 response team at the NCH Healthcare System in Collier County, disagrees.

Hospital staff is accustomed to working with traveling and seasonal nurses. He said NCH has a vigorous onboarding process.

“Drop me or any ICU nurse into most any unit in the world — language issues aside — and we’d be fully functional in days,” he said in an email. “This is such a common occurrence that it is not unusual to have staff from elsewhere.”

In Southwest Florida, hiring and working more shifts

The publicly operated Lee Health, the largest system in Lee, and those in Collier, acknowledge their staffing hardships as COVID-19 cases keep climbing.

Lee Health, with 14,000 employees, has hired 160 bedside nurses in June and July but still has vacancies, especially for critical care nurses, spokesman Jonathon Little said.

The system has more than 1,400 job openings and is actively recruiting candidates to fill essential positions, ranging from medical assistants to surgical technicians and pharmacy staff.

“With the current COVID-19 surge, we are experiencing a greater need for staff than we were a month ago and therefore are exploring all options to fill our needs,” Little said in an email.

“We’ve implemented market-based pay increases for retention, incentive pay for picking up additional shifts and are employing more student nurses and (emergency medical technicians) for additional support," Little said. “We are also looking at resources across the health system to redeploy staff based on daily census, critical needs and patient care.”

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Lee Health has asked employees who left bedside jobs for administrative roles to temporarily return to the bedside or help with vaccinations, testing or anywhere else their clinic background can help relieve some of the pressure, he said.

The patient-to-nurse ratio is one nurse to two patients and up to five patients. The ratio goal is the same for COVID-19 patients, Little said.

At the NCH system, staffing is tight and is a national issue, Lindner said.

“This means staff are working more shifts and taking heavier loads,” he said. “Typically, this is the time of year when staffing is lowest, and those of us who call Southwest Florida home attempt to take some time off.”

NCH follows national benchmarks for nurse-to-patient ratios, but that gets modified during surges, according to Ilia Echevarria, administrative director of the COVID-19 team. In critical care, the standard is one registered nurse to two patients or one patient, depending on the patient's need.

In the COVID-19 units, the ratio is one registered nurse for four patients, but it can be adjusted lower or higher depending on the acuity of the patient, Echevarria said.

NCH has brought in traveling nurses — more are arriving next week — and the system has offered financial incentives to existing staff to help with the need, she said.

Lindner said he fears burnout among physicians, nurses, respiratory therapists and support staff.

“We are all emotionally tired, as well as becoming physically tired and at this time we are in a sprint (until) delta burns out,” he said. “Without vaccination, this variant will continue to kill and maim more young people.”

At Physicians Regional Healthcare System, also in Collier County, staffing is challenging as COVID-19 admissions keep increasing, spokeswoman Brittney Thoman said.

“Our team has adapted regularly based on what we have learned during the pandemic and we are actively hiring for new nurses on our team and have invited many of our travel nurses back to help us during this surge,” she said in an email. 

She declined to share details of the number of job openings or what the current ratio is between nurses and patients during the surge.

“Our staff continues to rise to meet the community's needs and we are tremendously proud of them,” she said.

At Sarasota Memorial Health Care System, the staff are strained and the system is operating far beyond normal capacity, spokesman Kim Savage said. There are about 40 traveling nurses now helping and the system expects more of its seasonal nurses to return earlier than normal this year.

"The rate for agency nurses is rising exponentially and we can no longer count on them accepting our offers," she said in an email.

All nurses are providing patient care or directly supporting the nurses that do, and that includes managers and clinical educators, she said. The hospital has more than 100 clinical and non-clinical staff members who have volunteered to work extra shifts in an emergency labor pool to help bedside nurses, she said.

Optimal nursing ratios is one nurse to two patients in critical care and higher in other units, but that's not always possible and other staff in the emergency labor pool are called upon.

"We are facing very serious staffing issues that can become critical very quickly if we continue to have daily surges of new COVID patients," Savage said. "These continuing surges have taken a physical and emotional toll on our entire team. While we may feel disappointment that this fourth surge could have been avoided by vaccination, we are extremely proud of the care and compassion our team provides."

1,000 job openings in one south Florida health system

In heavily populated South Florida, hospital systems may be facing the brunt of strained resources and staffing.

Jackson Health System in Miami with 13,5000 employees has close to 1,000 job openings that include slots for 200 nurses, according to Julie Staub, executive vice president and chief human resources officer.

“Our greatest challenge is with continuing to increase our bed capacity and having staff to take care of the increasing need,” she said in an email. “For our current census, we are using agency nurses, incentivizing our own nurses to work additional shifts, increasing our per-diem staff and starting to redeploy nurses from our clinics and other areas. This is in addition to hiring 100-plus nurses per month.”

The ideal ratio is one critical care nurse for one to five patients depending on the severity of the patients, she said.

Jackson Health is trying to maintain the ratios in the COVID-19 units, but it has jumped to one nurse to six patients, she said.

In Palm Beach County, medical center officials say surging COVID-19 cases and a nursing shortage are creating a perfect storm that is threatening the ability of hospitals to care for patients.

“The health system is at the breaking point here,” said one local hospital administrator, who asked that his name not be used because he isn’t authorized to speak for the hospital. “It's really significantly bad. It’s a crisis.”

U.S. Rep. Lois Frankel said that hospital officials privately tell her they are worried. “They are afraid the healthcare system is going to be compromised,” she said. “The staffing shortages are getting bad.”

Diverting ambulance crews in Brevard

In Brevard County, Parrish Medical Center in Titusville is using an emergency overflow tent and a secondary overflow ICU unit, plus it converted nearly 50 patient rooms to function as “negative pressure rooms” geared for COVID-19 patients.

Last week, for a period of 10 hours, the hospital had to go on “full divert,” meaning that ambulance crews were directed to other hospitals rather than coming to their emergency room except in cardiac-related emergencies.

Non-emergency surgeries continue to be postponed to allow staffing resources to be deployed to areas of greatest need. As of Wednesday, the hospital had 70 COVID-19 patients, including 11 in the ICU.

“We agree with FHA, there is no set threshold but a critical shortage would be where availability of staff cannot meet the increasing demand and acuity of patients. By that definition and in the absence of measures taken to stem the COVID surge, critical shortages are inevitable,” Parrish Healthcare spokesperson Natalie Sellers said.

At Health First, which runs four hospitals in Brevard County, “we are implementing every solution available to support our associates and providers. Support efforts include flexible staffing, different levels of compensation incentives, enhanced recruitment efforts and even the use of available traveling nurses,” said Jessica Maynor, Health First System Director, Wellness and Workforce Optimization.

She said because they are part of a delivery network, they are able to redeploy resources from units where services are temporarily reduced. She noted that happens “in critical times of need — such as we are currently facing.”

Teaching hospitals have options

At the University of Florida Shands in Gainesville, being a teaching hospital means having more resources to address staffing needs through residents and student nurses, Chief Executive Officer Edward Jimenez said.

He also oversees two central Florida hospitals in Leesburg and The Villages. The three locations have a combined workforce of 14,000.

Shands has different triggers it can use to control bed capacity and resources that range from canceling elective surgeries when use of an intensive care bed is anticipated to the highest trigger of not accepting transfers from within the state, he said. He did not share which trigger, if any, Shands has used during the current surge.

Burnout among existing staff is already here, he said, coupled with a level of resentment that the delta surge was avoidable if the public had embraced vaccinations.

The statewide vaccination rate stands at 52%, while 63% of Floridians have at least one dose, according to data from the Centers for Disease Control and Prevention.

“I talk to doctors and nurses and they say, ‘I can’t believe we are back in this situation,'” he said.

No big hospital around the state was ever down to zero COVID-19 patients since the pandemic began last year.

“Their world has been go, go, go,” he said. “I am both in awe of my staff and also heartened for them because they don’t get to turn it off.”

Jimenez doesn’t see how large hospitals can transfer nurses to sister hospitals to fill needs. Having someone drive two hours one way for a shift isn’t sustainable.

People are quitting and giving four weeks’ notice, but there have been no cases where Shands employees have said they will not be back the next day.

Dr. Frederick Southwick, an infectious disease specialist at Shands, said in an email that burnout is moderately severe among the staff.

“Everyone is becoming discouraged because as of now there is no light at the end of the tunnel,” he said.

Southwick is active with the state affiliate of the Committee to Protect Health Care that is outspoken against DeSantis for not taking action to reduce the spread of the delta variant by supporting mask wearing and vaccination.

“Rather than focusing on prevention, the state is asking medical personnel to come to Florida to help,” he said. “I can’t tell you how frustrating this is to everyone working on the front lines. We saw this surge coming over a month ago with the arrival of the more contagious delta variant.”

- Reporters Jane Musgrave and Rick Neale contributed to this report.