Hospitals Can’t Accept This as ‘Normal’

At the height of the recent Omicron surge, Advocate Trinity Hospital, in Chicago, was inundated with patients who spent more than 40 hours in the waiting room, holding tight for a bed in the emergency room, which was itself heaving with people who were waiting for a spot in the intensive-care unit, which was also full. Someone admitted at night might have seen two sunrises before they saw a bed. The hospital received more COVID-19 patients than at any previous point during the pandemic. These patients waited, as did people with other conditions. “We had patients waiting with bacterial infections, surgical problems, you name it … people who were sick to a degree that we’d never keep them waiting in normal conditions,” Michael Anderson, the emergency department’s medical director, told me. That the hospital could be so besieged two years into the pandemic “is something I never thought in my wildest dreams would occur,” Matt Fox, a respiratory therapist, told me.

To see as many patients as quickly as possible, the hospital’s exhausted staff brought intensive care into the emergency room, using portable oxygen tanks sourced from a local company. They brought emergency services into the waiting room, installing catheters and ordering medical tests for people who couldn’t yet be given a bed. They resuscitated a patient who had had a heart attack while still in an ambulance, because there wasn’t anywhere for them to be off-loaded. But between staff shortages that had been getting steadily worse throughout the pandemic and the sheer deluge of sick people, the team simply couldn’t see everyone quickly enough.

During one recent shift when just four nurses were on duty, three of whom had been hired from an agency and were on their first day, a COVID patient went into cardiac arrest in the waiting room, where they had been sitting for 10 hours. “They were talking and in a split second they weren’t,” Berenice Zavala, an emergency-department nurse, told me. Someone checked: no pulse. One nurse leaped to start CPR, while her colleagues tried to put personal protective equipment on her. Somehow, they found a room, which at one point filled with almost every available health-care worker on the floor. The team spent 45 minutes trying to revive the patient. They could not. “It really affected us all. People blamed themselves,” Zavala said. “I’ve never worked under these conditions.”

Advocate Trinity is one of the few remaining health-care institutions that serves the predominantly Black communities of Chicago’s South Side—an area where several hospitals have either closed in recent decades or are now on the verge of doing so. A third of its patients are uninsured or on Medicaid. When the coronavirus arrived, Black Chicagoans were more likely to die from it than white ones; even before the pandemic, they already had shorter lives, poorer health, and fewer health-care services. Hospitals throughout the United States have struggled through the Omicron wave, but Advocate Trinity is America’s health-care system in microcosm. Its shrinking pool of workers is shouldering, at immense personal cost, several generations of inequality and neglect, and two years of a poorly controlled pandemic.

“We’re asking heroic things of people to pave over the problems that the health-care system faces,” Anderson said. Many of Advocate Trinity’s workers have already left, while Anderson and others who are still there are committed to staying for the sake of their community. “If they don’t come to us, where else are they going to go?” Michele Roe, a nurse, told me.

Many stressors from the early pandemic have abated. Having been vaccinated, Advocate Trinity’s staff members are less fearful about their own health or about fatally infecting their loved ones. With two years of experience under their belt, they better know how to treat COVID patients. They can save many people who might have died in early 2020.

But like many institutions, the hospital was already short of nurses before the pandemic. Last year, that shortage grew steadily worse. Worn down by the relentless surges, many employees retired or took positions that don’t involve acute care. Others were lured away by travel-nursing contracts, which allow them to work more flexibly and for several times more pay. “We do provide incentives to keep nurses here, but they pale in comparison to the prices being offered” by travel agencies, Roe said. The exodus got so bad that on Halloween morning, a single nurse showed up to cover the emergency department’s 21 beds. The team scrambled, successfully, to pull more people in, “but that was when reality hit,” Anderson said. Ideally, no ER nurse would take on more than four patients. Of late, some have had six in their care.

The staffing problems aren’t about just missing bodies, but also missing experience. As the oldest nurses resigned, their deep well of knowledge left too. Newly graduated nurses take twice as long to be onboarded as before the pandemic, Gwendolyn Oglesby-Odom, the chief nursing officer, told me, because the pandemic disrupted their training and left them with less clinical experience. Zavala said that travel nurses, too, used to be more seasoned and could be slotted into hospital routines after a short orientation, but agencies are now less stringent. Their workers need more hand-holding from experienced nurses who know that they’re earning significantly less. These factors all force physicians and veteran nurses to be extra vigilant about matters that they used to entrust to colleagues, adding to their already considerable strain.

Meanwhile, the patients haven’t stopped coming. Although Omicron is less severe than Delta, it is still potent enough and transmissible enough to fill Advocate Trinity with people struggling for breath, more than 90 percent of whom are either unvaccinated or partially vaccinated. COVID also exacerbated a slew of existing health problems: Before the pandemic, 80 percent of Advocate Trinity’s patients had diabetes, and many had asthma and chronic respiratory diseases. “Our patients are pretty sick coming in the door, because they haven’t been able to afford care and they haven’t seen a physician in years,” Zavala said.

COVID constrained sick people’s choices even further. Some people worried about contracting the disease in a hospital and spent months sitting on worsening chronic health problems. Others faced six-month wait times for a primary-care appointment and got sicker because they couldn’t get their medications. Opioid overdoses have surged, Anderson said, driven in part by the grief of losing loved ones and the pandemic’s other traumas. “We’ve been full since August, and there’s just a lot of people coming in for everything,” he said. “It’s not just that hospitals are busy on and off with COVID. We’re dealing with multiple crises at once, many of which are fueled by COVID.”

In response, the hospital delayed some nonemergency procedures, petitioned the state and the federal government for resources, and closed down one of two critical-care units to ensure that its staff could adequately care for the other’s patients. “We flipped every lever that we could,” Rashard Johnson, the president of Advocate Trinity, told me. But with the virus running amok, the hospital was powerless in one crucial respect: It couldn’t slow the influx of patients. Normally, the hospital could get some slack by transferring people to other facilities or asking for ambulances to be temporarily diverted. But with every hospital full, transfers were impossible, and ambulance diversions were restricted by the state. The waiting room swelled with on-edge, fed-up patients who took their anger out on the nurses. Some simply couldn’t believe that all the beds could be occupied for so long, and accused nurses of lying to them. “Every patient we encounter, I feel like we’re always one step behind in terms of having to regain their trust,” Zavala said.

The moral distress of being unable to sufficiently care for their patients is among the worst hardships that health-care workers have been forced to endure. “To feel like you aren’t able to give your patients the best, because the situation is poor, takes a deep toll,” Anderson said. “I’ve encouraged our physicians not to accept this as normal, but for their own well-being they also have to accept that some of these things, they can’t change.”

The surge appears to be subsiding at Advocate Trinity. Since its peak, in the week after Christmas, the number of COVID patients has halved, as has the number of patients being held in the emergency department. Wait times are still long, running to 11 hours two Sundays ago, but they are now merely excruciating instead of unmanageable. “We see the light at the end of the tunnel,” Oglesby-Odom told me.

But then what? With COVID set to be a permanent fixture in our lives, more surges and variants are possible. The hospital will have to deal with people whose care was postponed amid the surge and those with long-term problems because of their run-ins with COVID. Meanwhile, the staffing shortages that long preceded Omicron’s arrival will remain. A small community hospital will struggle to attract staff in a way that a larger, better-funded institution won’t. Nursing- and medical-school applications are up, but training the next generation will take several years. “We have to be able to navigate a path forward with less,” Oglesby-Odom said. “We’re never going to be able to go back to the way we were, because there’s not that same workforce.”

For the first time in two decades, Advocate Trinity has started hiring licensed practical nurses, who have less education than registered nurses and mostly work in nursing homes and long-term-care facilities. It is assigning groups of patients to teams of nurses, resurrecting a model developed during nursing shortages after World War II. It may have to make hard decisions about which services to stop or deprioritize. Johnson said that his focus is on protecting his staff’s mental health, by allowing people to take time off to recuperate, offering resources for therapy and spiritual care, and creating quiet spaces where people can exhale. The hospital is also offering retention bonuses to encourage its staff to stay.

Many of Advocate Trinity’s employees are staying. More than a third live in the area that the hospital serves. Nurses and doctors have treated one another’s family members. Oglesby-Odom was born near the hospital, went to high school a mile away, and visited as a patient long before arriving as a nurse. She has seen the area become a desert for both health and health care. The number of grocery stores has fallen. Other hospitals disappeared or scaled back their operations to the point where Advocate Trinity is the sole port of call for some necessary services, including obstetrics. So much rides on the hospital finding a way to survive the pandemic and the subsequent spell of scarcity. Its failures would ripple out far beyond its walls.

But so would its successes. Over the summer, Advocate Trinity launched a mobile vaccination service that has since vaccinated almost 3,200 people in their homes and more than 350 at local churches. On a recent Sunday, the team vaccinated 44 people, including 10 in a single home, ages 5 to 90. Rosie Bernard, who leads the service, told me that the people she meets are not the belligerent, hard-line anti-vaxxers of stereotypes. They’re folks who had concerns about safety but came around after seeing that their vaccinated loved ones were still healthy; or who changed their mind once mandates came into force; or who were afraid about getting COVID by going to a vaccination site but were thrilled when the vaccines came to them; or who distrusted a medical establishment that has historically mistreated Black people but were persuaded when someone from their own community reassured them. “It’s a combination of trust and time,” Bernard said. “We’re getting more and more people to take that first dose.”

The mobile unit reflects Advocate Trinity’s plan “to go outside the four walls of the hospital and wrap our arms around the community,” Oglesby-Odom said. Together with 12 other health-care providers, the hospital is also leading an ambitious project to infuse Chicago’s South Side with a new wave of primary-care physicians and community health workers who can help residents deal with medical needs and chronic problems before they get bad enough to warrant an emergency-room visit. The project will also partner with social-service organizations to help residents address issues such as food and housing insecurity.

Such work normally falls within the purview of public health rather than medicine. A century ago, before the rise of modern hospitals, these disciplines were less disparate than they are now, and Advocate Trinity’s plans hint at a return to that era. After all, the pandemic has shown that if America simply waits for the victims of unchecked health problems to knock on its hospitals’ doors, those hospitals will be readily overwhelmed. The country needs to prevent more people from getting sick in the first place and address the social inequalities that make entire communities vulnerable to a new virus. So while Advocate Trinity works to deal with the aftermath of the past pandemic surges, it is also pursuing a longer-term solution to the hospital crisis: Keep as many people out of the hospital as possible.