What does it mean for Iowa hospitals to live with COVID-19 forever?

When the COVID-19 vaccines arrived a year ago, there was a belief among many that someday, perhaps soon, the coronavirus would be a thing of the past.

Especially among health care staff on the front lines of the pandemic, the first shots were considered the light at the end of the tunnel. Now, nearly two years since the virus first arrived in Iowa, many workers have a different feeling about the pandemic.

“I think we know it will be with us for a while,” said Kerri Feldhaus, an intensive care unit nurse manager at UnityPoint Health-St. Luke’s Hospital in Cedar Rapids. “Even when the majority of people are vaccinated, we will still have cases. We’re in it for the long haul.”

Experts agree that the COVID-19 pandemic someday will become endemic.

The coronavirus won’t go away forever but will continue to circulate. At some stage, enough people will gain immune protection from vaccinations or natural infections that COVID-19 hospitalizations and deaths will decline significantly.

That’s what happened with other pandemics throughout history, including the 1918 influenza pandemic, according to Yonaton Grad, an immunology and infectious diseases professor at the T.H. Chan School of Public Health at Harvard University.

Corridor health care officials say they expect providers eventually will address coronavirus illnesses in the same way they care for influenza or respiratory syncytial virus, or RSV, patients every year.

“One way or another, I think there will be a new normal and that new normal will have made COVID care more standard care,” said Suresh Gunasekaran, chief executive officer of University of Iowa Hospitals and Clinics.

What’s unclear is when that transition to endemic will occur.

In the meantime, health care systems in Iowa and across the country continue to face alarming spikes in COVID-19 cases — including the current ongoing surge that has begun to threaten facilities’ capacity.

“As we sit here today, a year and a half in this pandemic and the hospitalizations and surges are equal or greater than they were a year ago, we certainly are concerned about the long-term effects this will continue to have,” said Chris Mitchell, president and chief executive officer of the Iowa Hospital Association.

Because of this, with current vaccination rates and emerging coronavirus variants, practices such as masking, social distancing and other pandemic mitigation strategies will be necessary in the immediate foreseeable future to help protect health care systems.

COVID-19 fundamentally has changed normal operations at hospitals. As they look further into the future, leaders at Eastern Iowa hospitals expect to face a number of challenges as they prepare for a long-term relationship with the virus.

And the top of their list of concerns? Maintaining an adequate health care workforce.

“It is literally the first meeting of our day and it determines the direction of what we do every day,” said Dr. Timothy Quinn, chief of clinical operations at Mercy Medical Center in Cedar Rapids. “And not just from the number of people in the hospital, but also the big COVID impact that wasn’t anticipated early on was the impact on the labor market.”

Staffing

Feldhaus, the ICU nurse manager, oversees a staff of 86 who provide care in the 24-bed unit at St. Luke’s. She has been there through all stages of the pandemic and its hurdles, including grappling low supplies personal protective gear and attempting to fit 50 beds in the 24-bed unit during one surge.

In the past year, she also has witnessed staff members quit their jobs for other opportunities outside the hospital, or even leave the health care workforce altogether. According to Feldhaus, they’re mostly driven by “sheer burnout.”

"It’s a realization, just a sadness on the side of health care workers, knowing that people could still be with us had they been vaccinated,“ Feldhaus said.

Across the hospital, UnityPoint Health-Cedar Rapids President and CEO Michelle Niermann said staff are experiencing compassion fatigue, or the psychological exhaustion that can result from repeated exposure to trauma.

“I think team members just have an extra psychological burden that’s really causing people to examine whether they want to be in this field or not,” Niermann said.

The trend within the St. Luke’s reflects a broader issue faced within the industry. Health care staff, who are exhausted from responding to COVID-19, are leaving their jobs in droves nationwide.

This comes as the latest surge has pushed new COVID-19 patient admissions across the state to levels not seen since December 2020. This past week, total available intensive care beds dipped to an all-time low with just 130 open beds statewide on Dec. 21, according to the state’s latest coronavirus data.

In Iowa, that means there now are fewer health care workers in hospitals to care for the higher-than-normal patient numbers, said Jennifer Nutt, vice president of nursing and clinical services at the Iowa Hospital Association.

The association represents all 119 hospitals and health systems statewide.

“That’s why it seems so much worse — it’s because it is,” Nutt said.

Statewide, hospitals are warning Iowans of the realities they’re facing within their facilities — if staff are further overwhelmed, they say, hospitals may not have capacity to care for everyone who needs their help.

“We fear not having capacity to care for your family members,” health care officials in the Quad Cities wrote in a statement this past week. “… Your father’s heart attack, your son’s injury or your grandmother’s pneumonia. We fear not having the capacity to care for our family members.”

At the same time, patients who had put off care since March 2020 are seeking out that treatment. This trend likely will worsen over time, meaning providers likely will see patients sicker with non-coronavirus chronic diseases, which will put health care system under even more stress, Gunasekaran said.

The industry struggled with recruitment and retention long before the coronavirus first appeared in 2020. COVID-19 exacerbated that issue even further for Iowa’s health care organizations.

“What this revealed is how close to the edge we were,” said Dr. Tony Myers, Mercy Medical Center’s chief medical officer.

Financial viability

The combination of decreased volumes in nonemergent and emergency care with the increases in COVID-19-related care “unfortunately has had a counterbalancing effect financially,” Dr. Will Schpero, health economist at Cornell University, said in a media briefing with SciLine.

The immediate solution to staff shortages is further straining hospital finances. To fill the gaps, organizations increasingly are turning to traveling agencies to hire contract health care staff, including nurses, respiratory therapists and other professionals.

But the cost for contract staff through these agencies has risen exponentially throughout the pandemic, the Iowa Hospital Association and local hospital officials say, often reaching three times the cost it entailed pre-COVID-19.

The trend has been described by some hospital officials as price gouging.

At St. Luke’s, for example, hospital leaders already have spent about three times the amount they budgeted to hire for contract staff in 2021, Niermann said.

Those traveling agencies are able to hire health care workers at double — or more — than what they’re paid by other employers, thus drawing more staff away from hospitals.

There are conversations around more oversight of these agencies to alleviate the strain on the health care system, but Mitchell said an effective approach needs to come from the federal level to benefit all health care organizations.

However, the price inflation may not be a cause for alarm, according to the UIHC’s Gunasekaran. As COVID-19 becomes more standard care, he expects staffing slowly will return to health care organizations, trending back toward what the industry experienced before the pandemic, he said.

Mitchell also pointed out that Medicaid and Medicare reimbursement services from Iowa-based facilities haven’t been updated since 2013.

“We're not even using an updated fee schedule for Medicaid and a number of other payers, so we just don't have the same tools to fluctuate with the market and it's creating some financial strain for our members,” Mitchell said.

That has been a particular challenge for critical access hospitals and other rural hospitals across the state, who already were facing concerning financial standing before COVID-19 upended everyday activity.

The majority of Iowa’s critical access hospitals ended the 2020 fiscal year with negative operating margins, according to an IowaWatch report.

Federal coronavirus relief and state dollars have provided some short-term relief, but if the pandemic will be around for a long period of time, “significant funding” will need to reach Iowa hospitals to address their needs, Mitchell said.

Improving the pipeline and other solutions

The emotional and mental health toll front line workers have faced has sparked a new conversation within health care organizations about the need to support its staff, particularly as typical ways for individuals to relieve stress has been taken away.

When addressing limited staffing, hospital leadership also are in discussions around health care professionals practicing to their license, Niermann said. That includes discussions of whether other staff members — such as licensed practical nurses and certified nursing assistants — could be brought into hospital settings to fulfill certain duties and otherwise help nursing staff.

However, innovation in those spaces also may be challenged by workforce shortages, which has crossed into all sectors of health care. For example, Niermann said many home health care agencies in Cedar Rapids are accepting patients in recent weeks because of the staffing shortages.

“So what does that mean? Well it means that throughput (from the hospital) becomes problematic because, if we don’t feel like we have a safe discharge plan, we’re going to keep them until we can figure that out. That then backs you up further in terms of your availability,” Niermann said.

In addition to immediate supports for current staff, there’s also work to be done long term to improve the pipeline of professionals coming into the workforce. That’s especially true as the state’s overall population continues to age — meaning patients will have more complex needs that may be difficult to provide at every hospital.

The health care industry is working to strengthen the career pathways to their facilities expanding recruitment efforts, going beyond community colleges and trade school to start as early as high school in some cases.

Oftentimes, that recruitment is done by individual hospitals, Myers said, “because we can’t really wait for somebody to fix this problem anymore.”

As health care systems work to create solutions to these challenges, hospital leaders say they also need help from the public. They continue to emphasize the need for individuals to be fully vaccinated against COVID-19 and practice coronavirus mitigation strategies throughout this current surge.

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