In Bismarck, N.D., where Leslie McKamey is a nurse in the emergency department at CHI St. Alexius Health, caregivers have been so overwhelmed by COVID-19 patients in the past few weeks that ambulances are sometimes diverted to the other major hospital in town.

Until that hospital, Sanford Medical Center, fills up as well. Then, there is no choice but to treat the flood of sick people who have made the state the worst coronavirus hot spot in this unprecedented surge of the pandemic.

“Our nurses are working longer shifts, a majority are picking up extra shifts, and we’re still short-staffed,” McKamey said, attributing the crisis in part to a hospital policy of reducing personnel in recent years. “We are taking on more patients than what we can really handle and what our patients deserve.”

As the virus stampedes across the country, setting previously unimaginable infection records nearly every day of its third major surge, some hospitals are desperately searching for staffers and paying dearly for it.

There is record demand for travel nurses, who take out-of-town assignments on short-term contracts of 13 weeks or less at elevated wages. Per-diem nurses, who are willing to take a shift or two in their local hospitals, have been pressed into service. The military is chipping in.

And still, in some places, it is not nearly enough.

“This is a disaster everywhere. This is outstripping capacity in many states at the same time,” said Karen Donelan, a professor of health policy at Brandeis University who studies medical staffing. “So people are competing for labor that they used to just pass around.”


More on the COVID-19 pandemic

Staffing in U.S. hospitals, particularly among nurses, has reflected a patchwork of local shortages in recent years, with a ready reserve of traveling and per-diem personnel deployed in response to sudden demand — a flu outbreak here, a hurricane there, a strike elsewhere.

But now, the once-in-a-century pandemic is exposing the liabilities of this just-in-time, cost-conscious approach at some hospitals, chronic staff shortages in others and the toll of the pandemic on an exhausted workforce.

In this fall surge of infections, supplies and equipment for patients and protective gear for health care workers are not as scarce as they were early in the pandemic, though sporadic shortages still exist, especially in some rural areas.

But in Salt Lake City, the University of Utah Medical Center is paying traveling nurses brought in on short-term contracts “at least double” the wages it offers its staff, said Russell Vinik, the chief medical operations officer. Still, he said in an email, they “are not an effective way for us to staff.”

In El Paso, Texas, University Medical Center has added 150 travel nurses, respiratory techs, respiratory therapists, doctors and medical technicians, plus 60 doctors and nurses supplied by the military, according to hospital spokesman Ryan Mielke.


Fastaff, a company that specializes in providing travel nurses in a matter of days, is filling twice the number of orders as it did in 2019, according to Lauren Pasquale Bartlett, senior vice president of marketing. Aya Healthcare, which calls itself the largest travel nurse company in the United States, is experiencing “all-time-high demand” for intensive care, telemetry and medical/surgical nurses, said its president, Alan Braynin.

In 2019, a little more than 47,000 registered nurses worked temporary jobs and 17,000 licensed practical nurses did the same, according to the U.S. Bureau of Labor Statistics. That is a small fraction of the 3.7 million nurses from both categories who were employed last year.

The health care system last year spent $6.1 billion on travel nurses, a figure that will rise by at least 10% this year, said Barry Asin, president of Staffing Industry Analysts, a research firm that specializes in health care staffing. While COVID-related hiring of supplemental health care workers is skyrocketing, employment of other health care workers is down sharply because of the cancellation of elective procedures and other care, Asin said.

The impact on patients in the current coronavirus surge has yet to be determined, but everyone is fearful. Overstretched staffs cannot give patients the attention they typically receive under normal conditions, whether they are in the emergency room, intensive care or the COVID-19 wards that make up ever-larger portions of hospitals amid the crisis.

There is little independent research on the impact temporary nurses have on the quality of care. A 2012 study of a single hospital found they had neither a positive nor negative effect on patient outcomes.

Only one state, California, mandates staff-to-patient ratios. Standards are written into some union contracts. But in many places, it is up to nurses to speak up when they feel conditions are unsafe, which can endanger their jobs, said Jean Ross, co-president of National Nurses United, a nurses labor union.


In the current circumstances, some nurses feel as if they are just trying to survive the onslaught.

“We are just completely overrun,” said Rachel Heintz, who works in the emergency department at CHI St. Alexius with McKamey. Both are stewards for the labor union.

Hospital President Kurt Schley said there are vacancies in the emergency department and acknowledged that the surge has created “an additional strain to a well-recognized nursing shortage in our community and the region.”

The hospital has added travel nurses to the emergency department, moved leaders back into patient care and reassigned clinical staffers from other departments to help with emergency patients, Schley said in an emailed response to written questions. Schley said the hospital diverts patients when they require a higher level of care than the hospital can provide.

“Staff, just like [in] every other hospital in the country, is the issue,” he said. “We can, and we have, called on the resources of our large health system to care for our community.”

In March and April, the first coronavirus surge devastated the New York area, and the second one last summer brought a spike in infections and deaths to the Sun Belt. This tide of infections is worst in small towns and cities in the Upper Midwest and Mountain West, the types of places where hospitals have long had trouble recruiting nurses and other staffers.


“In rural communities, it is harder to find those backup folks,” said Nancy Foster, the American Hospital Association’s vice president for quality and patient safety. “They have fewer health care workers in the communities. There are fewer transient workers who will come in.”

The nation has regularly set daily records in recent weeks for new cases and hospitalizations. At least 245,000 Americans have died of COVID-19, according to data tracked by The Washington Post, and more than 11.1 million people have been infected since the start of the pandemic.

Despite dire predictions of a looming nationwide nursing shortage at the beginning of the century, a concerted effort led by foundations and the Johnson & Johnson company staved off that development, ultimately increasing the number of registered nurses in the workforce by more than 1.1 million by 2015, according to a study published in the journal Nursing Economic$ in 2017.

There are 3.5 million to 4 million registered nurses in the nation, but not all of them work full time or are still in nursing, said Donelan, the Brandeis researcher. She estimated that 60 to 65% have jobs in acute-care hospitals.

Now, in addition to the perennial problems, hospitals are facing significant new challenges: Nurses and other caregivers are burned out from nearly a year of caring for COVID-19 patients. Some are leaving their jobs to care for children who cannot attend school, or some have become infected themselves. Others nearing retirement see this as a good time to get out of the profession before they become sick, experts said.

“Nurses who are furloughed chose not to come back to work, either because of health concerns or now they are staying home because they have children they are home schooling,” said Soumi Saha, vice president for advocacy for Premier, a consulting firm that works with thousands of hospitals and nursing homes.


That leaves more opportunities for people like Lydia Mobley, a 30-year-old Fastaff travel nurse working overnights in an intensive care unit in Lansing, Mich. Making $70 an hour, much more than she could earn as a staff nurse, Mobley works as many shifts as she can handle. She will bank the money and take a significant break when her current contract ends Jan. 3, a pattern she has followed for years.

Mobley said she feels called to help in the current crisis and fits in well on the unit where she is working.

“This is the warmest welcome I’ve ever had as a travel nurse,” she said. “They are so happy to have another pair of hands.”

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The Washington Post’s Amy Goldstein and Lena H. Sun contributed to this report.