Critically short of nurses, central Oregon hospital system quietly declares crisis
Late in the afternoon of July 15, St. Charles Health System leaders took the unprecedented step of declaring “crisis care standards” at their four sites — Oregon’s first health system to do so during the COVID-19 pandemic, according to the Oregon Health Authority.
“As of 5 p.m. today, July 15, 2022, the St. Charles Health System is operating in a crisis situation. [sic] standards of care,” COO Iman Simmons wrote in an internal email the OPB obtained via a public record request.
The decision came in the wake of a severe staffing shortage that has left St. Charles and other state hospitals struggling to manage their many patients. It also happened just two hours after a temporary state rule on crisis standards expired. The rule required hospitals to publicly announce crisis standards and notify state officials.
But St. Charles leaders never announced their decision to the public. Emails obtained in a public records request show that state officials were not fully briefed until four days later.
Crisis standards are meant to be implemented when emergency situations, such as natural disasters, overwhelm a hospital’s ability to treat patients with the highest standard of care. According to American Association of Medical Collegesthe purpose of crisis standards is to “graciously downgrade services to the minimum degree necessary to meet demands”.
Hospitals in other states declared crisis standards as COVID-19 patients flooded intensive care units and stretched resources to their absolute limits, albeit rarely.
St. Charles officials told the OPB and state regulators that they have never, during the current crisis, rationed care or turned away critically ill patients. Health system officials also said they had not canceled elective surgeries, a typical — and costly — step many have used to manage patient flow and staffing shortages during the pandemic.
What is less clear, based on interviews and records, is whether the hospital’s staffing crisis is having other implications for patient care.
Records show that St. Charles officials, who struggled for months to fill critical nursing and nursing assistant positions, attempted to use a standard crisis declaration for a different reason: to deviate from the their hospital’s nursing staffing plan.
“We felt we had to pull the cord and let people know we were in a state of exhaustion,” said chief nursing officer Joan Ching.
The declaration of crisis standards did not last long. St. Charles executives reversed course six days later after Oregon Health Authority officials informed them that the hospital did not qualify for such a statement and that they may be violating state law. ‘State.
Oregon Nurses Association spokesman Scott Palmer called St. Charles’ communications with the state “inept and chaotic” and said future decisions on changes to standards of care must be made public. .
“Finding that…St. Charles management was unaware of the specifics of Oregon law on when a hospital can and cannot transition to crisis care standards is deeply concerning,” wrote Palmer in an email Tuesday.
A troubled system
Public records provided by the Oregon Health Authority show Simmons, the system’s chief operating officer, initially declared an internal emergency in an email sent shortly after 7 p.m. on Friday, July 19.
This included all four St. Charles campuses: Bend, Madras, Redmond and Prineville.
This decision came as the health system juggled multiple crises. St. Charles has lost $40 million on its operations so far this year, a spokesperson said, resulting in the layoff of more than 100 employees in May and two executives last week. The system was severely understaffed, not because of any particular surge in COVID-19 patient admissions, but because of the stress that built up over two years while the healthcare system was operating at or near 100% of its capacity.
Approximately 20% of RN positions in the St. Charles system are vacant. And federal emergency funds that paid temporary workers to fill those vacancies during the pandemic have dried up, leaving St. Charles to foot the bill for expensive travel nurses.
Ching, the chief nursing officer at St. Charles, said at the heart of the crisis is an acute shortage of certified practical nurses. Although special training is required to do the job, nursing assistants are low-paid workers who provide time-consuming patient care – turning patients to prevent pressure sores, taking vital signs and helping people use the bathroom – so nurses can focus on medical needs.
With a critical shortage of nursing assistants, nurses have been forced to take on more direct patient care work, leaving them overwhelmed and unable to take meal breaks during their 12-hour shifts, said Ching.
“It allows nurses and not just nurses, clinicians, to feel good about prioritizing tasks that are really necessarily central to the care of this patient, versus what we can postpone,” she said. .
She did not provide specific examples of the care that is being deferred.
The email records that the OPB reviewed do not include any discussion of what prompted the health system’s chief operating officer to say hospitals had entered a crisis. Nor do they include a description of how staffing levels or patient care would be different. And exactly why the decision came on July 15, the day the public notice rule expired, is also unclear.
No one in the St. Charles system made an announcement to the public.
The Oregon Health Authority was also left in the dark for three days. The first written communication they received from St. Charles was on July 18 and only referred to an “internal emergency.” This email was from a mid-level compliance officer. It also included a request: that the state postpone any planned inspection of St. Charles.
“Because of this urgency, we would like to request that any pending investigations be postponed until we are able to stabilize our staffing situation,” wrote Samantha Coleman, Accreditation and Licensing Specialist at quality for St. Charles.
At 6 p.m. on July 19, the OHA received a more formal notification that St. Charles had implemented crisis standards four days prior, but without any details as to why. State regulators responded immediately, asking for more information.
“It would be helpful if you could tell us more about the affected units and how operations have changed in those units,” wrote Anna Davis, attorney and health facility survey manager for the OHA. .
Davis also wrote that hospital leaders should inform the public that they have entered crisis care standards. She acknowledged the health authority’s temporary rule had expired, but said the agency still expects St. Charles to comply with requirements for posting information on its website and at the hospital. how they made triage decisions.
“The OHA believes it is extremely important for you to let the public know that you are implementing standards of crisis care,” Davis wrote.
Davis asked St. Charles’ accreditation manager, Ginger Walcutt, to let him know that evening if they had complied.
“To clarify, St. Charles does not ration care, but rather operates outside of approved nursing staffing plans,” Walcutt responded.
The next day, she emailed Davis saying the health system planned to publicly release information about the triage system used by the hospital. Walcutt then asked state regulators to clarify whether the hospital was still bound by state rules requiring it to notify the public when crisis standards are implemented, given that the interim rule of the state had expired on July 15. (Ching later said it was a “coincidence” that the decision to declare crisis standards coincided with the rule’s expiration.)
Davis wrote that the hospital system’s staffing shortages, while difficult, did not give him legal grounds to suspend their nursing staffing plans.
Additionally, because St. Charles leaders said they were not rationing patient care, Davis took issue with their claim that he had indeed implemented crisis care standards. Davis warned that if St. Charles suspends its nursing staffing plans in the absence of a state or federal emergency declaration, it could result in penalties, including fines for each of the four hospitals involved.
At the same time, Davis pointed Walcutt towards another option to lower staffing standards at the four St Charles hospitals. State nurse staffing rules allow hospitals to relax their standards if they can get an internal nurse staffing committee to approve the changes.
The nurse staffing committee at St. Charles Bend, the flagship hospital, met Wednesday to discuss its crisis staffing plan, according to emails.
Staffing has been an issue in Oregon hospitals. State epidemiologist Dean Sidelinger told reporters last week that many hospitals are unable to use all of their beds due to difficulties recruiting and retaining staff. And he pointed out that Central Oregon and St. Charles Health System were particularly hard hit by the problem.
Ching said St. Charles is trying to deal with an incredibly difficult situation and the public shouldn’t be afraid to go to the hospital if necessary.
“I would like the public to really take care of themselves and do as much prevention as possible,” Ching said. “That would be really helpful.”