Staff shortages make patient surges harder for children’s hospitals — and the situation won’t get better soon

By Jen Christensen, CNN

Amid a surge of respiratory infections, children’s hospitals across the United States are so busy that some had to set up tents to handle patient overflow.

The viruses are partly to blame for overwhelmed hospitals and packed emergency rooms, but for some, the problem is staffing: Many hospitals have empty beds, but not the people to care for someone in them.

“We’re extremely overwhelmed,” said Dr. Rishi Lulla, director of pediatric hematology/oncology at Hasbro Children’s Hospital in Providence, Rhode Island. “We’re doing the best that we can to try to use the resources that we have, expand where we have capacity to expand and serve the most vulnerable kids.”

Nationally, about 80% of pediatric hospital beds are occupied. But it’s much worse in certain areas: In Rhode Island, for example, beds are 99% full.

Seasonal respiratory viruses fill children’s hospitals every year, but the number of beds that are full now is well above the average.

Over the past couple years, only about two-thirds of pediatric beds have typically been in use — and that includes the height of the Covid-19 pandemic, according to a CNN analysis of data from the US Department of Health and Human Services.

Driving much of the current need for beds at children’s hospitals is a spike in cases of RSV, which are 60% higher than at 2021’s peak. The early start to the flu season and an increase in other respiratory viruses are compounding the need for care, on top of all the usual demands like kids with broken bones or asthma attacks.

Children’s National Hospital in Washington, DC, warned last week that “this surge in illness is exacerbated by the national healthcare workforce shortages.” A child with a life-threatening emergency will not wait, the statement said, but “families who come to us with non-urgent issues will experience long waits to be seen.”

“The wait times in county emergency departments and children’s hospitals are stretching to longer they’ve ever been,” said Dr. Meghan Bernier, medical director of the pediatric intensive care unit at Johns Hopkins School of Medicine.

Complicating the issue is that the staff shortage problem isn’t new and won’t be solved quickly. US hospitals have been dealing with it for years.

Missing nurses the most

The country needs more doctors and technicians, as shortages are growing in both areas, experts say — but the lack of nurses may be the biggest gap that needs to be filled.

A 2022 analysis found that the total count of nurses in the US decreased by more than 100,000 from 2020 to 2021, the largest drop observed over the past four decades. Many who left were under the age of 35, and most worked at hospitals.

It’s a particular problem for children’s hospitals.

“The pediatric ICU specialty … is highly specialized and a difficult to recruit role in hospitals today,” Katie Boston-Leary, director of nursing programs at the American Nurses Association, told CNN in an email.

When new staffers come in, it costs more to train them. Everyone who works with children needs an additional layer of training beyond what they would get in standard nursing school. That narrows the pool of people eligible to work in these hospitals, too.

There’s also a serious problem with turnover. Nurse turnover is up 50% across the country since 2019, according to Mark Wietecha, CEO of the Children’s Hospital Association.

“Some of our nurses became (traveling nurses); some retired early; some were poached by our adult hospital colleagues,” he said. “We lost people, and costs are way up.”

This high demand means hospitals have to pay more to retain and hire nurses. And working with children is labor intensive, taking up more of staffers’ time.

Temporary tents to create additional capacity can help in the short term, but the country will probably see some of the same surge capacity problems with RSV next year and the year after that, Wietecha says. He thinks it will take a government effort to fix the problem.

“We know that there’s a train coming down the tracks. The government has been responsive at a level, but why don’t we have a road map for pediatric surge?”

Full children’s hospitals are just one example of a larger problem, Boston-Leary said.

“We have a nurse staffing crisis, and we need a whole-of-government response to address this public health crisis,” she said.

Lulla said his hospital in Rhode Island is “aggressively recruiting” to increase staff where it can, but it is competing with other hospitals, home health organizations, nursing homes and doctor’s offices that are also short-staffed.

“We’re doing the best that we can to try to use the resources that we have,” he said.

Longer waits and more mistakes

The Covid-19 pandemic exacerbated staff shortages across the health care industry, with people forced out by burnout, trauma and exhaustion, according to research from HHS. But even before 2020, stress and burnout were “already significant problems.”

During the pandemic, many staffers who weren’t dealing directly with Covid-19 were furloughed or saw their hours cut because so many people weren’t going to medical appointments or having elective surgeries, particularly during lockdowns. Some of that staff never returned.

A lack of staff doesn’t just mean long wait times to get a hospital bed. It can threaten patient safety, said Dr. Marcus Schabacker, president and CEO of ECRI, an independent nonprofit focused on health-care safety and technology.

Staffing shortages top the institute’s list of patient safety concerns for 2022.

“The higher the work volume, the higher the stress level, the more likely we’re going to make a mistake,” Schabacker said.

Hospitals have tried to put systems in place to catch potential mistakes, “but these redundant systems are stretched too,” he said.

With pediatric patients, a small mistake could quickly become catastrophic.

“The margin of error in peds is just smaller, right? So their systems are much more fragile,” Schabacker said. “When we talk about medication, their systems, their body system, organ system, just has much less margin for error.”

‘A self-perpetuating shortage’

Many of the experienced nurses working now probably won’t be in the near future. Nearly 20% of RNs are 65 or older, the largest age group in the profession, according to the National Nursing Workforce Study.

A 2019 survey from the US Registered Nurse Workforce Report Card and Shortage Forecast projected that a shortage of registered nurses would spread across the country through 2030.

Nursing colleges are not expanding capacity to meet the increased demand as the US population ages and are unlikely to grow enough to replace retiring nurses. In 2019, more than 80,000 qualified applicants were turned away, according to the American Association of Colleges of Nursing.

One reason is a lack of instructors. Faculty members are aging out, studies show, and although it requires an advanced degree, teaching often pays less than working as a nurse.

“It’s a self-perpetuating shortage in some ways where, if you don’t have enough nurses to be working the wards, you don’t have capacity for them to be training the next round of nurses,” said Katherine Baicker, an expert on the economic analysis of health policy and dean of the University of Chicago Harris School of Public Policy. “And in a world where you’re not actually expanding the supply, you end up with a sort of beggar-thy-neighbor competition for these scarce professionals.”

Baicker thinks technological advances could help. The rise of telemedicine has answered some demand issues, but “it doesn’t solve the problem: that we fundamentally need more supply of nurses and physicians and the whole health-care work force.”

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