Staff shortage causes System collapse

By any definition, a pandemic is an exogenous shock that substantially alters the needs, incentives, and capacities of many components of local, regional, and national healthcare systems. In a pandemic, disruptions to limited staffing pools (e.g., callouts, forced quarantine, etc.) can have outsized effects upon RHS ability to deliver care to patients and can mean that they prematurely reach patient saturation, particularly during times of heightened disease incidence. Existing heightened risk factors within rural populations could result in health systems becoming suddenly and unexpectedly inundated with new cases – overstretching bed and labor availability (Vestal, 2020). RHS often lack access to larger, more resilient, supply chains. Many have limited testing capacity and send tests to commercial labs that can take multiple days to return results. Often understaffed outside crisis, they can face serious workforce problems. RHS that lack slack can consequently experience system collapse and suboptimal and dangerous triage-based health care decision-making (Vestal, 2020). States like North Dakota, which has less than 20 ICU beds in the state (limited to hospitals in Dickinson, Fargo, and Bismark) saw the consequences of these concerns when patients had to be transferred as far as South Dakota or Montana to get the level of care needed (Vestal, 2020).

Many RHS lack resilience against external and internal stressors, so adding additional labor and resources can improve the capacity for the system to recover from spikes in demand for care that are inevitable in current and future crises. Because of potentially significant costs associated with adding a resilience component to RHS, careful resilience analytics and tradeoff analyses should be driving resource allocation. However, resilience is difficult to quantify due to the complex and diverse nature of its definition especially in attempting to compare across distinctly different communities.

Many remote, island or rural communities may exist within ‘healthcare deserts’ with 80% of the rural population in the United States being designated as medically underserved (Health Resources & Services Administration). Beyond being healthcare deserts, many rural communities exist within ICU deserts where 63% of rural hospitals are without any ICU beds, leaving 1 ICU bed available for approximately every 9500 rural Americans (The Chartis Group for Rural Health, 2020).

Data analysis conducted using susceptibility indicators taken from sources such as the US Census Bureau’s American Community Survey (ACS), County Business Patterns, and US Centers for Disease Control and Prevention’s National Vital Statistics System indicate that upwards of 33% of rural counties in the continental 48 states were highly susceptible to COVID-19. Existing issues facing rural health systems, such as rural hospital closures, increased vulnerability of rural health systems. These hospital closures, such as the closing of 62 hospitals with Emergency Departments from 2012 to 2018, saw the median distance to access an Emergency Departments increase from 3.3 miles to 24.2 miles as the crow flies during the same period (Government Accountability Office, 2020). Pre-pandemic hospital closures further saw the loss of 2066 inpatient beds and 6347 full-time-employee equivalents from 2013 to 2017 further increasing the vulnerability of rural communities to health emergencies such as pandemics (Government Accountability Office, 2020). These closures have resulted in low-income and elderly patients, notable at-risk populations during the COVID-19 pandemic, being more likely to delay care because of transportation concerns (Medicaid and CHIP Payment and Access Commission, 2021). COVID-19 has resulted in half of the rural hospitals seeing negative operating margins and further magnified existing factors that contribute to hospital closures, further outlining the unique resilience concerns faced by rural health systems (ASTHO Staff, 2021).

Outside of these preexisting vulnerabilities, the COVID-19 pandemic exacerbated specific issues that include infrastructure limitations, poor population health, and long distances to access advanced healthcare when compared to non-rural health systems (Sharma, 2020). This susceptibility was driven by physician shortage, lack of mental health services, high disability, lower insurance rates, poor internet access inhibiting telemedicine use, and a lack of social capital hindering local recovery efforts (Peters, 2020). Insurance rates in particular demonstrated challenges within rural communities where individuals are more likely to be uninsured because individuals are often in jobs that do not offer insurance, resulting in limits to where many rural residents can go for care (Medicaid and CHIP Payment Access Commission, 2021). It is specifically this susceptibility, paired with the lack of resilience, that indicates the crucial need for a change in policy.