Community Regional Medical Center in downtown Fresno photographed on Saturday, Jan. 22, 2022. Credit: CRAIG KOHLRUSS / Fresno Bee file

What's at stake?

Now that the state of California's COVID-19 emergency order has ended, Fresno County officials say local hospitals may be forced to cut the number of beds available to patient to accommodate a staffing "crisis."

Fresno area hospitals are bracing for more setbacks to the Central Valley’s medical system after California officially ended its COVID-19 declaration of emergency on Tuesday.

Terminating the state’s emergency order means local hospitals can no longer hire travel nurses with out-of-state licensing. During the COVID-19 pandemic, healthcare providers with out-of-state licenses were temporarily authorized to work in California by the Emergency Medical Service Authority.

The end of the state’s emergency declaration will also have implications for nurse-to-patient ratios and the ability to relax the space configuration of physical space in hospitals that was granted by the state to accommodate the pandemic-era surge of patients.

Dan Lynch is the emergency medical services director for Fresno County and the Central California Emergency Medical Services Agency. In a Feb. 16 interview with The Bee/Fresnoland, Lynch said the timing of the order being lifted is difficult for Fresno County because “hospitals here are incredibly impacted by capacity issues.”

Fresno area hospitals – namely Community Regional Medical Center, Clovis Community Hospital, and St. Agnes Medical Center – “rely heavily” on travel nurses. Local hospitals rely on travel nurses for a number of reasons, such as the difficulty of recruiting and retaining medical professionals in the Central Valley, especially after many nurses left the profession after experiencing burnout during the coronavirus pandemic, Lynch said.

It wasn’t immediately clear how many out-of-state licensed travel nurses Fresno hospitals utilize.

Lynch estimated around 40% of the nursing workforce could be lost by the lifting of the order. At the highest point of the last year, Lynch estimated, Fresno County had close to 500 travel nurses, but the number changed daily. The county, however, didn’t track how many of these travel nurses were licensed in-state versus out-of-state.

“The loss of potentially half of our nursing staff because they’re from out of state is a significant impact for our hospitals,” he said. “They’re going to have to make adjustments.”

Lynch said losing nursing staff could soon force hospitals to cut the number of beds available to patients.

“Which, at this time, would be very difficult,” Lynch said, “because all those beds are full.”

Fresno hospitals address nurse staffing challenges

Robyn Gonzales, chief operating officer of CRMC, said in a Feb. 7 Fresno County Board of Supervisors meeting that the hospital uses a “fair number” of out-of-state travel nurses.

Systemwide, the Community Health System, the parent company of CRMC and Clovis Community Medical Center, employs 3,900 nursing staff members, including registered nurses, licensed vocational nurses, and per diem nurses, according to an August 2022 fact sheet.

CRMC spokesperson Mary Lisa Russell refused to say how many out-of-state travel nurses the hospital system employs.

During the Feb. 7 board of supervisors meeting, however, Gonzales said losing the ability to hire travel nurses with out-of-state licenses would “contribute to our staffing crisis.”

Other area hospitals are also bracing for the change.

In a Feb. 24 email statement to The Bee/Fresnoland, Deanette Sisson, chief nursing officer for St. Agnes Medical Center, said that the hospital transitioned to employing only California-licensed “travelers.”

The hospital belongs to the Trinity Health healthcare system, which provides around 34 travel nurses to the hospital. Sisson said the hospital also has around 50 “travelers” from outside travel agencies.

Competing with bigger California cities is also a challenge. With the exception of Kaiser Permanente Fresno, Sisson said, “Central Valley hospitals have lower salaries compared to LA and the Bay area.”

A spokesperson for Kaiser Permanente Fresno did not respond to specific questions about their hiring of out-of-state travel nurses – but said the hospital’s nursing staff has grown rather than dwindled.

“Our commitment to being the best place for nurses to work has enabled Kaiser Permanente Northern California (which includes Fresno) to hire 3,300 additional nurses since 2021, despite the national nursing shortage,” spokesperson Jordan Scott said in an email statement to The Bee/Fresnoland. KPNC is also adding 650 new nurses to the workforce through its nurse residency program, he said.

‘Crisis ratios’ the norm, CRMC says

Lynch said another way lifting the state’s emergency declaration would impact hospitals is that it could be harder for hospitals to relax their patient-to-nurse staffing ratios.

The emergency declaration made it easier for the California Department of Public Health to process “waivers,” Lynch said, or approvals for a hospital to increase patient-to-nurse ratios above the state’s mandated regulation.

Gonzales, of CRMC, said in the Feb. 7 board of supervisors meeting that half of the hospital’s nurses are operating at “crisis ratios,” which means they’re operating above a ratio the state has mandated for them. Gonzales gave the example that a typical nurse on a surgical floor takes care of five patients, but now, “most of them are working at least one to six – some more.”

Scott, of Kaiser Permanente, meanwhile, said, “our hospitals meet or exceed state-mandated nurse staffing ratios.”

Lynch said that while hospitals will still have the ability to put in waivers to expand those ratios, the lifting of the emergency order might make it “a little bit more difficult” to get these waivers approved.

Gonzales also said CRMC is concerned about “surge spaces” going away with the end of the emergency order, which are tent spaces the hospital has set up for the emergency department.

“While not optimal,” she said, “it allows us to see patients – especially those non-admitted patients.”

CRMC submitted a “flex” letter to the state with the county’s support to continue to treat emergency department patients in these surge space tents areas.

Nurses say state space waivers create ‘unsafe’ conditions

Nurses, on the other hand, say it’s not a solution — it’s actually a problem.

Some California nurses are voicing their opposition to what they call “unsafe” patient conditions that the CDPH space waiver creates.

On Tuesday, registered nurses at UCSF and union members of the California Nurses Association rallied outside the Parnassus Medical Center in San Francisco to demand safe patient care conditions and end CDPH space waivers.

RN and CNA Nurse Representative Thuy Nguyen said in the release that the practice should be used only “when absolutely necessary, not a band-aid for deeper failures by management to plan for inevitable surges in patients.”

As for Lynch, he said the Central Valley needs to shift towards investing in preventative care to keep people out of hospitals as much as possible. He said public health has taken a “huge lead” in recent years in helping to create healthier communities, especially with the leadership of community-based organizations.

“We really, we really need to make that shift, he said, “and that’s going to take the whole community.”

He also said telemedicine could take care of many minor issues before someone ends up in the emergency department.

“We realize that there’s not enough primary care physicians out there to take care of our population,” he said, “but there’s the ability to use telemedicine and talk to a physician.”

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Melissa is a labor and economic inequality reporter with The Fresno Bee and Fresnoland.

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