Hawaii health officials say the pandemic has spurred investment in new hospital equipment, like ventilators and intensive care patient monitoring technology, but a problem that hospitals faced well before the arrival of COVID-19 — a staffing shortage  — persists.

When the need swells, Hawaii has had to rely on expensive outside help from traveling nurses and respiratory therapists.

“One thing the pandemic taught us is that we have more than adequate physical space and tech capacity,” said Lt. Gov. Josh Green, Hawaii’s pandemic medical liaison who has tracked hospital capacity statistics and shared them daily with the public on social media.

“We never got anywhere close to running out of ventilators, with the exception of the peak of the first surge in August,” he said. “But that said, we did learn that our critical care nursing capacity and physicians’ capacity was strained.”

Yet from a financial perspective, hospital executives such as Dr. Melinda Ashton, executive vice president and chief quality officer of Hawaii Pacific Health, doubt Hawaii hospitals could ever afford to build specialty clinical staffs to be ready for every possible emergency.

“It is not ever going to be economically feasible to build enough capacity to take whatever is thrown at us, whatever the next pandemic is,” she said.

Overall, health care leaders are confident in Hawaii’s capacity to respond to future COVID-19 surges, citing investments in critical care space, more treatment options and the ongoing vaccination program.

Executives like Ashton do not anticipate more shutdowns but say the closures last year avoided the worst-case scenarios of hospitals running out of space.

“If we had not had the shutdowns, then clearly we would have seen those horrific images and we would have been overrun,” Ashton said.

A Changing Picture

Hawaii is no longer in the position it faced last year, health leaders say.

The current situation looks brighter, despite recent increases in COVID-19 cases on Oahu and Maui. The number of COVID-19 patients in Hawaii hospitals has decreased since the most recent peak of infection in January.

“We have enough capacity and we do not have too many people in the hospital that we should be alarmed by because the average case count is higher,” Green said, “Several months ago we had a lot of kupuna who were sick and therefore high hospitalization numbers. Now most individuals are younger so we’re seeing fewer hospitalizations.”

Adding to the confidence is modest investments in equipment and technology.

Overall, the number of ventilators in Hawaii hospitals hasn’t changed substantially, according to Hilton Raethel, the president and CEO of the Healthcare Association of Hawaii.

And new equipment has been added slowly. Hawaii Pacific Health placed an order for 23 ventilators for its four medical centers last April. The first shipments didn’t arrive until September and the order was only completed in February — almost a year later, according to Ashton.

Ventilator inventory continues to be smaller on neighbor islands, with the fewest on Kauai.

Hawaii hospitals have more than enough beds, Raethel said — about 3,000, with 1,900 to 2,200 typically occupied. During the pandemic, hospitals opted to convert existing space instead of building new square footage, like Adventist Health Castle and Kuakini Medical Center, and The Queen’s Medical Center, which upgraded surgery beds by adding intensive care technology to monitor high-risk patients.

Fears about running out of oxygen and beds were never realized.

“The biggest issue is staffing,” Raethel said. “We entered the pandemic with a shortage of nursing in some other areas and for a variety of reasons, we’ve had a number of people retire or resign, some because of the pandemic, some because of other reasons. Some had gotten burnt out. We continue to be challenged to find enough staff.”

Staffing Shortages Persist

Hawaii routinely relies on outside help especially during the flu and cold season. But COVID-19 meant Hawaii hospitals had to rely on traveling nurses even more.

“In the very beginning as we watched what was happening in the rest of the world and the U.S., we were really worried that this was going to be a bed-capacity issue,” said Jason Chang, the president of The Queen’s Medical Center and chief operating officer of The Queen’s Health Systems. “As hospitals we canceled selective procedures and tried to clear beds in anticipation of what was going to happen.”

Ultimately, what they found, Chang said, was that nurses who would traditionally be able to care for five patients at a time needed to focus on fewer patients who needed much more attention.

“It did strain the number of qualified nurses and that’s why we brought in travelers,” Chang said.

At its peak, Queen’s had as many as 130 traveling nurses and clinical staff on site, he said. It signed its own contracts with travel nurse agencies in addition to getting dozens more through a state contract overseen by the Healthcare Association of Hawaii.

Hawaii’s experience shows when infections surge, the state has to spend millions to bolster its specialized medical staff.

Raethel said a total of $16 million in federal COVID-19 relief funding was spent on travel nurses last year.

Those dollars covered the cost of the nurses’ pay, airfare, hotels, food allowances and car rentals, adding up to an average of $49,000 for each of the 326 contracted staff members between September and December. The traveling staff included nurses specializing in critical care, telemetry, surgery, dialysis and emergencies, as well as respiratory therapists.

Raethel acknowledged it was expensive, but said that Hawaii hospitals had already exhausted local resources, including paying overtime. He said there isn’t a cheaper alternative.

“Most hospitals work essentially on a just-in-time staffing model where they staff for a certain model, and if volumes increase, maybe they have part time staff who will work for a shift for a few weeks or a couple of months. They may bring in travelers,” he said. “There are mechanisms they can use to increase staffing, but they don’t have staff that are employed and trained who are just sitting there waiting for a surge. The financial model for health care just doesn’t allow for that type of capability and that’s a real challenge.”

Nationally, travel nurses have become even more expensive during the pandemic, as hospital bidding wars shifted from personal protective equipment, ventilators, and COVID-19 tests to clinical staff, Kaiser Health News reported.