Hospitals in at least 25 states are critically short of nurses, doctors, and other staff as coronavirus cases surge across the United States, according to the industrys trade association and a tally conducted by STAT. The situation has gotten so bad that in some places, severely ill patients have been transferred hundreds of miles for an available bed from Texas to Arizona, and from central Missouri to Iowa.

Many of these hospitals spent months building up stockpiles of medical equipment and protective gear in response to Covid-19, but the supplies are of little use without adequate staffing.

Care is about more than a room with a hospital bed. Its about medical professionals taking care of patients, said John Henderson, chief executive of the Texas Organization of Rural & Community Hospitals (TORCH). If you dont have the staff to do that, people are going to die.

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Staffing shortages are a serious concern in multiple regions. Intensive care unit nurses, who typically oversee no more than two patients at a time, are now being pushed to care for six to eight patients to make up for the shortfall in parts of Texas, said Robert Hancock, president of the Texas College of Emergency Physicians. In Ohio, some 20% of the 240 hospitals tied to the Ohio Hospital Association are reporting staffing shortages, according to spokesperson John Palmer.

The American Hospital Associations vice president of quality and patient safety, Nancy Foster, said shes heard from two dozen hospital leaders over the past two weeks, warning her of staffing shortages in states including Texas, North and South Dakota, Minnesota, Wisconsin, and Illinois. Health care providers in Kansas, Oklahoma, Arkansas, Ohio, Missouri, Michigan, and Utah said theyre facing the same problem, as do local reports from New Mexico, Nebraska, Colorado, Wyoming, Tennessee, Georgia, Alabama, Indiana, Montana, California, Rhode Island, and South Carolina.

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The shortages are primarily caused by overwhelming numbers of patients as coronavirus spreads, combined with decreasing staff levels as nurses and doctors themselves fall sick or have to quarantine after being exposed to infected people. Covid-19 is also prevalent in rural areas that have been struggling with a shortage of health professionals for years; hospitals in more remote regions dont have equipment such as ventilators, and so must transfer severely ill patients to already-overwhelmed urban health care systems. The scale of the problem makes it harder to address: Systems designed to offset shortages by bringing in backup from other areas dont work when so many states are affected simultaneously.

States that sent doctors and nurses to New York at the beginning of the pandemic now have no one to turn to as hospitals across the country experience the same problem. Early on, Texas was sending teams of caregivers to states like New York to help with their surge, said Henderson. You cant do that when 48 states are going through a surge in the wrong direction and they all need help. Where do you pull from?

As the crisis proliferates, several health care systems are struggling to transfer urgent patients to hospitals with adequate support. Hospitals in Lubbock, Texas, had to send severe Covid-19 patients to Arizona, said Henderson. A Missouri patient who urgently needed surgery to remove a mass in his brain was sent to a hospital in Iowa, said Alex Garza, head of the St. Louis regional pandemic task force and community health officer at SSM Health in St. Louis.

The mechanics of how you transport and accelerate care are broken at the moment, said Henderson. Even major cities in Texas, such as Houston, Dallas, and Austin, are facing their own staff limitations, and so many rural hospitals in Texas are forced to try and treat patients that they would typically transfer out.

Covid-19 has so overwhelmed parts of Texas, including El Paso and Lubbock, that hospitals are running short of both beds and staff. I treated a clinical patient in a recliner, because it was the only thing close to a bed we could find, said Hancock, who works at hospitals in Oklahoma, Dallas-Fort Worth, and Amarillo, Texas, but declined to say where the incident happened. We knew the patient was sick and had nowhere to put them. You look at what resources youve got and make it happen.

The lack of staff reflects the dramatic increase in patients. There has been an average of 157,318 new cases per day over the past week, according to the STAT Covid-19 Tracker 74% more than two weeks ago and there simply arent enough ICU nurses, in particular, to meet the need. Hospitals currently have 2,000 ICU nurse jobs open on Trusted Health, a company that connects travel nurses, who hop from job to job around the country, with hospitals.

The situation is exacerbated as staff get sick with coronavirus themselves, or else have to quarantine after exposure. The staffing need is so dire, hospital workers who have tested positive for Covid-19 but are asymptomatic have been told to continue working in North Dakota.

One rural hospital in Texas is struggling with 30% of staff nurses out of commission because of infection with or exposure to Covid-19, said TORCHs Henderson. At one point earlier this month, more than 1,000 staff from the Mayo Clinic were out of work because of Covid-19, said Amy Williams, executive dean of Mayo Clinic Practice.

It could be caring for a family member who has Covid, it could be on quarantine because of being exposed in the community, or it could be because the staff member actually has Covid, Williams said. More than 90% of possible exposures occurred in the community as transmission picked up, she said, not in the hospital.

As health care systems compete for additional staff, salaries skyrocket. ICU nurses are a hot commodity, said Dan Weberg, a former emergency room nurse and head of clinical innovation at Trusted Health, and their fees are currently twice as much as pre-Covid rates, at around $5,000 to $6,000 per week.

This is how PPE was in the beginning of the pandemic. When youre competing with everyone else in town, and state, and the country, that creates a market thats not sustainable, said SSM Healths Garza.

In response to the staffing shortage, several hospitals are postponing elective surgeries as many did in the spring at the start of the pandemic. This decision carries risks: They call them elective but a lot are what Id call urgent cases, said Hancock, the Texas emergency physician. A surgeon recently had to cancel two intestinal surgeries for patients who were struggling to eat, said Kencee Graves, associate chief medical officer at University of Utah Health. Patients waiting for knee surgeries may well struggle to walk.

But there are few alternatives for health care systems. You can always add more beds. Its much more difficult to add more workforce, said Alan Morgan, chief executive of the National Rural Health Association. Some hospitals are turning to local dentists and Red Cross volunteers, and people with basic health experience to help with tasks that require less training, said the American Hospital Associations Foster.

The only other option is to ask existing staff to work more hours. University of Utah Health has been using additional ICU beds for months, which means nurses and providers are working extra shifts. Our numbers keep increasing but they are tired. Our nurses feel like theres no end in sight, said Graves. They get here, work 12 hour shifts in PPE, its just this churn of seeing critically ill patients. And then you go to your community and see peak numbers, and having people continue to go to bars and restaurants.

Trusted Health is trying to set a maximum of 60 hours per week in its nursing contracts. After working more than three 12-hour shifts in a row, error rates go up exponentially, said Weberg.

What most worries hospital officials is that Covid-19 has not yet reached its peak. What Im scared of, leading up to the holidays, is whats going to happen immediately after Thanksgiving, said Hancock. Then everyone gets into a crisis situation and theres nobody who can go help.

Their only hope is for demand to decrease by people reducing Covid-19 transmission through quarantining and wearing masks, they said. Many of us feel powerless because we feel people arent listening when we say dont gather for Thanksgiving or Christmas, said Graves. After months of dealing with the crisis, she worries that some nurses will be so burned out theyll quit, making the staffing shortage even worse.

Both hospitalizations and deaths are lagging indicators, meaning it takes a couple of weeks for newly diagnosed cases to translate into more ICU patients. Were in for a very rough Thanksgiving and Christmas, said Henderson.

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'People are going to die': Hospitals in half the states are facing a massive staffing shortage - STAT