Hospital Staffing Crisis: What's the Role of Locums Workers?

This discussion was recorded on July 21, 2022. This transcript has been edited for clarity.

Robert D. Glatter, MD: Welcome. I'm Dr Robert Glatter, medical advisor for Medscape Emergency Medicine. Today we have Dr Peter Papadakos, professor of anesthesiology and director of critical care medicine at University of Rochester Medical Center in New York, to discuss the ongoing staffing shortages affecting hospitals throughout the United States.

Welcome, Dr Papadakos.

Peter J. Papadakos, MD: Thank you very much for inviting me.

Glatter: Thank you so much for joining me. I wanted to talk about an interesting piece that you wrote in Anesthesiology News, titled "In the Care of Strangers: The Post-Pandemic Staffing Crisis." It really rang home to me because you visit many important points about the influx of locums providers, especially during COVID-19, and how it affected morale, team building, and cohesiveness among hospital staff. It was very eye-opening. Why are we in the midst of a national post–COVID-19 staffing crisis? What are the root causes of this?

Papadakos: As I point out in the article, it's a multiplicity of reasons. One is burnout. Many people worked incredibly long hours during COVID-19, including physicians, nurses, respiratory therapists, and all kinds of technicians. Then you had another component that added to this, which was the mandates for vaccinations, and some staff said, "I just don't want to deal with this." Then we had people who left the professions because of the pandemic, such as people with concomitant medical conditions who were afraid that suddenly working in a hospital was going to endanger their health, a spouse's health, or whatever.

We had a large drain of staffing at that point in time during the post-pandemic period. There's some pushback of young people entering healthcare fields because they saw that healthcare workers were on the front lines, endangering themselves initially, whereas a spouse or sibling who had an office job was working from home. As the demographic of people that enter healthcare changes, the level of dedication is not what it was 20, 30, or 40 years ago.

Glatter: How does this affect patient care directly? When you have many locums providers, temporary staffing agencies that are filling hospitals with people that are unfamiliar with certain protocols and take time to get up to speed, are there adverse effects on patient outcomes?

Papadakos: We have a multidisciplinary team made up of physicians, mid-level providers, nurses, and therapists. We've all practiced together and we work together on a daily basis as a team. It takes time to develop relationships.

Suddenly, with the influx of locums tenens and temporary people, you have people on 3- and 6-week contracts. They don't get oriented. They don't know who you are. You don't know what their capabilities are, what problems they might have, what skillsets are honed for them, and what skillsets they are deficient in. It completely decays that trust of the team that we use every day in the care of very sick patients in various environs of the hospital.

It's not only critical care areas but also the EDs and operating rooms that are affected by this team. We also have teams and groups that work on the floors taking care of less ill patients. Anecdotally, one of my colleagues told me they were running a code as an emergency medicine physician in a hospital in the Midwest. Suddenly the nurse goes, "Doctor, I'm not going to do that. We don't do that in California. That's not our first-line drug in California." That's not an appropriate conversation to be having during an acute event.

Glatter: I agree. Uniformity is an important point. When you bring in a temporary locums provider, do they go through training or simulation? Are there any protocols that hospitals have in place when they bring in people that are credentialed but maybe not familiar with the local flavor of how things run?

Papadakos: Initially, for nurses and our house staff, we're talking week-long orientations over extended periods of time that were normally happening prior to the pandemic. When you have somebody on a 5-week contract, you're not going to be able to do an orientation program for them. You're using that person immediately because you're filling a hole in your schedule or a hole to keep your beds open because many states require nurse-to-patient ratios. If you don't have enough staff, you're going to be browning out beds, which is going to be a major problem.

It's not only hospitals. It's also nursing homes that are going through this. They don't have enough certified nurse assistants and nurses so they're not able to take admissions. Then you get another backlog at the hospital.

This whole shift from permanent employment at a hospital, nursing home, doctor office, or satellite clinic has massively impacted the patient flow.

Glatter: What can we do to reduce attrition and migration to staffing agencies that current employees are seeing, and new graduates? Offer salary increases, bonuses, paid time off, wellness, and so on?

Papadakos: What I think we need to do as clinicians is start working with the people in our C-suites (ie, the leadership of the hospital) because we and they cannot survive this as a long-term staffing issue. In healthcare, you need to have teams. You need to have people who are experienced working together on a regular basis, so we need to try to mitigate that attrition.

One of the problems that we have is when we bring in locums in any hospital, their salary is many multiples over your current bedside staff, which makes the bedside staff develop a certain hatred.

One of the things that we can't control as clinicians is how to start elevating the salary of our allied health providers, including nurses, respiratory therapists, technologists, and x-ray techs, so that they're less likely to leave the institution.

If you talk to any locums or anybody else, what you make as a salary is a very important thing. We're very material people. Obviously, working conditions, being more open for scheduling. One of the things I've been told by colleagues is the ability to provide daycare onsite for health providers who have young children. Professional education benefits (ie, CME for physicians, nursing credits), helping with tuition for a nurse to get a more advanced degree to become a nurse practitioner, or a therapist to move up the academic ranks. These are all things that we can do. Again, what is the mechanism with the limited funds of hospitals to be able to do those things?

Glatter: The reality is that locum staffing is not going to go away. We both know that. It does fill a need when someone has an accident, an injury, or is sick and we need someone immediately. There is a role for it, but sustainability is the question here, and in terms of the solvency of hospitals, is really at risk. I think you pointed that out in your article.

Papadakos: You hit the nail on the head. The solvency of the hospitals has definitely decayed. The bottom line is decay. The hospitals are bleeding money because they are paying many more multiples of salaries that they never expected, based on fixed reimbursement from Medicare and Medicaid. Your private insurance companies did not increase reimbursement because you are now staffing 50% of your staff as locum tenants. The hospital will eventually become insolvent, or before they become insolvent, hospitals will start cutting down services, be it freestanding emergency rooms, obstetrics and gynecology services, outpatient clinics, and so on.

Hospitals throughout the country, as it's been pointed out in the literature, are closing down services in a time where we need more services.

Glatter: Absolutely, and this is a problem. The rural areas especially are going to be the hardest hit with closures, but also urban areas are not immune. The federal government may have to play a role here to rescue some of these institutions because of the staffing crisis and the economics of it.

Papadakos: You bring up an important point, but I have not seen any of our legislators, be it at the state or the national level, that are even aware that this is happening, and the whole American health system is becoming insolvent. I would think, as I pointed out in my article, that this would be breaking news that most hospitals are now staffed by nontraditional means. They're all in financial distress. Services are being cut down. I've not seen anything or heard much on the national or local media reporting on this.

Glatter: Absolutely. The effect of climate change on the practice of medicine is another thing we can't ignore.

Papadakos: We're also going to see seasonal variation. It's not only the heat wave. Many nurses from northern states who don't like driving through snowstorms are going to leave the area to go down South and take contracts in the Sun Belt. Nurses who normally would come up from the Sun Belt to the northern environments are not exactly going to want to work in Buffalo in January.

The other thing that's happening, which is kind of interesting, is when you talk to physicians and other health providers in large cities, what we have are "musical chairs" locums. You have major university hospitals that have nurses from the other major university hospital down the street. It's just like rotating chairs. Nurses from hospital A are working in hospital B, nurses in D are working in E, and they keep rotating vs having a set staff. They don't even have to leave their area.

Big cities might have an advantage with what I call local locums people vs small, rural, acute care hospitals. They're not going to get staff that's in the area and have been working at a competing institution. They're going to close beds and may have to close down. Closing down a rural, acute need hospital is catastrophic for the people in the area.

Glatter: I think this should be front and center in the news cycle. I think that the public really needs to have an awareness of this, and it must be brought to a legislative level — if not at the hospital level, then at the state level — to really look at this critical staffing shortage that exists.

Papadakos: Another thing is happening that makes no sense to me. Yes, you can make more money traveling, but suddenly you also have no insurance and no 401(k). There are many other benefits that people get. You now have possibly many healthcare professionals who are uninsured.

The temptation is you get lots of money, but you're used to somebody else paying your premiums (ie, your employer). Your employer used to give you a 401(k), educational benefits, or whatever. You're not getting any of those things. We're creating people who have temporary financial gain but may not have long-term stability.

Glatter: The locums companies will give you data saying that the typical profile of a provider is someone who is 20-25 years in practice, older into their fifties or sixties, and at the end of their career. A very small percentage are younger. I believe it was 10%, according to one report. This age differential and experience gap is what they will show you in terms of their data. The kind of providers that we're seeing, or at least on my end, are younger rather than the older provider. Maybe you could explain this disconnect.

Papadakos: You're right. The model 10-15 years ago was the retiree who would want to see the country and get put up in a garden apartment in Arizona with a pool. There was a limited number of locums people. The locums company telling me about something that existed 5-10 years ago is not the truth that you will have now. If you look around any hospital, you'll see that the majority of your locums nurses or anesthesia providers are young people who are 1-2 years out of training. We're talking about people in their twenties and thirties. We're not talking about the data that they're showing, with retirees and people at the end of their career. That is what they used to do.

Also, if you talked to a locums company previously, they may have had 20 or 30 people on contract. The locums companies now have tens of thousands of people on contracts. I was not being actively recruited to join a locums company 20 or 30 years ago. It was something you heard about from an older physician through word of mouth. Now it's out there and everybody knows about it.

When you bring locums into a hospital — especially as nursing, mid-level, advanced practitioner, respiratory therapy, x-ray tech, lab technologists, anesthesia techs, operating room scrub technologists — the technologist who is working at your institution finds out about the cash rewards of joining the locums company, and they will want to join the locums company.

Glatter: The reality is that many young doctors are in debt and they see the financial rewards of locums as a way to pay back their debt. That might be a motivation that lures them in.

Papadakos: One of the other things is that we need a new type of hospital management because none of them have ever dealt with this problem before. Every C-suite, chair, and nursing director is in shock because this has never happened before. I've heard of CEOs of hospitals planning early retirement so that they're not at the helm of a health system when it goes bankrupt.

Glatter: Absolutely. Patient outcomes will be the important part of this crisis that we're facing. Are we going to see increased numbers of patients with poor outcomes or longer lengths of stay? It's going to translate into adverse effects.

Papadakos: We already have some reports. Hospital-acquired infections have gone up because people are not familiar with the guidelines and protocols of a specific institution that they're now working in. Regarding the reporting system for quality, a locums doesn't know how to report an issue in the quality-assurance system of whatever institution they are in. It takes time and practice to develop that. We're going to see massive increases in outcome problems and a decay in a robust quality-assurance patient safety system that's been developed over the last number of decades. There's no buy-in if you're there as a temporary.

Glatter: Right. There's no federal reporting system in the era of locums, especially since COVID-19, that I'm aware of, that integrates these outcomes or patient safety issues with these providers that come into hospitals at a moment's notice. That's an important thing that we need to address.

Papadakos: What is going to happen to the medical-legal system, the malpractice system? What is the coverage and responsibility of the locums company for providing a subpar individual who suddenly caused a bad outcome? What is the legal responsibility of the employer, the hospital, that suddenly has somebody who isn't fully vetted in their own system and does something (ie, there's a bad outcome)? It's a multilevel problem that needs to be addressed.

Glatter: These are important issues that we've discussed and hopefully these can be addressed. Thank you for your time, your expertise, and your insight on this issue.

Robert D. Glatter, MD, is assistant professor of emergency medicine at Lenox Hill Hospital in New York City and at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. He is an editorial advisor and hosts the Hot Topics in EM series on Medscape. He is also a medical contributor for Forbes.

Peter J. Papadakos, MD, is professor of anesthesiology and director of critical care medicine at University of Rochester Medical Center in New York, a position he has held since 2000. His research focuses on pulmonary critical care management, including work on septic shock and oxygen delivery, the pathophysiology of acute lung failure, and the use of nitric oxide in acute respiratory distress syndrome. He is extensively published in professional journals and has been featured as a guest expert for various media outlets, including The New York Times and The Washington Post.

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