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When COVID-19 cases began to surface on the mainland in February, Hawaii health officials worried about how hospitals would keep up with an inevitable surge of cases in the islands.

Hawaii’s hospital capacity was already limited before the pandemic, and the health care system was strapped for specialized workers. To prepare, hospitals ran admission drills, gathered emergency supplies and identified rooms that could be equipped for COVID-19 patients in need of intensive care.

Six months into the pandemic, hospital administrators say they’re managing — but hospital workers say they are tired and feel more anxious than ever. ��

“It is taxing,” said Dr. Rachel Villacorta-Lyew, a lieutenant colonel, medical director and emergency physician at Tripler Army Medical Center. “We’re in it for a marathon.”

To date, 7% of people diagnosed with COVID-19 in Hawaii have required hospitalization.

But even hospitals that have not been inundated with COVID-19 patients are under enormous pressure: they must constantly screen for patients who may be infected, take extra precautions to prevent the virus from spreading, cut back on elective procedures and limit interactions among staff and other patients. They must also deal with infections among staff.

 

“COVID patients in particular, with the protective equipment and all the precautions and the extra psychological fears that everybody has — it makes things more challenging,” said Dr. Sreenandh Krishnagopalan, chief of critical care at Kaiser Permanente Moanalua Medical Center.

As cases appear to hit a plateau on Oahu, hospitals are looking at how to prepare for a surge in cases that could come with the upcoming winter and flu season and an influx of travelers as the state works to restart tourism.

Making It Through The First Wave

Because the virus spread in other states first, hospitals in Hawaii had more time to prepare before the state started getting cases in March and again before the surge that occurred in August.

“There was a lull where we were able to gather equipment and set up more places for COVID-19 patients like negative air pressure rooms, and training staff and physicians who don’t normally work in the hospital or ICU setting,” Krishnagopalan said.

Still, at the start of the pandemic, clinics struggled to get enough gloves, face shields, masks and gowns and had to ration supplies. Limited testing equipment and supplies were also a source of tension as the state conserved resources.

The peak of Hawaii’s first wave of infections in April seems like a blip compared to the surge in cases on Oahu that occurred throughout August and into September.

In August, things got so bad that several emergency rooms on Oahu turned ambulances away and rerouted them to other hospitals, Queen’s Health Systems also had to transfer non-critical patients to Wahiawa General Hospital.

The state put in a request to the Federal Emergency Management Agency for more than 100 medical workers. The federal government sent two teams of 36 people for two weeks — a fraction of the size Hawaii had asked for. Those workers are gone now, though more help is on the way.

The state is spending $14 million in federal coronavirus relief funding to hire 230 traveling nurses and respiratory therapists to work in 10 Hawaii hospitals over the next two months, according to Hilton Raethel, the president and CEO of the Healthcare Association of Hawaii.

Oahu has survived a surge in cases, but challenges are bound to persist.

“The good news is that the most recent stay-at-home order appears to have dropped the case numbers by half,” said Lee Altenberg, a University of Hawaii population biologist and member of the Hawaii Pandemic Applied Modeling Work Group. “The bad news is that Hawaii is not doing this lockdown nearly as well as the first one, which brought the case numbers to zero. And our daily numbers after this second lockdown are three times as high as the peak during the first lockdown.”

At Kaiser, Krishnagopalan said the hospital is still very busy — even as cases on the island seem to have plateaued. He expects that to be the case for a while.

Frontline Workers Are Exhausted

Last month, hospital administrators painted a picture of stability to the House COVID-19 committee. Hospitals and clinics collectively received $100 million in federal coronavirus relief funding. They told legislators that they were able to expand their in-house testing systems, and they’ve expanded space and reassigned and trained other staff to be able to jump in to help with COVID-19 care.

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“Fault Lines” is a special project that explores disruption and discord in Hawaii and what we as a community can do to bridge some of the social and political gaps that are developing. Read more here.

Still, that agility takes a toll. While the initial worries were about bed space and testing capacity, concerns have shifted to staffing. Health care workers say they are exhausted and feel there is no reprieve in sight.

“It’s kind of alarming every day to see the numbers, but all we can do as a provider is protect ourselves,” said Edwin Koh, a nurse in Tripler Army Medical Center’s telemetry unit. “We go home at the end of the day and make sure we don’t bring this virus to our family, and that the next day we can still function.”

While the majority of cases have been among Hawaii residents and associated with community transmission, several health care workers said they worry that restarting tourism will cause another surge. And many are still worried about getting sick themselves.

“Hospital health care workers are trying to maintain a good work face,” said Rasa Thom, a respiratory therapist on Maui. “They want to be there for patients and each other, but privately they think many of them are suffering and in fear but concerned, having real legitimate concerns.”

Dr. Ryan Roth, one of the state’s few traveling physicians who works shifts on Oahu, Kauai and Hawaii island, has increased his hours to pick up extra shifts needed at hospitals across the state. Rural hospitals have less opportunity to increase staffing or make more space for coronavirus care.

“We worry about our wellness too, because if you are working too much, get sick, or if any doctor gets knocked out, there’s no backup system,” he said.

The availability of protective masks and the directions some hospital workers receive on when they can use them are a major cause of stress, said Thom.

“A lot of us are not feeling safe,” he said. “I’m not the one making the decision — I’m at the whims of others who aren’t clinical practitioners.”

Daniel Ross, the president of the Hawaii Nurses’ Association, said he was aware of several nurses who fell ill with COVID-19 or were exposed and are in isolation. Many feel frustrated by the guidelines for masks and other protective equipment imposed by hospitals. The feel the guidelines are insufficient — even if they are in line with federal standards.

“There are nurses getting sick with COVID, and we don’t know exactly how many,” Ross said.

Ross said his organization is asking for greater transparency from hospitals, but that it’s difficult to get any information about staff illnesses.

As Hawaii embarks on implementing a new pre-travel test program for incoming travelers in mid-October, Raethel said the influx of mainland nurses will not only help relieve local workers but will also assist with what he anticipates could be an increase in COVID-19 cases.

In the meantime, health workers will continue to work long hours of intense and demanding rotations.

“Obviously, everyone is tired of having this pandemic for so long and a lot of those feelings are intensified when you’re in the health care setting — it is exhausting,” Krishnagopalan said. “We’ve come to realize this really is going to be a long haul.”