Working as a travel nurse in the early days of the Covid pandemic was emotionally exhausting for Reese Brown — she was forced to leave her young daughter with her family as she moved from one gig to the next, and she watched too many of her intensive care patients die.
“It was a lot of loneliness,” Brown, 30, said. “I’m a single mom, I just wanted to have my daughter, her hugs, and see her face and not just through FaceTime.”
But the money was too good to say no. In July 2020, she had started earning $5,000 or more a week, almost triple her pre-pandemic pay. That was the year the money was so enticing that thousands of hospital staffers quit their jobs and hit the road as travel nurses as the pandemic raged.
Two years later, the gold rush is over. Brown is home in Louisiana with her daughter and turning down work. The highest paid travel gigs she’s offered are $2,200 weekly, a rate that would have thrilled her pre-pandemic. But after two “traumatic” years of tending to Covid patients, she said, it doesn’t feel worth it.
“I think it’s disgusting because we went from being praised to literally, two years later, our rates dropped,” she said. “People are still sick, and people are still dying.”
The drop in pay doesn’t mean, however, that travel nurses are going to head back to staff jobs. The short-lived travel nurse boom was a temporary fix for a long-term decline in the profession that predates the pandemic. According to a report from McKinsey & Co., the United States may see a shortage of up to 450,000 registered nurses within three years barring aggressive action by health care providers and the government to recruit new people. Nurses are quitting, and hospitals are struggling to field enough staff to cover shifts.
Nine nurses around the country, including Brown, told NBC News they are considering alternate career paths, studying for advanced degrees or exiting the profession altogether.
“We’re burned out, tired nurses working for $2,200 a week,” Brown said. People are leaving the field, she said, “because there’s no point in staying in nursing if we’re expendable.”
$124.96 an hour
Travel nursing seems to have started as a profession, industry experts say, in the late 1970s in New Orleans, where hospitals needed to add temporary staff to care for sick tourists during Mardi Gras. In the 1980s and the 1990s, travel nurses were often covering for staff nurses who were on maternity leave, meaning that 13-week contracts become common.
By 2000, over a hundred agencies provided travel contracts, a number that quadrupled by the end of the decade. It had become a lucrative business for the agencies, given the generous commissions that hospitals pay them. A fee of 40 percent on top of the nurse’s contracted salary is not unheard of, according to a spokesperson for the American Health Care Association, which represents long-term care providers.
Just before the pandemic, in January 2020, there were about 50,000 travel nurses in the U.S., or about 1.5 percent of the nation’s registered nurses, according to Timothy Landhuis, vice president of research at Staffing Industry Analysts, an industry research firm. That pool doubled in size to at least 100,000 as Covid spread, and he says the actual number at the peak of the pandemic may have far exceeded that estimate.
By 2021, travel nurses were earning an average of $124.96 an hour, according to the research firm — three times the hourly rate of staff nurses, according to federal statistics.
That year, according to the 2022 National Health Care Retention & RN Staffing Report from Nursing Solutions Inc., a nurse recruiting firm, the travel pay available to registered nurses contributed to 2.47% of them leaving hospital staff jobs.
But then, as the rate of deaths and hospitalizations from Covid waned, the demand for travel nurses fell hard, according to industry statistics, as did the pay.
Demand dropped 42 percent from January to July this year, according to Aya Healthcare, one of the largest staffing firms in the country.
That doesn’t mean the travel nurses are going back to staff jobs.
Brown said she’s now thinking about leaving the nursing field altogether and has started her own business. Natalie Smith of Michigan, who became a travel nurse during the pandemic, says she intends to pursue an advanced degree in nursing but possibly outside of bedside nursing.
Pamela Esmond of northern Illinois, who also became a travel nurse during the pandemic, said she’ll keep working as a travel nurse, but only because she needs the money to retire by 65. She’s now 59.
“The reality is they don’t pay staff nurses enough, and if they would pay staff nurses enough, we wouldn’t have this problem,” she said. “I would love to go back to staff nursing, but on my staff job, I would never be able to retire.”
The coronavirus exacerbated issues that were already driving health care workers out of their professions, Landhuis said. “A nursing shortage was on the horizon before the pandemic,” he said.
According to this year’s Nursing Solutions staffing report, nurses are exiting the bedside at “an alarming rate” because of rising patient ratios, and their own fatigue and burnout. The average hospital has turned over 100.5% of its workforce in the past five years, according to the report, and the annual turnover rate has now hit 25.9%, exceeding every previous survey.
There are now more than 203,000 open registered nurse positions nationwide, more than twice the number just before the pandemic in January 2020, according to Aya Healthcare.
An obvious short-term solution would be to keep using travel nurses. Even with salaries falling, however, the cost of hiring them is punishing.
LaNelle Weems, executive director of Mississippi Hospital Association’s Center for Quality and Workforce, said hospitals can’t keep spending like they did during the peak of the pandemic.
“Hospitals cannot sustain paying these exorbitant labor costs,” Weems said. “One nuance that I want to make sure you understand is that what a travel agency charges the hospitals is not what is paid to the nurse.”
Ultimately, it’s the patients who will suffer from the shortage of nurses, whether they are staff or gig workers.
“Each patient added to a hospital nurse’s workload is associated with a 7%-12% increase in hospital mortality,” said Linda Aiken, founding director of the University of Pennsylvania’s Center for Health Outcomes and Policy Research.
Nurses across the country told NBC News that they chose the profession because they cared about patient safety and wanted to be at the bedside in the first line of care.
“People say it’s burnout but it’s not,” Esmond said about why nurses are quitting. “It’s the moral injury of watching patients not being taken care of on a day-to-day basis. You just can’t take it anymore.”
One of China’s biggest cities, Chengdu, announced a lockdown of its 21.2 million residents as it launched four days of citywide Covid-19 testing, as some of country’s most populous and economically important urban centers battle outbreaks.
All residents in Chengdu, the capital of Sichuan province, were ordered to stay largely at home from 6 p.m. on Thursday, with households allowed to send one person per day to shop for necessities, the city government said in a statement.
The southwestern Chinese metropolis of Chengdu announced a lockdown of its 21.2 million residents as it launched four days of citywide Covid-19 testing, as some of the country’s most populous and economically important cities battle outbreaks.
Residents of Chengdu, the capital of Sichuan province, were ordered to stay home from 6 p.m. on Thursday, with households allowed to send one person per day to shop for necessities, the city government said in a statement.
Chengdu, which reported 157 domestically transmitted infections on Wednesday, is the largest Chinese city to be locked down since Shanghai in April and May. It remained unclear whether the lockdown would be lifted after the mass testing ends on Sunday.
Other major cities including Shenzhen in the south and Dalian in the northeast have also stepped up Covid restrictions this week, ranging from work-from-home requirements to the closure of entertainment businesses in some districts.
The moves curtail the activities of tens of millions of people, intensifying the challenges for China to minimize the economic impact of a “dynamic-zero” Covid policy that has kept China’s borders mostly shut to international visitors and make it an outlier as other countries try to live with the coronavirus.
Most of the curbs are intended to last a few days for now, although two provincial cities in northern China have extended curbs slightly beyond initial promises.
Chengdu’s lockdown sparked panic buying of essentials among residents.
“I am waiting in a very long queue to get in the grocery near my home,” 28-year-old engineer Kya Zhang said, adding that she was worried about access to fresh food if the lockdown is extended.
Hwabao Trust economist Nie Wen said that because Chengdu acted quickly to lock down, it was unlikely to see a repeat of Shanghai’s two-month ordeal.
Non-essential employees in Chengdu were asked to work from home and residents were urged not to leave the city unless needed. Residents who must leave their residential compounds for hospital visits or other special needs must obtain approval from neighborhood staffers.
Industrial firms engaged in important manufacturing and able to manage on closed campuses were exempted from work-from-home requirements.
Sweden’s Volvo Cars said it would temporarily close its Chengdu plant.
Flights to and from Chengdu were dramatically curtailed, according to Flight Master data. At 10 a.m. local time (0200 GMT) on Thursday, it showed 398 flights had been canceled at Shuangliu Airport in Chengdu, with a cancellation rate of 62%. At Chengdu’s Tianfu Airport, 79%, or 725 flights, were canceled.
In Shenzhen, which has the third-highest economic output among Chinese cities, the most populous district Baoan and tech hub Nanshan suspended large events and indoor entertainment for a few days and ordered stricter checks of digital health credentials for people entering residential compounds.
Nanshan is home to internet giant Tencent and the world’s biggest dronemaker, DJI, among other major Chinese companies.
More than half of Shenzhen’s ten districts, home to over 15 million people, have ordered blanket closure of entertainment venues and halted or reduced restaurant dining for a few days, with curbs in two districts initially planned to be lifted by the end of Thursday.
Shenzhen authorities have largely avoided shutting down offices and factories as they did during a week-long lockdown in March.
Data on Thursday showed that Chinese factory activity contracted for the first time in three months in August amid weakening demand, while power shortages and fresh Covid-19 flare-ups disrupted production.
In Shanghai, schools reopened on Thursday after being closed for months.
Mainland China has reported no Covid death since May, leaving the death toll at 5,226.
The AHA wants Congress to halt Medicare payment cuts and extend or make permanent certain waivers, among other requests.
The American Hospital Association has released a report on patient acuity that shows hospital patients are sicker and more medically complex than they were before the COVID-19 pandemic.
This is driving up hospital costs for labor, drugs and supplies, according to the AHA report.
Hospital patient acuity, as measured by average length of stay, rose almost 10% between 2019 and 2021, including a 6% increase for non-COVID-19 Medicare patients as the pandemic contributed to delayed and avoided care, the report said. For example, the average length of stay rose 89% for patients with rheumatoid arthritis and 65% for patients with neuroblastoma and adrenal cancer.
In 2022, patient acuity as reflected in the case mix index rose 11.1% for mastectomy patients, 15% for appendectomy patients and 7% for hysterectomy patients.
WHY THIS MATTERS
Mounting costs, combined with economy-wide inflation and reimbursement shortfalls, are threatening the financial stability of hospitals around the country, according to the AHA report.
The length of stay due to increasing acuity is occurring at a time of significant financial challenges for hospitals and health systems, which have still not received support to address the Delta and Omicron surges that have comprised the majority of all COVID-19 admissions, the AHA said.
The AHA is asking Congress to halt its Medicare payment cuts to hospitals and other providers; extend or make permanent certain waivers that improve efficiency and access to care; extend expiring health insurance subsidies for millions of patients; and hold commercial insurers accountable for improper and burdensome business practices.
THE LARGER TREND
Hospitals, through the AHA, have long been asking the federal government for relief beyond what’s been allocated in provider relief funds.
In January, the American Hospital Association sought at least $25 billion for hospitals to help combat workforce shortages and labor costs exacerbated by what the AHA called “exorbitant” rates on the part of some staffing agencies. The Department of Health and Human Services released $2 billion in additional funding for hospitals.
In March, the AHA asked Congress to allocate additional provider relief funds beyond the original $175 billion in the Coronavirus Aid, Relief and Economic Security Act.
Earlier this month, the Centers for Medicare and Medicaid Services increased what it originally proposed for payment in the Inpatient Prospective Payment system rule. The AHA said the increase was not enough to offset expenses and inflation.
Hospital-acquired, antibiotic-resistant infections grew 15% from 2019 to 2020, according to data out Tuesday from the Centers for Disease Control and Prevention.
Nearly 30,000 people died from infections associated with healthcare settings in the first year of the pandemic and about 40% were infected during a hospital stay, according to the CDC.
Personal protective equipment and staffing shortages; longer patient stays and use of devices like catheters and ventilators; and significant surges in antibiotic use contributed to the rise in infections, the CDC said.
The new data erases years of progress — from 2012 to 2017, hospital-acquired, antimicrobial-resistant infections fell 27%, according to data from the CDC.
Hospitals struggled to follow infection prevention and control guidance during the first year of the pandemic as they faced resource strains and treated sicker patients who needed longer stays. At the same time, hospitals boosted their use of antibiotics, reducing their effectiveness.
In many cases, patients who exhibited pneumonia-like symptoms at hospitals were given antibiotics as a first option even though they were infected with COVID-19. Antibiotics are not effective in treating COVID-19.
Nearly 80% of patients hospitalized with COVID-19 from March to October of 2020 received an antibiotic, according to the CDC.
Antimicrobrial resistance testing was also down in 2020. The CDC’s AR lab network reported receiving 23% fewer testing specimens during 2020 compared to 2019. Due to the pandemic, some CDC progams that focused on antimicrobrial resistance were also repurposed to offer surge capacity COVID-19 testing, the report said.
Without infrastructure and preparedness, it warned, critical data could be “delayed again when the next threat emerges.”
“This setback can and must be temporary,” Michael Craig, director of the CDC’s antibiotic resistance coordination and strategy unit, said in a report analyzing the data.
“The best way to avert a pandemic caused by an antimicrobial-resistant pathogen is to identify gaps and invest in prevention to keep our nation safe,” he said.
Monkeypox is a virus in the Orthopoxvirus genus which also includes the variola virus (which causes smallpox) and the cowpox virus. The primary symptoms include fever, swollen lymph nodes, and a distinctive bumpy rash.
There are two major strains of the virus that pose very different risks:
Congo Basin strain: 1 in 10 people infected with this strain have died
West African strain: Approximately 1 in 100 people infected with this strain died
At the moment, health authorities in the UK have indicated they’re seeing the milder strain in patients there.
Where did Monkeypox Originate From?
The virus was originally discovered in the Democratic Republic of Congo in monkeys kept for research purposes (hence the name). Eventually, the virus made the jump to humans more than a decade after its discovery in 1958.
It is widely assumed that vaccination against another similar virus, smallpox, helped keep monkeypox outbreaks from occurring in human populations. Ironically, the successful eradication of smallpox, and eventual winding down of that vaccine program, has opened the door to a new viral threat. There is now a growing population of people who no longer have immunity against the virus.
Now that travel restrictions are lifting in many parts of the world, viruses are now able to hop between nations again. As of the publishing of this article, a handful of cases have now been reported in the U.S., Canada, the UK, and a number of European countries.
On the upside, contact tracing has helped authorities piece together the transmission of the virus. While cases are rare in Europe and North America, it is considered endemic in parts of West Africa. For example, the World Health Organization reports that Nigeria has experienced over 550 reported monkeypox cases from 2017 to today. The current UK outbreak originated from an individual who returned from a trip to Nigeria.
Could Monkeypox become a new pandemic?
Monkeypox, which primarily spreads through animal-to-human interaction, is not known to spread easily between humans. Most individuals infected with monkeypox pass the virus to between zero and one person, so outbreaks typically fizzle out. For this reason, the fact that outbreaks are occurring in several countries simultaneously is concerning for health authorities and organizations that monitor viral transmission. Experts are entertaining the possibility that the virus’ rate of transmission has increased.
Images of people covered in monkeypox lesions are shocking, and people are understandably concerned by this virus, but the good news is that members of the general public have little to fear at this stage.
I think the risk to the general public at this point, from the information we have, is very, very low. –TOM INGLESBY, DIRECTOR, JOHNS HOPKINS CENTER FOR HEALTH SECURITY
As this summer heats up, so has the spread of the hot new version of COVID-19.
Why it matters: This subvariant of Omicron called BA.5 — the most transmissible subvariant yet — quickly overtook previous strains to become the dominant version circulating the U.S. and much of the world.
BA.5 is so transmissible — and different enough from previous versions — that even those with immunity from prior Omicron infections may not have to wait long before falling ill again.
What they’re saying: “I had plenty of friends and family who said: ‘I didn’t want to get it but I’m sort of glad I got it because it’s out of the way and I won’t get it again’,” Bob Wachter, chairman of the University of California, San Francisco Department of Medicine told Axios. “Unfortunately that doesn’t hold the way it once did.”
“Even this one bit of good news people found in the gloom, it’s like, ‘Sorry’,” Wachter said.
State of play: This week, the CDC reported BA.5 became the dominant variant in the U.S., accounting for nearly 54% of total COVID cases. Studies show extra mutations in the spike protein make the strain three or four times more resistant to antibodies, though it doesn’t appear to cause more serious illness.
Hospital admissions are starting to trend upward again, CDC data shows, though they’re still well below what was seen during the initial spread of Omicron.
It’s unclear whether that could be indicating an increase in patients in for COVID, or patients who happen to have COVID, Wachter said. “We’re up in hospitalizations around 20% but with a relatively small number of ICU patients,” Wachter said about COVID cases at UCSF.
In South Africa, the variant had no impact on hospitalizations while Portugal saw hospitalizations rise dramatically, Megan Ranney, academic dean at the Brown University School of Public Health told Axios.
“So the big unknown is what effect it’s going to have on the health care system and the numbers of folks living with long COVID,” she said.
Yes, but: “I’m certainly hearing about more reinfections and more fairly quick reinfections than at any other time in the last two and a half years,” Wachter said.
Zoom in: That is also largely the experience of the surge seen firsthand in New York City by Henry Chen, president of SOMOS Community Care, who serves as a primary care physician across three boroughs of the city.
With this particular variant, he said: “The symptoms are pretty much the same but a little bit more severe than the last wave. It’s more high fever, body ache, sore throat and coughing,” Chen said, adding his patient roster is mostly vaccinated.
But it is occurring among patients who’d gotten the virus only three or four months ago, he said.
The big picture: Another summertime wave of cases could prolong the pandemic, coming after many public health precautions were lifted and with available vaccines losing their efficacy against the ever-evolving virus.
The bottom line: The messaging isn’t to panic, but to understand the virus is likely spreading in local communities much more than individuals realize due to shrinking testing programs — and without the level of protection they might assume they have.
“If you don’t want to get sick, you still need to be taking at least some precautions,” Ranney said. “[COVID] is still very much among us.”
Numerous viruses that were seemingly dormant during the pandemic are returning in new and atypical ways, CNBC reported June 10.
Flu, respiratory syncytial virus, adenovirus, tuberculosis and monkeypox are among the viruses that have recently surged or exhibited unusual behaviors.
The U.S. saw extremely mild flu seasons in 2020-21 and 2021-22, likely due to high rates of mask-wearing, social distancing and other COVID-19 prevention measures. However, flu cases started to rise this February and continued to climb through the spring as more public health measures receded.
“We’ve never seen a flu season in the U.S. extend into June,” Scott Roberts, MD, associate medical director for infection prevention at Yale New Haven (Conn.) Hospital, told CNBC. “COVID has clearly had a very big impact on that. Now that people have unmasked [and] places are opening up, we’re seeing viruses behave in very odd ways that they weren’t before.”
Washington state is also reporting its most severe tuberculosis outbreak in 20 years, while the world is grappling with a monkeypox outbreak that’s affected more than 1,000 people.
These viruses, suppressed during the pandemic, now have more opportunities to spread as people resume daily life, become more social and travel more. Society, as a whole, also has less immunity against the viruses after two years of reduced exposure to them, according to the report.
The pandemic has also boosted surveillance efforts and public interest in other outbreaks, experts say.
“COVID has raised the profile of public health matters so that we are perhaps paying more attention to these events when they occur,” Jennifer Horney, PhD, professor of epidemiology at the University of Delaware in Newark, told CNBC.
COVID-19 cases have risen in the U.S. to around 100,000 per day, and the real number could be as much as five times that, given many go unreported.
But the situation is far different from the early months of the pandemic. There are now vaccines and booster shots, and new treatments that dramatically cut the risk of the virus. So how much do cases alone still matter?
That question has prompted debate among experts, even as much of America goes on with their lives, despite the recent surge in cases.
How much concern high case numbers alone should prompt is “the trillion-dollar question,” said Bob Wachter, chair of the department of medicine at the University of California-San Francisco.
In the early days of the pandemic, dying of COVID-19 was a concern for him, but now, in an era of vaccines and treatments, “it doesn’t even cross my mind anymore,” he said.
But he noted there are other risks, including long COVID-19: symptoms like fatigue or difficulty concentrating that can linger for months.
“I think long COVID is pretty scary,” he said.
While cases have risen to around 100,000 reported per day, deaths have stayed flat, a testament to the power of vaccines and booster shots in preventing severe illness, as well as the Pfizer treatment pills Paxlovid, which cut the risk of hospitalization or death by around 90 percent.
Hospitalizations have risen, but only modestly, to around 27,000, one of the lowest points of the pandemic, according to a New York Times tracker.
Cases have now been “partially decoupled” from causing hospitalizations and deaths, said Preeti Malani, an infectious disease expert at the University of Michigan, such that hospitals are no longer overwhelmed.
“[Cases are] not without any consequence, but in terms of pressure on the health system, so far we’re not seeing that, which is really what drove all of this,” she said.
The behavior of much of America reflects a lessened concern about the risk of being infected. Restaurants and bars are packed. Many people do not wear masks even on airplanes or on the subway.
An Axios-Ipsos poll in May found just 36 percent of Americans said there was significant risk in returning to their “normal pre-coronavirus life.”
In the Biden administration, health officials are still advising people to wear masks in areas the Centers for Disease Control and Prevention classifies as at “high” risk. But President Biden himself is talking about the virus far less than he did at the start of his administration, and is not making sustained calls for people to wear masks.
White House COVID-19 response coordinator Ashish Jha touted progress in defanging cases on Thursday.
“We see cases rising, nearly 100,000 cases a day, and yet we’re still seeing death numbers that are substantially, about 90 percent lower, than where they were when the president first took office,” he told reporters.
Some experts are pushing back on the deemphasis of case numbers, saying they still matter.
“The bunk that cases are not important is preposterous,” Eric Topol, professor of molecular medicine at Scripps Research, wrote last month. “They are infections that beget more cases, they beget Long Covid, they beget sickness, hospitalizations and deaths. They are also the underpinning of new variants.”
Even if one does not get severely ill oneself, more cases mean more chances for the virus to spread on to someone who is more vulnerable, like the elderly or immunocompromised.
While deaths are way down from their peak earlier in the pandemic, there are still around 300 people dying from the virus every day, a number that would have proved shocking in a pre-COVID-19 world.
Leana Wen, a public health professor at George Washington University, recommended that people take a rapid test before visiting a more vulnerable person, as a safeguard that avoids more burdensome restrictions.
“Cases alone do not tell the whole story,” she said, adding, “As a policy matter we need to stop using the same comparisons we were in 2020 and 2021.”
There is still much that is unknown about long COVID-19, one of the biggest risks remaining for healthy, younger people who are vaccinated.
A recent article in the Journal of the American Medical Association estimated 10 percent to 30 percent of COVID-19 infections result in long COVID-19 symptoms, but there is no precise estimate.
Experts also urge people who have not gotten their booster shots, or not been vaccinated at all, to do so, given that many are more vulnerable to the virus if they are not up-to-date on their shots.
A new variant also always holds the risk of upending the current risk-benefit calculations. The virus has continued to evolve to spread more easily, and a future mutation could cause more severe illness or more greatly evade vaccines.
Pfizer and Moderna are working on updated vaccines to better target the omicron variant, but the Biden administration warns it will not have enough money to purchase those new vaccines for all Americans this fall unless Congress provides more funding. The funding request has been stalled for months, though, itself a sign of the reduced sense of urgency around the virus fight.
At least for now, though, while many people are getting COVID-19, fewer are getting extremely sick.
“It’s a very risky time if you don’t want to get COVID [at all],” Wachter said. “But a relatively less risky time if your goal is to not get severe COVID or die.”
This week we heard from three healthcare executives that they’ve seen a recent uptick in emergency department (ED) volumes. As we’ve discussed before, ED visits plummeted at the beginning of the pandemic, and were the slowest class of care volume to rebound. Over the past year, many systems reported that ED volume had remained persistently stuck at 10 to 15 percent lower than pre-COVID levels, leading us to question whether there had been a secular shift in patient demand, with consumers choosing alternative options like telemedicine or urgent care as a first stop for minor acute care needs.
An uptick in ED volume would be welcome news to many hospital executives, as the emergency department is the source of half or more of inpatient admissions for many hospitals. But according to what we’re hearing, the recent rise in emergency department patient volume has not resulted in an expected bump in inpatient volume.
“We’ve dug into it, and it seems like the jump in ED visits is a function of COVID,” one leader shared. “There’s just so much COVID out there now…even though the disease is milder, there are still a lot of patients coming to the ED. But unlike last year, most aren’t sick enough to be admitted.”
And ED visits for other causes have not rebounded in the same way: “We’re hoping patients aren’t still staying away because they’re afraid of catching the virus.” We’ll be watching closely across the summer to see how volumes trend as the pandemic waxes and wanes across the country—we’d still bet that many consumers have changed their thinking on where and how they will seek care when the need arises.