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On October 8, overwhelmed with the patients that kept arriving at the emergency department (ED), a nurse called in the local fire department for help. Against a backdrop of crises at EDs across the country, the perfect storm had hit St. Michael Medical Center in Silverdale, Washington.

Kelsay Irby, RN, the charge nurse who made the call, recounted the night's events to MedPage Today.

'Flying Blind'

The ED staff at St. Michael were struggling, with available rooms all full and around 40 walk-in patients waiting to be seen. Ambulances were also backed up, waiting with their patients for rooms to open up and unable to go back out on new calls.

Worse yet, the electronic health record (EHR) system at St. Michael was down due to a cyber attack, and staff were making do with paper charts and an impromptu spreadsheet on Google Drive. This made it impossible to keep track of patients, labs, and medications effectively, and patient histories that normally provide context were gone, Irby said.

Contributing to the stress were a handful of chest pain patients who appeared on the board. "I'm flying blind because I can't see anything about them," she said, recalling the confusion over whether these were true heart attack patients or people experiencing anxiety or muscle pain.

"Everything was just a mess and chaotic and moving very slow," she said.

Irby and her staff tried to keep up with everyone, but lost track of some patients who had missed their names being called, or had dropped off the spreadsheet accidentally. The house supervisor couldn't find any more staff, and outside paramedics, from an ambulance company Irby had turned to before, couldn't come in time.

At 10:30 pm, she was due to lose six of the other 11 nurses in the next half hour when their shifts ended.

"We had done all of the things ... and kind of exhausted all the resources that I had available, so I was just [going] ... in my mind, 'How am I going to get extra eyes in the lobby to be able to keep an eye on these people?'"

Irby says she ran out of options after following escalation protocol, so she used a backline number to connect with a 911 dispatcher for Kitsap County. The dispatcher connected her to the fire chief, who sent a crew.

A two-person team arrived and took vital signs in the waiting room, helping to determine if anyone had taken a turn for the worse. Someone had -- and they were able to get them on oxygen. The duo also cleared rooms, changed beds, and moved patients, staying for about an hour and a half until the ED could get back on track, according to Central Kitsap Fire & Rescue.

Building Problems

It was an unusually busy night, but an emergency like this had, Irby said, been a long time coming. She said St. Michael was subject to problems that have been plaguing EDs across the country -- understaffing, boarding, , and the confusion that comes with hospital consolidation and changing management.

"We have a mass paging system that will call and say, 'Hey, we're short-staffed tonight. Hey, we're short staffed today.' And it pretty much runs every day," said Irby. While 10 nurses usually staffed the ED during the day, the night shift would drop to six nurses at 1 a.m., and four at 3 a.m. Irby said she's thought to herself, "Why am I so short staffed, like, did the rapture happen and I missed it?"

When MedPage Today reached out and asked if there were staffing issues leading up to that October 8 night, Chad Melton, the president of St. Michael Medical Center, said in a statement, "Yes, we, like all healthcare organizations, are facing some very real pressures as we adapt to a post pandemic reality that includes ongoing upheaval in our industry."

Melton said that in line with national benchmarks, the nurse ratio in the ED is consistently 1:4, though Irby noted that this ratio does not account for patients in the waiting room, where there had been just one nurse.

Melton also said his hospital "closely reviewed the events that led up to that phone call and determined that our escalation processes were not followed, and hospital leadership did not receive a written or verbal request to go on divert."

Irby said she had followed escalation protocol and requested a divert from her house supervisor, but wasn't sure what happened thereafter.

On top of insufficient staff, the ED was also adjusting to a newer, larger facility. St. Michael had relocated from Bremerton to a building with more capacity in 2020, but there wasn't enough pre-planning on how to adapt ED processes, according to Irby.

"It was like when you move to a new house and you're all kind of trying to figure out where this spatula goes and everybody thinks that it goes in a different spot. It was like that multiplied by 1,000 because everybody had their different ideas about what needed to be in the room," she said.

The hospital itself was changing management frequently.

Catholic Health Initiatives (CHI) acquired the community hospital, then known as Harrison Medical Center, back in 2013. But in 2019, to form CommonSpirit Health, which would run the facility. In 2020, Harrison changed its name to St. Michael Medical Center, with a new parent company, CHI Franciscan, that would answer to CommonSpirit Health. CHI Franciscan then merged with Seattle-based Virginia Mason in January of 2021 to form Virginia Mason Franciscan, which now runs St. Michael.

The hospital is also affected by boarding, a nationwide problem that drew attention last week after the American College of Emergency Physicians (ACEP) sent a about it. "Part of the issue is, we have patients in the hospital who have been in the hospital for a long time, and the only reason that they're in the hospital because there is no place to put them outside of the hospital," Irby said. In a from September, Irby wrote that boarders were in 43 of 50 ED beds, leaving only seven open for incoming patients.

Then there was on CommonSpirit Health, which knocked out Epic for at least 10 days, Irby said. This wasn't an anomaly in a year when healthcare data breaches are averaging -- up from an average of one a month in 2017.

Organizing for Change

Irby's hopeful that conditions at the hospital will shift for the better. Irby said she was surprised at all the attention from her call to the fire department, which has led to actions being taken by the hospital.

She said she is confident in a new director for emergency services, Lori Danko, MSN, DNP, who started out as an ED nurse herself. The previous director, Mike Hastings, had departed following negative press coverage about the October 8 incident.

The local nurses union, UFCW 3000, which had been negotiating for better staffing ratios, pay structure, and employee retention efforts , is petitioning for for Melton and chief nursing officer, Jeanell Rasmussen, MN.

For now, Irby said hospital and union staff are meeting periodically with hospital leadership.

"Those of us that have stayed have stayed because we really have a good group of people," she said. "We're all motivated to make things better. We go to meetings, and we have discussions and we show up on our own time, and we participate in union stuff and we're definitely willing to put in the effort ... We meet management in the middle, and they have to meet us too."

In his statement to MedPage Today, Melton cited a shortage of critical care professionals as a particular challenge for St. Michael, along with a high number of patients presenting to the ED with needs more suited to the urgent or primary care setting.

"We're doing everything we can to alleviate those challenges by listening to our staff and community, redoubling our recruitment and workforce development efforts, bringing in additional travelers to support operations and paying our nursing staff some of the highest rates in the state," he said.

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