Jenifer Logan lost her sister, Jamie Langston, on October 18, 2022.
"She was the funniest person that I think I’ve ever met in person. She was just so, so funny. She could tell a story, and she was sweet and kind and loved animals," said Logan.
Langston was 37-years-old when she died from a pulmonary embolism last year after waiting almost nine hours to be admitted to the hospital in the emergency department at Mercy Springfield, according to her family. Health care professionals at Mercy have told the family that the long wait didn’t contribute to her death.
Long wait times in emergency rooms have become the norm in recent decades. A study last year by Yale University found that the problem of overcrowding in the ER has resulted in negative effects for patients and hospital staff — including higher turnover of clinicians and nurses.
Mercy has taken steps recently to try to address the long wait times patients sometimes experience in the ER.
Jamie Langston's story
Jenifer Logan said she got a call from her sister about 10:30 a.m. on October 18, 2022. Jamie Langston told her she was having trouble breathing. Logan called an ambulance and waited to hear from her sister.
Logan said her sister "texted and said she was at Mercy and that she was in the waiting room in the ER. Finding out that she was in the waiting room, I thought maybe it wasn’t that big of a deal, maybe it was a panic attack or something.”
Langston’s mother, Jeri Hill, said her daughter had been ill for two days at that point but hadn’t sought medical treatment.
At 2:42 p.m., Langston texted her sister that she was still in the waiting room, but she’d had blood drawn, an EKG, a chest x-ray and she was put on oxygen. She hadn’t yet seen a doctor, according to Logan.
Early that evening, Logan said she got a text from her mom letting her know that she was with Langston and that she was still in the waiting room.
Logan texted her sister, “ ‘I am on my way, because clearly something is crazy wrong.’ So, I went there and got there close to 7," she said. "I walked into that waiting room, and it was as crowded as I’ve ever seen. Every seat was full. There were people on the floor sitting all the way up the hallway. I find Jamie, and her lips are blue.”
Logan said Langston was called back around 9 p.m. and finally got a diagnosis of a pulmonary embolism.
Logan and Hill said the treatment administered to Langston was oxygen and blood thinners. Health care workers told them, if that didn't work, they might have to do surgery. The next morning, they said, doctors decided to go ahead with the procedure.
Hill went home to get some items for her daughter. Less than an hour later, around 11 a.m., Hill said she got a call from Mercy letting her know that Langston was in bad shape, and the family should get to the hospital as soon as possible.
The family said, when they arrived, they were told Langston had checked out of the hospital. After asking multiple hospital staff and getting no answers, they said, they found out where Langston was after calling the number back. A staff member took them to Langston.
“And...she takes us through these winding hallways and finally to where they are at," said Logan. "And we go through the doors, and they ask who we are, and we say who we are there for. As soon as I saw the look on her face, I knew it was not okay. And a doctor and two chaplains came out, and I lost it. I hit the floor.”
Hill and Logan said doctors told them Langston’s heart stopped about 20 minutes into the procedure, and she didn’t survive. Hill said doctors told her Langston was in bad shape when she arrived at the hospital, and she should have sought medical treatment sooner than she did.
The family said they were told the long wait time in the ED didn’t affect the outcome. But Logan is upset her sister had to wait so long for care.
“It’s not just, 'oh she’s uncomfortable for a little while and then we are going to see her.' She is spending the last day on earth that she will ever have scared, alone, thirsty, in a crowded room where nobody is paying attention to her. That is not okay," Logan said.
Mercy's response
KSMU talked with multiple sources at Mercy and CoxHealth about the care patients received in the ER during the pandemic. Here’s Mercy Springfield Chief of Nursing Marie Moore’s response to hearing Langston’s story.
“Anytime that events like that or patients and families have experiences like that, that is absolutely not what we want for anyone that comes through our doors," said Moore. "And we have — I would say every situation is a little bit different, and I want to say, too, I hope that they know that is our mission is to care for everyone, their unique needs, and care for the whole person, including their family.”
In response to the family saying they couldn’t find their loved one when they arrived at the hospital, Moore said that's an opportunity for the health care system to implement some better processes for families who are urgently looking for someone admitted to the hospital.
KSMU asked why someone who was seriously ill had to wait hours to receive care. Moore said, “I wasn’t necessarily in the emergency room during that time, so to speak from firsthand experiences can be challenging. But I think that’s a big reason why you may have seen why we’re investing and building another E.R. on the South Campus.”
Moore said, anytime a family doesn’t believe their loved one received the care they feel that person needed, it prompts Mercy to try to do better.
ER wait times
Wait times have always been an issue for hospital emergency departments, according to Dave Dillon with the Missouri Hospital Association, which advocates for policies that improve health and health care in the state, among other things. He said most hospitals with emergency care are required to follow the Emergency Medical treatment and Active Labor Act.
"Hospitals are required to identify, treat and stabilize any individual who comes in through the emergency department,” Dillon said.
Emergency departments are required to follow this regardless of a patient's ability to pay. Dillon said that’s one reason why hospital ERs often have long wait times. Those who are uninsured, he said, might seek care for non-emergency conditions at the ER.
According to the 2020 U.S. Census data, Greene County has an estimated uninsured rate of 11.8% for people under 65-years-old.
Kathryn Patterson, Missouri State University’s nursing program director, also works at MSU’s Care Clinic, which provides free select health services to uninsured individuals. She said episodic care tends to happen in the emergency room.
“It’s not uncommon for me to see a diabetic who is so out of control that they do need to go to the hospital. And when that has to happen, that takes a lot of resources," Patterson said. "So, one of the things that we struggle with, I feel, in our health care system is we are very much still episodic."
Ashley Casad is president of Springfield hospitals and senior vice president of system operations at CoxHealth, and she served as the deputy incident commander during the pandemic. She said the number of patients in their ER actually went down during the pandemic, but patient acuity –- or the severity of illness -- was higher.
“Anytime you have higher acuity levels, chances are that the throughput in the ED [emergency department] — takes longer to take care of those higher acuity levels. Even though our volume was down, it made it feel like the ED was always really, really busy," said Casad.
Mercy said they experienced the same trend in their emergency room during the pandemic.
Casad said, in general, there is a risk when you have long wait times.
“Anytime you see wait times increase in emergency departments, there’s always a chance that it creates safety risks," she said.
Marie Moore, the chief of nursing at Mercy, agreed there is a greater risk when ERs are crowded.
“Anytime that you have maybe an overwhelmed waiting room, the risk is, is that you might miss something in the triage process," said Moore.
Moore said she didn’t know if the risks were higher during the pandemic because “the triage position in the front is one that we always fill. You have to have that there. So, in the pandemic, we didn’t necessarily pull back from having a triage nurse out front to assess patients.”
One of the biggest reasons for the long emergency department wait times during the pandemic, according to both Cox and Mercy, was not enough nurses. According to the Missouri Hospital Association or MHA, staff nurses make up the largest single group of employees in a hospital.
The statewide vacancy rate — meaning employees needed but not filled — for registered nurses was at its highest in 2021 at around 20%, according to the Missouri Hospital Association’s 2023 annual workforce report. It improved slightly in 2022 with a rate of about 17%.
Nurses leaving health care
Ashley Casad said the pandemic was difficult for healthcare workers, "health care providers, nurses, physicians, all of them. Therapists, rad [radiology] techs, lab techs — everyone was stretched really thin.”
According to the same MHA report, the turnover rate for registered nurses in 2021 was about 22%, and it dropped to 19% in 2022.
Marie Moore, Mercy’s chief of nursing, said nurses are typically called to serve. "We went into the profession to care for others. And, I think, especially throughout the pandemic, there was a sense of ‘I feel torn in caring for my family, keeping my family safe and also caring for patients, she said.’ "
A higher than usual turnover was seen nationwide. According to the National Council of State Boards of Nursing, 100,000 nurses left the profession during the pandemic.
A nurse's role
Kathryn Patterson has worked in the nursing profession for nearly 40 years and has served in various leadership roles in hospitals and on nursing boards.
She said the role of the nurse is to be the eyes and ears of a physician and “being there for the patient and making sure they get the care that they need, but, also, a huge part of it is bridging that and helping the families understand what’s going on.”
Patterson said being a nurse requires flexibility and compassion.
“I feel like it’s an honor to be a nurse because you see people at their worst and you see them at their best," she said. "Especially in the emergency, I think one of the most challenging pieces is the unexpected.”
Patterson was not working at the bedside during the pandemic, but she was in the classroom, and she also works at MSU’s care clinic.
Known nursing shortage
Dave Dillon, with the MHA, and Patterson said a decrease in the number of nurses has been anticipated for about a decade.
“The baby boomers were retiring out. There’s a lot of baby boomers, and when you look at the folks that are following us, the numbers are decreased," she said.
Missouri nursing education programs have not been admitting to their full capacity —even before the pandemic, according to the Missouri State Board of Nursing. In an email to KSMU, it blamed open teaching positions, limited budgets and a decrease in clinical site slots for nurses-in-training to get hands-on experience.
Patterson said most nurses believe they need to do it all when it comes to patient care, and, in an understaffed hospital, they are stretched thin.
“As things get cut, a lot of jobs fall to the nurse. So, if you don’t have your laboratory personnel to draw the blood, the nurse can draw the blood. If you don’t have your respiratory therapist to give the breathing treatment, the nurse can give the breathing treatment," she said.
Another reason nurses were leaving during the pandemic was the impact on their mental health, Patterson said.
According to the Centers for Disease Control and Prevention, there were about 1.1 million deaths in America between 2020-2023 due to COVID-19. Hospitals restricted guests — including family — during the pandemic, and nurses were their stand-ins when patients took their last breath.
“There were so many people that were dying and, not only dying, but dying alone. So, what happens is that falls to the nurse, right? So, who’s going to be in there? I don’t think any of us would want to die alone," Patterson said.
Workplace violence
According to a study by the National Center for Biotechnology Information, workplace violence in hospitals increased during the pandemic. The same study reports nurses were victims of physical violence at twice the rate of physicians.
Patterson said the political controversy surrounding COVID-19 also took a toll.
“You had folks that adamantly refused the vaccine, but then when they came in and couldn’t breathe, they wanted the vaccine. And, it’s like, it’s too late," said Patterson.
According to MHA workforce data, nurses didn’t start leaving the field until about a year after the pandemic began. Patterson said the passion nurses had for their jobs appeared to diminish during the pandemic, and “it led to frustration. It led to anger. And they had to push that all down. It leads to guilt, because you don’t want to feel guilty — I mean, it was just this huge emotional PTSD kind of situation that they lived through," she said. "You know, you can only zip up a body bag so many times in a day.”
Taxpayer involvement
In 2011, the Nursing Education Incentive Program was passed by the Missouri General Assembly. It is used to allocate taxpayer money to the Missouri State Board of Nursing to deal with Missouri’s nursing workforce.
This year, the board awarded about $1.8 million to nursing education programs, according to the Missouri State Board of Nursing 2023 report. That is the most it has ever awarded in one fiscal year since 2011.
Additionally, Governor Parson approved $3 million in September of 2022 to the Missouri State Board of Nursing for nursing education program grants.
And the governor's office announced this month that $5 million in grant funding has been approved for 20 Missouri colleges and universities "to continue enhancing nursing education programs statewide."
The 20 competitive grants totaling $5 million were part of a special appropriation to the Missouri State Board of Nursing that was recommended and approved by Governor Parson. The approved grants include:
- $172,760 to Bolivar Technical College
- $165,590 to College of the Ozarks
- $211,855 to Crowder College
- $159,856 to Lincoln University
- $227,000 to Maryville University
- $441,405 to Missouri Baptist University
- $394,772 to Missouri State University
- $532,944 to Missouri State University - West Plains
- $386,780 to Missouri Western State University
- $198,000 to North Central Missouri College
- $147,500 to Northwest Missouri State University
- $135,563 to Research College of Nursing
- $293,400 to St. Charles Community College
- $99,704 to St. Louis University
- $450,000 to St. Luke’s College - Rockhurst University
- $150,000 to Truman State University
- $256,875 to University of Central Missouri
- $285,996 to University of Missouri - Columbia
- $150,000 to University of Missouri - Kansas City
- $140,000 to William Jewell University
The nursing programs that were awarded funds will provide scholarships and tuition assistance for nursing faculty, clinical simulation equipment and staffing, technology enhancements, faculty pay increases, nursing faculty professional development, and graduate nursing program development to educate more nursing faculty, according to Parson's Office.
Pandemic highlights need for change in nursing education
Patterson said the pandemic highlighted a need for change in nursing education.
“We have learned that soft skills are incredibly important. Focusing on the nurses’ well-being is incredibly important and better preparing them for some of that emotional turmoil. It’s not really just about the tasks and learning the science," said Patterson.
She said nursing programs are pushing for hands-on experience earlier in programs and encouraging students to get part-time jobs in healthcare during their studies.
She also said she’s hopeful for the future of nursing education.
Changes in the nursing profession
Having enough staff to handle all of the patients coming to an emergency room for care is critical.
According to the Missouri Hospital Association’s 2023 Workforce Report, the registered nurse turnover and vacancy rates were at their peak in 2021. The latest vacancy rates for 2022 are about 19%, whereas pre-pandemic levels sat around the mid-teens.
Hospitals are recognizing the need for registered nurses to work at the top of their skill set.
Marie Moore, Mercy’s chief of nursing, said, pre-pandemic, it was typical for an RN to handle tasks that someone with less certification could do.
"Twenty years ago, nurses were doing patient baths. We were taking out the trash. We were caring for the whole care environment. So, we kind of saw a little bit of that shift in the profession before," Moore said. "During the pandemic, I would say there was a need to expand nursing resources.”
The MHA's Dave Dillon said, historically, hospitals have preferred to employ registered nurses because they have a wider skill set. For example, both a nurse assistant and an RN can change a bedpan, but a registered nurse can administer a catheter.
Ashley Casad, president of the Springfield Hospital Group for Cox, said, to deal with low nursing numbers during the pandemic, CoxHealth began thinking of how to make an RN’s job more manageable.
“We started really figuring out what is time that maybe RNs are spending doing something that you don’t need an RN to be doing," she said. "Maybe someone who is a college student working part time can go help move things, move papers between areas or take patient back to different parts of the hospital."
During the pandemic, Cox and Mercy said they began offering additional mental health resources to employees.
Urgent care
Again, one reason for longer wait times in local ERs during the pandemic was the fact that both Mercy and Cox ERs treated higher acuity patients. Casad said sicker patients take longer to treat.
She said, "people got where they were waiting until they felt awful and were really nervous that it was something more major. So, then they would come and it would have turned into something that, if it would have been dealt with weeks earlier, wouldn’t have been as challenging.”
She pointed out that urgent care clinics fill a need for patients who aren’t as sick.
However, that may not be an option for uninsured people, as the ER legally has to treat anyone who comes in, regardless of ability to pay. Urgent care is not subject to the same law.
The solution to that is preventative care and education, such as having a primary care physician, Patterson said. But, even if one has access to a PCP, she said it’s still not always easy to receive care. She points to mental health services.
“There’s no beds or there’s no services or there’s no meds, and to try to get them into a psychiatrist. Six months? Eight months? A year? That’s a long time for them to have to live with that," Patterson said.
Lasting changes
Marie Moore said the pandemic required health systems to provide alternative forms of care, and she said those are sticking around.
“If there are alternatives of helping to support patients in the community, such as primary care access or GoHealth or urgent care access, that’s what we want to invest in, too. And, be able to provide some advanced procedures in the community versus having to come to the hospital," Moore said.
Casad said Cox is also providing alternative forms of care.
And Mercy is building a second emergency room – on Springfield’s southeast side, which it hopes will decrease wait times.
The health care system held a groundbreaking on October 6, and Devin Boss, who will be the medical director of the new facility, spoke to KSMU.
"We already lack space, and it’s been a challenge to meet the needs of our community. This new facility, hopefully, will add to our capacity to be able to care for more patients," said Boss.
Casad said the pandemic created a sense of urgency for hospitals.
“In general, we’ve seen the health care system realize we can move much quicker than what we have historically," she said. "And, so I think that’s a change that is going to stick with us."
Both Cox and Mercy said the pandemic brought on many challenges, and both agree it had a lasting impact on emergency care and health care in southwest Missouri.
Jenifer Logan's response
Jenifer Logan, Jamie Langston's sister, said the family is doing okay, the holidays have been hard, but they are leaning on each other to cope with their loss.
“I understand that the pandemic has made things difficult for many different industries, health care especially. I understand the nurse shortage has been a problem," said Logan. "I’m optimistic that they are at least working on it, that they recognize that there is a problem, and they realized that they do need to fix it.”
