Nurses tackle a challenge exacerbated by the pandemic.

Bed shortages remain a concern in hospitals across the country. Washington, the 18th largest state in the nation, has the fewest beds per capita. In 2023, according to the Washington State Hospital Association, Washington had an estimated population of 7.8 million, with about 19% of residents living in rural areas.

The state has 95 hospitals, 39 of which are critical access hospitals with limited or no specialty services. Critical access hospitals, located in more rural areas of the state, have limited resources due to their small size, and most have no affiliation with larger hospital systems. Many patients require a higher level of care or specialty service not offered locally.

Traditionally, patients who required a higher level of care or specialty service not offered at the critical access hospital were quickly transferred to the nearest larger hospital or tertiary center. However, since the COVID-19 pandemic, most of Washington’s larger hospitals and tertiary centers operate well above daily capacity. These conditions lead to smaller hospitals facing significant delays in transferring patients. These long delays in care contribute to overcrowding in emergency departments (EDs) and inpatient areas, and many patients who aren’t critically ill wait days or even weeks before transferring to a facility that can provide necessary care.

How did Washington respond to the COVID-19 bed shortage?

Before the pandemic, when a care team determined that a patient’s medical needs couldn’t be met or the patient would be better served at another facility, they contacted a larger hospital to coordinate the transfer process. This simply involved making a few phone calls to a transfer center or house supervisor and connecting physicians to facilitate the transfer. However, the current critical bed shortage leaves limited or no availability to accept incoming patient transfers. Most facilities remain overwhelmed with patients from within their own hospital system and can’t accept patient transfers from unaffiliated hospitals as readily as they had before the pandemic.

In response to the pandemic bed shortage crisis, the Washington Medical Coordination Center (WMCC) formed as a collaboration between the Disaster Medical Coordination Center at Harborview Medical Center and the Northwest Healthcare Response Network. The WMCC, which isn’t a transfer center, serves as a statewide system designed to expedite the patient transfer process, load balance patients throughout the state, and provide equitable access to care.

Minnesota and Arizona established similar centers during the pandemic. The Administration for Strategic Preparedness and Response, an arm of the U.S. Department of Health and Human Services, considers these state systems Medical Operations Coordination Centers; each state has different operating procedures.

What’s the WMCC process?

The WMCC serves any hospital in Washington and assists with coordinating placement for patients who require any level of care, giving the highest priority to critically ill patients. Currently, the WMCC doesn’t facilitate the placement of patients who need primarily psychiatric care or those from hospitals outside of the state. Most requests come for patients in EDs within hospitals that lack specialty care or are at overcapacity and can’t place patients.

When a facility can’t find placement for a patient through the usual procedures, they call the WMCC, which is staffed 24 hours a day, 7 days a week by RNs with experience in critical care or emergency nursing. An RN completes an intake, communicates with the physician, and collects key patient information such as diagnosis and history, vital signs, relevant labs and diagnostic imaging results, current medications, drips, level of care, and specialty services needed. Based on this information, the RN triages the patient.

WMCC nurses have access to statewide data on bed availability and remain in constant contact with transfer centers and house supervisors at hospitals across the state. They stay apprised of staffing issues, gaps in specialty service coverage, and situational updates across the state. The WMCC attempts to load balance by not overwhelming one facility or healthcare system with multiple patients at once.

WMCC nurses take a big-picture perspective of patient placement. Individual facilities focus on their own hospital or hospital system’s bed situation, but the WMCC monitors hospitals’ capacity across the entire state. Most smaller facilities and critical access hospitals immediately call the closest large tertiary center when searching for bed placement, regardless of the specific needs. The WMCC considers whether alternative solutions exist and may know of a facility with the necessary services to accommodate a patient’s specific needs while conserving bed resources in tertiary centers for the most medically complex patients.

Washington State residents who live in rural communities experience unique disparities in care access. The WMCC seeks to ensure these patients receive timely necessary care.

What are the benefits of WMCC?

The WMCC serves as a statewide resource, sup­porting smaller and rural hospitals with limited support. In small critical access hospitals, nurses must take on administrative tasks related to patient placement, including multiple phone calls, form completion, and transportation arrangements. These tasks take nurses away from their number one priority—providing safe, high-quality patient care.

Holding patients in facilities for extended periods while waiting for placement contributes to hospital overcrowding, a lack of beds for incoming patients, and increased nurse–patient ratios. These conditions can leave nurses unable to provide optimal care because they’re overwhelmed with increased patient loads and high-acuity patients.

Allowing nurses to care for patients without proper resources, support, equipment, or training puts them in compromising situations. For example, a nurse caring for a patient needing emergent dialysis in a facility with no dialysis capability has limited interventions they can perform. The nurse recognizes that the patient’s outcome depends on how quickly they have access to necessary care. Placing nurses in these situations can result in moral distress.

Nationwide, nurses continue to struggle with short-staffing, increased workloads, and high nurse–patient ratios, which all contribute to burnout. In a 2020 survey conducted by the American Nurses Association, 62% of nurse respondents reported experiencing burnout.

The WMCC works behind the scenes to support nurses working at the bedside in a strained system. When a nurse understands their facility’s capabilities and limitations, they may immediately contact the WMCC when they identify a medical need that can’t be met. Ultimately, this prompt action can help reduce delays in care, decrease a patient’s length of stay, and improve outcomes. The WMCC serves as an extra set of hands. The staff work to expedite the transfer of patients to the care they need while also alleviating some of the nurse workload during the search for placement and offering moral support.

Ideally, all patients should receive necessary medical care promptly and in relatively close proximity to home. Washington comprises 71,300 square miles of land with several large mountain ranges. Transferring a patient across the state solely because of an available bed isn’t necessarily in the patient’s best interest. Moving a patient across the state may prevent family support during their hospitalization, and transportation or weather may present an obstacle when planning to discharge home. These delayed discharges contribute to the bed shortage. The WMCC works strategically to find the most appropriate placement for a patient while meeting their medical needs and bearing in mind geographic considerations.

The WMCC receives more than 2,000 requests annually. The COVID-19 Delta and Omicron surges of July 2021 to May 2022 caused significant patient placement challenges. (See WMCC call data.)

Can other states establish coordination centers?

All nurses use the same process—assessment, diagnosis, planning, implementation, and evaluation. The WMCC uses those same five steps as a foundation for guiding its practice. Other states that want to create coordination centers should consider taking the same approach.

Assessment

The WMCC assesses the statewide bed situation, staying apprised of any situational updates, including inclement weather, natural disasters, current public health concerns, or issues that impact the daily operations and patient care in hospitals and healthcare systems statewide.

Diagnosis

A nursing diagnosis is determined based on a larger community overview. This requires determining and addressing the needs of patients and communities from a statewide perspective to guide the plan of care and develop a response. For example, Mr. Tom Johnson* has a history of hypertension and diabetes and receives outpatient hemodialysis three times a week. He arrives at Hospital A with chest pain. After completing the patient assessment, the provider, Dr. Fern Martin, determines that Mr. Johnson requires admission and a cardiac catheterization procedure. In addition, he’ll need his routine dialysis run in 2 days. However, Hospital A, a critical access hospital, has no cardiology, interventional radiology, or dialysis services. Hospital A has followed and exhausted its usual procedures for finding alternative placement for Mr. Johnson. Hospital A calls the WMCC for assistance.

Planning (and outcomes)

Nursing assessment and diagnosis plays a role in determining outcomes. The established plan aims to achieve the desired goal. Peter, the WMCC nurse, speaks with Dr. Martin and collects vital information about Mr. Johnson’s condition and the specialty services needed. Peter then contacts facilities with the necessary resources to search for a bed opening.

Implementation

The plan is executed. When Peter locates an appropriate accepting hospital, the sending and accepting facilities communicate directly to discuss handoff care.

Evaluation

The WMCC tracks data and routinely analyzes and reevaluates it to determine whether goals related to serving patients across the state have been met. This procedure helps identify where WMCC can make process improvements. The WMCC, which launched in 2020 in response to the COVID-19 pandemic, continues to evolve, and the team regularly re-evaluates processes and makes necessary adjustments to meet statewide community needs.

Learn from our experience

As nurses representing the WMCC, we hope to educate nurses and leaders from other states about our program. We want to help them learn from our experience and develop similar programs to facilitate equitable care access, help minimize delays, establish load balance, improve patient outcomes, and benefit nurses. Although the WMCC isn’t an end solution to the greater healthcare system issues, it serves as a framework to help alleviate pressure, support nursing staff, and improve outcomes for patients throughout the state.

*Names are fictitious.

The authors are nurses at Harborview Medical Center in Seattle, Washington.

American Nurse Journal. 2025; 20(1). Doi: 10.51256/ANJ012553

References

American Nurses Association. What is nurse burnout? How to prevent it. April 25, 2024. nursingworld.org/content-hub/resources/workplace/what-is-nurse-burnout-how-to-prevent-it

American Nurses Association. What is nursing? nursingworld.org/practice-policy/workforce/what-is-nursing

KFF. State health facts: Total hospital beds. 2022. bit.ly/40DgCUm

Mitchell SH, Rigler J, Baum K. Regional transfer coordination and hospital load balancing during COVID-19 surges. JAMA Health Forum. 2022;3(2):e215048. doi:10.1001/jamahealthforum.2021.5048

Washington Medical Coordination Center. Washington Medical Coordination Center Data. Seattle, Washington. January 2024.

Washington State Health. Rural health systems. bit.ly/4hvXWMl

Washington State Hospital Association. Health inequities in rural communities. March 16, 2017. bit.ly/4hG9ywm

Key words: bed shortages, patient placement, patient transfer