Reflecting on pandemic five years later, Maui hospital officials say crisis prepared them for fires, future emergencies

On the night of Aug. 8, 2023, staff at Maui Memorial Medical Center braced for an influx of patients from the wildfire in Lahaina.

Expecting mass casualties, they discharged patients to nearby Hale Makua to free up beds, made plans to transfer potential burn patients and kept the night shift on until they knew how many wounded were coming in the morning after the fire. The 10 patients who arrived in the first wave, they thought, were likely just the start.

But the fire burned so hot and so fast that there were few major injuries — most people had either escaped or died. The hospital was never overrun. Instead, hospital leaders shifted to setting up a temporary community clinic on the west side of Maui.  

The fire was an early test of Maui Health’s preparation to respond to a mass emergency in the wake of the COVID-19 pandemic. Hospital officials say the lessons they learned and the connections they made with other health care facilities in the pandemic was crucial after the fire.

“I think now we understand how important communication is in situations like this, and I think the fires were a perfect example,” said Dr. Michael Shea, chief medical director for Maui Health. “When this hit, we knew exactly how to run an emergency operations center because we ran one for over two years (during the pandemic).”

Five years after the first case of COVID-19 arrived in Maui County in the spring of 2020, the back-to-back crises of the pandemic and the fires have put an unprecedented strain on local health care workers and resources.

And while the data show the decline in health care staffing has improved since the start of the pandemic — bolstered by the hiring of local graduates and career advancement programs for current employees — there are still critical gaps and a growing risk of more people leaving the islands.

COVID now is manageable. During the week ending April 2, there were just 50 total cases in Hawaiʻi, including six in Maui County. Statewide, only eight patients were hospitalized for COVID, with one in the ICU.

That’s a drastic change from the early years of the pandemic, which began in the spring of 2020 when the first case of COVID was reported in Hawai‘i. At one point in January 2022, there were more than 2,400 patients hospitalized with COVID.

In those early days of the pandemic, Maui Health faced plenty of criticism — from workers who disagreed with policies and felt management wasn’t communicating with staff, and from community members who said the hospital wasn’t being transparent or doing enough to stop the clusters of cases at the hospital. Policies on masks and other protocols kept changing.

Looking back, Shea said that recommendations from the Centers for Disease Control were changing daily, and hospital management shared what it knew at the time. He acknowledged that the changing messaging “led to fear and mistrust and confusion,” but that they worked to improve through more frequent updates and town halls. 

“We did not do a good job of communicating, and we learned from that,” Shea said.

After the crises of the past few years, Shea said Maui Health “would respond much better” to other potential health issues like the rise of bird flu and measles, which are much more familiar diseases. 

Just on Tuesday, Hawaiʻi Gov. Josh Green signed emergency rules to help prevent a measles outbreak in the state after there was a confirmed case of an unvaccinated 5-year-old on Oʻahu.

Leadership at the hospital has changed since the start of the pandemic, most notably at the top where CEO Lynn Fulton took over for the retiring Mike Rembis at the start of 2024. Marian Horikawa-Barth, a veteran Maui Memorial nurse who was named chief nurse executive in 2021, pointed out that every health official in the country now comes with experience in a global health crisis. 

If a disease broke out now, Horikawa-Barth said Maui Health would first open a command center and gather its team of leaders to look at the situation and make a plan for clinical care and other support services, as well as communication. 

She said if they could change anything moving forward, it would be to listen and communicate more with the frontline staff who felt they weren’t heard during COVID. 

“We want them to speak up,” she said.

Crucially, the pandemic also gave Maui Health experience running community clinics due to the vaccination clinics that ran for months during COVID. After the fire, Maui Health set up a temporary community clinic on the west side to treat injuries and offer resources to shellshocked fire survivors.

The connections they made with other health care organizations during the pandemic proved vital during this time. Hospitals around the state dispatched volunteers when Horikawa-Barth reached out to a group of fellow nursing executives. Air ambulance services sent over an extra plane. The Queen’s Health System brought over behavioral health resources to support local providers. If they needed something, they could call somebody, Horikawa-Barth said. 

Shea said the importance of behavioral health resources was another lesson of the pandemic, as the community was once again reeling from widespread trauma after the fire.

The impacts also hit home for Maui Health’s workforce, with 29 hospital employees losing everything in the fire. Maui Health Foundation recently received a grant to build more transitional housing for the displaced employees.

Retaining workers after the pandemic and the fire is an even greater challenge as the loss of housing and jobs is pushing more people to leave the state, according to a UH Economic Research Organization analysis released in January. 

In the health care industry, the pandemic accelerated retirement for many older workers who were near the end of their careers, said Hilton Raethel, president and CEO of the Healthcare Association of Hawai‘i.

In 2019, the year before the pandemic, a report by the association found that 10% of health care positions statewide, not counting physicians, were unfilled.

By 2022, two years into the pandemic, that vacancy rate had grown to 17%, and overall annual turnover had risen from 16% in 2019 to 20% in 2022. 

The situation was worse in Maui County. Lāna‘i’s health care facilities had the largest percentage of openings in the state at 48%, followed by Maui at 36% and Moloka‘i at 22%.

“We lost a lot of experienced nurses and other health care professionals in the first 12 months of the pandemic,” said Hilton Raethel, president and CEO of the Healthcare Association of Hawai‘i. “And that, along with the increased demand on our hospitals and health care delivery system, created a significantly increased demand for workers.”

By 2024, the numbers had improved somewhat, with the statewide vacancy rate dropping to 14%. Lāna‘i’s vacancy rate fell but was still the highest in the state at 32%. Maui’s vacancy rate improved to 15%, while Moloka‘i’s dropped to 14%.

The scope of the association’s report has grown each year, and 2024 was the largest, based on responses from 119 organizations. Their findings don’t represent 100% of Hawai‘i’s health care industry, but they help show the needs across the majority of the workforce, the report said. 

Raethel attributes the improvements in recent years to better recruitment and relationships between the health care and educational systems, which was in the works before the pandemic but grew even more vital during the crisis. 

Years ago, Raethel said, hospitals were reluctant to hire new graduates, preferring they got some experience first. Now, there is more of a push to hire new grads, especially ones who are from the islands and more likely to stay long term. 

“There were some things that we were doing as an industry that wasn’t conducive to really supporting or growing our own workforce,” Raethel said. “So we’ve learned a lot during the pandemic.” 

Raethel pointed to programs like the CNA to LPN Bridge Program, launched in 2023 as a partnership between UH-Maui College, Hale Makua Health Services and Ohana Pacific Health. The 12-month hybrid program allows certified nursing assistants — an entry-level position with high turnover — to continue working while they train to become licensed practical nurses with a bump in pay. 

That same year, UH-Maui, Kaiser Permanente and UNITE Here! Local 5 union launched the Practical Nurse Trainee Program, an 18-month program for current Kaiser employees. 

Early results suggest they’re working. In 2022, Maui had 31 of 79 licensed practical nurse positions unfilled, or 39%. By 2024, that dropped to 26 of 106 positions, or 25%.

At Maui Health, Shea said the organization tries to hire the entire nursing class from UH-Maui every year, and their Nurse Residency Program helps new graduates transition to the hospital setting and train in specialties so they can care for higher-acuity patients.

“There was an exodus of people right after the pandemic,” Shea said. “Because anyone who was close to retirement age, a lot of people said, ‘Why am I doing this? I’m done.’ And they walked. And that’s nurses, physicians, surgical techs, everywhere. It was no one particular population. And so staffing was challenging. And I think over the last several years, because we keep hiring as many of the graduate nurses that we can, we’ve built up a new cadre of people.”

In Maui Memorial’s obstetrics department, longtime nurse Leimomi Melamai said that 10 of the estimated 50 current staff are new grads. While this involves some learning curves, Melamai said the new hires have “beefed up” staffing levels following several departures in the years after Kaiser took over operations of Maui Memorial, Kula Hospital and Lāna‘i Community Hospital in 2017. She estimated that their unit lost about 15 nurses over a span of three to five years.

Melamai said she didn’t feel overworked during the pandemic — “not physically, maybe mentally” — but that there were times when staffing levels got so low that the hospital called back COVID-positive workers before the end of the 10-day isolation period recommended in the early days. 

When asked about that, Shea said in general, people who were sick were told to stay home. But if some areas were understaffed or only one person could provide a specific skillset, such as neurosurgery, Centers for Disease Control protocols at one point allowed them to come back to work in the appropriate personal protective equipment if their fever had been gone for 24 hours and their symptoms were improving. He said it was rare and they did it “less than five times.”

While the data show improvements, shortstaffing remains an issue for employees, who raised concerns over changing patient-to-employee ratios in the hospital that they said were putting workers and patients at risk. In December, the union that represents over 900 employees at the three Maui Health hospitals went on strike for three days while contract talks stalled.

Shea explained that before, the hospital used to be fully staffed regardless of whether it was at full patient capacity. Now that the hospital census is lower, they adjust staffing ratios based on the number of patients, which they never did in the past. That’s why some workers may feel their workload is increasing, Shea said.

Maui County also still has a ways to go to address its physician shortage. Like other positions, the number of physicians in Hawai‘i followed a similar trend — dipping during the first years of the pandemic before improving in more recent years. In 2019, there were 2,974 full-time physicians statewide. That number fell to 2,812 in 2020 but has steadily climbed back up to 3,075 in 2024, according to the University of Hawai‘i’s annual report. Maui County’s shortage of 174 physicians, or 41%, was the worst in the state.  

Raethel said the cost of living, particularly housing, remains “one of the single biggest factors” impacting the state’s ability to attract health care workers. If people can’t see a path to homeownership, it’s hard to get them to stay. 

“It’s more important than ever that we’re getting as many people in the workforce as we can, especially after the pandemic and then something like the wildfire,” Raethel said. 

The fire, which destroyed a Kaiser Permanente clinic and damaged a Maui Medical Group clinic in West Maui, “impacted the health care system more from the personnel side in that people got displaced,” Raethel said.

“It put a real stress on the system in the short term,” Raethel said. “But the long-term impact, you know, was more psychological. … Even though physically they could go back to work, they weren’t psychologically ready to go back to work. And those effects still linger.”

That’s perhaps one of the biggest changes to the health care workforce after the crises of the last few years. During the pandemic, Shea remembers having a conversation with his wife about getting paperwork drawn up should anything happen to him. 

“I think it changed health care workers’ perspective on what our patients go through,” Shea said. “I think it really helped us understand our own mortality. And I think in some ways that was good, but also in some ways it’s really made health care more challenging these days.”