U.S. healthcare systems are struggling to stay financially afloat and are lacking in equipment necessary to combat and protect themselves against the growing COVID-19 crisis.

The pandemic has pushed a number of hospitals to the brink of exhausting what’s left of their financial resolve as the need to pay additional staff members, social distancing mandates and cutbacks in elective procedures continue to shrink revenues intended for operations. Administrators, clinicians and nurses are urging the government to provide federal aid for purchasing equipment to help treat patients, as well as personal protective equipment (PPE) to protect staff members from becoming infected, according to the American Hospital Association.

“We’re trying to figure out how to stay in business,” said Scott Graham, CEO of Three Rivers and North Valley Hospitals in rural Washington state, at an AHA press briefing on Saturday. “The revenue that typically comes in that we need to cover the cost of operating has dried up. We are now in a negative cash position and are using credit. We will exhaust all avenues to make payroll in the next three or four weeks.”

The effect is also being felt in urban areas, according to LaRay Brown, president and CEO of One Brooklyn Health System in New York. Prior to the outbreak, her practice was relying on more than $20 million a month from New York State to keep its safety net hospitals open.

“We are now looking at an additional cost of $30-$34 million a month from projected staff increases to cover surge capacity” she said, adding that replacing staff who are on furlough, self-isolating or caring for their children while city schools are closed has added to the exacerbation brought by the crisis.

A nationwide survey of more than 6,500 nurses conducted earlier this month by the union National Nurses United found the majority of U.S. health systems were ill-equipped to handle and contain the spread of COVID-19. A follow-up this week of more than 8,200 nurses from all 50 states, Puerto Rico, the Marshall Islands and Virgin Islands found little change, and even a worsening of conditions regarding the availability and supply of personal protection equipment (PPE) for a surge in patients — a very highly expected outcome.

Of respondents, only 55% reported having access to N95 respirators on their units, and 27% had access to power air-purifying respirators. Just 24% reported that their employer had sufficient PPE stock on hand to protect staff in case of a surge in coronavirus patients, and only 31% reported a plan in place to isolate patients with a possible COVID-19 infection. Twenty-three percent said their practice had no plan in place, and only 63% said they were trained in the last year on how to put on and remove PPE safely.

“Clearly, the nation’s health facilities are still not ready, and are in even worse shape than before in some respects, to handle COVID-19,” said Bonnie Castillo, RN and executive director of National Nurses United, in a statement. “We need to act now and act fast. Priority number one is to protect the health and safety of our nurses and health care workers so that they can continue to take care of patients and keep our communities as healthy as possible through this pandemic.”

The union recommends that local, state and federal government enact policies that expand bed capacity, reopen closed hospitals, build additional facilities, and work with the healthcare industry to immediately begin manufacturing PPE equipment, rather than roll back infection control and worker protection standards to offset the shortage in PPE supplies. “That’s not how proper infection control works,” Zenei Cortez, RN and a president of NNU, said in a statement. "You maintain those standards, and figure out a way to get the equipment you need.”

The AHA, along with the American Medical Association and American Nurses Association, has also called for the government to step up, calling for congressional leaders on Thursday to provide $100 billion to equip frontline healthcare personnel and staff with necessary resources and to offset financial woes. They additionally emphasized the need for enough tests and for results to be returned quickly in order to have a more accurate view of the infection rate.

“We’ve already seen facilities facing shortages of needed equipment and high expenses in providing critical care, and this hurts our country’s ability to respond,” said AHA President and CEO Rick Pollack at the AHA press briefing. “The reality is that we are in a war in which hospitals and health systems are on the front lines and our health care workers are putting their lives on the line to fight this battle … No one ever sends their troops into battle without the right protection and ammunition and tools.”