The rapidly escalating surge in COVID-19 infections across the U.S. has caused a shortage of nurses and other front-line staff in virus hotspots that can no longer keep up with the flood of unvaccinated patients and are losing workers to burnout and lucrative out-of-state temporary gigs.

Florida, Arkansas and Louisiana all have more people hospitalized with COVID-19 than any other point in the pandemic, and nursing staff is being stretched thin.

In Florida, COVID-19 cases have filled so many hospital beds that ambulance services and fire departments are straining to respond to emergencies. Some patients wait inside ambulances for up to an hour before hospitals in St. Petersburg, Florida, can admit them — a process that usually takes about 15 minutes, Pinellas County Administrator Barry Burton said.

One person who suffered a heart attack was bounced from six hospitals before finding an emergency room in New Orleans that could take him in, said Joe Kanter, Louisiana’s chief public health officer.

“It’s a real dire situation,” Kanter said. “There’s just not enough qualified staff in the state right now to care for all these patients.”

Miami’s Jackson Memorial Health System, Florida’s largest medical provider, has been losing nurses to staffing agencies, other hospitals and pandemic burnout, executive vice president Julie Staub said. The hospital’s CEO says nurses are being lured away to jobs in other states at double and triple the salary.

Staub said its hospitals have started paying retention bonuses to nurses who agree to stay with the system for a set period. To cover shortages, nurses who agree to work extra are getting the typical time-and-a-half for overtime plus $500 per additional 12-hour shift. Even with that, the hospital still has to sometimes turn to agencies itself to fill openings.

“You are seeing folks chase the dollars,” Staub said. “If they have the flexibility to pick up and go somewhere else and live for a week, months, whatever and make more money, it is a very enticing thing to do. I think every health care system is facing that.”

Texas Gov. Greg Abbott on Monday directed state officials to use staffing agencies to find additional medical staff from beyond the state’s borders as the delta variant overwhelms its present staffing resources. He also has sent a letter to the Texas Hospital Association to request that hospitals postpone all elective medical procedures voluntarily.

The U.S. is averaging more than 116,000 new coronavirus infections a day along with about 50,000 hospitalizations, levels not experienced since the winter surge. Unlike other points in the pandemic, hospitals now have more non-COVID patients for everything from car accidents to surgeries that were postponed during the outbreak.

That has put even more burden on nurses who were already fatigued after dealing with constant death among patients and illnesses in their ranks.

“Anecdotally, I’m seeing more and more nurses say, ‘I’m leaving, I’ve had enough,’” said Gerard Brogan, director of nursing practice with National Nurses United, an umbrella organization of nurses unions across the U.S. “’The risk to me and my family is just too much.’”

COVID-19 hospitalizations have now surpassed the pandemic’s worst previous surge in Florida, with no signs of letting up, setting a record of 13,600 on Monday, according to the U.S. Department of Health and Human Services. More than 2,800 required intensive care. At the height of last year’s summer surge, there were more than 10,170 COVID-19 hospitalizations.

At Westside Regional Medical Center in Plantation, Florida, the number of COVID patients has been doubling each week for the past month, wearing down the already-short staff, said Penny Ceasar, who handles admissions there.

The hospital has converted overflow areas to accommodate the rise in COVID admissions. Some staffers have fallen ill with COVID-19.

“It’s just hard. We’re just tired. I just want this thing over,” Ceasar said.