Before the pandemic, South Shore Health typically would receive 80 to 90 ambulances a day as the region’s only Level II trauma center south of Boston, caring for critically injured patients from a number of communities.
Yet 2½ years into the pandemic, with COVID numbers at the hospital trending much lower than in the January surge, the number of ambulances arriving every day is far exceeding its old pace. Dr. Jason Tracy, chief of emergency medicine at South Shore Health, said the emergency department is getting 105 ambulances a day on average.
On a particularly bad day two weeks ago, there were 165 patients in its 70-bed emergency department. While over the course of a single day the emergency room would normally see 280 patients, on average, two weeks ago it had nearly 380.
COVID cases account for some of the emergency department’s volume, but the hospital is also dealing with “a constellation of factors,” Tracy said, which range from sicker patients who delayed care during the pandemic and an unprecedented volume of behavioral health patients, to people who are having trouble accessing more mundane services like MRIs.
“We would have expected the spring/early summer to be a low volume period of time. It’s turned out to be our busiest. Which has us worried,” said Tracy. The summer is usually the busiest time for the South Shore hospital, and “if we continue to have additional volume on top of our current volume, it will be even more challenging.”
The overcrowding is not unique to South Shore. Scores of health systems say they are dealing with record emergency department volume, sicker patients, a compounding mental health crisis, and an ever-beleaguered workforce.
“It’s absolutely unrelenting — people coming, sick people coming, and people who aren’t that sick showing up in the ER more so than usual,” said Dr. Andrew Artenstein, chief physician executive for Baystate Health, which runs the largest hospital in Western Massachusetts. “This time of year you expect [that around] Memorial Day you get a relief.”
Executives say patients are coming in to emergency departments because they can’t access primary care or mental health care, or have seen their health deteriorate after delaying treatment for illnesses earlier in the pandemic. Hospitals are having a hard time discharging patients who should not go directly home, due to staffing shortages and longer stays at nursing homes and rehabilitation centers. And the strains on inpatient care ripple all the way to the emergency department.
The ripples extend even further: Hospitals that care for the sickest patients sometimes have have to decline patient transfer requests from smaller or less wealthy ones, leaving the latter institutions to scramble for alternatives.
“What we’re seeing across the whole health care system is there is still more demand for care than there ever has been,” said Dr. Paul Biddinger, chief preparedness and continuity officer for Mass General Brigham.
The tidal wave of illness comes just as COVID cases have become less of a burden for hospitals. Two-thirds of COVID patients currently in Massachusetts hospitals would have been there regardless of their infection because of other health issues. Though it has caused fewer cases of serious illness in recent weeks, COVID has complicated hospital operations. Patients with COVID still need to be isolated, and staff caring for them have to wear personal protective equipment, both of which eat up more time and resources.
Biddinger said Massachusetts General Hospital has hit “capacity disaster” more times in the last three months than it ever had before. The designation means the hospital’s usual actions to alleviate crowding, such as mobilizing teams to manage capacity and not accepting most new patient transfers, are insufficient. While he didn’t provide specifics, Biddinger said the hospital has set new patient volume records that were 10 percent higher than previous records.
Biddinger said the consequences go beyond just patients receiving care in ER hallways, or waiting longer to be seen. Studies have shown that patients who need to be admitted, but are waiting in the emergency department for a bed — a phenomenon known as boarding — end up in the hospital longer than patients who receive inpatient care more quickly.
“There are significant patient care consequences to this,” Biddinger said.
The health system is bolstering its programs that manage capacity among its nine acute-care hospitals to identify which have availability for new patients and transfers, and it is also trying to shift more care to the home.
Similarly, South Shore Health is also trying to persuade people to use primary care and urgent care locations for less-serious illnesses. The health system is also pushing more use of its services to treat patients at home.
Hospitals are confronting a simultaneous challenge: rising demand for behavioral health services. Tracy recalled that on one recent day there were 50 behavioral health patients in South Shore’s 70-bed emergency department. Multiple children have spent “a number of weeks” in the hospital’s emergency department, waiting for a place that could take them.
“When the entire system is over capacity and we’re unable to move people out of the ED, whether medical patients or behavioral health patients, that leads to increased boarding and boarding times overall for patients waiting for beds,” Tracy said.
At Lawrence General Hospital, there are typically 8 to 10 patients waiting for behavioral health care placement at another facility, some of whom wait for over a month. They and medical patients who are waiting to be admitted combine to claim 75 percent of the 41 beds in the hospital’s emergency department, said chief executive Deb Wilson.
The higher demand comes as hospitals struggle with staffing shortages, Wilson said. As a result, there are between 15 and 20 people in the waiting room at any given time, and wait times to be seen by an ER staffer have exceeded four hours. The percentage of people who leave the emergency department without being seen has also increased. Patients are often forced to wait on stretchers in hallways before they can be admitted.
“I often ask my peers, do you think there is an awareness in the public of how strained our health care system is? The answer is always no,” Wilson said.
Tufts Medical Center also said it has hit “Code Help” more times in the last month than in the past. The code signifies the hospital may have difficulty caring for the next critically ill patient, and requires administrators to be more strategic about which transfers they accept.
“When we’re there, other academic medical centers in Boston are in the same situation,” said Dr. Brien Barnewolt, chairman and chief of emergency medicine at Tufts.
Barnewolt said employees consider the hospital full when there are 320 to 330 admitted patients. At one point recently, Tufts had 380 patients. On several recent days, the 33-bed emergency department had 60 patients at one time.
COVID is also causing absences among workers that are compounding staff shortages, Barnewolt said. That’s required Tufts to get creative with scheduling, such as delaying some elective procedures during peak periods.
And like other hospitals, Tufts is trying to move less-sick patients to community hospitals.
“It’s trying to get through the crisis of the day,” Barnewolt said.
At Baystate Medical Center in Springfield, Artenstein said patient volumes hit critical overcapacity levels in late May, causing backups in the emergency department. There were days in the last few weeks when there were 50 to 60 people in the emergency department waiting for an inpatient bed.
Outreach is a big part of Baystate’s response; it’s urging residents to come to the emergency room only for emergencies, and encouraging people to perform COVID testing at home and use the state’s telehealth hot line for Paxlovid prescriptions.
“There’s only so much we can do,” he said.