Filled with people suffering from respiratory infections and chronic illnesses, Massachusetts hospitals are as strained now as they’ve been at any time during the pandemic. As a group they reported having fewer available beds in November than a year ago when the state ordered them to stop performing elective surgeries.
But no one is talking about shutting down non-emergency care today.
“It’s not a solution that makes sense,” said Steve Walsh, president and CEO of the Massachusetts Health & Hospital Association. The patients will need care eventually anyway, and will come back in worse condition, he said. Instead, this season, each hospital is performing its own juggling act, managing cases and surgeries in the best way it can. “There are scheduled events that are moved, canceled, rescheduled,” Walsh said. “It’s really a case-by-case basis, based on what’s happening.”
Dr. Eric Dickson, president and CEO of UMass Memorial Health in Central Massachusetts, said that when health officials ordered an end to elective surgeries during peak times of COVID-19, it was understood to be temporary. “The difference now is we don’t see the end. We’re not seeing the light at the end of the tunnel,” Dickson said. “This isn’t a surge we’re dealing with. This is a new reality.”
There are financial factors at play as well. Because of reimbursement policies, hospitals make money on heart surgery or joint replacement, but lose money on COVID-19 patients covered by Medicaid, said Dr. Mark Keroack, president and CEO of Baystate Health, in Springfield. “We’ve invested a tremendous amount of money in these programs,” he said. “We have five heart surgeons. We can’t ask them to stop what they’re doing.”
“You hear of hospitals closing or curtailing services,” Keroack said. “We’re trying like hell not to do that. We’re the only provider of essential services out here. "
Some hospitals are treating more patients than their licensed capacity, under pandemic emergency rules still in effect. Staffing shortages at nursing homes and home health agencies make it hard to find placements for people who are ready for discharge but can’t go home. As a result, beds are full of patients who don’t need to be there, while those who need care wait in the hallways. At the same time, hospitals are staggering under the cost of the high-priced contract labor needed to fill the many staff vacancies.
On a typical day at UMass, Justin Precourt, the official in charge of finding a bed for everyone who needs one, faces 100 or 110 people waiting for placement. Sometimes, he activates the emergency operations command center, because the number of patients had reached “a crisis situation and we have significant patient safety concerns” — something Precourt says happens “fairly frequently.”
In those situations, hospital officials will intensify the juggling act — perhaps keeping clinics open extra hours to handle patients who would otherwise head to the emergency room; or seeing if any admissions can safely be delayed a day or two, or if any discharges can happen faster; or checking with other hospitals who might be able to take patients.
And they evaluate the operating room schedule but are very cautious about cancellations, said Precourt, who is the hospital’s chief nursing officer and senior vice president of patient care services.
About a month ago, Dr. John J. Kelly, chief of the division of general surgery at UMass, had to cancel three surgeries in one day. But it hasn’t happened since, he said.
Instead, last week the hospital instituted a 5 p.m. cut-off time for surgeries, reducing surgical capacity to avoid cancellations and, also, Kelly said, to avoid burning out their staff at a time when anesthesiologists and their support staff are in short supply. “We are exhausting our staff,” Kelly said.
The policy is new so it’s not clear yet how well it will work. But, so far, the hospital has not had to send a would-be surgical patient home because they didn’t think they could finish in time, Kelly said.
The deadline applies to scheduled surgeries; the hospital is still staffed to handle emergencies and traumatic injuries.
Dickson said that UMass is not admitting more patients than in the past. But the patients are staying significantly longer as staff search for placements for them. This backs up the rest of the hospital.
UMass is the only hospital in Central Massachusetts that can handle the most advanced care and severe trauma. But it has been turning away 50 percent of patients that need to be transferred from community hospitals, Dickson said.
“That’s several hundred patients a month that need to come here, and we can’t take them because I just can’t put another patient in the hallway to wait for a bed,” Dickson said. “When the trauma center has to say no to a transfer, and you’ve got a patient with an acute, life-threatening, time-sensitive illness, that’s when real harm occurs.”
Patients have had to go to Boston, Hartford, even Washington, D.C., Dickson said.
Baystate, the only hospital system in Western Massachusetts capable of handling complex cases, is in a similar situation. Its four hospitals are licensed for nearly 1,000 beds but have been operating at 10 to 20 percent over capacity, said Keroack, the president. About 100 of the 1,151 patients in the hospital last week were ready to be discharged but had no place to go, while 66 people were waiting for a bed, some on gurneys in the hallway, he said. Baystate is employing more than 400 travel nurses, Keroack said, at a cost of $90 million.
“It’s been unremitting for 11 months now,” Keroack said. “We have people who have been here 30, 60, 90 days who don’t belong in a hospital and take up a bed other people could be using.”
Dickson thinks one possible solution would be a regional approach to post-hospital care. Many smaller hospitals are not as stressed as the academic medical centers, he said. When bigger hospitals are overloaded, they should get first dibs on any available nursing home beds, Dickson said. But the state has little authority to order such a process.
The community hospitals say they’re busy too. Because of the high demand for care, Lawrence General Hospital has tried to keep the same number of beds staffed as it has historically, by hiring 120 agency staffers among its 2,000 employees. The contract workers cost $2.7 million in October.
“We are looking at elective surgeries daily,” said Deborah J. Wilson, president and CEO. “We do reschedule cases as necessary. We have not discontinued elective surgery. We are trying to manage the schedule and trying to meet the needs of our patients.”
Christine Schuster, president and CEO of Emerson Hospital in Concord, said that, even as an independent community hospital, Emerson faces similar challenges: It has difficulty moving patients out of the hospital and has to rely on contract workers. As for curtailing elective surgeries, “We haven’t gotten to that point yet,” she said.