At Minnesota hospitals, ER 'boarding' a COVID-19 consequence

The second pandemic wave in Minnesota is putting unprecedented strain on hospital emergency departments, which have seen patients pile up in waiting rooms and treatment bays this fall.

A recent Friday shift seemed light at United Hospital in St. Paul, until 33 ER treatment bays filled — about one-third with patients who had confirmed or probable COVID-19. More ambulances were inbound and 20 patients settled into plexiglass-protected pods in the waiting room.

"Usually we have one or two days a week that are really busy," nurse Danielle Wilkerson said during that Nov. 20 shift. "Now, since the surge has started, every day we have a lot of people out in the waiting room and our rooms are always full here. There's people waiting three to five hours, and that's a good day."

Hospital leaders said busy ERs are preferable to the alternative last spring, when a statewide shutdown and public anxieties over COVID-19 led to people staying home who had bleeding wounds and even stroke symptoms. The crowded ERs this fall offer further proof of the need to contain the pandemic.

Minnesota could be on the downside of the latest COVID-19 wave, but hospital officials remain concerned about ER capacity because of the still-unknown impact of viral transmission over Thanksgiving along with the traditional increase in patients due to influenza and pneumonia, as well as the usual falls, car wrecks and other problems.

"Heart disease unfortunately did not go away with COVID-19," said Dr. Karyn Baum, vice president of system clinical operations at M Health Fairview.

The pressure on ERs has been as much about outflow as inflow, due to the struggle to find open intensive care beds for patients with severe COVID-19 or other illnesses or injuries requiring critical hospital care.

ERs are accustomed to the boarding of patients until open hospital beds are found, especially at the height of influenza season or because of the limited supply of inpatient psychiatric beds for patients in crisis.

Boardings have surged, though. Regions Hospital's ER in St. Paul at one point last month was boarding 30 patients.

M Health Fairview expanded its internal operations center in the old Midway Hospital campus in St. Paul into the state's Critical Care Coordination Center, or C4, to find open ICU beds when they were scarce for patients stuck in ERs. The center brokered four transfers in August, but that number jumped to 337 in November — with some patients moved to ICU beds hundreds of miles away.

On a shift at C4 last month, Monica Olivier had four patients on her call list needing transfers out of ERs and into critical care beds. It took two hours to move the first one.

"I was calling ICUs saying, 'I have four patients that need placement,' and they would just go like 'noooooooo,' " said Olivier, a fourth-year student at the University of Minnesota School of Medicine who was working in the center as part of her trauma training rotation.

ER crowding extended beyond metro areas in Minnesota. St. Cloud Hospital prioritized ICU admissions from within its CentraCare network, but that left independent hospitals in central Minnesota looking elsewhere.

"There was no place to put the patients, and everybody was looking for beds," said Dr. George Morris, coordinator of CentraCare's COVID-19 response.

Mondays are usually the busy days for ERs, when pent-up illnesses and injuries from the weekend result in patients calling their doctors and being directed to emergency care.

That seemed the case to Sheila Burbach on Nov. 23, when she entered the Regions ER with a fever above 103 and breathing problems due to worsening COVID-19. Waiting 30 minutes to get in, Burbach was shocked by the buildup of agitated patients. One was vomiting and another bled from a cut on his hand.

"I've never been in an ER when it's been like that," she said.

Burbach was monitored for nine hours and signed up for a clinical trial of donor plasma for treatment of her COVID-19.

She came in at the same time as James Johnston, who was airlifted from Cumberland, Wis., after he fell out of a deer stand and suffered broken bones and a punctured lung.

Hospitals had the benefit of time to prepare ERs for the latest surge. Reduced ER activity in the spring helped them bulk up on protective equipment for doctors and nurses, who have the added stress of never knowing for sure which patients might have COVID-19 and not realize it.

"There's such extremes between, 'I would never have guessed you have COVID' to 'oh yeah, this is for sure going to come back positive,' " said Wilkerson, the United nurse.

Home monitoring programs also helped by sending stable COVID-19 patients home from ERs with pulse oximeters to monitor their blood oxygen and regular check-in calls from doctors or nurses. Allina Health leaders said most COVID-19 patients sent home with monitoring from United and its other hospital ERs don't need to return.

Improving pandemic indicators in Minnesota suggest that ERs held up through the worst of the wave. The positivity rate of diagnostic testing has dropped — indicating a slowdown of viral transmission — and the number of COVID-19 patients in intensive care beds in Minnesota hospitals has fallen from 394 on Nov. 30 to 367 on Dec. 3.

But COVID-19 patients still make up one-third of the total ICU population in Minnesota hospitals, which have delayed non-urgent surgeries to preserve bed space.

ER directors at Regions and United said they are not only concerned about another COVID-19 wave amid flu season, but also that it could hit at year's end when M Health Fairview is scheduled to close the ER at St. Joseph's Hospital in St. Paul.

"Any hospital closure or slowdown is going to affect the others. We're symbiotic," said Matt Johnson, patient care supervisor of United's ER.

While pressure on ERs can often be regional, Baum said the fall COVID-19 wave has been unique for how it filled so many hospitals across the state. The C4 center that she manages was taking calls for patient transfers from many hospital ERs that hadn't reached out before.

"We were able to help a lot of small critical-access and outstate facilities," she said, "that in many cases were seeing COVID for the first time."

This is the fifth in a series on Minnesota hospitals' response to the surging COVID-19 pandemic.

Jeremy Olson • 612-673-7744