As she sprinted back and forth between groups of patients who overflowed the emergency room at the Elkhart General Hospital last week, Dr. Michelle Bache knew her hospital was going to run out of room soon.
For the last two months, she had seen a rising influx of patients needing to be hospitalized for Covid-19, which has run rampant in northern Indiana's Elkhart County. More than 14,000 have been infected, almost 1 percent of the county’s population.
By noon Tuesday, the hospital's 144 beds were over-capacity with 206 patients and the staff was stretched thin. Bache had to temporarily house patients in older areas of the hospital that had been previously closed and unstaffed while they figured out another solution. The staff was asked to take more shifts to man those spaces.
But even after exhausting all they could, patients kept coming and the hospital was forced to stop accepting ambulance traffic for a full seven hours until more space was made -- a process known as diversion.
“That’s not something we take lightly, and we rarely have had to do that,” Bache, who is also the vice president of medical affairs for the hospital, said. It was the second time in 20 years that Elkhart General, which is one of two hospitals in the county, had to make the call, she said.
“This is exactly why we were adamant about masks and flattening the curve. This is the situation that we wanted to avoid.”
With Covid-19 cases on the rise in all 50 states, the burden on hospitals has led to an increase in diversions. In addition, patient transfers are being significantly delayed due to capacity and staffing shortages, hospital administrators in some of the hardest hit states said.
In Idaho, one of the state's largest hospitals was so overwhelmed by Covid-19 cases that it was forced to go on diversion for 12 hours, according to the Idaho Statesman. And in Georgia, the medical staff had to call 14 hospitals before a facility more than 500 miles away was able to accept a patient.
"As Covid-19 cases and hospitalizations rise across the country, we have seen and heard anecdotal reports of hospitals having greater difficulty transferring patients and having to go on diversion due to capacity and staffing issues,” a spokesperson for the American Hospital Association said. “To make sure hospitals are able to continue to treat Covid-19 and non-Covid-19 patients who need care, we continue to urge the public to wear masks, maintain social distance, wash their hands and get a flu vaccine shot.”
While hospitals are working fervently to avoid diversions and transfer difficulties, those delays can become a concern, especially to those patients who may not be stable, said Dr. Benjamin Singer, an assistant professor of pulmonary and critical care at the Northwestern University Feinberg School of Medicine in Chicago.
“Someone who is stable and waiting can probably wait without much impact, but if someone is really unstable and waiting for critical care types of interventions, it can certainly be a challenge to manage them before they're in a facility where they can be definitively stabilized.”
Singer, who is also a physician at Northwestern Hospital, said transfers occur because a therapy or expertise can’t be provided at the hospital where patients are, and in the case of Covid-19 patients this could be a need to be intubated or put on a ventilator.
In those cases, time can be critical, he added. The fast rate at which hospitals are filling up now is the result of not flattening the curve, he said.
"We want to flatten the curve, so that we don't see large numbers of patients coming in all at once and stressing the health care system to the point where it's not just beds that become limiting but also people who staff those beds, and materials like PPE, and ventilators," he said.
The biggest challenge causing the capacity problems is staffing, Dave Dillon, vice president of public relations of the Missouri Hospital Association, said.
“The number of physical beds in hospitals are only as good as the staff you can put bedside,” he said. “We are doing the best we can to manage the workforce but these people also live in these communities and are vulnerable too.”
Dillon said that during the Covid-19 surge, between 5 and 10 percent of the workforce could be sidelined at any time due to quarantining protocols, and for many hospitals this is a significant blow.
The other challenge is an influx of patients from rural areas that are leading to a greater rate of transfers due to the surge in hospitalizations. This is especially problematic for them because backup options are not widely available, forcing patients to travel further away from their home or wait longer to get treatment.
Over the last few weeks, Carroll County Memorial Hospital, which is situated in a rural part of northern Missouri, had patient transfer wait times that extended for several hours and even sometime overnight in order to move Covid-19 patients to a larger hospital for treatment.
“Ten days ago, we could not find a bed available anywhere,” said Jeff Tindle, chief executive officer of Carroll County Memorial Hospital in Carrollton, Missouri. “Typically, patients wait minutes before we can get them a spot, so this has been very concerning because many times they are critical.”
According to the Missouri Department of Health, more than 60 percent of the state's hospital beds are occupied and 73 percent of the intensive care unit beds are currently full, making open spots very difficult to find for some hospitals.
The situation is not much different in Wisconsin, where Covid-19 has affected more than 334,000 residents. Over the past week, there has been an average of 6,906 cases per day, an increase of 43 percent from the average two weeks earlier, according to data tracked by NBC News.
“We are getting to the point where we won’t have anywhere left to divert patients to,” Eric Borgerding, president of the Wisconsin Hospital Association, said. He added that 90 percent of the state’s ICU beds are already full. “Transfers are becoming more and more difficult and challenging with no real end in sight.”
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Borgerding added that hospitals are considering canceling elective surgeries and sending less serious patients to smaller hospitals, so larger ones can take in the emergencies.
In Elkhart, Indiana, Bache said that several new areas have opened to accommodate the rise in hospitalizations but challenges continue to come up and the situation is far from improving. ICU space is now rapidly dwindling as cases of hospitalized patients are getting more severe, she said.
“It’s very hard because we are doing our best each day to take care of everyone, but there is so much Covid in the community and we don’t have very good compliance with masking in this county,” she said. “That’s just a recipe for disaster for everyone in this.”