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    The ripple effect of the delta surge

    Hospitals in states with fewer COVID-19 cases are fielding transfer requests from across the country, straining hospital resources.

    Two masked doctors in scrubs talk in a hospital room

    Hospitalists scheduled to work in the transfer center at Allegheny Health Network, which runs more than two dozen hospitals serving Pittsburgh and western Pennsylvania, used to look forward to the shift, says Margaret Thieman, MD, the transfer center’s director. It was a nice change of pace after the rigorous demands of being bedside and provided a break from dealing with insurance paperwork. Plus, they often had the opportunity to offer hope to doctors and their patients in need of a higher level of care.

    Before the delta variant began sweeping through the United States this summer, the center generally coordinated transfer requests from smaller regional health care centers that didn’t have access to the same specialty care the Allegheny Health Network could provide. Occasionally, they would receive requests to accept a Pittsburgher who had become seriously ill while traveling out of state.

    Now, the shifts involve hours spent fielding call after call from doctors — some of them several states and hundreds of miles away — desperate to find an open bed.  

    “We’ve had transfer requests come in from Tennessee, Kentucky, Texas, Florida, one of the Carolinas,” Thieman says.

    Usually, the patients are suffering from routine, emergent health problems — such as a heart attack or brain tumor — that require an urgent operation that could normally be provided at a health system closer to home, she says. But because many hospitals in states that are experiencing a severe COVID-19 surge are seeing more patients coming in — both with COVID-19 and with non-COVID-19 health problems — they frequently don’t have the capacity in their intensive care units (ICUs) to accept patients. In addition, hospitals are reporting an increase in the intensity of care needed for their non-COVID-19 cases — a trend seen across the country.

    Because these capacity issues are impacting multiple regions at once, patient representatives are having to call hospitals farther and farther away to find an open and staffed bed for their deteriorating patients.

    “We have physicians call us … and you can really hear the desperation in the doctor’s voice — the defeat,” Thieman says. “They’ve already called 20 other hospitals in their local region, and all have had to say no for one reason or another.”

    “You really hate to be number 21.”

    Emergency departments and ICUs face ‘perfect storm’

    Across the country, only 11 states were reporting that their total ICU capacity was less than 70% full as of Sept. 28, according to the Department of Health and Human Services (HHS). Fifteen states’ ICUs were more than 80% full, and in three states — Texas, Georgia, and Alabama — overall ICU capacity was more than 90% full. Several states, including Idaho and Alaska, have activated “crisis standards of care,” which means that, because of limited resources, care is prioritized for patients who are likely to have a good recovery.

    Unlike during earlier waves, when emergency department visits were down because more people were staying home, many hospitals have seen a significant increase in patients in the last couple of months.

    Hamad Husainy, DO, an emergency medicine physician in Sheffield, Alabama and a spokesperson for the American College of Emergency Physicians, says that emergency department volumes are up 25%-30% in his hospital compared to before the delta surge.

    This increase is on top of pandemic-weary health care workers having to shoulder more work due to a shortage of nurses and other medical tech workers that has impacted the entire nation.

    At one point in September, Alabama reported to the HHS that its ICUs were 100% full.

    “This has created a perfect storm,” Husainy says. “It’s become very difficult to transfer these patients for specialty care. It’s created something that I’ve never seen in my 15-year career.”

    The result is that many patients across the country — but especially those in hard-hit states — are waiting longer than usual for appropriate medical care, which can have consequences that range from less than ideal to fatal.

    “You’re seeing patients wait longer for all their care [and] waiting in the emergency department before being admitted.”

    Jeffrey Stowell, MD
    Clinical associate professor and interim chair of the Department of Emergency Medicine at the University of Arizona College of Medicine – Phoenix

    Husainy recalled one example from his hospital this summer where a patient required a gastrectomy — a procedure that the staff surgeon was not experienced in performing. The medical team tried reaching out to hospitals across Alabama and even into Georgia, Tennessee, and Mississippi in search of more specialized care, to no avail. The surgeon had to go forward with the procedure and the patient recovered well, but some outcomes are not as positive.

    Last month, the Washington Post reported that an Alabama man experiencing a cardiac emergency in August died after the hospital where he was first brought had to contact 43 other hospitals to find an available ICU bed. And ProPublica reported that a 12-year-old boy’s appendix burst in late July by the time he was able to see a pediatric surgeon in Florida — a serious complication that might have been avoided if the hospitals hadn’t been overwhelmed.

    “A lot of conditions are time-sensitive,” says Jeffrey Stowell, MD, a clinical associate professor and interim chair of the Department of Emergency Medicine at the University of Arizona College of Medicine – Phoenix. “The sooner you can get the treatment, the better the outcome.”

    Even though Arizona has comparatively more ICU capacity than most other states, Stowell says that Valleywise Health, where he works, is struggling to keep beds open for locals. That makes it harder to accept transfers from outside the region. Stowell reports they are seeing 30% more patients with non-COVID-19-related health conditions than earlier in the pandemic, in addition to COVID-19 patients — all while facing a staff reduced by 40%. Henry Ford Hospital in Detroit has even had to close beds due to a lack of nursing staff — a scenario that is beginning to spread.

    “You’re seeing patients wait longer for all their care,” Stowell says. “[And] waiting in the emergency department before being admitted.”

    Valleywise Health is also seeing about a 15% increase in transfer requests compared to before the delta surge.

    “It’s put our hospital system — and many hospital systems — in a tough position,” Stowell says.

    An extra layer of stress

    Coordinating a hospital transfer is no simple process. It requires time and resources for clinicians to call multiple health systems in search of a place to send a patient. Often, time and resources are already in short supply. 

    “It just adds an extra layer of stress,” says Ronald Hall, MD, an emergency medicine physician and associate professor of emergency medicine at Jefferson University Hospitals in Philadelphia. “There’s this game of playing chess trying to move patients around, which makes the job harder.”

    Because there is no national coordination system, it is left to states, regions, and health systems to work together on transfers for their patients. And health systems have a responsibility to care for the patients in their own service area before they accept transfers from different regions.

    “[Allegheny Health Network] faces the same challenges as everybody else, but given a growing reputation [for having] the occasional ability to help out, we’ve turned into a national referral center,” Thieman says. “There’s no easy way to send out a bat signal and ask for help from 20 places at one time. I wish there were.”

    As a result of increasingly having to say no to desperate cases, her team is experiencing compounding emotional stress.

    “The team in the transfer center is trained for this. They have an algorithm that evaluates each case, but ultimately, there is a person — a human health care professional — having to make and relay our final decision about whether or not we’re in a position to help,” Thieman says. “It’s extremely difficult.”

    “There’s no easy way to send out a bat signal and ask for help from 20 places at one time. I wish there were.”

    Margaret Thieman, MD
    Director of the Allegheny Health Network Transfer Center

    Husainy hopes that the dire situation will serve as a signal that the health care system needs to change the way it handles surge capacity.

    “We created a system that was capable of creating surge capacity at certain facilities if a hurricane hit, but when every hospital in a region — in this case, the Southeast — is at capacity and cannot care for any more patients … that’s not something that our health care system was created for,” he says. “My hope is that when we get through this, which I know we will, we recognize the need for more comprehensive capacity.There’s a huge opportunity for coordination of health care resources.”

    Vaccination as a tool to protect hospital capacity

    In the meantime, hospitals will continue to be strained while COVID-19 hospitalizations add to the already stressed health system. Hall says that COVID-19 prevention measures, such as masks and vaccines, make a big difference. Last year, he was seeing a lot more death from COVID-19, especially among the elderly. The vaccines have changed that.

    The HHS reported that there were 20,908 COVID-19 patients in ICU beds as of Sept. 29, 2021. The Centers for Disease Control and Prevention released a report in September that found that, out of nearly 38,000 COVID-19 hospitalizations analyzed, only 8% were among fully vaccinated people. And while COVID-19 deaths again climbed to a daily average of more than 2,000 in late September, only a small percentage of those deaths were among fully vaccinated people.

    “What I hope for is that those who aren’t vaccinated will take the time with their health care professional to learn the benefits of vaccination not only to themselves but to others,” Stowell says. “People don’t understand that contracting COVID-19 and being hospitalized for a long time impacts all the people trying to get into the hospital and the care they can get.”