HYANNIS — Cape Cod Hospital has been dealing with a triple threat: a recent swell in incoming Covid-19 patients, a backlog of inpatient discharges, and a pandemic-driven staffing shortage.
The fact that these challenges are faced by hospitals across the state prompted the Mass. Dept. of Public Health (DPH) on Dec. 15 to advise facilities to cut back on nonessential elective procedures by half. But last week, when Cape Cod Hospital’s inpatient population swelled past its maximum capacity, officials here opted to cancel elective surgeries altogether on Dec. 16 and 17.
Over the weekend, patient volume dipped, said Patrick Kane, senior vice president of communications for Cape Cod Healthcare, which owns the hospital, in an email. “All cases are back on the books for this week,” he wrote on Monday, Dec. 20.
The next day, however, the statewide swell in Covid-19 cases pushed the DPH to update its strategy. Effective Dec. 27, “all hospitals are directed to postpone or cancel all nonessential elective procedures likely to result in inpatient admission in order to maintain and increase inpatient capacity,” said Gov. Charlie Baker at a Dec. 21 press conference.
The hospital on Tuesday would not confirm whether another round of cancelations was slated post-Dec. 27. Hospital officials were “digesting” the new state guidelines, according to Dr. William Agel, the chief medical officer. “But we’ve been dealing with this for 21 months,” he added. “We’ve gotten pretty good at adjusting our schedules accordingly.”
The hospital uses a scoring system that ranks cases based on the level of attention each one is likely to need from staff. Urgent procedures, like the removal of a diseased gall bladder or a cancer surgery, would fall in the “nonelective” category. Certain cosmetic procedures and joint replacements, by contrast, verge more on “elective” and so are more likely to be delayed.
In between, there are cases that don’t fit neatly into either category, such as neurosurgery procedures for chronic back pain.
“It depends on the level of discomfort and the level of disability the person has,” Agel told the Independent. In these cases, he said, patients and their physicians need to discuss whether alternatives to surgical intervention, like continuing physical therapy, could be appropriate in the interim.
“It’s hard to tell someone that their pain is ‘elective,’ ” Agel said. “It requires a frank and honest conversation between the surgeon and the patient. Some folks have been waiting a while to begin with, so they’re usually a little disappointed because they’ve made some preparations. But our patients understand we’re in the middle of a pandemic.”
The Cape Cod Times reported last Friday that Cape Cod hospital had admitted 20 patients more than the 259 beds prescribed by its license, placing these people in surge areas. Meanwhile, Falmouth Hospital, with 95 beds, was operating at 85 percent capacity.
While the surge in Covid-19 cases has added new patients to Cape Cod Hospital’s population — as of Tuesday, there were 33 Covid-19 patients in the hospital, two of whom were in the ICU —the facility has also been managing the care of numerous non-Covid-19 patients needing longer stays before being discharged.
“In terms of what kinds of illnesses we’ve been seeing, it’s been acutely exacerbated chronic diseases,” explained Agel. “These are people with heart disease who may have put things off. Or people with diabetes who maybe didn’t take care of themselves during the pandemic. And then, there’s also the consequences of prolonged social isolation, like depression.”
When discharges do occur, some patients need to be transferred to a skilled nursing facility — where they encounter another widespread problem: a health care staffing crisis, driven by the pandemic.
“With the current labor shortage, those nurses just aren’t available,” Agel said. “So, you have some patients who end up staying in the hospital, just waiting for those nursing facility beds.”
Mass. Health and Human Services Secretary Marylou Sudders in a Dec. 21 press conference put it this way: “There remains a critical staffing shortage in many jobs and many roles to meet the needs of our patients.”
With workers nationwide leaving health care, Cape Cod Hospital is grappling with staffing shortages of its own.
“These are people who don’t want to be exposed or get overrun by 40 or 50 sick patients, so they’ve said, ‘It’s too much. I’m going into another business,’ ” Agel told the Independent. “That’s really what’s hurting us.
“Last I checked, we were at about 500 openings,” he added, “which is about 10 percent of our workforce.”
The unfilled positions go beyond the roles of doctors, nurses, and technicians. Cape Cod Hospital has also been searching for people to clean patient rooms, deliver food, work in environmental services, and answer phones at the reception desk.
“We need everything,” Agel said.
In the Emergency Room
Most hospitals, when overwhelmed, go on diversion, directing ambulances to ferry patients to the next closest hospital. Cape Cod Hospital can’t fall back on that option.
“There’s really nowhere to divert to,” said Mary Johnson, who has served as the hospital’s associate vice president of nursing and emergency services since 2020. “We just use our triage process, and we’ve opened up other areas of the hospital to move admitted patients.”
Johnson aims to get patients who need inpatient care upstairs within four hours following an initial screening in the emergency room. On Monday, Dec. 20, the average wait was 6½ hours.
“Over the last few months, we definitely haven’t been able to move patients through the system as quickly,” Johnson said. “We’re having to use hallway spaces during peak times to see patients.”
For the E.R. staff, a busy hospital means double shifts in personal protective equipment, plus overtime. “Being a nurse, in particular, is not a job — it’s a calling,” Agel said. “The large majority of the staff has said, ‘You know, we’re the safety net hospital for this community.’ They’ve stepped up in ways that put their families’ lives in danger.”
In the midst of crisis, the E.R. has held steady. “We’re a really strong, great team,” Johnson said. “We’re like a family, so we support each other.” If family matters crop up, coworkers offer to pick up extra shifts. “Some registered nurses who moved to administration have come down to help in times of need,” Johnson added.
“There’s no question the next few weeks will be enormously difficult for our health care community,” Gov. Baker said at his Dec. 21 press conference.
To support health care workers amid the state’s recent rise in cases, Baker, as of that day, activated 500 members of the Mass. National Guard. Of these, 300 people will be deployed to 55 acute care hospitals and 12 ambulance service providers.
Some Guard members will drive ambulances and transfer patients between hospitals and nursing homes; others will commandeer wheelchairs and stretchers, ferrying patients between the E.R., X-ray rooms, and the inpatient floor. Other roles include providing security support, delivering meals, and observing patients who may pose a risk to themselves.
The remaining 200 Guard members will be providing Covid-19 testing support or administrative support for the deployment or standing by until needed.
This week, the Guard members are undergoing training, and by Monday, Dec. 27, they will be dispatched to their assigned locations. Cape Cod Hospital does not yet have plans to use National Guard troops at this time, according to Agel.