Despite plans, precautions, COVID-19 nearly broke Minnesota hospitals. Why?
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Updated 11:10 a.m.
Even before the first case of COVID-19 was confirmed in Minnesota, state health care leaders were designing a strategy to ensure that supplies, equipment and hospital beds were available to respond to the previously unseen coronavirus that had already caused frightening scenes of mass death and stressed health care systems in other countries.
Simultaneously, Gov. Tim Walz invoked emergency powers in the spring of 2020 to restrict public gatherings and move schools to distance learning in an effort to “bend the curve” of infection to give hospitals breathing room and time to prepare for a worst case.
“We are building our hospital capacity so we can ensure that when our neighbors are sick and need the care they need, they’re able to get it,” Walz said in his 2020 State of the State address. “We are increasing ventilators and ICU beds for when our sickest neighbors need it.”
He went on, “We’re doing our best to find more personal protective equipment for the selfless doctors, nurses, first responders and so many others on the front-line in the fight against COVID-19.”
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Yet despite the planning, the shutdowns, the remote working and schools, the hundreds of millions of dollars spent, and an effective vaccine, December 2021 – nearly two years after that initial case was detected – was the high watermark for hospital bed shortages, where at times there were literally no intensive care unit beds available in the state.
Experts and people immersed in the COVID-19 fight have no simple answers for why the worst impact of the pandemic came so far into it, although it is clear the duration of the pandemic — one that sickened more than 1.3 million Minnesotans and claimed the lives of more than 11,900 of them — made it unlike any crisis officials could have planned for.
“We were in crisis for different reasons at different points throughout the pandemic,” said Dr. John Hick, an emergency room physician who regularly advised the Walz administration on hospital crisis planning.
And the length of the pandemic changed the nature of the crisis from a shortage of protective gear, equipment and beds to a shortage of people. Health care workers were driven out of the field after caring for a relentless stream of patients sick with COVID, some who refused to be vaccinated, prolonging the crisis inside hospitals.
The state that cried wolf?
One top Republican in the Minnesota Legislature attributes the current situation to a failure of communication at the highest levels of Minnesota’s government.
Sen. Jim Abeler, chair of the Senate Human Services Reform Finance and Policy Committee, said it made sense to stock up on critical supplies early in the pandemic. Abeler, R-Anoka, appreciated how the Walz team collaborated with lawmakers at the outset.
But that joint effort faded fast, Abeler said, and he believes that led to a one-size-fits-all approach to containing COVID-19 that caused “avoidable error.”
For example, an executive order to halt elective procedures left some hospitals struggling financially.
“When a small hospital loses a lot of money, it can’t afford to keep the staff it needs,” Abeler said. “And now when the real crisis comes, they’re short-staffed.”
In his view, the blanket approach sowed distrust and prolonged the pandemic.
“If there is no spread, there's nothing to contain. And all that happens is economic harm and personal loss,” Abeler said. “It affects the enthusiasm of those who have lost to believe the next thing when it's real, the boy who cried wolf thought it was funny to cry wolf and then the wolf came and people didn't pay attention.”
Sen. Matt Klein, a DFLer from Mendota Heights and a physician at Hennepin Healthcare who was in the thick of the fight, views the state’s initial response differently.
“We were a victim of our own success initially. We shut down so completely and so effectively, we masked so diligently that deaths and morbidity dropped rapidly early in the pandemic,” Klein said. “People began to feel there wasn’t as much to fear and we had been over-alerted, which was not the case. It’s simply the fact that our shutdown had worked.”
Minnesota was hardly alone, said Dr. Amesh Adalja, who is an infectious disease expert and senior scholar at the Johns Hopkins Center for Health Security.
State leaders everywhere made panicked decisions based on what they were seeing in epicenters like New York City — shutting businesses, schools and limiting what hospitals could do, he said.
And when cases didn’t materialize right away, people were less likely to comply with public health measures such as masking or social distancing.
“Because they saw their lives disrupted in the spring of 2020. They saw their businesses shuttered. They were told they were not essential,” Adalja said. “And that’s going to breed contempt.”
Plans were in place, extra staff wasn’t
It would be a mistake to say health care systems were unprepared for a pandemic, said Dr. Dan Hanfling, an emergency room doctor in northern Virginia and an expert in helping hospitals prepare for crisis situations.
Crisis planning accelerated after the deadly 2005 Hurricane Katrina when hospitals in Louisiana suffered and again in 2009 after the H1N1 flu outbreak. That led to a convening of health and emergency response leaders.
In a 2013 National Academy of Sciences document Hanfling helped create to guide hospitals in times of crisis, he predicted a scenario much like what the world experienced with COVID-19.
Referring to the onset of the pandemic, Hanfling said it shouldn’t have been a surprise.
“You know, the president himself at that time said, ‘Well, who would ever imagine a disaster of this magnitude,’” Hanfling said. “Yes, actually we imagined and laid out and all of the various elements that we could anticipate were going to happen.”
But he added that from a staffing perspective, hospitals were already at a disadvantage because it’s just too expensive to employ more people than they need when there isn’t a crisis.
“You cannot maintain extra fat in the system, assuming that it’s going to rain,” Hanfling said. “Being able to maintain extra capacity whether that be in their supply chain or in staffing or beds, just it was not economically doable.”
In Minnesota, Dr. John Hick helped write the state’s crisis standards of care documents — a blueprint to guide hospitals when there’s a crisis and there’s not enough resources to go around.
It’s often used during smaller and shorter situations, such as an explosion or a large car accident and not necessarily for a prolonged crisis.
“That's a very temporary thing because you're going to bring in the helicopters and ambulances, and you're going to move those patients within an hour or two,” said Hick, a prominent doctor at Hennepin Healthcare.
And temporary is a key word. The length of the COVID-19 crisis made planning challenging in ways that were hard to imagine.
“As soon as it started, we were in crisis standards of care for personal protective equipment,” Hick said. “And as time went on, we hit crisis standards of care for high flow nasal cannula, and certain medications.”
Staff trumps equipment
At the start of the pandemic, most of the effort was on ensuring that hospitals had the gear they needed to respond, said state Health Commissioner Jan Malcolm.
“Our first focus was really on equipment capacity,” Malcolm said. “Were there going to be enough ventilators and enough beds and could we open more beds quickly?”
Other states were scrambling for the same supplies, creating fierce competition. A federal stockpile of equipment turned out to be far more limited than state leaders anticipated.
In those first months, the state purchased 550 ventilators, 11 million surgical masks and almost 7 million gowns. Anticipating there would be more dead bodies than the state could handle, it spent more than $5 million on temporary morgue space — a building that never got used and has since been sold.
Staff shortages were not high on the list of concerns then.
“We had no idea in February [of 2020], the scale, the scope that COVID would represent and certainly the duration,” Malcolm said. “It's been this almost unimaginable duration of the pressures on health care that has caused a lot of the departures that we've seen from the health care workforce.”
What no one fully understood in the early days is that COVID-19 patients would stay longer than the average ICU patient. They require larger care teams and more resources.
And when the vaccine arrived, health workers thought they were seeing a light at the end of the tunnel. But with vaccination rates lagging, the stream of patients didn’t stop — and health care workers struggled to maintain empathy.
By one estimate, 1 in 5 health workers left the field since the pandemic began.
Emergency powers end
Last summer, it might have been easy to ignore the flight of workers from the field. There was plenty of slack in hospital capacity and cases had declined. Vaccines were widely available — though uptake was far slower than the state had hoped.
And it was in that context that Walz’s emergency powers expired under pressure from state lawmakers.
“We were down at case levels we hadn't seen since the beginning of the pandemic. So at the time those things went away, it didn't seem like it was premature in the slightest,” Malcolm said.
With the end of the emergency went the governor’s ability to require things like masks to prevent the spread of COVID. Many government employees brought together to manage the response went back to their regular jobs.
By then, people were well aware of what they needed to do to protect themselves against COVID-19, and Malcolm said it was reasonable to think that people would make sound decisions based on that information.
But to her dismay, “the surge started building again” and it wouldn’t be as easy to address because “putting something back after it's been gone is a different kind of a question.”
In retrospect, letting those emergency powers expire proved an important inflection point going into the fall of 2021.
Former state infectious disease director Kris Ehresmann said in the early days of the pandemic, people were willing to cooperate with stay-at-home orders and other tools used by public health officials such as masking and crowd limits to help blunt spread of COVID.
“That was kind of a different time in terms of what was happening in our schools and in our communities in terms of transmission,” Ehresmann said. “And so, this fall we didn't have the universal use of some of those tools, like we had in the past.”
Though hospitals continued to work together through regional partnerships and a system set up exclusively to help hospitals move patients around when they were full, Hick, the doctor at Hennepin Healthcare, said that from his perspective, transferring patients, especially from rural Minnesota where there are fewer services, got harder when the emergency powers expired.
“What we failed to anticipate was once beds got really tight, and nobody had any beds, then the systems were really not willing to accept responsibility for patients outside of their health care system,” Hick said. “And absent a governor's emergency declaration or governor's emergency order, we weren't going to have any way to leverage the health care systems to do that.”
Emergency rooms became bottlenecks, and some patients, Hick said, suffered unnecessarily as a result.
Delta and omicron
And just as restrictions were removed and COVID fatigue grew, the highly contagious delta variant arrived, landing mostly unvaccinated people in the hospital and putting more weight on a system trying to catch up with care it delayed earlier.
Unlike prior waves, there were fewer health workers to shoulder the burden, Ehresmann said.
“It doesn't matter how many beds you have, or how many ventilators are available, if you don't have someone who is able to work, to staff that bed, care for the patient with that ventilator, then you're in a problem,” Ehresmann said.
Minnesota hospitals had hardly started to see relief from delta when omicron — a more contagious variant that can evade vaccines — put thousands of health care workers out sick all at once.
A more resilient system
At the Capitol, Republican legislators have suggested streamlining some regulatory practices to make it easier to hire health care workers quickly. They say making it easier for hospitals to hire nurses licensed by other states would help, too.
The pandemic and the political infighting it caused put a dent in confidence of the state’s renowned public health apparatus. Abeler said that is among the things that will need to be repaired when COVID is less of a pressing concern. His own faith in what he described as a “legendary” Minnesota Department of Health has been diminished.
“I have a lot of regard for how hard they're trying. But simply trying hard doesn't mean you're being successful,” Abeler said. “And being successful means you listen to voices beyond those in your own department and your trusted close advisers.”
For her part, Malcolm said that there has been cooperation across the government and health sectors. She said the state pulled out all the stops to relieve hospitals. The federal government sent in military response teams to the hardest hit hospitals. The National Guard stepped in. And the state recently spent $40 million to bring in a cadre of traveling nurses to be deployed around the state.
But, Malcolm said, it’s an unsustainable and expensive model.
Amid the chaos of COVID-19, Malcolm said she sees silver linings — greater use of telehealth, a renewed focus on bolstering the health care workforce in rural areas.
“I think there have been innovations that have come out of the pandemic that can actually help to inform a more resilient system going forward,” Malcolm said.