During this winter’s COVID-19 surge, hospitals across Rhode Island and Massachusetts suspended all but the most urgent surgeries to free up staff and beds to care for the influx of patients. 

But not CharterCare Health Partners, which operates Our Lady of Fatima Hospital and Roger Williams Medical Center. Even when their emergency departments were so overwhelmed that they diverted ambulances to other area hospitals, Fatima and Roger Williams kept up their usual surgical volume.

“Hip replacements, knee replacements…gall bladders, hernias, plastic surgical cases,’’ said Lynn Blais, a recovery room nurse at Fatima and president of United Nurses and Allied Professionals. “They've kept running as if there was no pandemic.”

One night in early January, the emergency department at Fatima, in North Providence, was so short-staffed that state officials had to negotiate a deal with other hospitals to accept more ambulances. 

In Massachusetts, Governor Charlie Baker in December ordered all hospitals to cancel or postpone all “non-essential, non-urgent” procedures. The statewide order was designed to ensure that all Bay State hospitals freed up staff and beds to prevent the omicron wave from overwhelming their health care systems.

Rhode Island Governor Daniel J. McKee left the decision up to hospital operators. Lifespan and Care New England, the state’s two largest hospital networks, temporarily stopped all but the most urgent surgeries. During the peak of the omicron surge, surgical volume at Rhode Island Hospital, operated by Lifespan, fell to about 25% of its normal capacity. 

“Like all hospitals, the pandemic has had far reaching impacts on CharterCare,’’ a company spokesman, Otis Brown, said in a Jan. 26 email. “Fortunately, we have been able to maintain all types of surgeries and surgical volume safely at our hospitals at this point.”

McKee defended CharterCare’s decision. “They feel as though they can continue to have elective procedures and still take care of the patients,’’ McKee said at a news conference in late January. “And I think that's positive for the state of Rhode Island, quite frankly.”

Fatima nurses report ‘unsafe staffing’

But reports filed by Fatima’s nurses in early January raise questions about the impact of CharterCare’s decision on its emergency department. On the night of Sunday, Jan. 9, Fatima’s emergency department was so short-staffed that the shift managers wanted to divert ambulances to other area hospitals. But Fatima was prohibited from doing so because two other hospitals – Rhode Island Hospital and Landmark Medical Center –  were already “on diversion,’’ Joseph Wendelken, a health department spokesman, confirmed.

State regulations prohibit more than two hospitals in the northern region from going on diversion at the same time to ensure patients have access to emergency care. So when a third hospital requests to divert ambulances, the state’s capacity software automatically bumps all three hospitals’ emergency departments to “forced open” status.

If that happened, Rhode Island Hospital, which runs the state’s busiest emergency department;  and Landmark, a community hospital in Woonsocket, would have to immediately reopen their emergency departments to ambulances. 

Fatima contacted Dawn M. Lewis. A registered nurse, Lewis holds a dual role as emergency management director of the Hospital Association of Rhode Island (HARI), a trade group of which Fatima is a member, and as an unpaid member of the state Department of Health’s COVID-response team. 

Lewis declined requests to be interviewed for this story; she referred all questions to Wendelken, the state health department’s spokesman. 

Fatima contacted Lewis “in her capacity” as co-chair of the Healthcare Coalition of Rhode Island, which coordinates emergency planning and response between the state and HARI, Wendelken said in an email.

Lewis alerted state health officials, who then called nurses in charge of the emergency departments at each of the five hospitals in the northern group to assess their staffing and patient volume. Rhode Island Hospital agreed to re-open its emergency department to ambulances starting at 11 p.m., Wendelken said.

Landmark, in Woonsocket, also had to re-open to ambulances within an hour, Wendelken, said.  Fatima was then allowed to divert ambulances for the next eight hours, he said, until 7 a.m. Monday. 

Even so, Fatima’s emergency department was so short-handed that nurses filed at least four “unsafe staffing” reports during a six-hour period starting at 11 p.m. Sunday, according to  records obtained by The Public’s Radio. By Monday at 5 a.m. Fatima's emergency department had 23 patients and only one registered nurse on duty, instead of three nurses normally assigned to that shift, records show. 

Upsetting a ‘delicate balance’ 

Rhode Island is so small that anytime one hospital’s emergency department becomes overwhelmed and temporarily stops accepting ambulances it creates a “domino effect” on other area hospitals. 

“When a hospital stops accepting [patients], there's a very delicate balance,’’ said Denise Brennan, director of emergency services at The Miriam Hospital, in Providence, which is operated by Lifespan. When that balance gets tipped, she said, “It's like a domino effect where other hospitals become overwhelmed and are unable to manage their flow.”

Rhode Island Hospital, in Providence, is the state’s only Level 1 Trauma Center, caring for people injured in car crashes and fires in addition to performing complex cancer and heart surgeries. And some of its most critical patients can’t be shifted to another hospital for care. So when one of the smaller, community hospitals closes its emergency department to ambulances, Rhode Island Hospital has to take on more routine cases, physicians said, such as broken bones or appendicitis, which could be handled by the community hospitals.

“What's happened a lot during this wave of the pandemic is a really unequal distribution of patients,’’ said Dr. William Cioffi, chair of surgery for Lifespan, which runs Rhode Island Hospital.

As a result, he said, “care is not being able to be offered to those who need it most all the time.’’

Rhode Island could have mitigated the impact of the staffing shortage during the omicron surge, Cioffi said, if McKee had used his emergency powers to halt elective surgeries at all hospitals so they could better “share the burden” of patients flooding their emergency departments. That would have allowed Rhode Island Hospital to treat more “urgent but not emergency cases,” he said, and improved outcomes for those patients.

Instead, the decisions were left up to hospital operators. 

Profits vs. patients

Elective and “non-urgent” surgeries, particularly orthopedic and cardiac surgical procedures, are among the most profitable services for hospitals. Elective or scheduled admissions, on average, are almost $700 more profitable to hospitals than emergency department admissions, according to a 2008 study of Medicare data published in Academic Emergency Medicine. During the pandemic’s first wave, hospitals nationwide lost an estimated $22.3 billion when they stopped performing elective surgeries between March and May of 2020, according to a January 2021 study published in Annals of Surgery.

Attention to the bottom line may have been the primary motivator behind CharterCare’s decision to continue performing elective surgeries during the latest omicron surge, said Dr. David Himmelstein, a distinguished professor of public health at the City University of New York’s Hunter College. 

Unlike Lifespan and Care New England, which are both nonprofits, CharterCare’s parent is the for-profit hospital chain Prospect Medical Holdings, based in Los Angeles. 

“Hospitals seek to offload the burdens of things that are money losers, or not lucrative, onto other hospitals, '' Himmelstein said. “And, unfortunately, we've seen that for-profit hospitals tend to be the ones most likely to offload those socially and morally requisite duties.”

Rhode Island was among the states hardest hit by the hospital staffing shortage, and one of only six states where President Biden sent in military medical troops to assist hospitals. About 74 members of the Rhode Island National Guard also were deployed to hospitals to help with non-clinical jobs to relieve staffing shortages. 

Rhode Island needs a better statewide response to its hospital staffing and capacity problems, said Cioffi, Lifespan’s chief of surgery.

“This was the fourth major surge,’’ Cioffi said. “We're going to have another one. And we need to learn as a state…how to react better when we get the fifth surge.”

Health reporter Lynn Arditi can be reached at larditi@ThePublicsRadio.org. Follow her on Twitter @LynnArditi