In the middle of May, when some 40 Chicagoans a day were dying of COVID-19, Norwegian American Hospital’s 12-bed intensive care unit for the sickest patients was full. Some patients lingered in the emergency room waiting for a bed upstairs.
A statewide database that hospitals are supposed to enter data into every day about their ability to treat patients showed there were beds available across the Chicago area.
So six employees at Norwegian, a small community hospital on the West Side that treats a large portion of low-income patients of color, got to work. They called one hospital after another trying to find more ICU beds for their patients to free up space at Norwegian. But they largely ran into roadblocks.
Some hospitals told Norwegian they actually were full, despite reporting to the state otherwise, the employees later recalled. Others said they weren’t taking transfers, or only transfers for patients who needed a higher level of care. Some hospitals said they didn’t take the publicly-funded insurance Norwegian’s patient had.
“All day, it was eight to ten hours of calling to not get anywhere,” said a frustrated Heather Khan, Norwegian’s vice president of patient care services and one of the callers.
An executive at another hospital made calls on Norwegian’s behalf. Norwegian even reached out to Chicago and Illinois emergency medical care liaisons asking for help.
One day, Norwegian contacted 21 hospitals — some in suburbs nearly an hour’s drive from the West Side — and were able to transfer just two patients.
They attempted another tactic: try to transfer less sick patients to the $65 million field hospital with room for 3,000 beds set up inside McCormick Place, the giant convention center just south of downtown. Illinois Gov. JB Pritzker and Chicago Mayor Lori Lightfoot touted McCormick as a place that would take COVID patients with mild symptoms to relieve overwhelmed hospitals.
“They took maybe two or three patients the entire time,” Khan said. “That’s all that qualified. I needed beds.”
So Norwegian stopped even trying to send patients to McCormick.
The COVID-19 pandemic has revealed yet another gap in the health care system — in Chicago, there’s no agency coordinating how patients flow from one hospital to another. In fact, there’s no agency in Illinois that has the power to force hospitals to take patient transfers, including public health officials who are making crucial decisions about how to respond to the crisis, WBEZ has learned.
That’s unlike other regional health crisis initiatives. For example, when a person gets shot, hit by a car or severely injured in a fall, there’s a protocol in place to get that person to the closest trauma center as quickly as possible to save their life.
Instead, in the midst of a pandemic, hospitals have had to play a stressful game of “who do you know,” leaning on long-standing relationships to transfer COVID-19 patients. They call hospitals where they trained as residents decades ago, or where they used to work. Like Norwegian, they call around until they find a bed.
It’s a patchwork system that has left some hospitals scrambling, usually the ones with the least amount of resources— and typically treating patients who are dying most of COVID-19, African Americans and Latinos.
“We have an opportunity to better coordinate a response here in Chicago,” said Dr. Paul Casey, chief medical officer at Rush University Medical Center, which has treated more than 400 patients diagnosed with COVID-19 or suspected of having the virus transferred from other hospitals. “We didn’t hit that point where there was really a free sharing of information around what the beds and capacities were throughout the city, so that we could be sure that if a patient was sitting in Jackson Park Hospital that they had equal opportunity to get to whatever hospital would be able to take care of them.”
Jackson Park is a community hospital on the South Side that mostly treats low-income and elderly Black patients.
In Chicago, the public health department should be able to steer patients to where hospital beds are available, and call out hospitals that are shutting their doors to transfers, Casey suggested.
No tracking of patient transfers
In late February, weeks before the pandemic started to grow in Chicago, leaders at Rush decided to reach out to hospitals they knew might struggle to treat COVID-19 patients, instead of waiting for them to get overwhelmed and call for help. Norwegian was on their list. So were several other so-called medical safety nets on the South and West sides.
“Our philosophy was, there’s going to be patients out there like we saw in New York City that, if there’s not a coordinated response … there’s going to be patients unfortunately that suffer and patients that end up dying that may have otherwise been saved,” Casey said.
Rush is a prominent teaching hospital just west of downtown that, in 2012, opened a new butterfly-shaped tower built to handle patients during an epic disaster, like a pandemic. When COVID-19 was on the horizon, Rush made big plans to handle a barrage of expected infected patients who would need to be hospitalized.
In the height of the pandemic here —cases surged in late April into May — hospitals no matter the size were slammed with patients.
Even Rush at times turned away patient transfers. But the hospital in April and May accepted nearly 600 patients transferred from other medical centers, according to Rush. Of those, roughly 70% were COVID-19 related patients. Almost one-third came from struggling safety net hospitals, including Norwegian.
The majority of all COVID-related patients transferred to Rush were African American or Latino, and about one-third either didn’t have insurance or were on Medicaid, the government-funded insurance for low-income and disabled people. Nearly 150 of the patients were on life-saving ventilators to help them breathe.
Dr. David Ansell, a senior vice president at Rush who studies health disparities, said one of the ways to further dismantle structural racism is to be more responsive.
“You know these hospitals were going to suffer,” Ansell said of the safety nets. “But more than that, the patients were going to suffer because they would run out of capacity. We knew this in the beginning of COVID, and as we were expanding up, I called everyone I knew on the West Side and just said, ‘If you need help, call.’”
Khan at Norwegian said Ansell would check in with her on weekends to see how the hospital was doing.
“We were able to take care of the patients in our ER,” Khan said of those Norwegian couldn’t transfer to other hospitals. “The problem is, it’s the potential, right? You could have something happen. It’s not good patient care to leave patients in an emergency room.”
It’s not clear how often hospitals across Illinois tried to transfer patients with COVID-19 or those suspected of having the virus — or if any patients were harmed because they couldn’t move to another facility. Hospitals typically keep transfer logs but no government agency appears to be collecting and tracking the data.
So WBEZ attempted its own analysis to better understand the scope. WBEZ asked community hospitals and health systems in Chicago and surrounding suburbs that combined total nearly 50 local facilities to detail patient transfers in April and May compared to the same time period last year. WBEZ also asked for the race of patients and the type of insurance they had.
Providers representing a combined 12 hospitals responded with varying levels of information. Here’s what WBEZ learned from that group:
- Large health systems with multiple hospitals had the bandwidth to transfer patients within their own networks. The bulk of transfers Loyola University Medical Center in the western suburbs accepted came from the two other hospitals in its health system, followed by a mix of other suburban hospitals, Loyola Chief Medical Officer Dr. Kevin Smith said. When Loyola was getting full, the hospital sent ICU nurses to its sister hospitals to treat patients.
- NorthShore University HealthSystem in the northern suburbs transferred nearly 900 patients in May alone. But that’s a mix of moving COVID patients to one hospital designated to treat them and moving patients who didn’t have the virus to other hospitals in the network. AMITA Health, which stretches from northwest suburban Elgin to Kankakee, more than 60 miles south of the Loop, avoided transferring critically-ill patients and instead sent more resources to hospitals to treat them, said Michelle Hereford, a senior vice president.
- Not all small community staples like Norwegian that treat low-income people of color had trouble transferring patients to other hospitals. Dr. Mira Iliescu-Levine, chief medical officer at Loretto Hospital, a safety net hospital on the West Side, said she had to wait only a few times to transfer patients out.
“I never heard anybody being mean or pushing back because I don’t want to take another patient,” Iliescu-Levine said. “If you don’t have room, you don’t.”
- Not all hospitals transferred patients. Tim Caveney, CEO of South Shore Hospital, a small financially-struggling anchor on the South Side near Lake Michigan, said he tried to meet every patient’s needs because the hospital would lose money if patients left for other facilities.
- Several hospitals said they had trouble transferring patients to McCormick Place’s field hospital because patients didn’t meet what hospitals viewed as strict criteria. For example, patients couldn’t be obese, with a body mass index of more than 40.
A spokeswoman for Chicago Mayor Lori Lightfoot said this requirement was in place because patients infected with COVID-19 who had a high body mass index were more likely to have complications and the field hospital was designed for patients with mild symptoms.
Of the four field hospitals set up in the Chicago area, all of the transfer patients went to McCormick Place. That field hospital treated 38 patients. There were another 68 transfers rejected for a variety of reasons, including patients who required extensive nursing care or who had poor oxygen levels, a spokeswoman for the Illinois Department of Public Health said.
‘There were no rule books’
Michele Mazurek, chief nursing officer for Sinai Health System on the Southwest Side, points out that hospitals were blindsided by COVID-19.
“There were no rule books,” Mazurek said. “There were no gold standards. So I think that the relationships that the hospitals had, especially with hospitals in our specific area, we learned to do this together.”
Sinai has a longstanding relationship with Rush, a less than 10-minute-drive away. Of the 57 COVID-related patients who Sinai transferred from March to May, the majority were Black and low-income or elderly, reflecting the communities that Sinai treats. More than half of the patients went to Rush. Sinai transferred patients when they needed special bypass machines the health system didn’t have, or when Sinai didn’t have enough critical care nurses to treat patients, Mazurek said. Others went to VA hospitals, and three to McCormick Place.
Sinai reciprocated the effort by sharing ventilators with Rush.
But when hospitals did need help transferring patients, they sometimes called Anna Scaccia. She’s the go-to coordinator for hospitals in Chicago to prepare for emergencies. There are coordinators like her around Illinois.
“That’s kind of our job … to make sure our region is to be able to take care of our patients the best way we can,” Scaccia said.
But despite her role, she said she doesn’t have any real authority. She can’t force hospitals to take patients, even if another hospital is drowning.
“This is a pandemic that we’ve never had to work with,” Scaccia said. “I think it also acknowledges each of the smaller hospitals need to … plan, not just be super-dependent on the larger academic hospitals to help them.”
Other regions in the country with hospitals as competitive as those in Chicago managed the same urgent need to coordinate transfers of COVID-19 patients, but in different ways.
In Boston, Dr. Paul Biddinger said medical centers formed a group early on to prevent them from becoming overwhelmed. They went beyond just sharing metrics, like hospitals do here.
“We agreed together who had capacity and how we should best try and urge transfers to be shared among hospitals, so that we would evenly balance the load and make sure there were ICU beds available,” said Biddinger, medical director for emergency preparedness at Mass General Brigham, one of the major health systems in Boston. “It helps skip a couple of steps or skip a couple of phone calls if you already knew at the outset that hospital X that day was not going to be able to provide that service.”
In New York, among the states hardest hit by COVID, Gov. Andrew Cuomo created a team to coordinate resources among hospitals, including patient transfers. But a Wall Street Journal investigation detailed how some patients were too sick to be transferred, some arrived at the transferred hospital with no name and little medical information and political bickering got in the way. A spokesman for New York’s public health department declined an interview request.
Doctors in Chicago and elsewhere around the country say it’s not surprising some hospitals don’t quickly share information that would give others a window into how they operate, such as if they could take on more patients during the pandemic They are businesses after all, that compete for patients and the best reimbursement rates from insurance companies.
“There’s never been a good reason prior to COVID for hospitals to cooperate in this way,” said Dr. Jeremy Kahn, an ICU physician and a professor at the University of Pittsburgh. “If anything, our health system creates incentives for hospitals to compete.”
What happens next time?
In Illinois and closer to home in Chicago, COVID-19 cases have generally been on the decline in the past month. State and city leaders have been reopening more and more of the economy. But public health officials and hospitals are looking to the fall and winter, when cases could rise again.
Hospitals could be bustling with people who get COVID, and need to transfer some to prevent overcrowding.
“We certainly have heard the concerns with transfers of patients,” said Dr. Jennifer Layden, chief medical officer at the Chicago Department of Public Health.
But the state regulates hospitals, not the city, she said.
“Without that authority and oversight of hospitals, it would be hard to enforce [transfers] unless there was a significant change in rules or policy,” Layden said.
Coordinating transfers still would be tough, she said. Some patients might not want to be transferred to a hospital far from home, and hospitals might not take their insurance to help cover their medical costs.
Chicago officials say they’re working on a possible solution. The city’s public health department is working with hospitals to create a dashboard that aims to show in real time which beds are full versus which are available for patients. This would also help monitor how rapidly things change, Layden said.
The data hub would electronically capture information from hospitals. Now, they manually enter various metrics into a statewide portal that represents just a snapshot in time, not truly where beds are full or empty. That’s why people like Khan at Norwegian call around for hours searching for beds.
So far almost all of the hospitals in Chicago have signed on to the department’s data hub, Layden said. It could launch as soon as August, around when kids might be back in the classroom and before flu season ramps up.
Kristen Schorsch covers public health on WBEZ’s government and politics team. Follow her @kschorsch.