'Unprecedented': Exeter Hospital ER under duress as COVID and psychiatric cases rise

EXETER — People seeking emergency room care at Exeter Hospital have been confronted recently with multi-hour wait times, even for some of the most potentially dire ailments, due to an uptick in psychiatric and COVID cases. 

Chief Executive Physician Dr. Neil Meehan said the hospital is seeing an “unprecedented” level of patients seeking emergency care for a number of issues, including COVID-19 with cases on the rise at a pace similar to last year at the end of fall.

“The biggest challenge right now, is the trifecta increase in our COVID burden, the overall needs of core services, and a staffing crisis, so it’s a nexus of stress the system has never seen before,” Meehan said. “In my 25 years, I’ve never seen a system under this much duress and that’s the feeling of everyone in the country right now.”

Meehan said for Exeter Hospital, and others, a “crisis standards of care” scenario, which offers clinicians legal and ethical guidelines to ration the delivery of healthcare to patients when hospital resources are overwhelmed – is not off the table in the coming months.

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However, Meehan said, before that would happen, other contingencies would have to be exhausted, such as calling up the National Guard to assist in the delivery of medical care and/or utilizing other non-hospital medical facilities for space before a crisis standards of care scenario unfolds.

“I don’t think we have a crystal ball for what is coming in December and January. In the near term, we have some capacity for the work ahead of us,” Meehan said. “I don’t think of crisis term of care as being the avenue for medical service in New Hampshire, but that may change in the upcoming months.”

Psychiatric care in high demand

Meehan said approximately 50% of Exeter Hospital’s 21 emergency room beds have been occupied by patients in need of urgent psychiatric care. He said psychiatric issues vary widely, such as threats of self-harm, seniors suffering from dementia waiting to be placed into long-term care and pent-up pandemic-related stresses. He said the number of younger patients being hospitalized with psychiatric issues is increasing as well, with some also threatening self-harm and others with uncontrolled behavioral issues their guardians are unable to handle.

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Meehan said the psychiatric patients are often placed in emergency room holds for 24, 48 or 72 hours, or even longer, with some patients held for weeks at a time. He said patients admitted and held with psychiatric issues require one-on-one counseling with a specialist and they are visited by psychiatrists, among other resources. Seniors being held with cognitive ailments, he said, are held until they are placed in in-patient rehabilitation or connected to home health services.

“It’s a double-whammy as we have our normal volume of people seeking behavioral health care and that’s been consistent, but during and post pandemic those rates are even higher,” Meehan said. “Those demands have not only outstripped the resources of the hospital, but also in-patient and out-patient psychiatric care, and rehabilitation facilities. While there are a lot of different reasons for the boarding of patients, the overarching motif is to ensure patient safety before we have definitive care to place them in outside the hospital.”

As a result of these psychiatric holds, Meehan said patients who come to the ER with ailments that otherwise would have a person rushed into care, such as chest pains, has put a strain on bed capacity and meant these patients have been unable to access care immediately.

COVID cases continue to increase 

Meehan said the number of patients admitted for COVID-19 has been steadily increasing since the summer. He said the summer typically saw one or two COVID-19 hospitalizations at a time. He said that number has ballooned to an average of 20 with some patients requiring life support in intensive care and others being placed into an isolated COVID-19 medical unit, a step down from intensive care.

Meehan said 20 people being admitted to the hospital for COVID-19 accounts for 25% of the hospital’s entire beds. 

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“People who would normally move through the system fairly quickly are unable to move through the system and have to wait for delayed admissions, but there’s also a significant burden on the in-patient bed capacity as well and that’s the experience of every hospital in our region,” Meehan said. “You can see the immediate strain on the system.”

Meehan said the driving force behind the strains on hospital resources are multi-factorial on the patient side.

Meehan said once hospitals reopened again for elective procedures after the initial COVID-19 surge in spring of last year, Exeter and others had a backlog of patients who delayed receiving care for any number of health issues until they felt comfortable re-entering a hospital. In turn, when they have finally had to seek out emergency care for their ailment, Meehan said, that leads to more acute symptoms requiring longer hospital stays.

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“There are currently reduced resources in the community; physicians’ offices are constrained and they’re not operating as efficiently as they used to because they are promoting social distancing in waiting rooms, etc.,” Meehan said. “Collectively, that all funnels more demand to the emergency room and not standard care. There are a lot of resources being expended as they occupy more and more of the emergency department.”

'Unprecedented' exodus of healthcare workers 

The rush on hospital and emergency care is occurring at the same time as the largest exodus from the medical field Meehan said he has ever witnessed. Also, the hospital is required to screen staff for COVID-19 daily and all employees “under investigation” for COVID-19 exposure and those who have breakthrough cases are required to quarantine or self-isolate at home, causing further day-to-day attrition. He said 97% of the hospital staff is vaccinated against COVID-19.

“The exodus from the healthcare field by workers is unprecedented,” Meehan said.

Meehan said the best way to reduce the COVID-19 burden the hospital will face through the coming winter is to increase the vaccination rate. He said models indicate New Hampshire could be in for a long winter if the vaccination rate doesn’t improve. At 54.9% of state residents fully vaccinated against COVID-19, according to the state Department of Health and Human Services, New Hampshire is last in New England.

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“Given the lack of vaccine uptake, that is calculated into those scenarios for the foreseeable months,” Meehan said. “Even though New England’s vaccination rates have fallen off, the people who are vaccinated who were eligible have bought us some time to protect those most vulnerable. We could be wrong and COVID declines but we don’t expect to see that this winter, and that is only if we do not see another variant or some other unforeseen variable like the delta variant or the U.K. variant that came on the scene in the summer.”

Meehan said, lately, 20-25% of recent COVID-19 hospitalizations nationally have been children, many of whom suffer long-haul virus symptoms. He said Exeter Hospital recently had to transfer a COVID-19 positive child to a Boston hospital who was suffering from Multi System Inflammation Syndrome (MSIS), where various organs become inflamed like the heart and lungs. MSIS has been a side effect children have suffered from after being infected with COVID-19, according to the CDC.

Meehan said parents getting their children vaccinated and getting the booster shot was the best means of reaching herd immunity to COVID-19 among the wider population. He said there was “little downside” to receiving a booster shot for already vaccinated individuals and may prove to be the best way to prevent a breakthrough case over the winter.

“We’ve been at a tipping point for some time now,” Meehan said. “It’s been proven time and time again the vaccine is the best way to keep you and your family safe; it’s the best thing we can do for our children right now."