It's not surprising, when you understand what she does, to hear Sue Hamel sometimes use the word "crazy" about an aspect of her job.
As in, "Our volumes have not been as crazy as they were."
As in, "It's not crazy slow, but it's not through the roof like it was last year."
As vice president and chief of nursing at St. Luke's hospital, Hamel is one of those looking almost constantly at the hospital's patient census in seeking to make sure there's a bed for every patient.
It might be compared to managing vacancies at a hotel, except occupants are coming and going constantly. And although it's true that not all hotel rooms are the same, rooms in hospitals are starkly different from one unit to another.
"We do not put more critically ill specialty patients in other areas of the hospital," said Cindy Kent, chief nursing officer for Essentia Health. "We have stroke patients going to our neuro units. We have cardiac patients going to our cardiac unit."
To take the analogy one step further, hotels probably don't like to put the "no vacancy" sign out. Hospitals - which don't literally have such signs - really, really don't like to do it.
In hospital lingo, if there's no room left, a patient isn't left to her own devices. Instead, she may be "diverted" to another hospital.
It's not a word hospital officials like to use. Kent said, for example, that if necessary, Essentia can move patients among its three Twin Ports hospitals - Essentia Health-St. Mary's Medical Center, Essentia Health-Duluth (still often referred to as Miller-Dwan) and St. Mary's Hospital-Superior.
Related content"We don't really call that diverting," Kent said. "Sometimes that has a connotation that doesn't sound welcoming."
If either St. Luke's or Essentia does have to divert, they're most likely to divert to each other.
"We always work with St Luke's every day when we talk about our patient flow," Kent said. "We know if St. Luke's is on divert or what their capacity is."
But when one hospital is full, the other one might be, too.
"Frequently what we experience is when we're on divert, Essentia's on divert also," Hamel said.
Despite that, local hospitals say it's extremely rare for patients to be diverted beyond the Twin Ports. Kent said she couldn't think of a time when it happened. John Strange, CEO of St. Luke's, said once last year a patient was diverted to Community Memorial Hospital in Cloquet.
Which is not to say that the hospitals don't come close.
"It's been busier in our hospitals at least over the last six months, and there is no specific type of patient coming to us," Kent said. "It's a variety of patients."
The pattern has been a little different at St. Luke's, Hamel said. Last year, the hospital was crazy full in January, July and October, but in November and December, it tapered off. Last January coincided with the worst flu season in recent years, but the other months aren't as easily explained.
The hospitals can't just add beds if they're too often close to capacity, the officials said. They are licensed for a set number of beds by the state. In fact, both St. Luke's and St. Mary's are licensed for slightly more beds than they actually have available. St. Luke's, for example, is licensed for 267 beds, but the highest it has hit in recent months was 253, Kent said.
If either hospital plans to seek licensing for more beds as part of their upcoming redevelopment plans, they aren't saying so yet. St. Luke's is focused for now on the transfer of its emergency department to Building A, Hamel said.
But that department will include longer-stay "observation beds," to take more of a look at emergency room patients who might not have to be admitted. That "would have a positive impact on our inpatient units," she said.
At the new St. Mary's, all patient rooms will be private, Kent said. "And that's going to be wonderful. Every so often now in a hospital when you have the double rooms, there's certain patients who cannot have a roommate for one reason or another. ... And when we have private rooms, that will avoid that challenge."
Ebbs and flows
Across the state, hospital capacity is adequate, said Dr. Rahul Koranne, chief medical officer for the Minnesota Hospital Association.
"We can see that there is capacity across all regions of the state," Koranne said. "If they need a hospital level of care, they are absolutely going to get that."
But there are ebbs and flows in patient numbers, he said, and in rare cases, a patient must be diverted to another hospital.
When that can't be helped, it's done with great care, Koranne added.
"The health-care systems in Minnesota are very sophisticated when it comes to knowing how many patients they have, what capacity they have," Koranne said. "Many times, our hospitals actually know their capacity every eight hours, so every shift, they know how many beds they have available. ... So typically it's never a surprise."
The review of capacity occurs every four hours at St. Luke's, Hamel said, but, in reality, "probably every hour."
In a divert, Koranne said, the emergency department would make sure the patient is able to undergo the transfer, the nearest hospital with space would be identified, and attending physicians and nurses at the first hospital would discuss the patient's diagnosis with their counterparts at the second. "It's very intentional, very orchestrated and very smooth."
Behavioral units jammed
One area that's often full at hospitals is what's generally described as the behavioral health unit.
"Our behavioral health unit is frequently full," Hamel said. "That one, you know, changes hourly. That's one that fills up on a regular basis."
Patients in that unit are diverted "all over the place," Strange said.
Patients in what Essentia calls the inpatient mental health unit at Essentia Health-Duluth come from other parts of the state and are sent to other parts of the state, according to Diane Holliday-Welsh, operations administrator in the behavioral health and emergency medicine divisions for Essentia Health-East.
"Not all patients in need of inpatient mental health can be accommodated in the Duluth community," Holliday-Welsh wrote in an email. "As a result, it is necessary to transfer patients for the care they need to facilities outside of our community, which can be several hours away."
Moreover, there frequently are no beds available in community-based or residential facilities when patients are ready to be discharged to that level of mental health care, Holliday-Welsh added.
It's a statewide problem, Koranne said. In a sampling of inpatient psychiatric units a few years ago, the Minnesota Hospital Association found that almost one in five psychiatric patients were being held in the hospital units because there were no safe community destinations to discharge them to.
"In that particular service line, we need to do more," Koranne said. "We need to partner with the Department of Human Services, we need to partner - and we are partnering - with other community-based organizations and the government to make that capacity available for Minnesotans."