As emergency rooms filled with patients, Honolulu's head of emergency services was tasked with coordinating ambulance arrivals.
Jim Ireland, who oversees Honolulu’s paramedic operations, started his day just before 5 a.m. on March 18.
It wasn’t an ordinary Monday. At midnight, the only emergency room in the Wahiawa area had temporarily closed its doors for an undetermined time. The first public warning was a press release issued the Friday before marked “URGENT.”
Now, fewer emergency room beds exist to serve that population, and the closest remaining emergency room for much of the North Shore and Koolauloa is a facility in Kahuku. The next closest is in Kailua.
“This closure is extraordinary,” Ireland said.
About 60 people are transported via ambulance to the emergency room each day in Central Oahu, and about 10 of them had been going to the 16-bed unit at Wahiawa General Hospital, Ireland said — not to mention those who come without an ambulance.
On an island with limited ER capacity, the closure has a cascading effect.
Fewer available emergency room beds means the ERs that are still open have longer wait times. That means that ambulances dropping off patients at these facilities sit in the parking lots waiting for their patients to be admitted.
This problem is further exacerbated by the fact that some of these ambulances that would have transported patients to Wahiawa General Hospital now have to drive further to other hospitals.
Consistent with a recent trend nationwide, Honolulu’s emergency rooms are struggling with patient capacity. The reasons range from an aging population to people putting off dealing with or screening for medical conditions during the pandemic.
Ireland’s Monday consisted of bouncing between different hospitals to see how they were doing with the influx of patients.
That afternoon, at the ambulance facility in Waipio, he perused a display of emergency room capacities on a city computer system installed in the last couple of months.
A little after 1:30 p.m., it showed The Queen’s Medical Center West Oahu was at 350% capacity with 77 patients. Pali Momi Medical Center, the other nearby hospital, was at 185% of capacity with 37 patients.
“We still have five hours of our busiest time of day, and we’re going to stuff more patients into these two ERs,” Ireland said. “If they get totally overwhelmed and can’t take it anymore — Wahiawa used to be our safety valve. Gone.”
In a way, Ireland is already used to this kind of high-intensity matchmaking between ambulances and emergency rooms.
As head of the city’s Department of Emergency Services, Ireland told the Honolulu City Council at a recent budget hearing that ambulances bringing their patients to emergency rooms sometimes have to wait in the parking lots because no bed is available.
“Some of the ERs on Oahu were not letting the patient out of the ambulance for three hours,” he said at the time.
In a domino effect, every ambulance waiting in the parking lot of an emergency room represents an ambulance not available to pick up and treat new patients. For regions that don’t have many ambulances – none exist on the North Shore between Waialua and Kahuku – that means a longer wait if somebody needs emergency transport.
Wahiawa General Hospital, which did not respond to a request for comment, temporarily and suddenly closed its emergency room on Monday for HVAC repairs. It’s unclear when the facility will reopen, and that leaves the city with one fewer emergency room option for the foreseeable future.
Ireland said that hospitals previously had more leeway to tell ambulances they were on “reroute” — too full to receive any more patients.
“But what we were finding is some hospitals would go on reroute for days, and it would impact all the other hospitals. And the other hospitals would want to go on reroute, and essentially everybody would just want to go on reroute,” he told the City Council.
To combat this, ambulances now follow a “round robin” strategy that involves rotating where they deliver patients during the busiest hours. Hospitals can still request to be put on reroute status, but for a span of hours rather than days, Ireland said at the budget hearing.
A sign posted outside Wahiawa General Hospital alerts the public that the emergency room is closed.
Ireland and paramedic supervisor Sunny Johnson drove to Wahiawa General Hospital a little after 2 p.m. on Monday to find out if people knew they should go elsewhere. A staffer posted outside said that nobody had tried be seen in the emergency room.
“I was afraid somebody was going to show up with an asthma attack and knocking on the window,” Ireland said.
“That part of it was probably my biggest initial fear.”
He also worried how other hospitals would fare.
“I knew they would be this busy. But what I don’t know is over the next two to four hours how much more busy — so we’re still letting the rigs go there,” Ireland said as he drove out of Wahiawa.
Monday’s next stop was at the The Queen’s Medical Center West Oahu. Around 2:30 p.m., three ambulances sat outside the hospital as their crews waited with patients in the back.
Ireland walked over to talk to the crews.
“So this ambulance has been here an hour,” he said, pointing to one of them. “The patient’s still in the back.” Another ambulance had been waiting over an hour before it left.
“There’s other ambulances that want to come here, but they’re just sitting out front like this,” Ireland said.
Pali Momi also had a patient waiting, though just with a swollen lip. Critical life-threatening emergencies skip the line, he said — “they make room for us.”
Even before Wahiawa General’s closure, Honolulu’s emergency rooms were having trouble meeting patient demand.
Honolulu’s situation isn’t unique. Emergency rooms around the country are overwhelmed with patients. A January press release from Massachusetts General Hospital says that beds and hallway stretchers in the hospital’s emergency department were full almost every day for 16 months.
Essentially, patient demand is outpacing the emergency care that hospitals can supply.
This is despite – and in some ways related to – the pandemic winding down during the last couple years.
In 2019 and early 2020 — when many people avoided hospitals for fear of infection — Hawaii’s average patient count was about 2,000.
That number jumped about 20% as the pandemic continued, said Hilton Raethel, president and CEO of the Healthcare Association of Hawaii.
Health care professionals assumed that the bulge in emergency room visits would gradually fall again as the pandemic subsided, Raethel said. But about a year and a half ago, they noticed that it actually remained stubbornly high.
Part of the reason is Hawaii’s aging population, which “would’ve happened anyway without Covid,” Raethel said.
In addition, he said, when otherwise healthy people avoided hospitals during the pandemic, it sometimes meant that they were skipping preventative screenings that would have detected illnesses before they progressed to the point of needing more care.
As a result, more people are entering the health care system and staying for longer, meaning that there are fewer vacant beds available for emergency room patients when they no longer need that immediate care.
Some hospitals, like Straub Medical Center and The Queen’s West Oahu, are expanding their space to increase the number of available beds.
But Raethel cautioned that there’s still the separate issue of a shortage of medical workers.
“If we were to double the number of beds in our emergency rooms overnight, that would not necessarily solve the problem,” he said. Training enough new nurses and doctors to care for these extra patients is the current challenge.
“Our educational systems have ramped up,” he said. “But it takes a while.”
It’s an issue for Ireland too as he tries to make sure patients can be transported to hospitals.
He said that the number of vacancies among Honolulu’s paramedics will soon be the lowest in 20 years. His department is still experimenting with educational partnerships and different work schedules to try to attract and retain people.
Boosting capacity also involves contracting for three ambulances from the private service American Medical Response, as well as having an agreement with the Federal Fire Department to use one of its ambulance crews based at Wheeler Army Airfield if needed.
The emergency room closure at Wahiawa General presents an extra challenge. After visiting different hospitals on Monday, Ireland said it was about what he expected.
Ambulances waited outside The Queen’s West Oahu for about an hour or more, “Pali Momi’s really busy, but we knew that was possible. No one has needed a 911 call from the parking lot of Wahiawa,” he said. “I’m happy about that.”
Civil Beat’s community health coverage is supported by the Swayne Family Fund of Hawaii Community Foundation, the Cooke Foundation, Atherton Family Foundation and Papa Ola Lokahi.
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