Big Island’s hospitals in Kona and Hilo dealing with overcapacity; what can be done?
A day after Cari Miranda’s husband was bit by an unknown insect, his arm and hand swelled, and the pain got so bad he couldn’t get into a vehicle. 911 was called.
When EMTs arrived, he was confused, his color had changed and his oxygen levels were low. Suspecting he may have been bitten by a venomous spider in the recluse family, the EMTs transported him to Kona Community Hospital by ambulance.
It would be another hour after that before he was seen by a doctor, and it took until 7 p.m. for medication to be administered. He needed more medical care, but with no beds immediately available he was held in the emergency room — and he would have stayed there all night except that he got lucky and a hospital bed opened up later that night.
Miranda said her husband, who didn’t want to be named in the story, was crammed in a room with four to five other patients: “There was no sleep. No privacy. Everywhere you could put a bed, there was a bed. … Everyone’s care was compromised because of the overcrowding.”
Being at overcapacity is a problem routinely experienced at Kona Community Hospital — and also at the Big Island’s other primary hospital, Hilo Medical Center, according to spokespersons for each medical facility.
On Dec. 23, Kona Community Hospital had all 94 of its beds in use, forcing seven people who needed more care to be held in its Emergency Department, also known as ED, until a bed opened up at the hospital or at another facility off-island. At Hilo Medical Center, all 166 beds were in use, with the number of patients holding in its Emergency Department even higher, at 15.
“We have had patients wait several hours to days, or in a truly unfortunate situation, received all their care in the ER because a bed never opened up,” Hilo Medical Center spokesperson Elena Cabatu said.
Two months ago, the facility had 20-plus patients waiting in the emergency room for beds to open up somewhere. They were put in hallway beds crammed between the Emergency and Imaging departments and around both nursing stations.
“It gets tight when we have a lot of patients, but our staff work hard to deliver care,” Cabatu said.
For Hilo Medical Center, there is some expected help on the way. Hawaiʻi’s newly elected governor, Josh Green, has included $50 million for the hospital in his Executive Budget for 2023-2025. Green, who worked for years as a doctor on the Big Island, said it is one of his “high-priority” items.
The funding, if it is approved by the State Legislature, would be for the expansion of Hilo Medical Centerʻs Intensive Care Unit and medical Surgical Unit at the hospital.
“Governor Green’s leadership in identifying our ICU and Hospital Bed Expansion project among his priorities in his budget is key in helping us establish the importance of our project for the healthcare of our neighbor island communities,” Hilo Medical Center CEO Dan Brinkman said. “Emergency Department holds are unfortunately routine as patients wait for beds to open up in the hospital. These waits for inpatient and ICU beds are in spite of the addition of temporary emergency beds located within our long-term care facility, where patients are four to a room.
“This situation is why we need to secure capital funding through legislative prioritization in order to expand our hospital’s capacity to serve.”
Kona Community Hospital is seeking Capital Improvement Project funding from the State Legislature for critical upgrades just to keep the hospital open and operational, not for expansion. The hospital’s request is $4.9 million for the fiscal year 2024 and $11 million for fiscal year 2025.
Projects include replacing old and failing utility equipment. Additionally, the hospital hopes to secure funding for internal building systems whose parts are becoming obsolete or can no longer be found to purchase. This includes the fire alarm, fire Sprinkler, electrical, IT and plumbing systems. The goal is to replace these systems to improve operational function and reduce ongoing responses to system failures.
While the projects won’t have a direct impact on the waitlist issue, Kona Community Hospital spokesperson Judy Donovan said it will lay the groundwork for an emergency department expansion, which will ease some of the overcrowding.
Six months ago, the Kona hospital erected a self-contained negative-pressure medical tent with eight medical-grade cots outside the Emergency Department to handle overflow.
But Dr. Audrey McCandless, the emergency department’s medical director, said the hospital has used the tent only a handful of times. It requires about seven nurses to keep it open 24-7, and patients are usually too sick to be appropriately treated in the tent. It can be used for patients with minor health issues, like a sprain, small lacerations or minor respiratory issues.
“We had discussed taking it down because it’s been less useful,” McCandless said.
Kona Community Hospital now has been conducting what Dr. McCandless calls “waiting room medicine,” with doctors treating simple ailments like sprains, minor cuts or colds without being admitted to the emergency room.
Some people with more serious issues and life-threatening conditions, which can’t be addressed with the equipment and personnel at Kona Community Hospital, can wait up to two days to be transferred to another facility off-island.
Donovan said clinical staff has voiced concerns about their ability to provide quality care with the lack of actual beds and critical medical devices, including monitors and IV pumps.
The crowding in the emergency rooms at Hawai’i County’s two main hospitals is compounded by patients who no longer need to be there, but are taking up beds because they have no safe place to be discharged or no place to receive necessary extended care.
Cabatu said long-term care facilities and care homes also are dealing with their own resource constraints and difficulties.
On Dec. 23, of the 91 patients in beds at Kona Community Hospital, 28 of them were waiting to be discharged for a higher level of care, also known as being waitlisted.
At Hilo Medical Center, of the 158 patients in beds, 34 are waitlisted. The hospital has set up 24 temporary licensed beds in the Transitional Care Unit as an overflow. The medical center also has overflow areas in its Short Stay Unit that can accommodate up to 13 patients and additional bed capacity in the Obstetrics Unit, which can take six to eight patients.
“When inpatient units are at capacity, admitted inpatients from the ED have nowhere to go, other than sit in the ED,” said Hilo Medical Center Department Nurse Manager Toni Higa. “Inpatients holding in the ED take up beds that are normally used for only ED patients.”
As a result of having no available beds, Higa said healthcare workers must see many emergency department patients in the hallway gurneys and chairs.
“It also causes longer wait times in the ED, which impacts our patient’s experiences,” Higa said. “Unlike other units in the hospital, we can never say we are full and can’t take any additional patients. The ED is always open, even when we have 20 to 30 patients waiting in the lobby to be seen and wait times up to 6 hours.”
Donovan, with Kona Community Hospital, encourages community members to use local urgent care clinics whenever possible. There are short-term solutions that the hospital is executing to mitigate the problem of patients languishing in hospital beds longer than necessary. They include transferring patients to Kohala Hospital or Life Care Center of Kona, one of the county’s skilled nursing facilities.
But those facilities can only accept as many patients as they have staff to take care of them.
Maryedith Motas Liberato, Executive Director of Life Care Center of Kona, said Hawai’i was already dealing with a shortage of health care professionals before the onset of COVID-19; the pandemic only exacerbated those shortages.
“At a time when there are more open health care jobs across the state than there are qualified candidates to fill them, our remote location and the lack of affordable housing in our area add another layer of difficulty to our ability to hire or bring in additional staff,” Liberato said.
Liberato said staffing levels are reviewed daily, and while the facility continues to accept new admissions, they are limiting them to accommodate current staffing levels and to ensure health care workers can maintain their commitment to safe and personalized care.
Liberato said the organization is working closely with the Healthcare Association of Hawai’i to manage staffing challenges and is partnering with local organizations to hire and train additional health care workers in the coming year, specifically CNAs and LPNs.
After Miranda’s experience with her husband, she said the bottom line is Kona Community Hospital needs to be a bigger hospital. There’s nothing staff can do if there’s nowhere for the patients to go.
“They’re doing the best they can do,” she said of the staff. “We need help.”