No seat was available outside the St. John's Hospital emergency department on one recent afternoon — not in two waiting rooms, or the hallway between them, or the benches at the sliding glass front door, or near the decorative Snoopy.

Some patients slept, others writhed in pain, others twitched and wondered if they should leave. Some had received care, just not inside the ER. It was a mass of 40 sick people, all of them waiting.

"It's dehumanizing," said Amy Lockwood of St. Paul, who sat with kidney pains in a hallway chair for four hours. "This is a good hospital. I've never seen it like this. This is crazy."

Crisis-level crowding was expected at the peaks of COVID-19, when the infectious disease sent people gasping for breath to ERs. But overwhelming patient volumes have continued to challenge the Maplewood hospital and others like it in Minnesota, long after the pandemic crisis eased.

Minnesota ranked among the best states for the efficiency of emergency rooms before the pandemic, but its performance has slipped, according to new federal hospital data. The median time from ER arrival to discharge increased from 104 minutes in 2016 to 133 in 2021 in Minnesota, and the state slid from 2nd to 13th among states in this measure.

Waits are longest in large hospitals, which take complex cases from smaller hospitals and patients from broad geographic areas. The median in 2021 for non-mental health patients was 245 minutes at Methodist Hospital in St. Louis Park and 236 minutes at United Hospital in St. Paul. The median was 233 minutes at Mayo Clinic in Rochester and 188 at St. John's.

The packed waiting room on Nov. 3 exemplified problems across Minnesota, said Dr. Will Nicholson, vice president of medical affairs for M Health Fairview's east metro hospitals, including St. John's. The state lacks preventive services to keep patients out of hospitals and transitional services to discharge them when they are ready, he added.

"The hospital is in the middle of all of this, doing what we always do, which is step up and do the best we can to take care of patients," Nicholson said. "COVID didn't beat us. This isn't going to beat us. But people are tired, and we need help."

St. John's has unique challenges. Fairview closed the St. Joseph's Hospital ER in St. Paul in 2020. East metro hospitals have absorbed the loss of ER capacity.

St. John's was state-of-the-art when it opened in 1986, but it hasn't undergone major upgrades — like multimillion-dollar ER expansions at competing hospitals in St. Paul.

ER nurse Debra Leach said the crowding is worse at St. John's, but the workload is eased by inpatient nurses coming down to monitor patients waiting for admission. Leach said she has spent many shifts treating patients in the lobby, where she can check vitals, give intravenous fluids, draw blood and perform other basics.

"These people are so sick and we're stacking them there," she said.

Patients Sally Bangura and David Hill didn't know one another, but they depended on each other as they huddled in a corner of the St. John's ER lobby. They saved seats for one another if they were called up for triage care.

"That's what we've been doing for hours," said Hill, who had an IV line in his wrist. His hands were shaking.

Bangura passed out at work, probably after switching blood pressure medications. She was dizzy and her head hurt, but she was thinking of leaving because she was overdue to pick up her infant from daycare.

"I just want to see the doctor and figure out what's going on so I can go pick up my daughter," she said.

St. John's has converted every inch of ER space to the service of patient care. Drapes close off a makeshift treatment area between waiting rooms. A triage area across from the welcome desk is now used to treat patients as well rather than just assess them.

Administrative space is being converted in two months into more patient rooms. Finding more nurses to staff the beds is hard, but Nicholson said on-the-fly challenges have been routine since the pandemic.

"I don't know what we used to worry about," he said.

The overcrowding carries into the full ER, where a half-dozen patients lay on gurneys in the hallway. Occasionally, patients are moved back out of treatment bays to make way for others with life-threatening conditions.

Jennifer Heifort of Big Lake stood next to her mom, Mavis, who had been at the hospital for hours with chest pains.

"We're still in the hallway," she said. "She has had many tests and we've had people come by and see how she is doing. I know everybody here is working really hard ... but it's not a healing environment."

Nowhere else to go

Job vacancies have tripled this year in Minnesota hospitals, which as a result can't staff as many beds to meet demand. Patients instead wait in ERs, which by federal law can't turn away anyone with medical needs.

St. John's staffed all beds on Nov. 3, but they were full anyway. The problem was at the next level, Nicholson said, with staffing shortages at nursing homes preventing them from taking patients ready for discharge. On one unit, 14 of 32 patients were ready to leave.

Kristen Gates was admitted with diabetes and problems swallowing, but her stay was lengthened by COVID-19 and a cancer diagnosis. She wanted transitional care to adjust to a new insulin regimen and other changes, but nursing homes hesitate to take patients starting chemotherapy.

"That's another strike against me," she said. "We're just in limbo here. Nobody can tell me what's going to happen next, or where I'm going."

An early start to the respiratory illness season also is increasing pressure on hospitals this fall, sending more children with RSV and adults with severe flu to ERs.

One patient was done waiting. "I'm leaving!" she said as she exited the ER into the darkening afternoon.

Another limped behind her, but just to his car in the crammed parking lot for a moment. Joshua Springborn had a hernia injury and wasn't going anywhere. Without treatment, he couldn't stand as a chef. He laughed thinking of the different expectations at work..

"People get upset waiting 20 minutes for dinner," he said, "but then you have to wait four hours at the emergency department."