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Gayle Nourse avoided surgery on her left knee as long as she could — having endured a right knee replacement last year — but when the pain became intolerable in September, it was too late.

A COVID-19 wave consumed hospital beds, forcing patients with urgent but not emergent conditions to wait. Nourse made it into pre-op at Mercy Hospital in Coon Rapids on Sept. 13 before her procedure was canceled last minute. Three months later, she is still waiting — with cortisone shots providing stopgap relief but not the mobility to play with her grandkids.

"I just want my quality of life back," said Nourse, 57, of Shoreview. "It's not like I was Wonder Woman."

Delayed surgeries are a downstream consequence of the pandemic and the pressure it has placed on Minnesota's hospitals, which on Monday reported 1,636 COVID-19 cases in inpatient beds and only 21 open adult intensive care beds.

Hospitals aren't required to delay non-urgent procedures, as they were during the first COVID-19 wave in spring 2020 when Gov. Tim Walz issued an emergency order to preserve bed space. But the choice is being made for them. Patient demand over the past month has been the highest in the 21 months of the pandemic.

"I'm not sure the public is truly aware that all systems in the state have been delaying surgical procedures. When you add it all up, it's a lot of people," said Dr. Robert Quickel, vice president of surgical care for Allina Health, which operates Mercy.

COVID-19 patients made up 21% of the 7,794 hospitalizations in Minnesota on Monday, the highest share all year. But hospital leaders said they have been unable to keep as many non-COVID patients out of beds, partly because delayed care during earlier pandemic waves exacerbated their health problems. The 6,158 non-COVID patients on Monday compared with 5,760 on Dec. 13 last year.

Patients who refrained from seeking emergency care for strokes and urgent needs earlier in the pandemic got sicker. A report from Minnesota Community Measurement (MNCM) on Tuesday also showed that many fell behind on preventive care.

The share of hypertensive patients with adequate control of their blood pressure dropped 11 percentage points from 2018 to 2020, along with the rate of elderly women receiving optimal osteoporosis management after bone fractures. Screenings for cervical and breast cancers also declined.

"That means ... that cancer gets diagnosed at a more advanced stage," which hastens the need for surgeries, said Julie Sonier, MNCM's chief executive.

The rate of coronavirus infections has declined in Minnesota since Dec. 6, suggesting a peak in the COVID-19 wave, according to the Centers for Disease Control and Prevention. But the state's new infection rate remains third highest in the country, and the Minnesota Department of Health on Tuesday reported 9,042 infections that were identified over the weekend.

The state also reported 46 COVID-19 deaths, including four people age 30 to 39 and three people 40 to 49. While 85% of Minnesota's 9,964 COVID-19 deaths have been in seniors, that rate dropped to 73% after July 1 when the fast-spreading delta variant emerged.

Even a peak now would be later than hoped. Hospitals started in September delaying surgeries that could be safely pushed back 90 or more days, and then moved on to those that could wait 30 to 60 days. Many surgeries have come due.

"We've been doing this for over 90 days, so delaying those folks has really flipped some of them into the category of, 'really can't wait anymore,'" Quickel said.

Nourse changed jobs so she could work from home as an accountant, but she said she can't stand or sit for too long. Her youngest grandchild is 2 years old and wants her to carry her and play on the floor. Bowling and golf with a cart were possible last year, but not now.

Her surgery was rescheduled Nov. 22, and delayed again. Doctors offered her another cortisone shot, which would require her to wait three months for surgery, or the option to live with the pain and hope for an opening. She chose the shot. Because of complications following previous hip procedures, outpatient surgery wasn't an option.

"Now I have to wait until February because I couldn't wait any longer," she said. "I was miserable."

Allina has delayed more than 1,000 surgeries over the past three months, but it is hardly alone.

Dr. Hamid Abbasi, an independent spinal surgeon in northern Minnesota, said his patients in need of inpatient spine surgeries this fall have struggled to get them.

"Lots of patients with back pain, even though their pain can be really high — 8, 9 or 10 — are not getting the treatment they need," he said.

For some, the question isn't availability but risks. Mary Swanson of Edina said her 56-year-old daughter needs a gastrointestinal surgery at Mayo Clinic in Rochester but is holding off because the trip could expose her to a coronavirus infection that would be dangerous in her condition.

"The risk is very high right now," she said.

State leaders are hopeful that Minnesota's progress in providing booster COVID-19 vaccine doses will disrupt the latest COVID-19 wave and restore hospital schedules. Minnesota ranks second among states with 44% of fully vaccinated adults receiving boosters, but still has 1 million people who haven't received any shots.

Sanford Health's Dr. David Wilcox urged more people to seek vaccinations, and to take steps to reduce viral risks at holiday gatherings. Sanford Bemidji Medical Center is full, and Sanford Medical Center in Fargo recently admitted a teenager, parent and grandparent from one family who were likely infected at the same gathering, he said.

Sanford's hospitals in Minnesota and the Dakotas were caring for 224 inpatient COVID-19 cases Monday, and 206 involved unvaccinated patients. Of 70 ICU patients, 67 were unvaccinated.

"We can predict and prevent COVID-19," he said. "We can't predict when you are going to have a heart attack, when you are going to have a car accident, when you are going to fall and break your hip."