There’s COVID, there’s the “tripledemic” of respiratory viruses, there’s years of pandemic stress and overwork, there’s a shortage of healthcare alternatives, there’s drugs overdoses, car crashes and an aging, overweight society.

There are no shortage of possible culprits to explain why virtually all hospitals are always overcrowded these days. There’ just a shortage of answers.

“I don’t think anybody yet understands what the source of that is,” said Dr. Christopher Fore, an emergency medicine doctor and Chief Quality Officer at Concord Hospital.

All three acute-care hospitals in the Concord Hospital Health System – Concord, Franklin and Laconia – have been at or above 100% capacity for the past few months, with little or no let-up. Virtually every hospital in New Hampshire and neighboring states is reporting the same thing.

“We know we’re making you wait, seeing people in hallways, but we want to be there for folks,” he said.

The situation should not get in the way of people seeking medical attention, he said, although things won’t go as easily as they once did.

“People should not delay care. If you need to, come here,” Fore said. “Just please bring some grace and patience.”

New Hampshire and the Northeast are not alone in this situation – it’s true in most of the U.S. and many other countries. The Economist magazine, in a mid-January article titled “Now is an especially bad time to suffer a heart attack,” wrote that hospitals are overwhelmed from Australia to Europe and North America due to an accumulation of problems that date back to the start of the pandemic. “Healthcare systems in the rich world are closer to collapse than at any point since the disease started to spread,” it said.

The obvious culprit of overcrowding is the pandemic, but Fore says that’s no longer the main driver.

“COVID has been more of a constant, more of an endemic. There are about 20 in the whole system on any given day hospitalized with COVID. There haven’t been big waves up and down,” he said.

According to the New Hampshire Hospital Association, the number of hospitalized COVID patients in the state rose in December but has stayed stable through January, declining slightly in the past week, with no sign of the spikes seen in past winters.

The RSV virus and the rise in influenza cases that raised alarm in the fall are part of the problem, Fore said, but not a major factor.

Perhaps the biggest change from past winters is that more patients are staying longer.

“We’re seeing lots of acuity of complex illnesses. They need to be in the hospital for a long time, need surgery or extended care,” Fore said. This may be due to people having put off preventive care because of the COVID shutdowns or resulting strain on family finances, or perhaps the reflection of the state’s aging population, but that isn’t clear.

However, it’s not just sickness or trauma keeping people in hospital beds. It’s also a shortage of alternatives.

Long-term care sites, skilled nursing facilities, rehabilitation facilities and hospice houses – the places where sick patients go after hospitals stabilize or improve their condition – are struggling.

“Those resources are all having troubles. There are beds closed all over the state due to staffing shortages, COVID, supply chain problems,” Fore said. That ripple effect forces patients to stay longer in hospitals as they wait, occupying beds that would otherwise be available.

The pandemic has also worsened non-medical factors that make it harder for hospitals to transfer patients, according to a Hospital Association study. Two issues in particular are establishing legal guardianship status for patients unable to care for themselves and establishing Medicaid coverage of long-term care.

When these two factors were combined with the shortage of beds in long-term care sites, the Hospital Association said they resulted in 231 patients having to stay longer than necessary in one of New Hampshire’s 23 hospitals last summer. On average, each patient spent 68 “unnecessary days” in the hospital, the study said.

Another factor is workforce shortages in hospitals themselves. Three years of overwork and stress caused by the pandemic and opposition to COVID protocols have driven some people out of health care.

“We could open more beds if we could recruit and retain more staff,” Fore said.

He said Concord Hospital has been able to keep virtually all of its 242 beds available, but Laconia has had trouble keeping its roughly 50 beds open, while in Franklin “there are six beds we could open if we had enough staff.”

Even getting an ambulance ride is more difficult due to a shortage of EMTs and paramedics.

Fore said Concord Hospital Health System sees no obvious end to overcrowding in sight, at least not in the short term.

“I think this takes a couple years to course-correct,” he said. “It will take time.”