When John Lang arrived at Mayo Clinic's Albert Lea hospital with chest pain and swelling that bloated his legs to twice their normal circumference, doctors knew he needed an echocardiogram to check his heart.

Thirteen hours later, he got one.

"That's a lot of stress on the family when you have no idea what's going on," said his wife, Carol, who recalled doctors debating whether to perform the scan on site or transfer him to hospitals in Austin or Rochester. Lang, 75, was eventually diagnosed with congestive heart failure.

The delay didn't cause long-term damage, but it was the kind of nuisance and discomfort that many Albert Lea residents feared when Mayo Clinic announced in 2017 that it was consolidating care at two of its southern Minnesota facilities, moving inpatient medical and surgical care out of their hometown hospital and into its twin hospital in Austin, 23 miles to the east.

Mayo leaders, who have been fielding complaints since the decision was announced, say the consolidation has been successful and was the best option given the pressures that have shuttered dozens of rural hospitals across the United States. They announced the latest step last Thursday with the shutdown of Albert Lea's inpatient medical-surgical unit and the opening of a newly renovated unit at the Austin hospital.

Intensive care had already moved to Austin last year, with psychiatric care swapped to Albert Lea. Both hospital campuses have maintained emergency departments.

Operating separately, the hospitals had costly redundancies and were losing doctors, who grew frustrated over the busy days when they lacked backup support and the slow days that made it harder to keep their skills sharp, said Dr. Sumit Bhagra, medical director of Mayo's Albert Lea-Austin health system.

"This move had to happen," he said.

But it remains a hard sell for the residents of Albert Lea, who lobbied civic leaders, the state attorney general and lawmakers to block Mayo's move, and then courted other hospital operators to move into town. Opponents still protest at a city park every Wednesday, angry that their community hospital was stripped of services that went to a neighboring town that will reap the benefits.

"The removal of services has had a devastating effect on the elderly whose family and friends must scramble back and forth over longer distances to care for them," said Jennifer Vogt-Erickson, a member of the Albert Lea Save Our Hospital group.

The outcome is being closely watched across the state, partly because of the civic fervor and public attention it generated, but also because other hospitals face similar financial and staffing pressures.

"The issues aren't unique to Mayo or that region," said Wendy Burt of the Minnesota Hospital Association. "I think we will continue to see that not every hospital will be able to provide every service."

In addition to medical concerns, Albert Lea residents worry about the economic impact — and whether highly paid doctors will move out of town. They also ask why Mayo didn't choose their hospital for the inpatient beds and surgeries, considering that it is farther than Austin from Mayo's flagship hospital in Rochester and sits at the junction of Interstates 90 and 35.

Mayo officials cited several reasons for their plan. Moving inpatient psychiatric care to Albert Lea made sense because it lies in Freeborn County, which is a federally designated shortage area for mental health professionals. That aids in recruiting, because specialists working in shortage areas get federal bonus payments. Austin is not in a shortage area, Bhagra said.

The final phase of the merger was slated for next year — the move of all deliveries to a renovated ward in Austin — but Mayo might accelerate the switch this year due to retirements and the unexpected loss of an obstetrician.

Bhagra said Mayo's leaders listened to the Albert Lea concerns. One solution was adding observation beds to the Albert Lea ER, where patients can remain up to 24 hours to determine whether they can recover without the need for inpatient admission.

Another is the addition of more ambulance capacity in Albert Lea. Bhagra noted that transfers from Albert Lea's ER to Austin's inpatient beds are free to patients.

"I understand the emotional aspect of any change," Bhagra said. "The change is real for the people in the Albert Lea service area."

'I blame the system'

Albert Lea opponents remain suspicious, especially given experiences of people such as the Langs.

On the winter day John Lang arrived at the hospital, doctors ruled out moving him to Austin because the hospital had no open beds; doctors debated whether it was worth shipping him 63 miles to Rochester in windy and snowy conditions. By late afternoon, the Langs said, the Albert Lea hospital no longer had staff to perform the echocardiogram, so Rochester was the only option.

The Langs didn't complain about the care — they're grateful to Mayo for treating his heart problem and, earlier, helping him survive pancreatic cancer — just the delay in receiving it that they attribute to the consolidation of hospitals.

"I don't blame the personnel," Carol Lang said. "I blame the system."

LouAnn Stoen, a retired nurse, said her 96-year-old father was transported to Rochester for repair of a broken hip over Memorial Day weekend in 2018 because neither Albert Lea nor Austin had surgeons available. Stoen and her husband paid for hotels and travel, as well as private transportation home for her father after he recovered.

"It was a huge inconvenience," she said. "We spent $1,000 just trying to keep up with Dad."

Mayo officials acknowledged the extra transportation requirements created in some cases, but they stressed that 90% of the care at the Albert Lea hospital remains outpatient — and that the facility still has a top-flight cancer center and a hyperbaric center that is rare for rural facilities.

The latest federal hospital quality data isn't current enough to show whether the consolidation has affected the quality of patient care. However, only 69% of patients surveyed at the Austin and Albert Lea campuses in mid-2018 said they always received care as soon as they wanted it. That's below state and national averages.

Consolidation should improve the quality numbers, said Lori Routh, nurse administrator for the two hospital campuses. Bringing specialties together under one roof will create more stable pools of local doctors, who will be able to cover for one another and reduce the need for temporary replacements, she said. And internal data from the combined hospitals shows positive trends in patient satisfaction, preventing falls and reducing hospital-acquired infections, she said.