Amal Algahtani thought she was too busy to get the COVID-19 vaccine and too homebound as a mother of five to be at risk for coronavirus infection, but that changed Sept. 6 when she fought for breath and was admitted to the University of Minnesota Medical Center.

"I felt like dying," said Algahtani, 50, of Minneapolis. "I am a strong woman. I didn't think this [would] happen to me. I think I am strong, but ..."

Algahtani is part of a summer pandemic wave that might not be as bad numerically as the one last fall — when hospitals were jammed at one point with 1,864 COVID-19 patients — but is pressing hospitals as they confront growing staffing shortages and a rebound in surgeries and emergencies.

The 748 COVID-19 hospitalizations Monday exceeded the peak of 699 in this spring's pandemic wave and underscored the toll of the fast-spreading delta variant of the coronavirus. The hospitalizations included 208 patients in intensive care, the highest total since December.

While admissions declined as usual over the weekend, hospitals reported 7,958 admitted patients Friday, a level that didn't occur this spring and has been exceeded on only 31 days during the 18-month pandemic.

"The pressures on the system are as bad as they've been since the beginning of the pandemic. If we can get rid of as much COVID as possible, it would really help," said Dr. Andrew Olson, director of COVID-19 hospital medicine for M Health Fairview, which includes the U hospital.

The pressures are different, though. When COVID-19 emerged in spring 2020, supply shortages left caregivers rationing masks and gowns — at one point, the state ordered rain ponchos as a backup — and worrying that they were putting themselves at risk by treating patients.

Today, the stress is more about enduring a fourth COVID-19 wave after losing patients in prior waves and about the number of people who haven't protected themselves with vaccine. Minnesota's COVID-19 death toll has reached 7,915, including 12 deaths reported Tuesday. Nobody complains about protective supplies anymore.

"Ah, the smell of a nice clean N95," said Olson, donning a fresh mask before entering a fifth-floor general medical unit Thursday.

All 25 beds in the unit were full. Five had COVID-19 patients, including Algahtani. Most COVID-19 patients in hospital care are unvaccinated. Of 137 COVID-19 patients admitted to M Health Fairview hospitals at the time, only 29 were fully vaccinated.

A report last week by the Centers for Disease Control and Prevention, including data from Minnesota and 12 other states, found that 14% of hospitalizations earlier this summer amid the spread of the delta variant were in vaccinated individuals. However, the study still found vaccinated people more than 10 times less likely to be hospitalized.

"When I drive home, I think so much of it is preventable," Olson said, "and it starts to get to you."

He checked on Algahtani, then walked by 17 other rooms — occupied by patients with pancreatitis and kidney failure and wound infections — to see COVID-19 patient Bud Makepeace. The 69-year-old Hopkins man was improving but felt sorry for himself as someone who had been vaccinated. He was diagnosed with a chronic form of leukemia two years ago that weakened his immune system and its response to the vaccine.

"Why me?" said Makepeace, who was admitted Aug. 24 after his wife had COVID-19. "There's 7 billion people in the world!"

Minnesota has reported 673,774 diagnosed coronavirus infections, including 4,603 identified over the weekend and reported Tuesday. More than 3.5 million Minnesotans have received at least a first dose of COVID-19 vaccine — 73.7% of the eligible 12 and older population, according to CDC data.

Olson assured Makepeace that his vaccination made a difference, even if it didn't keep him out of the hospital.

"We didn't have patients like you before," Olson said, "because they would be dead."

Hospital leaders said the demographics of patients have changed in the latest wave.

"It's a very different ballgame than it was before," said Dr. Amy Williams, executive dean of practice at Rochester-based Mayo Clinic. "We're seeing a lot of younger patients. We're seeing patients that are not vaccinated and go downhill very quickly, which is why they come into the hospital. We also have breakthrough patients, those that are vaccinated, but usually those that are in the hospital have other underlying conditions that put them at more risk."

The state has identified 1,095 hospitalizations for patients with COVID-19 who had been fully vaccinated.

None of the patients at the U last week receiving the COVID-19 treatment of last resort — placement on a heart-lung bypass machine to take over the work of their failing lungs — was vaccinated.

U respiratory therapist Kayla Rabideaux said some patients try to stay out of the hospital as long as they can, but that backfires. Inpatient treatments such as the antiviral remdesivir work best when administered earlier.

"They come a little too late," she said. "It's hard because they are usually intubated, but I have had some patients who say, 'I wish I would have taken this seriously. I didn't think it was a real threat.' "

The rising pressure of COVID-19 hospitalizations is statewide. Twin Cities hospitals at one point were handling 60% to 70% of the COVID-19 volume, when Fairview operated one of the nation's only stand-alone COVID-19 hospitals in St. Paul.

Standardized COVID-19 treatment protocols have emerged during the pandemic and allowed for more care in smaller hospitals closer to patients' homes. Now, almost half of inpatient COVID care happens outside the Twin Cities area, and small hospitals are feeling the burden.

Rainy Lake Medical Center in International Falls on Monday asked patients with non-urgent conditions to seek treatment at the local clinic rather than the emergency department, which was overwhelmed in part by an increase in COVID-19 patients.

A staffing shortage is part of the problem, Rainy Lake spokeswoman Mickie Olson said, as the hospital is seeking a chief nursing officer, a registered nurse lead and several front-line nurses. The hospital coaxed ex-nurses out of retirement to provide COVID-19 vaccinations, but not back into inpatient care.

"They're tired," Olson said. "Our nursing staff is picking up extra shifts, longer shifts, and they're trying to balance their families as well as [their children going] back to school."

M Health Fairview has 2,674 job vacancies, compared with 1,248 at this time last year.

Rabideaux said the difference in her work comes when she receives several requests at once — to help with transferring, moving or intubating patients — and has to triage which one needs attention first.

On the other hand, caregivers have become more efficient after performing the same procedures. Rabideaux on Thursday donned protective gear and with two nurses went into the ICU room of a COVID-19 patient to move his head from one side to another to prevent pressure sores.

A lift hoisted the facedown patient, and Rabideaux carefully repositioned his head, adjusting his tubes so they wouldn't become snagged. Research has found that moving patients and switching them from back to front — a procedure that takes at least a half-dozen nurses — promotes lung recovery.

"Looking back to the first time I had to do this, it was like, 'This is terrifying!' " she said.

Burnout is taking its toll. The U has some of the best COVID-19 results in the world using the heart-lung bypass machine — or extracorporeal membrane oxygenation — but Thursday, critical care nurse Kelsey Fair was feeling down after seeing the condition of some patients decline and having some tough conversations with relatives.

"It's just drug on so long," she said. "Sometimes I feel like I'm not helping anyone."

Hospital outcomes have improved. The median length of stay has declined from five days at the start of the pandemic to four, and from 11 days to seven among more severely ill patients, according to a monthly state outcomes report. The cumulative mortality rate of hospitalized patients declined from 11% in spring 2020 to 9%.

Algahtani and Makepeace went home last weekend after their oxygen levels stabilized. After the experience of five days of labored breathing in the hospital, Algahtani planned to get vaccinated as soon as advised to do so.

"I will make time," she said.