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By Rose Hoban and Liora Engel-Smith
As the World Health Organization warns the new coronavirus has “pandemic potential,” state and national experts worry that in the case of a widespread and sustained outbreak, an influx of patients could lay bare the glaring resource inequities between urban and rural hospitals.
Since the pathogen was first identified nearly two months ago in the city of Wuhan, China, coronavirus has spread to nearly every continent. As of Sunday, dozens of countries across the world, including the United States, reported infections. On Tuesday, CDC officials said they expect the virus to spread in the United States.
North Carolina has seen no confirmed cases thus far, but state officials said last week that while the risk for coronavirus in the state remains low, they are preparing for potential respiratory infections.
COVID-19 infections run the gamut. Some people have mild symptoms, some get pretty sick but don’t require hospitalization, and the virus can cause severe symptoms in some people, who will require hospitalization. At present, health authorities think the death rate from the disease is about 2 percent, but there’s still uncertainty about the total number of cases.
The expectation is that patients with COVID-19-related pneumonias would initially show up in urban centers with more health care resources and surge capacity to handle excess patients. Eventually, smaller hospitals could be called on to handle complex respiratory care.
But decades of hospital mergers, consolidations and closings may have left the nation’s rural hospital infrastructure potentially vulnerable in the case of a worst-case scenario of a widespread infectious disease outbreak.
“Even if you had the beds available, set up and ready to use, do you have the staff to be able to appropriately handle the patient load?” said Brock Slabach, senior vice president of member services at the National Rural Health Association, a nonprofit advocacy and research organization. “And then if you throw in that really complex care, particularly those needing ventilators, then that throws another huge contingency factor into the discussion that we’re just not, well, we’re just simply not prepared for it.”
Years of pressure, cuts
With almost half of rural hospitals nationwide operating at a loss, some may struggle to line up the extra staff, supplies and resources needed to respond to an outbreak, Slabach said. In North Carolina, these economic conditions pushed 11 rural hospitals to shutter since 2005, according to UNC Chapel Hill’s Sheps Center for Health Services Research, while other hospitals have declared bankruptcy.
As respiratory conditions such as coronavirus-induced pneumonia escalate, they may become too complex to handle in a limited rural setting, necessitating transfers to larger hospitals. But North Carolina’s largest facilities may not have enough beds to deal with a surge of patients, said David Weber, an infectious disease physician who now leads infectious disease response at UNC and for the state.
“Our hospital runs at virtually 100 percent occupancy at any given day,” he said. “We have patients sitting in the ED waiting to come in and waiting on patient discharges. We have people who would like to transfer patients to us from smaller hospitals that need the level of care a large academic center can provide and we tell them they have to wait [a] period of time because we don’t have empty beds.”
WakeMed CEO Donald Gintzig said larger systems such as his Raleigh-flagship hospital have the ability to convert entire units into isolation wards, set up treatment tents in the parking lot, and delay elective procedures as they handle increased demand. WakeMed even owns a mobile hospital with an intensive care unit which could be deployed.
Nonetheless, Gintzig expressed similar concerns to Weber this week while speaking to reporters at the annual N.C. Press Association meeting.
“Will it stress the system? Absolutely,” he said.
Hospitals across the state, for their part, have said they are confident in their abilities to handle the respiratory virus should it appear in their communities.
“We do not feel that we are at a disadvantage at all,” said Heather Wilkerson, spokeswoman for Martin General Hospital, a rural 49-bed facility in eastern North Carolina. “Our staff is very proactive when it comes to preparing for situations like this. … Anything that we see potentially affecting the community that we serve, we’re going to always be proactive to prepare for them. If that means having extra staff on call, then that’s what we’ll do. If that means making sure our supplies are stocked, that’s what we’re going to do.”
The Quorum Health hospital has been gathering supplies for the outbreak since news of the virus came out, Wilkerson added.
But, Wilkerson said on Friday, the rural hospital is currently at capacity and has no open beds. And though they have extra staff to call on in case of a rise in patient volumes, Wilkerson said that Martin General plans to route patients to other area hospitals if overcrowding occurs.
The Williamston hospital is in the process of convening an infectious disease control team, she added and will add a coronavirus-specific drill to the hospital’s regular emergency preparedness exercises. But as of Friday, the staff has not had a coronavirus-specific infectious disease drill. Wilkerson said there’s no date for the next exercise as of yet.
More than 90 miles south, Carteret Health Care, a 135-bed facility in the more urbanized Morehead City has the space to deal with a potential patient surge, said Valerie C. Payne, director of infection prevention.
On any given day, roughly half of the beds at the hospital are occupied, leaving ample space for additional patient volume, she said. The hospital also has dedicated airborne infection isolation rooms and plans on how to respond to pandemics. Carteret is also part of a Duke Infection Control Outreach Network, a partnership of 55 community hospitals spanning six states, focused on controlling and responding to infectious disease.
“We maintain a continual state of readiness for possible high consequence infectious disease through coordinated exercises with coalition emergency preparedness partners and the local [and] state health departments,” she wrote in an email.
At a press conference in Asheville on Friday, Mission Health Chief Medical Officer William Hathaway expressed similar confidence. The western North Carolina hospital system has been preparing for coronavirus by limiting the use of masks and reusing them when possible, as directed by the CDC, he added. Mission has already had a “tabletop” simulation of a coronavirus scenario, he added, and officials designated isolation areas at its facilities in Asheville and neighboring counties.
“We have a host of different emergency preparedness plans for surges that range from natural disasters to infectious diseases to casualty events that we practice in concert with others,” Hathaway said. “This is in many ways a variation on a theme for us … we would like to let the community know that we’ve been working actively on it in the last number of months.”
Though hospitals in North Carolina haven’t encountered coronavirus yet, they have experiences with other infectious respiratory illnesses, such as the flu. Jeff Engel, state epidemiologist during the H1N1 flu pandemic of 2009, said hospitals across the state coped with patient surges.
“To my knowledge, no hospital intensive care unit was overwhelmed,” he said. “They had surge plans, there might have been some inter-hospital transfers. And there might have been some emergency medical runs that were diverted to other hospitals. But it all seemed to work pretty well.
“I think hospitals have been keeping up their preparedness plans, keeping them polished.”
Complex care ahead?
Whether they care for critical patients with COVID-19 or not, health care professionals at hospitals across the state will need access to masks, gowns and other protective equipment, some of which are already in short supply worldwide.
UNC’s David Weber said that his institution has purchased extra supplies in case of emergencies, such as personal protective equipment and ventilators. In addition, the federal government maintains a strategic national stockpile of supplies.
“We would rely, in a real pandemic, on the National Stockpile,” he said. “For security reasons … I don’t actually know what’s in the National Stockpile. I know it has masks and gowns and gloves and ventilators.”
But Weber said he doesn’t know what model of ventilators are in the strategic supply.
“Obviously I can’t train our personnel on those types of ventilators,” he said.
Even if a hospital has plenty of ventilators, there may not be enough staff – nurses and respiratory therapists – to manage all those patients requiring help with breathing.
And one of the lessons health professionals learned during the H1N1 flu pandemic was that ventilators alone were not enough for some of the most critical patients, Engel said. Instead, some patients whose lungs were damaged needed extracorporeal membrane oxygenation (ECMO), where the blood is taken out of the body, circulated to an oxygenator and then put it back in the body.
“I don’t think anyone has real surge capacity for ECMO devices,” Engel said.
Slabach, of the National Rural Health Association, said that ramping up for the likely spread of coronavirus has strained some rural hospitals. Some members have already been reporting sporadic shortages in masks and gowns. One member hospital in Wisconsin came close to suspending its routine procedures because it didn’t have enough surgical gowns, but managed to avert the crisis by borrowing supplies from local veterinarians and dentists, he added.
“We could be a day late and a dollar short here when it comes to response to this problem,” he said.