DAYTON, WA - MARCH 14: A hospital employee is seen next to a sealed space for nursing staff to don ... [+]
As the Coronavirus (COVID-19) pandemic rages in the US, rural hospitals are dealing with the same issues that urban hospitals are facing, as well as additional unique issues found only in the rural hospital setting. Like urban hospitals, rural hospitals are severely lacking medical equipment to treat severe COVID-19 patients when they arrive, as well as the personal protective equipment they need to keep their workforce safe.
“At first they said COVID-19 was an airborne thing, so I was provided with one N95 respirator mask.” Says a nurse working in a rural hospital in Central Kentucky, “Now they are saying that it is just droplets so we can wear a really thin paper surgical masks, but I worry that they are just saying that because there is such a big shortage.” Continuing, “You know, we have leaders claiming that the paper masks are safe, but they're not going into the room. We’re the ones that are providing the care on the front lines and I feel like if the tables were turned they would probably have a different attitude about it.”
However, in addition to the overarching issues of the American healthcare system in trying to combat COVID-19 rural hospitals are facing another set of issues:
- Decreased bed capacity
- Lack of specialists
- Fewer nurses and support staff
- Lack of cash on hand
Rural hospitals across America range widely in their capacity, skill and resources. This is based on region, local economy, and access to larger hospitals systems. For example, a small hospital in the south of Florida may have 150 licensed beds, eight of which are intensive care unit (ICU) beds, and access to a pulmonologist but no experienced intensivists needed to treat acute patients with COVID-19-like symptoms, while a hospital in central Kentucky may only have 75 licensed beds, six of which are ICU beds, and no immediate committed pulmonologist to help plan for COVID-19 patients, yet have access to a variety of specialists within their hospital system to help them care for patients. Even still, a small hospital in northern California may have 150 beds, ten ICU beds, and seasoned pulmonologists and intensivists to help treat patients, but no negative air flow rooms to help decontaminate the hospital. All of these scenarios result in very different and very unique issues for rural hospitals across the country.
Drive time for rural Americans to rural hospitals.
Similarly, the systemic situation rural hospitals find themselves in also differs wildly and is indicative of the ‘freedom of choice’ model characterizing American healthcare that often feels more like the paradox of choice. While some small hospitals are linked into a regional hospital systems and therefore have access to a pipeline of resources, other community hospitals work independently. Some hospitals are a 30 minute drive for residents, while others are a two hour drive. Some hospitals are for profit, while others are non-profit or based on a university system. While still other hospitals base most of their care and financial planning on Medicare recipients, others base their planning on those with private insurance. All of these differences dictate everything from the level of care to whether or not a COVID-19 patient is turned away if they are uninsured.
There is no easy way to generalise how rural hospitals will be ready for COVID-19 patients as they come in. Yet, the above list does outline a few consistent vulnerabilities nationally.
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Decreased bed capacity coupled with a lack of specialists and nursing staff are two sides of the same struggle that threatens the lives of COVID-19 positive rural Americans in the coming months. “The number of beds [in rural hospitals] have gone down so dramatically. I can’t imagine - if we had any kind of outbreak, with a two percent or five percent fatality rate, we’re in deep trouble,” said Dan Brown, a former councilman for the riverside village of Bellaire, Ohio, “The whole thing is setting up for failure.” Brown’s hospital in Belmont Community Hospital in Bellaire closed in April of last year along with two other hospitals within a five mile radius, leaving only one hospital in operation in Wheeling, West Virginia.
NEW YORK, NY - MARCH 31: Workers prepare dozens of extra medical beds as they are delivered to Mount ... [+]
According to the World Health Organisation (WHO), the US has an average of 2.9 hospital beds per 1000 people. This is a ratio that we are currently desperately trying to increase as the COVID-19 pandemic ramps up. In parts of rural America however, you can be sure that the ratio of hospital beds per person is much lower and those beds will be harder to reach.
Similarly, rural EMS crews will often be tasked with transporting COVID-19 patients to the hospital and their capacity is also limited. EMS wait times are already twice as long in rural America as they are in urban areas according to one study. If a rural community only has one or two ambulances then there is an increased risk that the time it takes to get COVID-19 patients to the hospital will be even more extended.
The current need for additional personal protective equipment (PPE) also slows down emergency responders. “While we are doing OK at the moment with meeting the need to transport potential COVID-19 patients to the hospital or clinic, it is taking us a bit more time to reach them.” Says Steve Asbury, the Emergency Management Director of Powell County, Kentucky, “We are delayed because we have to take extra precautions such as putting on gloves, the N95 respirator masks, face shields, and gowns before we enter a structure we believe might be contaminated.”
Additionally, according to the WHO, in the US there are 2.6 physicians per 1000 people, and it is this ratio that gets at one of the biggest issues for rural hospitals when caring for patients. Even if rural hospitals are able to get the number of beds they need to house COVID-19 patients, will these new beds have sufficient capacity? Who will treat these patients? And will there be enough room for non-COVID-19 patients to get treatment without contracting the disease?
“It is important to note that it is not just the number of beds that a rural facility has, it is also important to consider the capacity of the beds.” Says Dr Roger Ray of the Chartis Group, “If you have a hospital with 25 beds and one ventilator, but you have seven patients who are critically ill and going to die without a ventilator, that's not a supply you can meet. You've got to have somewhere to send them that is willing to accept them.”
This concern is echoed by Justin Stephens, a travel nurse working at a hospital in southern Florida that already had three COVID-19 patients as of March 25th. “It is not enough to just have these beds, you have to have doctors and nurses who are experienced intensivists and know how to deal with these patients.” Continuing, “I was working with five other rural intensive care nurses and when one of our patients became critical I found myself having to teach my fellow nurses how to care for them.”
Appalachian Regional Commission is measuring how county by county in the US should plan for COVID-19 ... [+]
“My hospital has also got a pulmonologist,” says Stephens, “but they do not let him put in orders. He is there strictly to consult. So you've got a guy who you've brought in to pick his brain about stuff and who's smart enough, and skilled enough to treat these critically ill patients, and yet is not being allowed to do so.”
There is also talk about apparatuses that can make one ventilator usable for up to four people, but that only works in a large hospital system with a variety of patients whose pulmonological injuries are similar. “A lot goes into running one machine on four people.” Says Stephens, “You have to have patients that are of the same lung injury and roughly the same compliance. Plus, there has to be someone in the hospital who can run the new system and small hospitals just don’t have that kind of staff.” These solutions, while innovating and exciting, are often not an option for small rural hospitals.
However, specialised staff is not the only issue, staffing in general is a struggle for small rural hospitals and that gets into another major issue for rural hospitals, money.
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“I think the second vulnerability is the number of staff at these facilities.” Says Dr. Ray, “It doesn't take very many illnesses or outages of staff to just devastate a small hospital. We also have more than 40% of rural facilities losing money on an annual basis which limits how much staff they can have and creates a thin buffer between a rural hospital that can function effectively, and one that can’t.”
Staff vulnerabilities, at minimum, have to be combated in two ways in rural hospitals when it comes to COVID-19; there has to be distinct space for COVID-19 and non-COVID-19 related patients, and staff has to be effectively protected from contracting the disease. “With COVID-19 particularly, finding alternate spaces for either screening or working with patients while they're in the mild category rather than having them in the guts of the hospital is really important.” Says Dr. Ray, “The shortage of medical supplies is going to be just as bad or worst in rural hospitals. Plus, these hospitals will be dealing with a surge of patients that they are not professionally ready to deal with.” By creating distinct areas of care rural hospitals can undercut the risk of more essential nursing and doctors staff getting sick, since a few most assuredly will. However, finding new facilities is easier said than done and rural hospitals will have to develop these facilities in tandem with state government.
However, both of these needs take money and planning, which are currently in short supply in already strained rural hospitals. Many rural hospitals only have a weeks worth of cash on hand. According to a study by Navigant, 21%, or 430 rural hospitals across 43 states, are at high risk of closing unless their financial situations improve. “These hospitals represent 21,547 staffed beds, 707,000 annual discharges, 150,000 employees, and $21.2 billion total patient revenue.”*
Rural hospitals with the highest financial risk are clustered in the south and midwest region.
“Our analysis shines a new light on a rural hospital crisis that must be addressed and could significantly worsen with any downturn in the economy,” says study co-author David Mosley, managing director at Navigant, “Local, state, and federal politicians, as well as health system administrators, need to act.”
The slight delay in COVID-19 surges is giving rural hospitals time to do three things to prepare: increase the public service announcements in the community to increase social distancing measures early, coordinate with state governments to get supplies and increase cash flow, and utilise the various travel nurse systems to make up for staff shortages in the short term. All of these steps require a reversal of years of government disinvestment in rural hospital systems and public health departments and, as can be expected, the response by state governments has varied from state to state.
* It is an interesting side note that when these hospitals close, per capita income in the surrounding communitifalls 4% and the unemployment rate rises 1.6%.
