Perspective: An inside look at a rural hospital preparing for the wave

Our infection control nurse recounted a meme at a recent meeting that one of our nurse practitioners had shared. It said, “Last week I couldn’t use tape on the wall. This week I can use my sock for a mask.” 

We all had a good laugh. Health care workers and administrators tend to appreciate grim humor, and the cartoonish statement captured the spirit of the moment in a rural hospital: We’re adapting to a new reality. 

I am the communications manager for the Community HealthCare System based in Onaga, which is in northern Pottawatomie County, and I am part of its COVID-19 Response Team. The organization comprises two hospitals (the other is in St. Marys), seven rural health clinics, two nursing homes, one assisted living facility, four fitness centers and a home health care unit that serves Pottawatomie, Jackson and Nemaha counties, plus some areas of Marshall County. (These areas had a total of four cases as of April 6.)

Circumstances are nowhere close to anyone using socks as masks, but supplies are a pressing issue. Doctors, nurses and everyone else who cares for patients infected with COVID-19 will need personal protective equipment (PPE) way above and beyond our normal needs. We have been collecting supplies through the usual channels, and our purchasing agent is doing all she can to keep up with what we can order when, and from where. Much-publicized nationwide shortages of PPE have made this a struggle. N95 masks, isolation gowns, gloves and face shields are in chronically short supply. Our organization has done fairly well at gathering these items, but will it be enough? As we’ve watched the wave of COVID-19 cases swamp health care facilities in urban areas and creep toward the Midwest, we’re dubious. 

Partnerships and preparedness help, and both of these are strengths for us. In general, hospitals are good at emergency preparedness. They have to be. We conduct tabletop exercises, minidrills and full-scale drills for a variety of scenarios, including medical surge, or the ability to expand capacity rapidly in the face of a disaster or mass-casualty situation. Now we’re reading harrowing accounts of a real-world med surge, and we’re bracing for one here. We’re in a rural area, and our isolation has bought us time. About a week ago, our chief nursing officer said, “Every day we don’t have a case is another day we have to prepare.” She has worked tirelessly to identify ways to expand our capacity. We can add beds to rooms, making them semi private instead of private. We can use recliners if we have to. We can modify existing spaces so we have more negative pressure rooms to isolate infected patients. We can order additional ventilators. (Two portable units will be delivered soon.) 

We’ve drawn on local, county, state and regional partnerships. We’re receiving excellent guidance from the Kansas Department of Health and Environment and the Kansas Hospital Association along with other professional organizations that are providing rules related to testing patients for COVID-19, overall guidance and situational awareness, interpretations of regulatory changes in response to the crisis and much more. We’re in close contact with the Pottawatomie County Health Department and participating in Pottawatomie County Emergency Management meetings. A member of our team is chairman of the Northeast Kansas Healthcare Coalition, which was able to distribute masks and gowns to a number of hospitals, including ours. We’re working with local businesses and community members who have N95 masks and gloves to donate. We’re talking to local seamstresses who have volunteered their time and the supplies to sew surgical masks. We’re asking them to turn their attention to gowns. We’re looking into having our maintenance crew fabricate face shields. 

Community HealthCare System is screening patients and others entering their hospital in Onaga as part of their coronavirus preparations.

In the midst of preparations, we’re communicating with our employees. We have more than 450 associates, and their clinical knowledge, reactions and fears run the gamut. Our CEO has worked to express that we are taking a measured approach to the situation and to help everyone maintain an even keel. Managing ourselves has never been more important. Our employees cannot stay home, and although we could adapt some positions, we aren’t accustomed to a large number of remote workers. School building closures mean that many are scrambling to arrange for child care and manage online school. Employees also are wondering what will happen if they get sick, or if a family member gets sick. New leave options are available as a result of the recently passed federal Families First Coronavirus Response Act. Our human resources director has worked to interpret what that could mean for us. She has reminded us that when emotions run high, logic is low, so we shouldn’t take things personally. She is working with concerned employees individually. 

If a large number of employees take leave or get sick, we will face staffing shortages. In a rural hospital, filling positions is ordinarily difficult, particularly in nursing, dietary and environmental services. If we’re already short-staffed and employees take leave or get sick, then what? We’ve established a labor pool working group to inventory skill sets and cross-training potential. Some departments have lower volume right now because of delays in elective procedures, so, for example, surgical nurses could provide care on the hospital floor. Certified nursing assistants could be trained to help with cleaning to take some load off our environmental services team. College students who have previously worked for the organization and have now returned home to finish classes online could help in dietary, which oversees the nutrition needs of patients and operates the hospital cafeteria. 

Creativity is the order of the day. Our physicians are highly engaged and help guide preparations and adapt to new information. Regulatory waivers mean that our clinics are now allowed to offer telemedicine, so we’re setting that up for patients who would prefer to connect with their provider from home. Our seven clinics are in different types of buildings. They have limited space, so isolating a patient who may be infected with COVID-19 requires thinking carefully about how to direct patients to enter and exit and how to minimize the exposure of others while conserving precious PPE. Long-term care and assisted-living facilities have been closed to visitors for nearly a month already – protecting vulnerable populations required quick action – so staff are working to keep residents active and engaged. They are helping them connect to family and friends electronically, and coming up with special games and activities. One nurse said she and others were having dance-offs to entertain residents. 

We’re working to care for the vulnerable. Our home health care operation is large, and the nurses and therapists who visit the homes of patients who are medically fragile are taking special care to monitor themselves for signs of infection. Long-term care and assisted living staff are doing the same. No one wants to be the source of COVID-19 for anyone in our care. We’re wondering about others in our community who may need help. Do seniors need help getting groceries or other supplies? Is social isolation eroding their mental health? Can we develop a network of volunteers to check on people? We’re working on that. 

We’ve made good progress, but our list of questions grows every day. One big one is the impact on our business. For the moment, our hospital has the resources to weather financial difficulties wrought by canceling elective procedures and wellness visits and other things that bring revenue. We are in good shape compared with many rural facilities, and we know some relief will come eventually, but we also know the economic impact of this crisis will be real and lasting. 

Through it all, we strive to keep our communication measured and positive. We’re sharing information in new ways, including Facebook Live. Because circumstances have changed rapidly, we have struggled to reach those in our communities who don’t access our blog or use social media, so we’ve worked with local newspapers and radio stations to provide basic information. As we’ve restricted, then eliminated, hospital and long-term care visitors; screened those entering our facilities; changed clinic screening procedures according to evolving guidance; restricted, then closed, fitness centers; and shared important information, we’ve done so in hopes that when the wave hits, our patients know we’ll be ready. 

Moments of humor help us hold to purpose. Someone shared a joke at the beginning of another meeting: “They said a mask and gloves were enough to go to the grocery store. They lied – everyone else had clothes on.”  

We laughed, and then we got back to work. 

Sarah Caldwell Hancock is a KLC alumna and contributing editor to The Journal who has reported stories about the Kansas school redesign and the legacy of public health innovator Dr. Samuel Crumbine.

The Journal, the print and digital magazine of the Kansas Leadership Center, is publishing a digital newsletter that explores what is working, what isn’t working and what’s being learned during the response to COVID-19. To receive twice-a-week updates, subscribe here: https://kansasleadershipcenter.org/contact-us/join-our-email-list/

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