With KC beds sparse, rural hospitals in Kansas, Missouri face new COVID ‘tidal wave’

Kansas City Star | Kevin Hardy and Jonathan Shorman

Like just about every healthcare facility in the nation, Holton Community Hospital spent the early months of the year making big plans as leaders there awaited the arrival of the coronavirus.

There were disaster planning sessions, preparations to move around staff and plans to add temporary hospital beds.

“Then it didn’t happen,” said Krista Eylar, nursing director at the hospital about 30 miles north of Topeka.

Most patients who tested positive for COVID-19 were transferred to bigger facilities that touted ICUs and specialists who were better prepared to tend to the stubborn and sometimes unpredictable disease that has bedeviled many healthcare workers.

But now, the bigger hospitals are filling up as many parts of the Midwest see record levels of COVID cases. That’s forced smaller hospitals like Holton’s to treat more and more coronavirus patients in house, sometimes pushing the limits of what care can be provided by the smallest healthcare facilities.

And that has left those smaller hospitals facing their first crush of virus cases months after healthcare workers in bigger cities began battling the virus.

“We never got that kind of massive tidal wave right at the beginning that we were so terrified of,” Eylar said. “And unfortunately, now we are experiencing that.”

Fortunately, smaller hospitals feel more confident treating the disease now that it is better understood. Many are sharing a common set of protocols for medications and treatment shown to help patients recover.

But the overwhelming numbers of coronavirus patients could threaten the ability of doctors and nurses to treat all patients — not just those coming in with the virus.

“People don’t just stop having heart attacks or those sorts of things,” said Carrie Saia, CEO of the Holton hospital. “I just worry that we’re going to be so consumed that we’re not really able to care for some emergency that comes in.”

Those fears have only been exacerbated by the holiday season, when families will gather and potentially spread the disease even more.

“The last couple weeks we’ve just seen enormous volume increases,” Saia said. “We’re really, really concerned with what Thanksgiving is going to do and how we’re going to handle that.”

Kansas Rep. John Eplee, an Atchison Republican, said he has more anxiety about the virus now than at any time this year. A family physician affiliated with Atchison’s hospital, he fears that the Thanksgiving holiday could lead to ever more record numbers of infections and hospitalizations.

“We’re very busy right now. And it’s such an irony to how we were in the spring,” Eplee said. “We were really prepared for this in the spring and then it never came at all and we really had a lot of empty beds, we were sending staff home. Now it’s the opposite.”

COVID UPTURNS RURAL-URBAN SYSTEMS

The rural and urban healthcare systems in Kansas and Missouri have always been intertwined. Small hospitals identify when patients need more advanced care and have existing relationships with bigger facilities next door and in bigger cities like Joplin, Springfield, Topeka, Wichita and Kansas City.

But those long-standing relationships are now strained with small hospitals spending hours and hours searching for beds for patients in bigger cities. Sometimes they’re COVID patients, but it’s also difficult to find placement for someone who needs open-heart surgery or suffers a trauma like a car accident.

With an oversupply of patients in both states, some hospitals are now looking to Iowa, Oklahoma, Colorado and Texas in search of open beds.

On Monday, doctors at the University of Kansas Health System said the Kansas City, Kansas, hospital is increasingly receiving patients from other states where doctors are struggling to find beds.

U.S. Sen. Jerry Moran, R-Kansas, said the state’s smallest hospitals were designed to respond to emergency situations, stabilize critical patients and move them on to bigger urban facilities.

“So in that sense, the system is working as intended,” he said at a Topeka event last week. “The challenge is that the number of people who need to be sent exceeds the capacity of the hospitals who are capable of caring for those patients.”

The Kansas Department of Health and Environment hopes a new software tool will make it easier for hospital staff to move patients around. The department contracted with an outside firm this month on a program that allows hospitals to instantly see bed availability and set up transfers without making numerous calls hunting for a bed.

So far, 30 Kansas hospitals are participating and some 3,200 transfers have been facilitated by the new tool, KDHE officials said last week. They hope to have all hospitals participating by the end of the year.

Similarly, hospitals in the Kansas City area are using a website that allows for ultra-fast communication between facilities and ambulance services, said Steve Hoeger, director of safety and emergency management at Truman Medical Centers. The Missouri Hospital Association is also publishing a bed count twice a day to help inform providers.

“If I normally send someone to Truman, I look and see Truman has no beds, I don’t even have to pick up the phone and call,” said Hoeger, who is also co-chair of the healthcare coalition at the Mid-America Regional Council.

Both Kansas and Missouri officials have closely tracked the availability of hospital beds, ICU beds and critical equipment like ventilators throughout the pandemic. But now, many rural and urban hospitals are strained by the lack of an equally valuable resource: staff.

A national nursing shortage before the pandemic has only intensified as many healthcare workers are sent home. Some are sick with the virus itself, while others have had a close contact that requires them to quarantine for days or weeks at a time.

“It takes X amount of staff to deal with X amount of people,” Hoeger said. “So if I have less people, the only way I can manage that is to either dramatically alter my staffing levels or take care of less people.”

Though politicians in many rural areas remain opposed to measures like mask mandates, the raging virus has increasingly spread in small towns across the region.

Rich Felts, president of the Kansas Farm Bureau, said it was easy to view the coronavirus as a coastal or urban phenomenon earlier this year.

“But I think we’re at a point now where we’ve reached the migration inward and there really is an opportunity for folks all across rural and urban landscapes to take action and make a difference,” he said.

The Kansas Farm Bureau recently joined the Stop the Spread campaign with the Kansas Chamber, the Kansas Hospital Association and the Kansas Medical Society, urging residents to wear face coverings and avoid mass gatherings.

SMALL-TOWN TEAMS STEP UP

Hospitals like Holton’s attract certain kinds of healthcare workers. Doctors and nurses must be generalists able to tackle all kinds of problems, rather than specializing in one area of medicine like urology, surgery or obstetrics.

But the pandemic has tested them in new ways.

Take Malia Warner, who has worked as a family physician in Holton since 2009. She’s also the 12-bed hospital’s chief of medical staff. But she said that title doesn’t mean a whole lot in the town of 3,300.

Like other providers here, she sees her regular patients in the clinic and also helps staff the emergency room and inpatient beds.

The work is intimate. Providers treat their neighbors, people they go to church with and folks they pass in the grocery store aisles.

“Imagine that you’re taking care of people that you love and respect and their kid is in your class or whatever,” she said. “There’s that whole extra layer of, ‘Gosh you better get this right.’”

The pandemic has required doctors like her to help staff the public coronavirus testing unit outdoors at what had been a storage building, where they don cloth gowns made of bedsheets donated by community members to help preserve PPE.

And it’s made hospital shifts much more demanding. Last weekend, Warner covered the weekend doctor shift, which runs from Friday night to Monday morning.

In ordinary times, it’s not all that demanding, serving as a backstop for nurse practitioners and physician assistants who might need a hand with some of the more complex cases that come through the emergency room.

But now, it can be all consuming. Last weekend, Warner was juggling multiple COVID patients with illnesses more severe than would normally be treated at the hospital.

“You’re not getting sleep and you’re not getting a break until you’re off,” she said. “It’s hard.”

Providers like Warner aren’t winging it. They have spent hours researching the ever-evolving standard of care for coronavirus patients and receive regular briefings from academic experts.

While there are protocols in place for assessing patients, it can be tough to predict which patients are going to deteriorate quickly and might demand specialized care somewhere else.

“Sometimes it’s a guess,” she said, “and we’ve been pretty lucky in our guessing so far.”

Her biggest fear is what happens when there are no more ICU beds for the sickest patients. Holton’s hospital has one ventilator. And Warner said she hasn’t treated a ventilated patient in years.

“That is what I worry about,” she said. “Then I’m not going to feel comfortable but we’re going to do the best we can. Because that’s all we can do.”

HOSPITALS NEED MORE THAN JUST BEDS

A few weeks ago, Angie Johnson received a desperate call from a nurse practitioner at Abilene’s Memorial Health System.

She had a very ill patient who needed to be transferred. But the nearby regional hospital in Salina, where Abilene frequently sends more complex cases, had no room. They tried KU’s hospital 150 miles away in Kansas City, Kansas, but it also was full.

For Johson, the hospital’s chief nursing officer, the conundrum was unthinkable, unlike anything she had experienced in her nearly two decades of nursing. A small hospital unable to move patients up to bigger facilities upends the entire premise of rural healthcare.

“We just had this initial moment of panic. What do you do?” she said. “We’ve never had that happen where another hospital couldn’t take a transfer.”

Like others, Abilene’s hospital is increasingly treating coronavirus patients locally. For months on end, the hospital treated only one or two patients here and there for COVID. Now, they’re seeing five, six and seven patients a day. Some require stays of as long as two weeks.

Staff spend more and more time hunting for beds elsewhere. It’s a crapshoot: sometimes it takes only a few calls, other times it consumes hours and hours searching for a bed for a single patient, Johnson said.

The virus is stretching capacity limits, both for beds and staff. At one point, six of the 10 nurses at Abilene’s clinic were out sick.

Johnson said her staff is busy and tired. Some seem to be living in the hospital these days. But they’re also tired of being labeled as “overwhelmed.” They got into healthcare to help people and that’s what they’re doing, she said.

Still, rural hospital administrators across the region are increasingly concerned about the welfare of their employees, many of whom are just now facing their first big waves of the virus.

On Wednesday, Kansas Gov. Laura Kelly said healthcare workers in hospitals across the state were suffering from “severe burnout.”

“I’ve had one of the nurses literally break down right in front of me because of her concern for one of the patients, which is a wonderful thing but it takes a toll on the staff,” said Dennis Franks, CEO of Neosho Memorial Regional Medical Center in Chanute. “They’re working a lot.”

Leaders of the 25-bed hospital in southeast Kansas are studying ways to keep morale up as providers deal with increasing numbers of coronavirus inpatients. Aside from more patients, the hospital is increasingly treating sicker patients who require a variety of therapies and monitoring, said Jennifer Newton, the hospital’s chief nursing officer.

In recent weeks, the hospital, which includes a five-bed intensive care unit, has been at or close to capacity. It has relied on a previously closed eight-bed observation unit for overflow capacity.

The pandemic requires more education and training of all staff. Everyone from housekeeping employees to lab staff to respiratory therapists are working harder than ever to keep patients well, Newton said. And every hospital is facing staffing challenges exacerbated by the virus.

“Healthcare workers are extremely taxed during this event,” she said.

HOW COVID AFFECTS EMERGENCY CARE

Asking more of rural hospitals doesn’t come without risks.

Doctors and nurses must stretch beyond their experience, administer unfamiliar drugs and care for patients without the comfort of an in-house ICU if a patient quickly deteriorates.

But even with the “inherent risk,” this move has greatly helped bigger hospitals, said Dr. Robert Freelove, chief medical officer at Salina Regional Health Center.

“For patients mildly to moderately ill who can be taken care of there, it’s a good thing,” he said. “It creates space and breathing room at the larger hospitals, which we need. And not just for COVID patients.”

Like hospitals in mid-sized cities of Hays, Garden City and Hutchinson, Salina Regional frequently receives transfers from some of the state’s smallest facilities. But capacity is stretched. Last weekend, Salina housed a record high of 37 COVID patients.

With those kinds of numbers, it’s often difficult to admit new patients or accept transfers, as other hospitals call nearly constantly looking for beds.

So far, he doesn’t believe COVID has impaired the healthcare system’s ability to treat other illnesses and emergencies. But that threat is looming with a finite number of beds and staff.

Those other emergencies are what worry Valerie Davis the most.

She’s the administrator of Mercy’s hospitals in Cassville and Aurora, Missouri. Like other rural hospitals, her staff has learned a lot about COVID in recent months. They have ventilators, IV medications like remdesevir and the know-how to treat virus patients in house.

Mercy’s hospital in Springfield has been filling up, along with its main competitor CoxHealth. Similarly, the rural hospitals are struggling to move patients to Joplin, St. Louis, Kansas City and Rogers, Arkansas. And Davis worries that emergencies could leave her team with critically ill patients that have nowhere to go.

Things like heart attacks and strokes require immediate interventions. And every COVID patient, whether at one of her small hospitals or a major city hospital, is consuming resources.

“Those patients, when they come through our doors, honestly that’s a little more scary than COVID,” she said. “We have to get them somewhere as quick as we possibly can.”