Rural hospital systems are getting overwhelmed all across the country. "It's devastating, and really heartbreaking knowing people are fighting for their lives and it could have been prevented," said charge nurse Erin Boni, center, at Oregon Health and Science University's intensive care unit in Portland, Oregon. The hospital's ICU units are filled to capacity but the phone calls asking for help keep coming from rural Oregon hospitals. (Kristyna Wentz-Graff/Pool Photo via AP)

This story was originally published by North Carolina Health News.

Late last week, three rural hospital CEOs said the Covid-19 patients they’re treating are sicker than at any time during the pandemic. Yet, even as their hospital staff are growing weary; some remain hesitant to get the coronavirus vaccine.

“Our workforce is tired. It’s like you went to battle six months ago, you got some rest and now we’re having to go right back to battle again. It’s a little bit harder to do it that second time,” said Chuck Mantooth, president and CEO of Appalachian Regional Healthcare System during a virtual town hall hosted by the NC Healthcare Association.

“We’re here,” he added. “We’re weary, but we are still taking care of folks in western North Carolina.”

As hospitals across the state face yet another surge of Covid-19 patients due to the Delta variant, these patients are sicker than the ones before. Additionally, rural communities tend to be older and already struggle with access to health care services and higher rates of chronic disease, such as diabetes and hypertension.

“We feel like every day we can’t take another patient but we are obligated to fulfill our duty,” Mantooth wrote in response to emailed questions from NC Health News. “We have limited elective surgeries as a relief valve to manage the capacity issue.”

Sicker Patients with Nowhere to Go

“We are seeing sicker patients, and that progression to that severe illness is happening more quickly with the Delta variant than we are used to seeing,” said Roxie Wells, president of Cape Fear Valley Hoke Hospital.

Because hospitals are filling up everywhere, rural hospitals cannot send complex patients to their usual partners for higher levels of care. Last week, hospitals in the Triangle held a joint press conference saying they are already overcapacity.

On top of that, Covid-19 patients, even though they’re younger on average, are being hospitalized for much longer periods of time.

“We are seeing young/old, upper/middle/lower class, healthy/medically challenged, etc.,” Mantooth wrote. “I was quite surprised … I would have expected comorbidities to be a significant factor in hospitalization. Although our sample size is smaller, this is what we are seeing.”

Jonathan Snyder, chief medical officer at Hugh Chatham Memorial Hospital, said his staff is used to high volumes of patients, but typically patients are admitted to the hospital and leave within an average of three days.

“What we’re seeing now is these folks when they come into the emergency department, they are acutely ill, much more so than our normal population,” Snyder said. “And then they’re requiring much longer hospital stays, which I think is where we’re probably seeing the biggest strain.”

Staff in the overwhelmed hospitals have been “leveling up,” where people step into roles that are stretching them to the limits of their training and knowledge.

“It’s an all hands on deck approach at the moment,” Mantooth wrote. “Mostly, we have [operating room] staff covering on Covid floors and [are] back-filling unstaffed areas. Also, managers, executives and directors are all working in areas from the cafeteria to patient transport.”

UNC Health Southeastern hospital in Lumberton is so overwhelmed by Covid-19 patients that the hospital acquired a mobile morgue – a giant refrigerator the size of a trailer to store the overflow of bodies.

“​​These are the pictures of a mobile morgue. This is where we place a body until a funeral home can pick it up,” CEO of UNC Health Southeastern Joann Anderson wrote on Facebook over the weekend.

“We had to have it delivered and placed onsite at the hospital because we have had so many deaths from Covid in such a short period of time,” she wrote. “Yes, we have an on-site morgue. It’s full!!!! We were left with no choice. This is so sad and so senseless in many cases.”

Using New Tools

Since these rural hospitals can’t refer patients out, Wells said Cape Fear Valley is using telehealth to access critical care specialists so they can see complex patients virtually.

“We’re all seeing that we are not able to transfer our people as readily and as quickly as we’d like, because the tertiary centers are full, so what better ways to leverage telehealth for the good and the benefit of the people that we care for,” she said.

Though the state’s health care systems are under the same strain they experienced in January, this time there are “additional tools” to combat the virus, Mantooth said.

There has been an increase of primary care providers who are prescribing a combination of monoclonal antibodies made by drugmaker Regeneron, that can be used on patients with Covid-19 in the early stages of infection to reduce symptoms. Anecdotally, the hospital CEOs agreed that this therapy has been effective at reducing the number of critically ill Covid patients needing hospitalization.

Leaders from Hugh Chatham Memorial Hospital said they have gone from administering an average of five doses of monoclonal antibodies per week for the last eight months to 53 doses being given last week.

Wells said her system is trying to educate patients about the Regeneron treatment and encouraging people to seek it. 

Another intervention that hospitals first started using during the surge last winter was a so-called “hospital at home” program. Mantooth wrote that patients are able to get oxygen therapy, along with daily monitoring at coordination of care at home, leaving hospital beds for the more critically ill.

“We built out this program in early January and have not stopped using it. We have the current capacity to manage up to 30 patients in our virtual hospital and it has proved to be a successful tool in reducing admissions or re-admissions,” he wrote.

Vaccination Rates and Mandates

Rural communities in North Carolina have lower Covid-19 vaccination rates than those in more urban areas. In many cases, hospital staff vaccination rates reflect the community they are a part of.

“I think setting context is important,” Snyder said when asked about hospital staff vaccination rates. “In Surry County, we’re the sixth highest in the state in terms of transmission rates. And we’re also at the bottom in terms of vaccination rates of our community.”

This graph shows the percentage of the population 12 years and older who are fully vaccinated against Covid-19 by county as of Aug. 30, 2021. Graph and data courtesy of the NC Department of Health and Human Services

Forty-two percent of Surry County residents are fully vaccinated, according to the NCDHHS Covid-19 dashboard. Meanwhile, Snyder said just over 50 percent of his staff within the hospital are vaccinated.

“We continue to educate in creative ways,” he said. “We have multiple providers who are offering and providing one-on-one discussions, private conversations, with any organization member who would like to discuss the vaccine.”

Over on the western border, Mantooth said 70 percent of his staff got the Covid vaccine, and unvaccinated staff are required to wear N95 masks at all times. Before the FDA fully approved Pfizer’s vaccine earlier this month, he said the hospital leaders were hesitant to impose a vaccine mandate on staff. Now, they are re-evaluating their vaccine policy.

Meanwhile, Cape Fear Valley health system has a vaccine mandate in place which goes into effect Oct. 1. Currently, about 78 percent of employees have been vaccinated, Wells said.

“Of course there are the two potential exemptions: the medical exemption for people who have allergies to the vaccine or what have you, and then religious exemptions, but those things are being looked at on an individual basis,” Wells said.

We want to make sure the public and our staff are safe, she added.

“I have full faith in our staff. Now that we have the full FDA authorization, I think we will see an uptick in the number of people who have been reticent, particularly in health care,” she said. “There may be some we lose because of the mandate, but I think for the most part we will fare well in our population here.”

In Robeson County, Anderson is more concerned about the potential staffing shortages her hospital could face as a result of its vaccine mandate. The hospital CEO told WUNC last week that 48 percent of her staff are unvaccinated. Southeastern Health is now part of the UNC Health system, which has a vaccine mandate that goes into effect in September. Staff who remain unvaccinated could be furloughed or laid off.

Anderson said she’s concerned that she might have to fill up to 800 positions if workers don’t get their vaccines by then.

NC Health News editor Rose Hoban contributed to this story.

This article first appeared on North Carolina Health News and is republished here under a Creative Commons license.

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