Rural hospitals struggle to find places to transfer patients amid COVID-19 surges

Norton County Hospital is facing a major problem in recent days: Figuring out where to send patients that need a higher level of care.

As larger hospitals become overwhelmed with serious cases of COVID-19, the options are dwindling. For Norton, the closest hospital that it has been able to transport patients is six hours away.

“We are seeing more COVID-19 patients, in addition to traumas and other emergencies,“ said Katie Allen, community relations director for the 25-bed rural hospital in Kansas. “It is becoming more difficult to transfer any of these patients out to a higher level of care at this time.”

The transfer challenges are not just limited to Kansas, as states across the country are facing massive surges of COVID-19.

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Kootenai Health, a rural hospital in northern Idaho, said in a release last month that the hospital is 99% full of patients needing medical or surgical care.

“As we have been working to accommodate patients, several regional hospitals have either declined to accept transfers due to their own capacity/staffing, or they have been highly selective about which patients they can accommodate,” the hospital said. “For this reason, we are looking at hospitals beyond our normal transfer area to see what is available.”

Surges ramping up

The transfer problems come as rural hospitals are starting to face their first major surges of COVID-19.

Hospitals go into surge planning when 10% of hospitalizations are due to COVID-19, said Brock Slabach, senior vice president for the National Rural Health Association, a group that advocates for rural healthcare.

“We are well above that in many rural areas,” he said.

As rural hospitals face not just soaring COVID-19 cases but also transfer problems with larger facilities, they are looking to each other for help. “Some of the solutions potentially down the road is working with other rural hospitals in our area and keep in close contact with them,” said Allen of Norton County Hospital.

The hospitals could designate one facility that is strictly COVID-19 patients and then another facility that is designated for non-COVID-19 care.

Staffing crunch due to COVID-19

Rural hospitals were largely left unscathed during the initial wave of COVID-19 back in March.

“Everyone was watching with horror what was happening in New York City and New Orleans but that never seemed to arrive in rural America,” said Slabach, referring to the initial COVID-19 hot spots back in March and April. “Over the summer we thought perhaps rural areas were exempt from the impact of COVID.”

But experts aren’t thinking that now as cases have surged in midwestern states.

Largely rural states such as Idaho, North and South Dakota and Kansas have seen case positivity rates of 30-40% or more in recent weeks.

Rural hospitals have been preparing for an eventual surge of COVID-19.

“They did take the opportunity to beef up [personal protective equipment] where they can get it … [and] cohorting patients to try to firm up transfer relationships,” said Roger Ray, MD, chief physician executive for the Chartis Group, a healthcare analytics and advisory firm that has a rural healthcare center.

However, rural hospitals are facing another problem of trying to find enough healthcare staff to handle the surge of cases.

“This is all hands on deck time,” Schlabach said.

He added that he has heard of rural hospitals activating as many workers as they can to meet demand.

"They do the best they can," Schlabach, a former hospital administrator himself, said. "In one instance a hospital administrator who happens to be a nurse was working the floor this weekend."

On Monday, North Dakota’s governor announced that asymptomatic COVID-19 positive healthcare workers can continue to work as long as they take additional precautions.

“A number of hospitals have declined to do that but that is an option that they have,” Schlabach said.

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During the initial surges back in March, hospital workers from across the country traveled to hot spots to help overwhelmed hospital systems. But now that the virus is surging everywhere, those reinforcements may not be available.

“There were hospitals in the major parts of the country that were sitting idle and those nurses and doctors could go to New York under an emergency situation,” said Schlabach. “Now this is so widespread, we have 18 states and more that have reached 10% level of hospitalizations due to COVID, which is surge status.”

This means that rural hospitals will have to pay bonuses and hire expensive temporary staff to help meet the demand.

The increasing costs and surging cases have advocates calling for Congress to approve another round of relief funding. Congress passed a $175 billion provider relief fund as part of the CARES Act and Health and Human Services dedicated more than $10 billion of that specifically to rural providers.

“We are looking at and working with HHS to hopefully get the accounting on the last round of the provider relief funds,” Schlabach said.

HHS announced on Friday that it had distributed $106 billion of CARES Act relief money to 548,550 providers.

Congressional leaders are also in talks over another round of COVID-19 relief, but a stalemate over the size of the package continues.

Ray with the Chartis Group said that rural hospitals, which traditionally operate on narrow margins, have been able to stay afloat financially despite the cessation of elective procedures at the start of the pandemic.

“I would anticipate the stress of the next few months would send [Congress] to the table [for]another round at least of some relief,” Ray said.

Meanwhile, rural hospitals are turning to their communities to implore them to mitigate the spread by mask use and social distancing.

“They have credibility because there are a lot of communities that felt it would never get to them and it is there,” Ray said.

Norton, which has a population of about 17,000, has reported nearly 1,000 COVID-19 cases since the start of the pandemic, according to data from the New York Times.

Allen said a lot of the community’s cases stem from a nearby prison and an outbreak at a nursing home. The hospital though is pressing the community to take action to mitigate the virus, including by advocating mask use and social distancing.

“I do think more and more people are catching on that we need to hand wash and social distance and do our best to protect [our] community and healthcare workforce,” she said.