Three hundred people tuned into AHA’s April 14 webinar, Experience from the Front Lines: Managing COVID-19 in Rural Communities, showing how large the appetite is for new ideas and information on addressing coronavirus in rural areas. Even with a live Q&A portion of the event, there were still many unanswered questions, so we asked the two speakers, Rex McKinney, president and CEO at Decatur County Memorial Hospital in Greensburg, Ind., and Mary Ellen Pratt, CEO at St. James Parish Hospital in Lutcher, La., to provide an additional batch of answers.

Question: What is your hospital doing to help educate the community about ways to slow the spread of the virus?

Mary Ellen Pratt: We created a special website and continue to update it regularly. We also use Facebook to provide updates and announcements, and we used Facebook Live press conferences that allows people to ask questions in real-time. We also created short videos with our infection prevention coordinator and posted those. We have definitely served as the source for information.

Q: What information does your command center use on a daily basis to prepare?
Rex McKinney:
We designed a standard template and reviewed this twice per day to help keep us up to date. This template included information on beds occupied/available; number of patients with COVID-19; number of patients on ventilators; number of patients transferred; number of patients tested; critical staffing positions; personal protective equipment inventory; the local nursing home report; our daily objectives; and an incident command sections report (which is comprised of public information such as local FEMA, county board of health information, county commissioner information or requests, community requests; safety, operations, planning, logistics, finance).

Q: What workforce changes are you implementing in order to meet the demand?
MEP: Our emergency response plan allows us to rescind/suspend personal time off. We did that first because this ensures that we have available staff. The plan also allows for staff to work in a variety of different roles, depending on needs, so we reassigned staff to different roles. OR nurses/surgical techs were moved to medical/surgical inpatient care. Clinic receptionists and medical assistants were moved to screening and call center roles, radiology and physical therapy staff were reassigned to materials management, environmental services, and we developed a daycare amidst this crisis to help out our staff.

Q: How have your relationships with other organizations changed, and what do they now look like?
We have significantly strengthened our relationships with local nursing homes, employers and other agencies during this time. We strengthened relationships by sharing best practices related to COVID-19 care, providing needed PPE, and facilitating care in the nursing home rather than admitting certain patients. In addition, our community has donated several masks and funds to support hospital staff during the crisis. We have been intentional about being the source of COVID-19 facts in our community, and our community has noticed and appreciated this effort.

Q: What is your patient mix? Are there any patient populations that tend to get critical quicker or have worse outcomes?
MEP: This has been a huge debate in Louisiana. We are definitely seeing more African Americans test positive and die from the disease. Some speculate that this demographic has more comorbidities, which puts them at greater risk. Some think it relates to social determinants of health. We just don’t know, but the state has requested demographic data from hospitals to try to better understand why this is happening. 

Q: What has surprised you the most while managing this crisis?
RM: Early on, I was surprised by how many of our team members were exposed unknowingly and became symptomatic. Our primary challenge related to nursing staffing, and our team responded by filling all shifts. When a local nursing home was impacted, our team provided staffing to their facility.

Q: Your hospital has been particularly hard hit by COVID-19. Can you tell us what your biggest concerns are right now?
MEP: During the peak, my biggest concern was resources – having enough nursing staff to care for the patients (as more and more were getting sick), having PPE to protect my staff and having enough ventilators to save the lives of people in need.

Right now, we are beginning to open back up. My concerns now is still resources – enough PPE to perform surgery and COVID-19 inpatient care (we are using a tracker to project days of PPE on hand), enough testing material for screening OR patients and determining community spread (we do not have the rapid testing and have to send out for resulting); and staff to care for both outpatient services and responding to a potential “second wave.”

Q: How has your hospital maintained cash flow?
MEP: We have been tracking daily cash and revenue. Cash was not impacted immediately (obviously there is a lag in collections in health care), but our revenue dropped considerably (more than 50%) during the peak. We very quickly applied for the Centers for Medicare & Medicaid Services prepayment and received that very quickly. Some of our managed care organizations are doing the same. We are keeping abreast of the grants and applying for whatever we can. We are using consultants to help us with this since we are so busy managing the COVID-19 crisis.

RM: Over the past two years, our organization has put forth a focused effort to improve our financial position. This helped create a “rainy day” fund, which helped cash flow throughout this challenge. With the high degree of uncertainty, we did acquire a line of credit and are applying for several federal support programs.

Q: How are you working to protect your employees from exposure to COVID-19?
MEP: Our infection prevention coordinator was out on the floor constantly coaching and monitoring PPE. We observed the donning and doffing. We created standard operating procedures but followed up with active surveillance and monitoring. In the beginning, we had to dispel the misinformation and fears with accurate Centers for Disease Control and Prevention guidance. My advice is to monitor your inventory and stay ahead of it. If you get low, figure out what “Plan B” will be…reusing, disinfecting (using sterilizers), etc.

RM: Our PPE supplies have been sufficient throughout the crisis and available for all staff to use. We have implemented a variety of efforts to enhance safety, including masking and taking temperatures of everyone entering our facilities; creating a “pantry” for our staff to purchase greatly discounted items in effort to minimize their exposure by shopping at local retail stores; implementing conference calls for safety huddles and incident command; and providing respite areas and showers for staff.

Q: If you could give one tip to your fellow rural health care leaders, what would it be?
RM: Collaborate with everyone during the crisis – caregivers, medical staff, local, state and other leaders to ensure accurate information and resource availability for the hospital and community.

MEP: Plan for the worst and hope for the best. It’s better to know what you would do if you run completely out of something…what will you substitute? What would you do if you can no longer transfer to the bigger organizations/referral centers? Have a plan, even if you don’t need it, because once the situation unfolds, you have to move very quickly. Having a plan saves a lot of time.

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