Rural Hospitals Helping To Ease Virus Burden
South Dakota’s largest hospitals are at or above their capacity to care for critically ill COVID-19 patients, forcing some of the sickest patients to be flown out of state to receive care.
The strain of a months-long surge in coronavirus cases has reduced hospital capacity to care for those with severe symptoms, making it increasingly uncertain whether the sickest South Dakotans will be able to get treatment in the state, health providers say. Meanwhile, ICU space is quickly evaporating in neighboring states as well.
Both the Sanford USD Medical Center and Monument Health Rapid City Hospital have reported that their Intensive Care Units are out of space. On Dec. 2, Avera McKennan reported that 6.7% of its ICU beds were available for use. Statewide, the number of available ICU beds has been steadily declining as coronavirus cases have continued to climb.
Major hospitals are still taking patients when they can, but some sick South Dakotans are being sent out of state, forced to use expensive urgent transportation systems to get care hundreds of miles away from their families.
COVID-19 patient Robert J. Sliper of Lead, South Dakota, was flown on an air-plane in mid-November to Greeley, Colorado, because there wasn’t enough room in local hospitals, according to an emotional letter written by his son Mike Sliper. The letter, which Mike Sliper posted to Facebook on Nov. 18, detailed Robert Sliper’s life and the anguish his family felt watching him get loaded onto a plane to fly 340 miles to a hospital they couldn’t visit.
Robert Sliper, a Navy veteran and mining engineer who graduated from the South Dakota School of Mines and Technology, died in Greeley on Nov. 13 at the age of 84, the post said.
Sliper’s body was brought back to South Dakota for his funeral. “We want to bury him in the state that he loved so much but near the end didn’t have room for him,” Mike Sliper wrote.
In South Dakota, hospital critical-care capacity was limited long before COVID-19 hit. Rural residents in need of intensive care already were frequently expected to travel up to hundreds of miles by plane, helicopter or ambulance to get lifesaving treatment at major healthcare centers in Sioux Falls or Rapid City.
As the pandemic has stretched on, South Dakota’s three major hospitals —Avera McKennan and Sanford USD Medical Center in Sioux Falls and Monument Health Rapid City Hospital — are now struggling to find or make space to care for the most ill COVID-19 patients and others with serious health problems.
Hospitals are so full, and ICU bed availability is changing so fast at large hospitals, that data reported on the state Department of Health COVID-19 webpage often doesn’t reflect reality, said Dr. Srinivas K. Gangineni, the ICU medical director at Monument Health Rapid City Hospital. The result is that the state’s largest, best-equipped hospitals can’t always guarantee they’ll have space to care for the most critically-ill COVID-19 patients on any given day.
“To be honest, I don’t look at the Department of Health website,” he said. “The data I can give you right now, it could be different in 15 minutes.”
Sioux Falls-based Avera Health system, which owns Avera McKennan Hospital and dozens of smaller hospitals in South Dakota, Iowa, Minnesota and Nebraska, is well into its coronavirus surge plan, said Dr. David Basel, vice president of clinical quality. Avera McKernan has nearly doubled its ICU capacity by postponing some non-emergency surgeries, cross-training hospital staff to work with COVID-19 patients and repurposing some hospital space for intensive care.
Most of the hospitals affiliated with Avera Health, including in South Dakota and neighboring states, are “at, near or above” their capacity to treat COVID-19 patients, Basel said.
At Sanford Health’s flagship hospital, Sanford USD Medical Center in Sioux Falls, doctors and nurses have been volunteering for double shifts and cross-training to work with COVID-19 patients, said Andy Munce, vice president for operations. Earlier in the fall, Sanford Health was able to bring online an additional 16 hospital beds capable of handling patients who need intensive care, which significantly increased the system’s ICU capacity.
Sanford Health has also started placing two patients in some hospital rooms and has moved other patients to different parts of the Sanford USD Medical Center.
“We have had some of our adult non-COVID patients recover or receive in-patient care over at the (Sanford Children’s Hospital),” Munce said.
Hospital capacity data reported by the state Department of Health suggest there is plenty of room in hospital ICU units to handle more patients. The DOH reported on Dec. 2 that statewide about 16% of adult ICU beds in the state were available for use. Roughly 35.2% of all staffed hospital beds were available for use, the department reported.
But much of South Dakota’s open ICU space is in smaller, more rural hospitals that don’t have the staff or equipment to care for the most ill patients, including those with severe COVID-19 symptoms. Those most critical patients tend to stay in hospital beds and intensive care for weeks and often require a level of care that can only be found at major medical centers, experts say.
“A lot of our hospitals would be comfortable caring for a patient with pretty normal lungs after surgery. But these COVID patients are really, really sick and have really complex lungs, and they take an additional skill set,” Basel said. “Not all ICU beds are created equal.”
The states surrounding South Dakota are also seeing strains on hospital capacity. North Dakota Gov. Doug Burgum announced on Nov. 9 that the state’s hospitals had reached 100% of capacity. By Dec. 2, North Dakota’s hospitalization rate had fallen, and roughly 13% of the state’s capacity to treat COVID-19 in hospitals was available.
Hospitals in South Dakota and across the country are also undergoing challenges providing critical care due staffing shortages due to illness and burnout. Across South Dakota, hospitals were enduring longterm shortages of doctors and nurses long before the pandemic. Now, hospitals are seeing dozens of staff forced to take time off due to the virus.
That has left some hospital administrators worried that they may have enough beds but not enough staff to care for critically ill patients if the number of coronavirus cases begins climbing again.
South Dakotans who need hospital-level care, including intensive care, can still get it, though they may be sent far from their homes, including to hospitals in other states. But hospital capacity has tightened across the country amid the nationwide coronavirus surge, limiting options elsewhere. Nationally, more than 98,000 people were in hospitals and diagnosed with COVID-19 on Dec. 2; more than 19,000 coronavirus patients were in intensive care.
As the number of COVID-19 hospitalizations continues to climb nationally and remains high in South Dakota, healthcare providers worry that holiday travel and the nascent 2020-21 flu season could cause another surge in hospitalizations. The state’s hospitals may be forced to shut down clinics and restrict or ration care for chronic conditions such as diabetes and hypertension to free up doctors and nurses to treat COVID-19 patients. Even then, hospitals may reach the limit of their ability to care for everyone who gets sick.
“I don’t know what that limit is, but if cases were to double for another month or two, we would be making some hard decisions,” Basel said. “We’ve had reports that there are areas in Iowa where they are starting to really look at whether it’s good to put individuals who are over 75 with COVID-19 on ventilators. We’re not at that point, and I hope that we never get to any type of point like that. But there may come a day.”
Patients transferred out of state
Rose Mary Kor, who lives outside the Black Hills city of Custer, was rushed to the Emergency Room at Monument Health Custer Hospital on Nov. 2 after struggling to breathe for nearly a week. Kor, 70, said she thought her asthma had been acting up. Then, after an emergency X-ray, doctors told Kor that she had pneumonia due to COVID-19 and needed immediate hospitalization at a more well-equipped facility.
The problem was that Monument Health Rapid City Hospital, where critically ill patients from Custer are usually sent, was full and couldn’t accept new COVID-19 patients. Kor had to choose whether to be flown to a hospital in Gillette, Wyoming, or a hospital in Casper, Wyoming. Both options were more than 140 miles from her home.
“I was in disbelief,” Kor said. “The hospital in Rapid City is not small. The question in my mind was, ‘Why are they not prepared for this?’
Kor is not alone in her experience. Several other South Dakotans from East River and West River who belong to a closed COVID-19 discussion group on Facebook have shared similar stories of loved ones being diverted to hospitals far from their homes.
Monument Health Rapid City Hospital is the flagship hospital for the Monument system in western South Dakota and offers the highest level of care available in the region. The hospital’s 33-bed Intensive Care Unit has essentially been full through much of November, Gangineni said.
Monument Health took steps to prepare for surges in COVID-19 patients. Some hospital staff volunteered to work extra shifts, nurses have cross-trained to work in the ICU and the hospital is working to add six new ICU beds. Those new beds likely will come online in July 2021, Gangineni said. In the meantime, as patient volumes remain high and are expected to surge again following the holidays, Rapid City Regional’s ICU will have to continue diverting at least some patients to other hospitals.
The number of COVID-19 hospitalizations rose sharply during November in almost every part of the U.S and was still growing at the end of the month. On Dec. 2, the nationwide number of COVID-19 hospitalizations stood at 98,691.
On Nov. 24, members of the Iowa Hospital Association warned that hospitals in and around Des Moines had been down to three open ICU beds during the week before Thanksgiving. Media reports in Minnesota during the last week of November warned of similar
State data in Wyoming, Montana and Nebraska have shown sharply rising numbers of COVID-19 cases through the middle of November. Meanwhile, the number of ICU beds has been dwindling in those states.
“I was in disbelief ... the hospital in Rapid City is not small. The question in my mind was, ‘Why are they not prepared for this?”’ -- Custer resident Rose Mary Kor, who was flown to Wyoming for COVID-19 care
Ultimately, Kor chose to go to Casper, where she spent nearly two weeks at the Wyoming Medical Center with a high-flow oxygen mask helping her body function. The oxygen mask worked, and Kor narrowly avoided being placed on a ventilator. Still, the experience was painful.
“It was like sticking your head out of a car window at 80 miles per hour for two weeks,” Kor said. The trip took an emotional toll as well. “I was very lonely,” she said.
On Nov. 15, Kor was discharged from the Wyoming Medical Center. A family friend had to drive six hours to pick Kor up and bring her back to South Dakota.
Kor’s lungs still are not functioning properly, and she needs supplemental oxygen. She is tethered to a machine by a 50-foot hose for most of the day and struggles to breathe when walking around her home. Kor also worries about how much her COVID-19 transportation and hospitalization will cost.
Patients with COVID-19 in western South Dakota face a challenging set of circumstances if they need care they can’t get locally. Community hospitals tend to be isolated and usually send their most critically ill patients to Monument Health Rapid City Hospital. But if that hospital is full, the nearest comparable hospital is more than 100 miles away and in a different state.
“I don’t want to say we’re in the middle of nowhere, but if you look at tertiary care centers around our hospital, there aren’t that many,” Gangineni said.
Transfers from smaller hospitals to larger, better-equipped hospitals across state lines are routine in the healthcare industry. Small, rural hospitals can’t afford the equipment or the specialized staff necessary to care for severe heart attack or stroke victims, for example.
“That’s not unusual. Probably the majority of people in our Sioux Falls hospital were not from the immediate Sioux Falls area a year or two years ago,” Basel said. “We don’t pay too much attention to state lines. It’s more whether we’re sending patients to our closest hospital with the necessary resources for that individual patient. Within our family of hospitals, we certainly see people going back and forth across state lines a lot.”
Rural hospitals easing some burdens
One bright spot in terms of hospital capacity is that some rural hospitals have increased their ability to care for COVID-19 patients. When the pandemic began, Avera Health system hospitals started sending all of its COVID-19 patients to Avera McKennan in Sioux Falls because there were more specialists and space at the larger hospital.
Through the summer of 2020, rural hospital staff became more comfortable treating COVID-19 patients; supplies of personal protective equipment increased; and new treatment options were developed, Basel said. Now, roughly two-thirds of Avera Health’s COVID-19 patients are cared for outside of Sioux Falls, and only the most critically ill patients are sent to Sioux Falls.
The Huron Regional Medical Center was one of the first rural South Dakota hospitals to see a surge of COVID-19 patients. Consequently, the independent hospital pioneered some of the emergency remodeling that other smaller hospitals later used to treat coronavirus patients safely, said Erick Larson, hospital president and CEO.
“Utilizing temporary walls and additional HVAC equipment and venting, we were able to create negative pressure isolation areas. Now, the COVID unit is sealed off from the rest of the patient care areas,” Larson said.
The hospital’s COVID-19 unit has enough space for 14 patients at a time, with space for up to four patients in intensive care. The Huron hospital’s staff also created a new five-stage surge plan and secured a steady supply of personal protective equipment by working with the state health department and the federal Centers for Disease Control and Prevention.
Hospital staff also formed small groups, or pods, that work closely together but separately from other staff as a way to prevent widespread exposure to COVID-19 if someone gets sick, Larson said.
Since September, Huron Regional has been caring for up to 10 COVID-19 patients at a time without having to cancel non-emergency surgeries, Larson said. The hospital’s capacity has been improved through the use of telemedicine as well. Huron Regional participates in Avera Health’s E-Care network. The network allows doctors and nurses in Huron to consult with specialists in Sioux Falls via video conference, which reduces the need for patient transfers.
Huron Regional so far has not had a problem finding space in larger hospitals in Sioux Falls for patients who need more specialized care, Larson said.
“Our teams are well connected to both Avera and Sanford and work together with their staff on a regular basis to get patients to the appropriate care as quickly as possible,” Larson said.
COVID’s toll on health workers could impact hospital capacity
Right now, one of Huron Regional’s biggest concerns is having enough staff to care for patients in its beds, Larson said. Through the end of November, between ten to 15 of Huron Regional’s 300 staff members were out of work on any given day due to COVID-19. Some workers were sick; others took care of sick relatives or were exposed to the virus and needed to quarantine.
“Like most health care facilities, we do not have a lot of extra staff, so the teams must take extra shifts, and other departments have allowed their nursing staff to cross-train and work on the medical floor and in the COVID unit,” Larson said.
Much of South Dakota was critically short of nurses and doctors long before COVID-19. As coronavirus infections have surged, hospital systems such as Avera Health have seen their workforces shrink due to the virus. At any given time, 200 to 300 of the roughly 17,000 employees spread throughout the Avera system aren’t working due to coronavirus exposure infection or because they are taking care of a sick family member, Basel said.
“A lot of people are working in different areas than they normally would. We’re asking for volunteers to either take double shifts or to come in and work extra shifts in the hospital,” Basel said.
Monument Health Rapid City Hospital’s ICU has been fortunate that none of its physicians have gotten sick, Gangineni said. The hospital also has a plan in place to bring in another doctor if needed. Nurses, though, are in shorter supply.
“We’re stretched thin. A lot of these patients have very high acuity, plus our traditional ICU patients have a very high acuity as well. We’ve had to flex and work shorthanded from time to time. Usually, on a typical day, there are three to four nurses that are working extra shifts,” said George Sazama, director of the nursing unit at the ICU in Monument Health Rapid City Hospital.
In Iowa and North Dakota, some hospitals have relaxed their rules and have started allowing staff who have tested positive for COVID-19 but aren’t showing symptoms to continue working with coronavirus patients. The move was made in response to severe shortages of healthcare workers at all levels. So far, South Dakota hospitals have not implemented similar measures.
One of the most significant issues facing hospitals in terms of their capacity and staff wellbeing is the length of time COVID-19 patients tend to spend in the hospital. Some coronavirus patients are spending 60 days or more in hospitals, Sazama said. Typically, patients spend a few days at most in an ICU, not weeks or months.
“It’s a huge change,” Sazama said. “Usually, we live our days minute to minute, hour to hour; our patients’ condition typically changes that quickly. But dealing with COVID, they don’t change minute to minute or hour to hour, and typically they kind of get into a rut ... They’re so sick that you can’t really do anything.”
Though new drugs have been approved for use early on during a COVID-19 infection, few treatments are available for the most critically ill. Such patients are put on oxygen and often must be sedated so a tube can be inserted into their airways to pump oxygen directly into their lungs. Some patients can be rotated onto their stomachs as a way to improve their oxygen intake. But for the most part, many patients must rely on their bodies to fight off the disease.
“That takes a toll on staff, seeing how sick some of these patients get, how they stay sick for days and weeks, and sometimes months,” Sazama said. “These are the patients that a lot of people writeoff as the 2% who are going to die from COVID. I don’t think people outside the hospital know how difficult that is and how much mental and emotional trauma that’s causing when they make those comments, when they think that way.”