6 Steps for Rural Hospitals to Rise to the Coronavirus Challenge

The primary steps Margaret Mary Health took to address a surge of coronavirus patients included formation of a response team and expansion of telemedicine.

In response to the coronavirus pandemic, an Indiana-based rural hospital succeeded in boosting staff, increasing bed space, and securing essential equipment such as ventilators.

Rural hospitals are facing multiple challenges during the coronavirus disease 2019 (COVID-19) pandemic, including limited ICU beds, shortages of key specialists such as infectious disease experts, and narrow patient surge capacity. Unlike well-resourced medical centers in urban areas, admission of COVID-19 patients can quickly overwhelm a rural hospital.

Batesville, Indiana–based Margaret Mary Health, which features a 25-bed critical access hospital (CAH) and two health centers, started planning for the pandemic in early March and admitted its first COVID-19 patient on March 13. At the peak of the rural hospital's COVID-19 surge, nearly 20 coronavirus patients were admitted.        

"The big question was: What do we need to have? That is when we figured out how to rent hospital beds, find ventilators, and what we were likely to run out of," says Tim Putnam, president and CEO of Margaret Mary.

There were six primary steps that enabled Margaret Mary to cope with its COVID-19 patient surge, he says.

1. Response team formation

Margaret Mary's senior leadership started forming a coronavirus response team on March 4 and had the panel in place on March 12, Putnam says. "When we started, the response team was staffed by about 20 leaders from the organization."

Margaret Mary's chief nursing officer and vice president of patient services, Liz Leising, was picked to lead the response team because of her inpatient nursing and ER background, Putnam says.

The response team has six subcommittees: communications, community hotline, space, staffing, supplies, and testing, he says.

2. Increasing bed capacity

After Indiana officials lifted the CAH's 25-bed limit, the response team played a key role in expanding the rural hospital's bed capacity. "They created opportunities to create negative air flow rooms. They also looked at our inpatient capabilities and got as many patients into the hospital as possible. Now, we have phasing to go up to 60 beds," he says.

Finding space for new patient rooms was manageable, Putnam says.

"We were lucky to be in an older facility that was designed for larger patient volumes. A lot of critical access hospitals are in that situation, where they were 70-bed hospitals then came down to the 25-bed critical access hospital limit. What happens over time is that many of those patient rooms turn into offices, but they still have oxygen and other critical components."

3. Securing equipment

The two primary equipment challenges at Margaret Mary were finding adequate supplies of personal protective equipment (PPE) and procuring ventilators, he says.

The Margaret Mary purchasing staff was able to find PPE, but a larger measure of creativity and help from the organization's CFO, Brian Daeger, was necessary to increase the stock of ventilators. Before the pandemic, Margaret Mary had four ventilators. Daeger and the purchasing team were able to find an additional 12 ventilators, Putnam says. "The ventilators were in Tennessee on a used market. They were not new ventilators, but they were completely functional."

4. Boosting medical staff

Margaret Mary's anesthesia team played a pivotal role in staffing ventilator-equipped hospital beds, he says.

"Since we cancelled all elective surgeries, the anesthesia team became a great resource. That is what you see in rural hospitals—a lot of us can do a lot more than what is in our job description. So, we had nurses who used to work in the inpatient setting volunteer to work inpatient again. We had anesthesiologists who helped with airway issues when they arose. It was a strong teamwork effort."

In addition, medical assistants from outpatient offices and hospital departments with low volume due to the pandemic were redeployed to work as inpatient nurse assistants and nurse aides.

Several of the staff redeployment efforts required a training component, Putnam says. "We brought people in who had backgrounds in the inpatient setting—they had either worked in inpatient or were familiar with the setting. They went through an abbreviated orientation, then worked with experienced med-surge nurses."

5. Working with tertiary partners

Having solid relationships with tertiary partners was critically important for Margaret Mary, he says.

"They know the types of care that we deliver and which patients we will be sending to them. So, they know when they receive patients from us that the patients have been worked up appropriately and the information flows. They do not have to repeat anything, so the patient is not being set back to the starting point where they run all the tests again."

With these partnerships in place, Margaret Mary was able to transfer the hospital's most critically ill patients to tertiary centers and receive some less acute patients from tertiary centers, Putnam says.

6. Expanding telemedicine

Margaret Mary was able to expand an existing telemedicine relationship with an infectious disease expert, Stephen Blatt, MD, medical director for infectious diseases at Cincinnati-based TriHealth.

"He has been a big resource for how we prepared for COVID and how we treat the disease. Our medical staff has a conference call with him weekly to discuss the latest in treatment, testing, and resources," Putnam says.

Margaret Mary also bolstered an existing primary care telemedicine service, he says. "We have worked with several other community hospitals in Indiana to develop a primary care telehealth network that has expanded tremendously during the pandemic. The groundwork for it was already established."

Photo credit: Margaret Mary Health