What happens next for the Brainerd lakes area depends on how seriously people commit to following public health directives and stopping the spread of the coronavirus.
This is the primary message from local health care leaders as they watch case numbers rise at exponential rates and witness the challenges their organizations are facing. Those directives? Wear masks, stay at least 6 feet apart from others and avoid gathering in groups, especially indoors. There is no doubt fatigue among some surrounding these now-familiar refrains, but their importance has not waned.
“They need to be listening to experts,” said Dr. Jon Pryor, Essentia Health’s East Market president during a Thursday, Nov. 12, interview. “This does save lives. And it could be their life or their loved one’s life, and no one wants to be responsible for somebody in their family dying. So I’m begging people to take this really seriously and realize this. It may be emotionally hard for you to do, but it’s going to save a life.”
For months of relative calm, area hospitals worked to develop complex and ever-adapting plans for how to handle what may lie ahead in the coronavirus pandemic. Now facing more COVID-19 patients than ever before, an influx of people who’ve delayed care for chronic conditions, and reduced staff due to illness or quarantine, the difficult days that were once hypothetical are becoming more and more frequent.
With flu season on the horizon and families tempted to carry out their traditional gatherings during the holiday season, the road will likely become rockier as time goes on. Pryor said he already knows of regional examples in which rationing of medical devices, such as CPAP machines used to deliver oxygen for treating COVID-19, has occurred.
“These are terrible, heartbreaking ethical decisions that have to be made that no one wants to have to make,” he said. “ … And actually if everyone followed these rules, we wouldn’t have to do this. I mean, we’d be fine.”
Kyle Bauer, CEO of Cuyuna Regional Medical Center in Crosby, said Thursday he’s keenly aware of the rising hospitalizations and what that could mean as other viruses begin their annual spread.
“If we can’t slow this thing down, just given the trajectory we’ve been on just in the last couple weeks, if that continues, I’m very concerned about the increased hospitalizations that we’ll see,” Bauer said. “And the challenge is, it’s just not all COVID either. This is the time of year when there are other types of viruses — the flu is a good example — but just as people are no longer outside and they’re having to congregate inside, we typically see an increase in hospital volumes anyway.
“And now you’re adding COVID on top of it. Especially if … you could slow it down and people are just ignoring what really are simple and best practice ways to slow this down. Whether that’s a physical bed issue or staffing or both, that is definitely a concern for us.”
To the west, the head of Tri-County Health Care said he’s fearful about what his staff might be up against in the coming months. Joel Beiswenger, president and CEO of the Wadena hospital and its surrounding clinics, said the past two weeks mark the first time they are caring for COVID-19 patients. This is primarily because the St. Cloud Hospital no longer has the capacity to take those transfers, he said. They’re also keeping more stroke and cardiac patients, relying on telemedicine for advice from specialists who aren’t housed in the 25-bed critical access hospital.
“What I’m most worried about on an outcome perspective is that we and the rest of the health system will be overwhelmed,” Beiswenger said Thursday. “That is what keeps me up at night.”
About the beds
When it comes to discussions of how hospitals will handle the pandemic, it often turns to the number of beds available for not only COVID-19 patients but everyone else in need of care as well. Part of the planning efforts since spring meant determining just how many more beds could be added, should the need exceed normal capacity.
Bauer said CRMC is in the third stage of its surge planning, which meant expanding the physical space set aside for COVID-19 patients. One way the hospital is preserving beds is staffing the surgical recovery area later into the night. By doing this, Bauer said those recovering from surgeries who may have normally spent a night in a hospital room are able to discharge straight to home.
“They might need to recover until 8 at night and then they’re fine to go home,” Bauer said. “In the past that wouldn’t be an efficient model to keep staff late but obviously in the current situation that’s easy for us to do.”
Pryor said at Essentia, they recently pulled the trigger on reducing surgeries that aren’t time sensitive in an effort to preserve additional beds. But this can change day by day.
“When our beds free up, you know maybe in a few days, we’ll go back to doing those cases,” he said. “So it’s really, everything is in flux with our eye towards keeping our patients and staff safe and keeping beds available for patients who really need them.”
Pryor noted an important factor at play is whether people with chronic conditions or other ongoing health issues get the care they need in a timely manner. The mandated stoppage of some procedures in the spring compounded the issue, and orthopedic or cardiac conditions may have worsened in that time, said Dr. Peter Henry, chief medical officer for Essentia Health, during a late October interview.
Pryor emphasized these people need to continue seeking care and ensuring conditions like diabetes and hypertension are under control. Otherwise, they could find themselves occupying a hospital bed at a time when they’re becoming a precious commodity. He said some of this resistance to care is grounded in fears of COVID-19 infection, but he said Essentia Health’s clinics are most likely safer than the grocery store due to stringent and consistent practices.
“What’s happening is people are not getting their meds adjusted, their hypertension gets worse, and then they end up with a stroke. And then they come into our hospital as a stroke patient. Now that’s taking up a bed that potentially a COVID patient could’ve had,” Pryor said. “And so we want people who have chronic conditions, we want people who need preventive care to come in and get it.”
If need is stretched beyond what hospitals can contain within their walls, it’s possible auxiliary facilities would be erected. But Pryor said if it gets to that point, it would send off a cascade of other impacts that could snowball into a worsening crisis.
“Once you start doing that, you start pulling your primary care doctors from the clinics for helping to take care of these patients and then the patients that need to come in for hypertension and diabetes can’t get in there because their docs are taking care of these really sick patients,” he said. “And then everyone else gets sick, because they can’t come to see their primary care physicians. And then that just worsens and it’s a snowball effect.
“So I’m really hoping we don’t have that. Again, it will be terrible. Lots of people will die. … So I’m hoping we don't get there. But we’re ready to do it if we have to.”
A hospital could have all the beds in the world and it wouldn’t matter if there isn’t medical personnel to take care of the patients in them. The leaders of Essentia, CRMC and Tri-County all agreed on this point, noting a climate in which there was already a nursing shortage is further exacerbated by how vast the need is across the United States as the virus surges.
Bauer said as of Thursday, 34 CRMC employees were out on quarantine. Beiswenger said 35 of Tri-County’s employees were out the same day, and in a small organization, this can begin to add pressure.
“The stress of the staffing challenges is mounting, is the best way to put it,” Beiswenger said.
While not providing a specific number, Jessica Herron, director of inpatient surgical care at Essentia Health-St. Joseph’s Medical Center, said staff members are having to isolate due to positive results or exposures on a rolling basis. The vast majority of infection in workers in all three hospital systems is occurring outside the facilities and in the community, leaders noted.
“It does reinforce the importance of our staff in maintaining the same things that we’re asking the community to do, and then using the same things that they know from work outside of work like using that hand sanitizer, cleaning their hands and wearing those masks,” Herron said. “ … If we didn't have any staff out at all, that’d be excellent. It’d be great. But we do, and we continue to work through it.
“ … When a staff member goes down, then two more step up and you just see that passion for the community and for their co-workers.”
Pryor said at first, Essentia Health leaders contemplated whether it would be prudent to redirect primary care physicians and nurses in the case of a surge. But ultimately, he said the organization determined outside hires would be the best option for maintaining employee resilience. They began aggressively hiring hundreds of nurses in the past six weeks, relying on employees to help recruit.
Bauer said CRMC is also continuing to recruit and looking at employing traveling nurses through agencies. He said state government could help by relaxing licensing requirements when it comes to out-of-state medical professionals. They’re also stretching capacity by shifting registered nurses and other types of support staff where needed, although he noted intensive care unit nursing requires specialized training and not just anyone can fill that role.
Beiswenger reported similar plans to discontinue primary care services as well as most surgeries except those that are urgent, should it reach the point where the hospital staff needs to be bolstered. Again, there are challenges, such as moving nurses comfortable in a clinical setting to the emergency department. Training has begun for providers who aren’t typically in those environments.
If the situation calls for these moves, Beiswenger noted the need would intensify for housekeeping, laundry, food preparation and other areas.
“Everybody that works within our business functions or our human resource functions or administrative functions would be remobilized into doing all support roles alongside our normal support,” he said.
But Beiswenger is worried about what will happen if there’s still a need for staff. He said multiple health care agencies will be vying for local nursing students to offer helping hands, and the demand for traveling nurses will be widespread. And perhaps rural Minnesota in the frigid winter months isn’t the most attractive locale, he said.
He’d look to various governmental support agencies, too, from the National Guard to the Federal Emergency Management Agency. But it always comes back to the same issue — if everyone needs their help, how much help will there be to go around?
“That’s why I’m losing sleep at night over that issue because I just know there’s not help,” Beiswenger said. “We are anticipating generally that we’re going to have to be self-sufficient to make this work. And, you know, if we get to a point where we can’t take care of people, that’s what’s going to be so devastating for my people.”
‘You don’t want to be the next story’
Surge planning, staffing levels, shuffling beds — the details of this complicated decision-making can obscure the actual people involved, those impacted by COVID-19 and those who are tasked with caring for them.
Herron said the stress experienced by Essentia frontline workers is compounded by the fact they might personally know the patient who is lying in front of them.
“We live in a nice tight-knit community, so some of what you run into is it’s your friends and your neighbors and your family members, and so that can add additional stress,” she said. “You do see people posting things on social media reminding people, remember I’m your neighbor, I’m the one that is working in the hospital. When I’m telling you use that mask and do those pieces, I’m your neighbor and I’m also the doctor, so try to, you know, listen to me.”
CRMC’s Bauer said his overall message to the community is if they want to help their friends and neighbors in health care, it’s simple — take the steps to protect oneself and others.
“We all want the best care for ourselves and our loved ones and our friends and family and the things we can do to make sure we can continue to provide that high level of care is to help us out by protecting yourself and others,” Bauer said. “ … I cannot stress enough how far that can go to help everyone and let us do what we do best and not be in a situation where we’re overwhelmed. And we can continue to provide that high level of care that people expect.”
Hearing an increasing number of stories from those who’ve looked COVID-19 in the face, Beiswenger of Tri-County said he believes this will become very real for the region in the coming weeks and months ahead.
“For those who have been skeptical about the mitigation efforts or dismissive, it won’t become real until it actually gets very close to home for them — meaning a family member, a good friend, a relative is sick, or worse yet, passes on because of this disease,” he said. “I’m beginning to hear those stories from people. And part of my messaging I think the next couple of weeks is going to be, you don’t want to be the next story. Change your practices now before you have the next story to tell about your spouse or your parents or grandparents.”