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'Inventing by the seat of our pants': How this small, rural hospital handled its Covid-19 surge

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    Margaret Mary Community Hospital (MMCH) is a small, rural hospital in Batesville, Indiana, that often operates at 50% capacity. But when the Batesville area became a hot spot for cases of Covid-19, the disease caused by the new coronavirus, MMCH saw an influx of patients and had to improvise, Abby Goodnough reports for the New York Times.

    Your Covid-19 checklist to expand capacity

    'Burning' through protocols and 'cobbling stuff together'

    MMCH is a 25-bed hospital that often operates with about half of its beds unoccupied. But by March 20, MMCH had the majority of its beds filled with confirmed or suspected Covid-19 patients, with six of those patients on ventilators. The hospital had just five intensive care beds, and the staff had never before cared for more than one patient on a ventilator at the same time, Goodnough reports.


    MMCH also ran out of propofol, which is used to anesthetize patients receiving ventilators. As a result, MMCH had to consult with a larger hospital in Cincinnati, which is about 45 minutes away, about potential alternatives.

    "We were trying to manage them on a ventilator with limited support, burning through our sedation protocols, having to use sedatives we never typically use," Desmond Wah, a physician at MMCH, said. "We were just cobbling stuff together."

    MMCH also doesn't have so-called "proning beds," which are hospital beds that periodically rotate patients so they're facing down, which can help those with respiratory problems breathe. And if any staff members at the hospital got sick, there weren't many people to fill in. "[Y]our bench doesn't go very deep," Tim Putnam, CEO of MMCH, said.

    How MMCH handled the influx of patients

    MMCH has had to get creative to handle the influx of patients it's seen because of Covid-19.

    "We were inventing by the seat of our pants," Wah said. "At the big hospitals in Indianapolis, a patient gets admitted and you consult all the specialists you need. If they need the ICU, you hand them off to an intensivist. Rural medicine is a different kind of beast."

    In addition to consulting with larger hospitals on how to address medication shortages, MMCH has transferred 20 patients to bigger hospitals in Cincinnati—though doing so presented complications, as some patients' family members were hesitant to have their loved ones leave the hospital they knew for a bigger one.

    "How do you explain it to family who can't even be at the bedside and see how sick they are, or say their goodbyes before their loved one gets shipped off to, literally, another state?" Wah said.

    MMCH also has been recruiting doctors from other specialties to help treat patients.

    Michelle Shorten, a family doctor at the hospital, has been focusing on treating patients who don't have Covid-19 but have chronic illnesses like diabetes, high blood pressure, and asthma through video appointments or phone calls. Shorten said she's trying to ensure those patients don't need to come into the hospital—which would further reduce the facility's capacity.

    Shorten said she's also started working on a "surge plan" in case the hospital sees another influx of Covid-19 patients. Under that plan, MMCH would expand its capacity to take in up to 66 inpatients—which is nearly three times the hospital's typical capacity, Goodnough writes. The hospital would use its current labor and delivery department to hold two patients per room, and temporarily relocate labor and delivery to a portion of the hospital that's usually used for same-day surgeries.

    In addition, primary care doctors like Shorten would join Wah on the hospital's inpatient floors to care for patients with Covid-19, Goodnough reports. Shorten said she's been preparing for that possibility by reading Covid-19 treatment protocols every night. "I can manage high volume/low acuity, but if you start adding that high acuity, that's where it starts to get complicated really quickly," she said.

    Doctors from other specialties have volunteered to help out, too. "I even have a psychiatrist who informed me last week that he has pretty good experience working in an ICU, and if we need him, he will step up," Putnam said.

    All rural hospitals should prepare, Wah says

    Wah said rural hospitals nationwide should prepare for a possible surge of Covid-19 patients—and be prepared to recognize when they can't handle the increased volume.

    "Everyone wants to keep the business local, but you have to be aware of your limitations," he said. "If your [ED] cannot handle it, don't try to be gung ho" (Goodnough, New York Times, 4/16).

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