As the COVID-19 pandemic continues to ravage the nation, Missouri has been consistently rated as one of the worst hit by the novel coronavirus in recent months.
As of Sunday, more than 12 million cases of COVID-19 were reported in the United States, with more than 271,500 in Missouri. Across the country, more than 256,000 people have died from complications from the virus, including more than 3,500 Missourians.
The Missouri Department of Health and Human Services, citing numbers released Nov. 19, reported that more than 2,800 people were being treated for COVID-19 in hospitals, a number that, according to healthcare experts, is expected to continue to rise, and will soon overwhelm medical facilities across the state.
The situation is dire, and it’s not just urban hospitals facing the problem. Rural hospitals are also being forced to address a situation that many are ill-equipped to handle.
Last week, Dr. Alex Garza, chief community health officer of SSM Health and a member of the St. Louis Metropolitan Pandemic Task Force, issued a warning to that effect during a news conference where he outlined the dire circumstances on the horizon, which include cutting down or eliminating elective procedures, inability to transfer patients from rural facilities and finding enough resources to treat severely ill patients.
“Our healthcare heroes have fought valiantly day after day,” Garza said. “But we have no reserves. We have no backup that we can suddenly muster to come in and save the day. If we stay on the path that we’re on even just two more weeks, we will not have the staff we need to care for patients. It’s now just a numbers game.”
The situation Garza described may be difficult to think about, but Chris Wibbenmeyer, interim CEO at Perry County Memorial Hospital in Perryville, said it’s true nonetheless.
“It’s absolutely affecting us,” Wibbenmeyer said. “Our medical floor is operating near full capacity and our emergency department is doing the same. What [Garza is] describing in regards to rural health care is true right here in Perryville.”
PCMH, a 25-bed, critical access hospital, serves as the primary healthcare destination for many of Perry County’s approximately 19,150 residents. As such, it plays a vital role in the community, a role it is struggling to fill.
The continuing spread of COVID-19 in Perry County — which has often been ranked among the top 10 for positive cases per capita in the state, even topping the list for new cases in a seven-day period earlier this month — has put the hospital on the verge of becoming overwhelmed.
“From a staffing capability, we are right at the threshold,” Wibbenmeyer said.
On Monday, the Perry County Health Department reported 1,683 total cases — including 216 active cases — with 1,454 recoveries and 13 deaths. Monday’s totals represented an increase of 693 new cases since Oct. 30 and four additional deaths. Perry County’s positivity rate — the number of positive results compared to people tested for the virus — stands at 12.72 percent. For the seven-day period ending Nov. 22, that number was 45.7 percent.
“We are not on a sustainable course and we need to act now,” said Perry County Health Department director Sylvia Forester. “Life and death resources are limited. “Our lack of control of the virus is burdening not just our own citizens, but others throughout the state of Missouri.”
Because of its small size and status as a Critical Access Hospital, PCMH’s original plan for the pandemic was to transfer COVID-positive patients to larger facilities in St. Louis or Cape Girardeau that are better suited to treating patients requiring higher acuity care. That plan didn’t last long.
“Originally back in March, yes, that was our intention and we were able to do that to a certain degree,” Wibbenmeyer said. “However, the current spike is significantly larger and different than what had happened back in the first months of the pandemic. We have quickly learned that transferring patients to other facilities is very difficult.
We still attempt to transfer our most ill patients, but there are several cases where we have to be able to keep them and care for them on our own. Other facilities are full and f are being taxed as well, and they just do not have the staff and/or the space to take care of all of these critically ill patients.”
Even when transfers are absolutely necessary, Wibbenmeyer said it’s no easy matter.
“We’re having a very difficult time transferring patients to tertiary care centers to the south and north — the current spike has overwhelmed nearly all hospitals,” Wibbenmeyer said. “Beds are full. Staff are working at greater than full capacity and other facilities are not accepting transfers. We’ve recently had to transfer a patient as far as Columbia, MO, and even one last weekend to Kansas City, via a fixed-wing aircraft. It’s becoming very, very difficult, which is what’s forcing us to care for more COVID-positive patients in our facility.”
To do that, Perry County Memorial Hospital has had to make some adjustments, converting space to accommodate COVID-positive patients.
“We are up to eight rooms, currently, that we have designated for COVID-positive patients and we are making those adjustments as we go,” Wibbenmeyer said. “If the demand keeps increasing, we’ll have to try to create more space for COVID-positive patients.”
Wibbenmeyer stressed that space is not the main limiting factor. Of much more concern, he said, is staffing. Under normal circumstances, a hospital’s capacity is determined by the number of beds available. When it comes to a pandemic the like of COVID-19 where most patients require more intense care and a smaller nurse-to-patient ratio, the equation changes.
“Having the appropriate staff and the appropriate number of staff to be able to care for such a rush of critically ill patients is a different type of demand and it requires a different type of response,” Wibbenmeyer said. “It’s one that most healthcare organizations in their normal operating status are not capable of handling when it all comes at one time.
“We can put two beds in a room. We can put beds in hallways. We can make those types of adjustments, but there’s no point in doing that if you don’t have the staff to care for them.”
So far, Wibbenmeyer said the PCMH staff has been up to the challenge.
“I have to compliment our staff and say that they are coming together as true professionals and they’re stepping up to meet the needs of the community,” Wibbenmeyer said. “I’m overly proud of our providers, our administrative leaders and all of our frontline staff. Everyone — and I mean every employee in the organization — is doing more than they’ve probably ever been asked to do in their lives, and they’re doing it to support the community."
That dedication, Wibbenmeyer said, is common among hospitals all over the state, regardless of size.
“Cape Girardeau, St. Louis — they’re all being pushed to force their staff to work mandatory overtime,” Wibbenmeyer said. “We’re all doing that, but everybody has a threshold, even nurses and doctors.”
During a conference call with Gov. Mike Parson on Oct. 29, many healthcare system administrators warned that they would have to cut back, delay or temporarily eliminate elective or non-critical procedures in an effort to have enough staff to treat patients affected by the virus. Wibbenmeyer said PCMH hasn’t been forced to do that just yet, but it’s a move they might be forced to make.
“We haven’t limited our elective procedures yet, although it’s a variable and it’s a move that we can play, and it is discussed in our daily planning meetings,” Wibbenmeyer said. “But there are consequences to that, to eliminating elective procedures to help increase staffing in other areas to be able to care for more sick patients. It does so at the expense of possibly delaying health care for other people — non-COVID patients — and it also can significantly impact the organization’s revenue stream.”
When a larger hospital — such as BJC Healthcare in St. Louis, which recently cut back on elective procedures — takes that step, it has a ripple effect, reaching out across an entire region, forcing rural hospitals to bear a larger burden.
“It’s a chess game of sorts,” Wibbenmeyer said.
With hospital beds and staff at a premium, many hospitals are also forced to keep patients in the emergency room longer than normal as providers work to find space or a hospital able to accept a transfer.
“We do at times, just as other hospitals in the state, have to hold our patients longer in the [emergency department] setting,” Wibbenmeyer said. “However, our hospitalists, which are in-patient physicians, are still able to offer support to those emergency department physicians and help to manage patients that are being held in the ER.”
On Nov. 13, Herb Kuhn, executive director of the Missouri Hospital Association, wrote in a letter to Gov. Parson that the pandemic has grown beyond the ability of local health officials to control it and urged the governor to issue a statewide masking mandate, something he has consistently stood against.
“The wolf is at the door,” Kuhn wrote. “Missouri’s hospitals urge you to issue a statewide masking mandate. A mask mandate may be unappealing to some, but it has become necessary. We urge your immediate action on this issue.”
On Thursday, Parson said he wasn’t surprised by the hospital association’s request and that he’s never been against wearing face masks.
“I have been very clear on that from the beginning and that has not changed,” said Parson, who also signed an executive order extending the state of emergency in Missouri through March 31. “What I am opposed to is mandates from this position to the people of this state.”
Perry County officials have declined to even discuss such a measure locally, saying instead that local residents should take “personal responsibility” in following health department guidelines.
Wibbenmeyer said that regardless of government involvement, following the simple safety precautions laid out by the Centers for Disease Control and Prevention and regularly repeated by the county health department will always come down to personal responsibility, something he hopes more county residents will take seriously, especially with the holiday season approaching.
“A mask mandate is simply an order,” Wibbenmeyer said. “It’s up to individuals, it’s up to society to take personal responsibility in obeying that order or obeying that request. I urge everyone to wear a mask and avoid large social gatherings. It really boils down to that. We have to figure out a way to remain at a respectable distance — 6 feet— be responsible and practice all the basic safety principles that the CDC offers to keep each other safe.”
That concern, he said, especially applies to the older members of the community.
“Elderly patients that have other health conditions suffer greatly whenever they are exposed to this virus, and those are the people that are in the ICUs and that are on our medical floor and are very, very sick,” Wibbenmeyer said. “I urge everyone to wear a mask, wash and sanitize your hands frequently and avoid large social gatherings.
“Do what you have to do to stop the spread and keep your family safe.”