‘No Capacity’: COVID-19 Surge Leaves Some Rural Hospitals Scrambling

California’s most recent stay-at-home order zeroes in on a region’s ability to care for their sickest COVID-19 patients.

But for rural hospitals that don’t have an intensive care unit, administrators say the worsening surge is presenting new challenges. 

“The critical access hospital program was designed such that these hospitals would primarily be available to accept and stabilize patients and then transfer those patients to a higher level of care,” said Peggy Broussard Wheeler, vice president of rural health for the California Hospital Association. “Now that is whittling away because the larger facilities are all tremendously impacted by COVID and other patients.”

Small hospitals in the Sierra foothills and the North State rely on larger facilities in Roseville, Reno, Sacramento and other urban hubs to take on patients beyond their means.

But as the state’s COVID-19 hospitalizations climb in the aftermath of the Thanksgiving holiday, urban hospitals are filling up. According to an NPR analysis of Department of Health and Human Services data, 95% of adult inpatient beds are being used at the UC Davis Medical Center in Sacramento, as are 96% at the Mercy San Juan Medical Center in Carmichael, and 91% at the Kaiser Permanente South Sacramento Medical Center.

JoDee Read, chief executive officer of Plumas District Hospital in Quincy, says her staff hit a snag recently when trying to transfer a severely ill COVID-19 patient to a better equipped facility.

“We ended up keeping that patient for about 17 hours before they had a bed open up for them,” she said.

Ultimately they found the patient a bed at Renown Regional Medical Center in Reno, but only after calling hospitals “as far-reaching as Davis”

“We asked everywhere surrounding our hospital, and there was no capacity,” Read said.

For those 17 hours, she says staff did their best to care for that patient with the resources they had.

“We do have some ICU-trained staff to manage those patients for as long as we need to until we can transfer them or until they can recover,” she said. “When we get somebody super sick, we need to be able to — and have so far — take care of them.”

Anticipating that there would be challenges with transferring patients during the pandemic, some hospitals have taken steps to better equip themselves for treating advanced cases of COVID-19.

At Eastern Plumas Health Care in Portola, chief executive officer Doug McCoy says staff started providing COVID-19 treatment medications and employing new oxygen strategies to minimize the number of patients that would need to be transferred to a larger hospital. 

Further north at the Modoc Medical Center, chief executive officer Kevin Kramer says when COVID-19 patients are in bad shape, staff try their best to take care of them onsite with the handful of ventilators and trained ICU nurses they do have. If a patient needs more advanced help, they get in touch with Reno and Redding facilities to ask about a transfer.

According to the NPR data, both of those areas have been heavily impacted: Shasta Regional Medical Center in Redding is currently using 94% of its adult inpatient beds and Renown Regional Medical Center in Reno is using 99%.

“Our situation could change very quickly for us because our bed availability is limited and our staffing is also fairly limited in our little community,” Kramer wrote in an email. “So if we get a pretty good size run of cases in the community that need hospitalization we could quickly have to implement our surge plan and care for patients in rooms or other buildings that were not really designed for patient care, so that part of this virus and how contagious it is can be unsettling to many of us in smaller communities with a limited amount of staff and facilities.”

Wheeler, with the California Hospital Association, says she’s heard stories from many of the rural member facilities that have had to “MacGyver” solutions to treat COVID-19 patients that a few months ago they might have transferred.

“You now have to ask a nurse or maybe even a physical therapist or a respiratory therapist assigned to the COVID beds to be the deliverer of food so that you're not exposing other people in your hospital,” she said. “You're having to do this on the fly to keep those patients safe.”

The hospital association says the larger facilities are hitting a bottleneck with staffing. ICU capacity is measured not just by the number of physical beds, but by who is available to treat critically ill patients.

“A hospital might have beds available for patients but they don’t have the staff to support those patients,” said Read of Plumas District Hospital. “Usually they’ll say ‘we don’t have any beds’, but that’s really not true. They have the beds, they don’t have the staff. So opening up whatever bottleneck exists to have more staff available in our hospitals will be really helpful”

Gov. Gavin Newsom took a step in that direction this week when he loosened the required nurse-to-patient staffing ratio in ICUs. Under the change, a nurse can be assigned to three patients at a time instead of just two. The temporary order also loosens rations in other areas of the hospital.

Nurses unions have criticized the measure, arguing it could lower the quality of care, but the California Hospital Association says it will strengthen facilities’ ability to respond to the pandemic.

“California’s ability to care for COVID-19 patients depends on staff, not beds,” the association wrote in a statement. “Without this temporary staffing flexibility, very sick patients will wait on gurneys in the emergency department until a specially trained ICU nurse is available.”

The state has also deployed medical workers from the California National Guard, asked the federal government for medical personnel, and renewed calls for medical or nursing school students to join the volunteer California Health Corps, which launched earlier this year but initially yielded few qualified workers.