If a surge of COVID-19 patients fall seriously ill at around the same time, some of Northern California’s rural counties will be hit with an unprecedented health crisis that their hospital systems are not equipped to handle.
Many emergency room entrances throughout the state already look like scenes from science fiction movies, as some hospitals erect tunnel-shaped “surge tents” to screen incoming patients for COVID-19.
But even as hospitals take measures like this, health officials in some rural counties are worried about how they can serve residents when the surge comes, especially if they only have a few dozen patient beds.
“It doesn't take a lot to overwhelm a hospital that small,” said Calaveras County Public Health Officer Dr. Dean Kelaita. “Especially when the hospital might have other patients that it's caring for that are non-COVID-19-related patients.”
His county is home to one hospital, the Mark Twain Medical Center in San Andreas, which has just 25 beds to serve the county’s 45,000 residents.
It doesn't take a lot to overwhelm a hospital that small.
A CapRadio analysis of hospital capacity in 32 Northern California and north Central Valley counties found that many rural counties have a lower concentration of hospital beds per 100,000 residents than some more urban or suburban areas.
These rural areas face a number of concerns: running out of intensive care capacity, getting patients from isolated areas to the hospital on time, doing significant damage to their budgets by canceling elective procedures and more.
Many are short on hospital beds, ventilators and staff needed to treat a lot of complex respiratory cases at once.
Meanwhile, they’re also worrying about tourists coming in and depleting already sparse medical resources.
But as health systems around the globe consider how to handle a possible flood of patients, there’s uncertainty everywhere about how to handle the influx.
Jason Wells, president of two Adventist Health hospitals in Mendocino County, says he’s had to lean on larger hospitals in the Adventist network for help. He’s not sure how smaller, independent facilities will keep up.
“That’s the challenge with rural hospitals: We cannot afford to have excess respiratory therapists, excess pulmonologists, excess ventilators sitting on a shelf,” he said. “We run with what we absolutely have to have to survive.
“But we are not prepared for surges.”
Will Rural Counties Have Enough Beds?
Many rural counties have fewer hospital beds per 100,000 residents than more populated Northern California counties like Sacramento, San Joaquin and Stanislaus.
Kelaita’s Calaveras County showed up in CapRadio’s analysis as one of the five counties with the lowest capacity, with 55 beds per 100,000 residents.
He said that the potential for a surge poses a serious threat to rural counties like Calaveras because their communities are also at higher risk for severe illness from COVID-19.
“We have a disproportionate number of elderly and people with chronic diseases in our communities in the rural areas, and that's something that makes us very concerned,” Kelaita said.
CapRadio analyzed federal data about the number of beds in facilities across the region. Most of the data came from the Centers for Medicare and Medicaid Services, which shows the total number of medical beds in each hospital as of 2017.
For NorthBay VacaValley Hospital in Solano County and Kaiser Permanente Modesto Medical Center in Stanislaus County, CapRadio used data from the Department of Homeland Security & the Federal Geographic Data Committee dataset on hospitals, which shows the total number of overall beds, not just medical beds, in hospitals as of June 2019.
Compared with the 11 mostly rural counties in the region that had fewer than 100 beds per 100,000 residents, most of the larger, more urban or suburban counties analyzed were far better off.
Sacramento County, the largest population studied, had 170 beds per 100,000 people, while San Joaquin, home to Stockton, had 164; and Stanislaus, home to Modesto, had 219.
But even in Shasta County, the most prepared of the counties analyzed, health officials are on high alert.
Shasta is home to three general hospitals and one surgical hospital, which provide it with 279 hospital beds per 100,000 residents, the highest count in Northern California and the north Central Valley.
Valerie Lakey is emergency preparedness director for Mayers Memorial Hospital District in the rural town of Fall River Mills, almost an hour and a half east of Shasta Lake. She says she’s been in close talks with neighboring hospitals, and her staff plans to send patients on the mountainous 73 mile drive down to Mercy Medical Center Redding if they run out of space or equipment.
But one of the biggest concerns is getting people to the hospital in the first place.
“There are some people that live pretty far out, so that could be a worry,” Lakey said. ”We just do our best to get to them as quickly as possible and then get them where they need to be.”
What If There Isn’t A Hospital?
Concerns about a maxed-out health care system are even more dire in counties like Alpine and Sierra, where there isn’t a single hospital.
Alpine, California’s smallest county, is nestled in the Sierra Nevada along the state border. The only medical clinic in the county is a family practice operated by the county health department, which is open two days a week with a nurse practitioner.
So far, the clinic has been able to handle the need for COVID-19 testing along with regular care. But if residents need to seek out emergency or critical care, they have to do it in South Lake Tahoe, about a 40 minute drive from the county seat in Markleeville, or across the border in Nevada’s Carson Valley, according to county Health and Human Services Director Nichole Williamson.
If the surge comes to fruition, more people are going to want to shelter in place in these rural areas because we don't have as many cases, so it seems safer. But we don't have the capacity for an influx of people putting a drain on our resources.
The licensed medical staff in Alpine County consists of the county’s health officer, one nurse practitioner, a public health nurse and a registered nurse. That leaves the county with limited options to prepare for a COVID-19 surge.
“We really don’t have the staff that would be necessary for an alternate care site, and we won’t get any mutual aid from any surrounding areas,” Williamson said.
On top of the resources necessary to care for the county’s residents, many of whom are elderly, Williamson is worried about another population: tourists.
She’s concerned that people from urban areas like Sacramento will flee to areas like hers during the stay at home order, which she says she has already seen.
“If the surge comes to fruition, more people are going to want to shelter in place in these rural areas because we don't have as many cases, so it seems safer,” Williamson said. “But we don't have the capacity for an influx of people putting a drain on our resources.”
Visitors during this time put a strain on the county’s first responders and health system, Williamson said, even if they’re just up there for the day snowmobiling or otherwise enjoying the outdoors.
“They're consuming hospital resources if they break their leg and have to go to the emergency room around here,” she said. “And if they become ill with COVID-19 and go to one of these hospitals, they're consuming resources in a hospital system that was not meant for this influx of people at a time when we're having a surge.”
Ventilators: A ‘Limiting Factor’
But hospital beds aren’t the only thing worrying health officials and hospital staff.
Facilities are also grappling with shortages of equipment and staff to care for COVID-19 patients.
Ventilators are a key part of treating patients with severe cases of COVID-19. That’s because the virus attacks the lungs, causing a unique form of viral pneumonia, or an infection deep in the lungs. In COVID-19 patients, doctors have noted the virus forms a distinctive haze over the outside edge of both lungs, which can allow it to clog air sacs faster as the infection worsens.
Younger, healthier people with excess lung capacity can generally continue to breathe while the infection wreaks havoc, while older and medically fragile people are more likely to struggle and require assistance from a ventilator. That’s where backup supplies become crucial.
“Hospitals have an appropriate number [of ventilators] for a normal patient flow under normal circumstances,” said Amy Moore, director of science and research for the GO2 Foundation For Lung Cancer.
She said patients often need ventilators for days, possibly weeks, not just a few hours. “If we have hundreds of thousands of patients that need to be ventilated, how do we manage that?” Moore asked.
Lakey, with Mayers hospital in Shasta, says they only have four ventilators.
“Our hope is that everything would not peak at the same time,” she said.
If it does, the plan is to move patients to the larger hospital in Redding.
Ventilator supply is a major concern as COVID-19 continues to spread, according to Dr. Kavita Trivedi, a San Francisco-area physician who runs a consulting company that helps hospitals combat infectious disease.
“That is pretty much the limiting factor,” she said. Hospitals can always convert normal beds into intensive care beds. “But the one thing you worry about is whether you have enough ventilators for patients who might require it.”
Trivedi said the need for ventilators, more than anything, should convince people to help “flatten the curve,” or reduce the number of people who get sick at the peak of the virus’s spread.
“We need to take seriously all these social distancing measures so that we’re not fighting over that last 7,500th ventilator,” Trivedi said. “There’s a finite number right now, and that should make us even more concerned about limiting our exposure to one another.”
Gov. Gavin Newsom reported last month that there were 7,587 ventilators in hospitals across the state, which he said will not be nearly enough in his worst-case scenario. In an update on the situation April 6, he said that hospitals are now working to repair ventilators to bring that count up to 11,000, and that the state is in the progress of getting thousands more.
But he also announced this week that California is sending 500 ventilators to the national stockpile to aid other states that are short on equipment, calling it a “moral and ethical responsibility” to help those most in need. He added that the ventilators would return to California if needed.
Newsom has been giving regular updates about his efforts to increase the state’s health care capacity before the surge, including work to secure more ventilators and create more hospital bed capacity.
In addition to working with hospitals to create more space for patients, the state is working to secure about 20,000 more beds, including 2,000 at field medical stations.
A Rural Staffing Challenge
Even if California had the hospital beds and equipment needed to meet this surge, the need doesn’t stop there.
For every intensive care patient, there have to be providers with the training to perform ventilation and other critical tasks
In rural areas, specialized health staff can be hard to find.
We don’t have a bench that is very deep. That’s one of the things that keeps me up at night.
The state recently moved to make it easier for doctors from out of state to practice in California if they’re assisting with COVID-19 patients, and temporarily expanded the scope of practice for nurse practitioners and physician assistants. The governor also loosened requirements for nursing students who are nearing their graduation, in hopes of getting them into the field faster.
There are also new jobs available for health professionals, paramedics and medical students who want to join the new California Health Corps and be deployed to locations across the state as needed. So far more than 84,000 people have signed up, according to Newsom’s office.
Siri Nelson, CEO of Marshall Medical Center in Placerville, said they’re teaching the needed skills to surgical staff who would typically work on elective procedures.
“We’re refreshing the post-op nurses who do critical care, but maybe not to the extent that an ICU nurse does,” she said. “And that, I think will expand us to double what our core ICU staff is.”
But Wells of Adventist Health in Mendocino County, says he’s already down 30 nurses between his two hospitals, and he worries about what will happen if any of his current staff has to go home due to exposure to COVID-19.
“We don’t have a bench that is very deep,” he said. “That’s one of the things that keeps me up at night.”
Worker Safety: A Growing Concern
Nurse’s groups and health care labor unions have been disappointed with safety plans for the health care workforce.
Members of the Service Employees International Union – United Healthcare Workers West called on hospitals and local officials in March to provide more masks to staff, screen all patients who enter the hospital for coronavirus and isolate anyone exhibiting symptoms.
“Security and safety procedures are still too loose and must be tightened immediately,” wrote Dave Regan, the union’s president, in a statement. “The fear that the number of new coronavirus patients will overwhelm our healthcare system is real, and we will certainly not be able handle the growing caseload if large numbers of healthcare workers get sick or are quarantined.”
In late February, UC Davis sent 8
9 workers home for self-monitoring after they were exposed to a coronavirus patient. Their representatives recently confirmed that some workers have tested positive for coronavirus, but wouldn’t confirm how many.
Federal guidelines now allow nurses and doctors to keep working after they’ve been exposed as long as they are asymptomatic.
Personal protective equipment, or PPE, is a major concern. The state hospital association and hospital executives interviewed say they are trying to gather up N95 masks and other gear, while waiting on new shipments from the state.
Newsom says he’s planning to spend $1 billion to guarantee 200 million sets of PPE per month for California’s health care workforce
Meanwhile, some rural health centers are struggling to maintain their stock.
Mountain Valley Health Centers oversees eight small clinics in the area northeast of Redding. Director Susan Knoch says the usual medical supply companies are not fulfilling her orders.
Of course we’re smaller than urban areas, so our usage is going to be a lot less. So my perception is that the supplies are going to larger hospitals before us.
“Of course we’re smaller than urban areas, so our usage is going to be a lot less,” she said. “So my perception is that the supplies are going to larger hospitals before us.”
She says gowns are the biggest problem, but a solution is in the works.
“We have a lot of local sewing groups, so we purchased quite a bit of ripstop, it’s a parachute material, and we have sewers making those.”
Lubarsky said UC Davis has been creating inventory since the first case arrived in their emergency room in February.
“I’m very confident that we have the protective equipment,” he said. “I would always like to have more. … We are not limiting our personal protective equipment, and constantly seeking new ways to get around the supply chain.”
He says replacing used PPE is difficult, and ordering from China, where most of the equipment is made, is “now ten times as expensive as it was two months ago.” There are a number of hold-ups on the federal level that could be keeping PPE out of health workers’ hands.
Meanwhile, nurses across the state are holding candle light vigils to bring attention to what they feel is an unsafe work environment, and volunteer mask-makers are stepping up to help supplement N95 respirators.
Building Surge Capacity
Jan Emerson-Shea with the California Hospital Association says hospitals have detailed plans for how to react to natural disasters and mass shootings — but the novel coronavirus is another story.
“This is way beyond what any hospitals would have naturally planned for,” she said.
Kelaita with Calaveras Countysays the lack of surge capacity in these hospitals is a symptom of the way the healthcare system functions in the United States. Because of this, hospitals are kept full and busy.
“Hospitals don't have an intensive care unit of 20 or 50 beds that's just locked up with the lights turned off that they only open in the case of emergency,” he said. “That’s just because of the economics of our healthcare system and how they get paid and how healthcare financing takes place.”
But he says that even if hospitals weren’t prepared with extra capacity ahead of time, they can work on putting plans in place now to care for the influx of patients.
In counties where it’s possible, health and hospital officials are grappling with what they can do to increase the area’s capacity before the surge. But that has put a financial strain on some hospitals, and smaller facilities will likely see significant financial implications later.
Anne McLeod runs Private Essential Access Community Hospitals Inc., which represents about 30 private safety-net hospitals across the state. These are small hospitals that receive federal grant funding to care for low-income and often uninsured patients. McLeod says about 80% of their revenue comes from the government.
Much of that comes from billing Medicaid and Medicare after appointments and procedures, she said. With many of them canceled, hospitals are strapped.
“They’re working to keep staffed up so they can be prepared … purchasing the equipment they need,” she said. “And at the same time cash is going out the door or not even coming in the door because they’re having to cancel some of these elective surgeries and procedures that would otherwise help fill that gap.”
Emerson-Shea said there will likely be discussions about state funding to backfill hospital spending after the immediate crisis has passed.
“Hospitals aren’t able to keep afloat,” she said. “Having to cancel a lot of these procedures, it’s the right thing to do right now. But they are doing it with the knowledge that there is going to be a financial impact to their organization.”
In addition to canceling procedures, health systems are looking for facilities and equipment that could be created or reallocated to help with a surge.
Hospitals aren’t able to keep afloat. Having to cancel a lot of these procedures, it’s the right thing to do right now. But they are doing it with the knowledge that there is going to be a financial impact to their organization.
Rural hospitals that are part of large hospital networks have more support to lean on.
Dave Cheney, CEO of Sutter Medical Center in Sacramento and Sutter Valley Area Hospitals, said the health system has identified six of its facilities to take the brunt of COVID-19 patients.
If one of Sutter’s smaller, rural hospitals is filling up or running out of supplies, he says patients will be moved to one of these hub facilities. For example, if Sutter Auburn Faith Hospital gets an influx of patients from the Tahoe basin, they might transport patients to Sutter Roseville rather than use the open surge beds at Auburn. That way if Roseville is too full, Auburn still has extra beds they can fall back on.
“You never want to be totally maxed out,” he said. “You always want to have something available, even in the smallest hospitals, for that patient that walks through the door, or is pushed through the door from an ambulance.”
For the past three months, Wells of Adventist Health in Mendocino and other hospital staff have been investigating shuttered nursing homes and old hospitals in hopes that they can be used as treatment centers. They’ve been pulling unused beds out of storage.
He recently got approval from the Office of Statewide Planning and Development to reopen a closed intensive care unit and emergency room in Ukiah. But he says that, if the worst case scenario surge occurs, there’s still no way to increase capacity to meet that level of need.
“We need to flatten the curve,” Wells said.
Correction: A previous version of our data analysis included Adventist Health Feather River, which closed after the 2018 Camp Fire, in Butte County's hospital beds count. Butte County has 201 hospital beds per 100,000 residents now that Feather River has been removed. It has been corrected.
We have not included military hospitals, VA hospitals, psychiatric hospitals, long-term care facilities or specialized children’s hospitals like Shriners Hospitals For Children in our analysis for this story. Our analysis also does not include hospitals that have closed since 2017 or that have opened after June 2019.
The dataset used in this analysis is a merged dataset made up of spending reports from the Centers for Medicare & Medicaid Services (CMS) and hospital licensing data from the Homeland Infrastructure Foundation-Level Data (HIFLD). Most data used in this story came from CMS and includes each hospital’s number of medical beds as of 2017. Data on NorthBay VacaValley Hospital & Kaiser Hospital Modesto is from HIFLD and includes each hospital’s total count of all beds as of June 2019. The population numbers used in this story are the California Department of Finance’s January 2019 population estimates.
Special thanks to Alexandra Kanik from Louisville Public Media for providing us with this dataset.
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