Health system dealing with substantial community spread

Brookings Health System photo: OR Registered Nurse Mandy Newman prepares a patient room while floating to the inpatient care unit at Brookings Hospital. Sufficient clinical staffing to handle the added patient load created by the COVID-19 pandemic is an ongoing concern for Brookings Health System. One of the measures the health system is taking to handle the pandemic is reassigning clinical staff, like Newman, to areas where there is the most need. In addition, the health system has started an on-call sign-up, requiring staff to be available if needed for two extra shifts per week.

BROOKINGS – For over seven weeks now the South Dakota Department of Health (DOH) has classified Brookings County as having substantial community spread of COVID-19, meaning the county has greater than 100 cases per 100,000 people. 

As the number of positive cases in the region rises, so do the number of hospitalizations and deaths. On Thursday the DOH reported two new deaths from Brookings County, increasing the count to four. In addition, 40 people from Brookings County have ever been hospitalized for COVID-19.

“Right now we have to play the hand we’ve been dealt,” said Medical Surgical & Emergency Department Director Karen Weber when asked how Brookings Health is responding to the pandemic. “We’ve assembled a clinical response team, a collaborative group of nurse managers, senior leaders, and physicians who meet daily to discuss the current situation and how Brookings Health adapts as nimbly and quickly as possible.”

Those meetings focus on care for currently hospitalized patients, having the staffing in place to provide that care, and watching the curve to try to predict what is coming next. 

Hospital capacity

Recently the DOH updated how it reports staffed hospital bed capacity on its website, doh.sd.gov/news/coronavirus.aspx#SD. The DOH divides the state into four regions, grouping Brookings County in the Sioux Empire region. Data reflects what South Dakota hospitals, including Brookings Hospital, report by 6 p.m. the previous day. It includes the number of staffed hospital and ICU beds as well as ventilator capacity. In addition to hospital resources used by COVID-positive patients, the site also lists how many resources are occupied by non-COVID patients. 

“When we originally created our COVID-19 surge and bed management plans, everything was in theory,” Weber said. The health system first released its plan in April and has it available for download at brookingshealth.org/COVID. “At the time, we anticipated the majority of our patients would have COVID-19. Now that we have a significant virus outbreak in our area, the reality is we have a mix of COVID-positive and non-COVID patients who still need our care here at home.”

That need for hospital care is typical this time of year. During fall and winter months, infections transfer more readily from person-to-person as people spend more time together indoors. In addition, viruses typically live longer in colder temperatures with lower humidity. And for people with underlying chronic conditions such as asthma or chronic obstructive pulmonary disease (COPD), a respiratory infection can trigger serious conditions that require hospitalization. Add in significant snow falls and hospitalizations can continue to increase due to heart problems, stroke, injuries or falls from icy conditions. 

“We have 24 beds in our Inpatient Care Unit and being close to capacity is nothing new,” Medical Surgical & Emergency Department Director Karen Weber said. “Our inpatient care team has been at nearly full capacity before. It’s always stressful, but our team always comes together to help one another and to give the best patient care possible. The unique challenge this time around, however, is COVID-19.” 

The number of COVID-19 patients requiring hospital care adds to the demand healthcare providers typically see this time of year. Usually inpatient units do not fill to capacity until the winter months – December, January and February.

“Historically in the fall we and other hospitals around the region start to climb in the number of patients we care for,” Weber said. “COVID-19, however, is adding stress to that system. If our 24 inpatient care beds are full, no matter if we have COVID or non-COVID patients, we need to enact our surge and bed management plans. That means at patient 25, we’ll have to care for that person in our same-day surgical unit. And if we start caring for inpatients there, we’ll need to start reducing or even totally close to elective procedures in the OR. Instead of being closed to elective surgeries due to government mandate, we’ll be closed down due to necessity.”

The inability to transfer patients is another way hospitals are feeling COVID-19’s impact. Throughout the pandemic, area hospitals and health systems have stayed in close communication with one another.

“Historically if we are at or near capacity, we try to transfer patients to other area hospitals that have room,” Weber said. “However, right now the other area hospitals are in the same boat we are. Our only option may be to care for people right here in the space we have.”

Staffing concerns

Having physical resources, such as beds and spaces, is only one component of caring for a full house of patients. Human resources become just as critical.

“If we close down to elective procedures, our plan calls for us to reallocate staff to areas with need. For example, a perioperative nurse may find herself caring for people on inpatient care,” Weber said. “However, while we’ve taken measures to safeguard our staff while they care for COVID-19 patients, the reality is if a team member contracts the virus and becomes sick with symptoms, per CDC guidelines they’ll be required to quarantine. Having a full or overfilled hospital could intensify the potential hole in our workforce.”

The CDC guidelines do allow hospitals to let asymptomatic, COVID-positive team members care for COVID-positive patients in situations where the hospital faces staffing shortages. However, in hopes to accommodate all sick team members during times when the hospital is at max-plus capacity, Brookings Health has started an on-call sign-up, requiring clinical staff to sign-up for two extra shifts per week. If needed, on-call team members are asked to come in on what would otherwise be their day off.

Another staffing adaptation circles around help for the hospitalist, the doctor responsible for overseeing care on the inpatient unit. Doctors and advanced-care practitioners from Brookings Hospital’s emergency room and the Avera clinic have already started to see inpatients in an effort to ease the patient caseload for the hospitalist. But more will be asked of all levels of care providers as the outbreak deepens.

“Our community is asking a lot of local care professionals in both the clinic and hospital setting,” Weber said. “Just like in New York and other areas of outbreak early in the pandemic, we’re asking them to put themselves at risk to care for others. We’re asking them to spend time away from their spouses and families. We’re asking them to take on more emotional stress than they’d probably like to. The best way our community can support health care workers is by flattening the curve.”

Flattening the curve

“We know everyone is growing tired of social distancing, wearing masks, and not seeing friends and loved ones,” Infection Preventionist Bunny Christie said. “We get it. We’re tired of it, too. But now is the time, more than ever, to not let this microbe beat us. We need to work together to flatten the curve and slow the community spread of this virus.” 

Christie pays close attention to the numbers of positive cases in the community. A DOH trend stat she watches is the test positivity rate for the past 14 days which is the number of positive tests within 14 days divided by the total number of tests given during those 14 days. 

“A lower test positivity rate is better,” Christie said. “Right now, Brookings County sits at 17.8 percent positive rate for the past 14 days. Where we want that 14-day rate to be is at 5 percent or less. That’s when we’ll be classified as having minimal community spread and can relax some. A 10 percent 14-day positivity rate will downgrade us to moderate community spread.”

Christie points out there are two ways to get to the 5 percent rate: have 70 percent of the population contract the virus or as a community work together to flatten the curve.

“Flattening the curve doesn’t mean just doing one thing, like mask wearing or hand washing alone, and expecting it to work by itself,” said Christie. “We all need to practice every safety precaution.”

The list of precautions recommended by the CDC include: 

• Practice good respiratory etiquette and hygiene. Cover your coughs and sneezes with a tissue. If a tissue is not available, cough or sneeze in your upper sleeve. 

• Avoid touching your eyes, nose and mouth with unwashed hands. 

• Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available, use an alcohol-based sanitizer that contains at least 60% alcohol.

• Practice social distancing when out in the community by trying to stay six feet away from other people. Do not hug, kiss, shake hands or make other unnecessary contact. 

• Wear a cloth face covering that snugly covers both your mouth and nose in public settings, especially in situations where you may be closer than 6 feet to people.  

• Clean and disinfect high-touch surface areas, such as counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, etc. every day. COVID-19 is easily cleaned by household cleaners or soap and water.

• Monitor your health. Be alert for COVID-19 symptoms and take your temperature if symptoms develop.

• Stay at home if you’re sick and self-isolate to prevent the spread of illness.

“From a healthcare perspective, flattening the curve is preferred over having 70 percent of the population contract the virus,” Christie said. “The 70 percent route is a high-stakes gamble. We will continue to see increasing numbers of hospitalizations and deaths. What’s more are the unknown long-term health effects from this virus that could potentially impact our local population’s health for years to come. Young people may recover, but what does that recovery look like? Is it really worth the risk?”

More information about Brookings Health’s efforts to fight COVID-19 can be found at brookingshealth.org/covid.

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