Pushed to the brink
With nowhere to send surge of patients, rural hospitals scramble for solutions
Ron Nichols knew when the 911 call came in last Monday that neither of his ambulance crews could respond. One just left for the long drive to Beaumont. The other sat at Houston Methodist Baytown, where he said crews might wait hours to check in patients.
So the Chambers County emergency services director — who planned to spend his day on conference calls and payroll — instead rushed in his Tahoe to meet a supervisor who arrived with a third ambulance, which wasn’t staffed because so many crew members were quarantined.
Across the region, the rural health care system has been strained as the number of novel coronavirus cases has surged. Urban hospitals they relied on to take acute patients began to fill — requiring creative, if not desperate, solutions from EMTs needing to offload patients and rural hospital staff needing to get patients to a higher level of care.
At least one rural hospital was pushed to the brink. Matagorda Regional Medical Center at times was holding patients in the emergency room because its six ICU beds were full. One patient died waiting for a bed.
Others devoted valuable re
sources to finding places for patients who needed care they could not provide. Sweeny Community Hospital emergency room staff spent between nine and 24 hours trying to find somewhere to send three recent noncoronavirus patients — ultimately sending one 370 miles to San Angelo. A hospital in Anahuac made headlines transporting one patient 300 miles to Granbury and another 150 miles to El Campo.
The hospital in Anahuac, Bayside Community Hospital, was among rural facilities that also took lower-need patients from Houston to free up space, a flow several said they had never seen before, highlighting the regionwide need for out-of-the-ordinary actions to meet rising demand.
“We’re doing like everybody else is doing: trying to prepare for the worst and hoping for the best,” said Steve Gularte, the hospital’s CEO. “The worst for us would be to hit our total census of 14 and have more patients arriving and nowhere to send them. … The big hospitals too are having the same worry. What happens when we get full?”
Rural hospitals typically rely on urban hospitals to care for patients who have greater needs than they can accommodate, such as trauma, heart attacks or strokes. But the pandemic upended normal referral patterns, said Don McBeath, government relations director for the Texas Organization of Rural & Community Hospitals.
The SouthEast Texas Regional Advisory Council, or SETRAC, stepped in to help.
“Typically the big city serves as the place to call for a rural hospital needing to transfer a patient,” said Darrell Pile, SETRAC’s CEO. “However, because we are well aware of capacity levels and ER saturations, we have been used to (assisting) rural hospitals who have exhausted their normal chain.”
Already, a handful of rural hospitals in the region consistently needed help placing patients, said Lori Upton, vice president for disaster preparedness and response for SETRAC. They turned to the organization as “the last resort” for assistance, Upton said.
Texas Medical Center data on Monday showed the regular ICU bed capacity was full and additional ICU beds planned for the pandemic were being occupied. St. Luke’s Health said in a statement that it was working closely with SETRAC to accommodate the community’s needs. Memorial Hermann said it was “currently accepting patient transfers from a number of different hospitals across the region.”
Marc Boom, president and CEO of Houston Methodist, said that while the hospital had declined a couple of transfer requests from within the greater Houston region, the transfer process could be complicated even in normal times.
“We always work hard to do the best to service the greater Houston community but also the rural communities around us,” he said. “Obviously during a time when we have so many additional patients with COVID-19 it’s even more challenging.”
When ER staff in Baytown told 57-year-old David Hillyer he had blood clots in his lungs and needed to be hospitalized — but said Methodist could not take him — he told them, “Get me in wherever you can.”
Small hospitals knew how to make do. Since 2010, 27 rural Texas hospitals have closed, said John Henderson, president and CEO of TORCH, which advocates for rural health issues, and many were operating with worn-out staff and thin financial margins as they entered the spike.
At Matagorda Regional — which has 30 general beds and six ICU beds — hospital officials discharged enough patients to keep going every time they seemed to reach the breaking point, hospital spokesman Aaron Fox said.
In Sweeny, the two nurses staffing six ER beds juggled the time it took to arrange the transfers with treating their other patients, CEO Kelly Park said.
In Chambers County, Nichols sent supervisors to sit with patients on extra stretchers at hospitals so crews could return to responding to 911 calls. (A spokesperson for Houston Methodist said Monday the emergency department at Houston Methodist Baytown was not experiencing long delays.)
Bradley Gates, a paramedic supervisor for Chambers County who called himself the “air traffic controller” for local EMS, helped determine where paramedics should take patients by checking hospital bed availability and talking to family members about where those open beds were.
Relocation might mean hours of driving once a family member was released, so discussing alternate options with family members could be sensitive.
“We can’t always go exactly where everybody wants to go, so it’s kind of a give-and-take a little bit,” Gates said. As he talked, a loud bell went off in the background, notifying Gates that a truck was needed from his station.
With the coronavirus, every patient is impacted differently, said Wick Webber, 31, a paramedic who grew up in Chambers County. Paramedics can’t always predict how someone will respond, such as the Granbury patient who was stable and then suddenly started to decline.
Because of that, dialogue between smaller and larger hospitals about which patients to transfer
has been a benefit, said Nancy Dickey, executive director of the Texas A&M Rural and Community Health Institute.
Gularte at Bayside Community said the hospital usually transfers out about 17 of roughly 250 patients that come through its doors every month — typically to Houston. So far, its beds have not filled up , allowing it also to take Houston-area patients.
At TORCH, Henderson said he’s gotten roughly two dozen calls from rural hospitals over the past week that were accepting recovering COVID-19 patients and others requiring less-intensive care from urban hospitals.
El Campo Memorial took some 15 patients from the Houston area recently, said Nathan Tudor, CEO of the MidCoast Health System, which includes the hospital.
“Rural hospitals in general are always creative and always say we can do more with less … because that’s how we operate,” Tudor said. “We have to be really resourceful.”
On Monday afternoon at the hospital, three of four ICU beds were full with coronavirus patients when nurses heard a fourth COVID-19 patient needed an ICU bed. The small staff adjusted quickly, calling in another nurse to help and downgrading one ICU patient to keep a bed free.
Another patient needed an oncologist — something they couldn’t provide — and they got work finding her a bed in another hospital. No one sat idle.
They were tired — but the hospitals they called couldn’t take her, so they kept calling until they found someone who could.