Hospitals brace for COVID-19 cases, clamp down on visitors

Area hospitals have already implemented tight restrictions on visitors and say they have drawn up plans to deal with what many experts say could be a wave of patients infected with COVID-19.

But no one knows how big that wave — or multiple waves — will be and whether hospitals will be just busy or overwhelmed. Buncombe County had four known COVID-19 cases as of the morning of March 23, and numbers statewide continue to rise.

Area hospitals have taken somewhat differing approaches to the question of whether to stop performing elective surgeries and other medical procedures. There are worries nationally about whether there will be enough personal protective gear like masks and gloves for health care workers, but hospitals in the Asheville area say they have good supplies for now.

A model developed by researchers at the Harvard Global Health Institute and the Harvard T.H. Chan School of Public Health released March 17 suggests hospitals in Western North Carolina could meet the demand for hospital beds under its most conservative projections of COVID-19 cases in the region but not if the number of cases is high and they occur over only a few months. There would be a shortage of intensive care beds in the region under all scenarios the model considers.

Mission ready?

Mission Hospital in Asheville, by far the region’s largest, will be key to the WNC medical community’s response to COVID-19. It has been the subject of numerous complaints in recent weeks that it is understaffed.

A spokesperson for Mission Health, the regional system the hospital belongs to, downplays worries that the system of seven hospitals will not have enough workers if the region sees a spike in COVID-19 cases. “While we have the bed capacity, staffing, supplies and equipment we need at this time, we continue to plan by accessing the resources, support and best practices across HCA Healthcare to help ensure we remain able to meet the needs of the communities we serve as the situation continues to evolve,” Nancy Lindell said March 18.

Nashville-based HCA bought the hospitals, previously owned and operated by an independent nonprofit, in February 2019. HCA is the country’s largest for-profit hospital operator.

“To ensure we are prepared for an influx of patients, we have staffing contingency plans, and those include the use of HCA Healthcare’s in-house staffing agency,” Lindell says.

At meetings held in January and February by a consulting firm monitoring the performance of the system’s new owner, speaker after speaker complained that hospitals did not have enough nurses and that even housekeeping services had suffered because of a lack of workers. A shortage of staffers is “putting patient safety at risk,” a letter released then by several local officials and state legislators from Buncombe County said.

Jobs, jobs, jobs

On March 20, the state agency that helps job seekers find work said it had 355 listings for job openings at Mission Health facilities in Buncombe County alone. The system is the region’s largest employer.

Some Mission Hospital nurses are pushing for unionization, but it appears an election for nurses to decide whether to have National Nurses United represent them will be delayed for an undetermined period of time because of the new coronavirus. The National Labor Relations Board on March 19 suspended all union representation elections through April 3 and may well extend that period.

Attorneys for Mission won a delay in a hearing needed to set an election, saying in early March the need to prepare for it would distract senior staff from coronavirus response. A March 12 filing by an attorney for the union says Mission “is currently engaged in round-the-clock captive audience meetings with 15-20 nurses at a time” to discourage unionization.

Visitor restrictions

Hospitals in the region are limiting visitors and screening prospective patients and others for possible COVID-19 exposure. At the Charles George VA Medical Center in Oteen, for instance, people are being screened before they even park their cars, and on March 22, the center implemented a no-visitors policy, with exceptions only for “urgent circumstances, such as grave illness or imminent death of a family member.” Mission Health also announced on March 21 that it was allowing almost no visitors. Pediatric patients and mothers giving birth are allowed one adult visitor each.

Those coming to the VA are asked whether they have fever, cough or shortness of breath and about recent travel and contact with anyone confirmed or suspected to have COVID-19. The center said March 18 that it is “reviewing all elective surgical procedures with a plan to postpone or cancel them” and has been contacting some veterans to reschedule planned procedures. It is also asking patients to contact their providers before visiting the center to see if their needs can be handled remotely.

Steps by hospitals to reduce the number of medical procedures performed now would increase supplies of protective gear available later. Mission Health had continued performing elective surgeries until announcing March 21 that it would stop as of March 23. State Health and Human Services Secretary Mandy Cohen asked hospitals March 20 to postpone all surgeries that would not cause harm to patients if delayed four weeks.

Dr. William Hathaway, chief medical officer for Mission Health, said March 18 that postponing nonemergency surgeries is “a difficult question for us. … Not all scheduled surgeries are something that can be delayed.”

If a mass is found in a woman’s breast, for instance, doctors would want to do a biopsy quickly to determine whether it is cancerous and what treatment to undertake, he said.

Conserving protective gear

Lindell says Mission is asking staff to conserve protective gear “by following, but not exceeding, the guidelines for infection prevention.”

Pardee UNC Health Care, which includes a hospital in Hendersonville, continues to offer elective surgeries as of March 20, spokesperson Erica Allison said.

That decision is based on consultation with the local health department, monitoring of residents who have been testing for COVID-19 and an “adequate supply” of protective gear, she said.

“At this time, we have adequate supplies and are in ongoing communications with our vendors to maintain those levels,” Allison said. She said elective procedures are not compromising that supply but Pardee is “making every effort” to conserve the most crucial gear that would be needed to deal with COVID-19 cases.

AdventHealth Hendersonville in northern Henderson County had stopped performing elective surgeries “to protect surgery patients from potential exposure to COVID-19 first and foremost,” said spokesperson Victoria Dunkle. “It was also a proactive move to make sure we have enough supplies to manage a potential surge in patients when the virus becomes more widespread.”

Dunkle said March 20 that AdventHealth officials “are concerned about the availability of [personal protective] equipment going forward.” She said the hospital has received donations from community partners. “We cannot tell you how much this means to our team members.”

Forecasting hospital needs

The Harvard model illustrates why local, state and national officials are asking people to take steps to “flatten the curve,” i.e., spread out the period of time during which COVID-19 infections occur.

If 20% of the population of the portion of WNC from McDowell County west contracts the virus, 23,804 people would need to be hospitalized at some time during the outbreak, and 5,316 would need to be placed in an intensive care unit, the model says.

If those infections are spread over 18 months, COVID-19 patients would occupy about half of the hospital beds in the region that could be made available, and if the infections came in 12 months, COVID-19 patients would need three-quarters of potentially available beds. But if the cases came over just a six-month period, COVD-19 patients would need all hospital beds in the region likely to be available plus 51% more.

Even the lower percentages would be problematic, as the need for hospital beds for people suffering from other illnesses would presumably continue as usual. The number of potentially available beds assumes that half of all beds in the region would be occupied by people with other illnesses. About 64% of hospital beds in the region were occupied in 2018.

The model does not account for any temporary hospital beds that might be created in the region. It says many more beds would be needed if infection rates reach 40% or 60% during six- or 12-month periods.