Mission Health’s COVID-19 preparations have been like a high school prom, explains Dr. William Hathaway, the system’s chief medical officer. You buy a dress, pick out flowers, make dinner reservations, get a car. You primp and preen for the big day, but just when you think you’re ready, the school pushes the dance off until the next week. A few days later, it’s delayed again. And again. And again.
In January, Hathaway and his team began receiving the first reports that a pandemic was a possibility, and in February, they began to think through different scenarios of the coronavirus’s arrival in North Carolina. He watched as Italy and Iran, Seattle and New York reported case after case. Mission Health began to put protective measures in place.
Buncombe County reported its first case of COVID-19 on March 21. By April, Mission was averaging between two to six hospitalized COVID-19 patients per day. All nonessential surgeries were put on pause, and plans were readied to ramp up total capacity from 800 beds to 1,400. But the anticipated surge never came.
At least, it hasn’t yet.
On June 1, 650 COVID-19 patients were hospitalized across the state. By July 1, that number had risen to 901. If cases and hospitalizations continue to grow at the same rate, hospitals in Greenville, Charlotte and the Triangle may be completely full by late summer, according to a June report by researchers from UNC Chapel Hill, Duke University and RTI International.
In Western North Carolina, the main regional hospitals say they currently have more than enough capacity to provide care for area residents. But their approaches, protocols and treatment options for COVID-19 vary.
On the inside
If potential COVID-19 patients are deemed sick enough for hospitalization, short of breath and low on oxygen, they first arrive at the emergency department. At Mission Health, the patient then immediately goes to an isolation room. Staff in head-to-toe personal protective equipment — face mask, face shield, gown, gloves — evaluate if the patient needs a COVID-19 test, and if a test is necessary, the patient transfers to a special unit of the hospital.
Hathaway notes that all COVID-19 patients receive care from lung and infectious disease specialists who are assigned solely to that unit, which minimizes potential virus spread among staff. At Mission, the average hospital stay for a COVID-19 patient is seven days; patients who need intensive care, including ventilator support, average 2.5 days in the intensive care unit.
Mission averaged between 15 and 20 COVID-19 patients a day in June, with 116 COVID-19 patients passing through the hospital since Mission’s first case in March. Of those patients, roughly 25% have needed one of the hospital’s ventilators. Capacity isn’t a worry yet, Hathaway emphasized: The hospital has 90 ICU beds and if necessary, could double the ICU capacity to nearly 200 beds with 48 hours’ notice.
To the south
AdventHealth Hendersonville staff members in full personal protective equipment meet all suspected COVID-19 patients in the emergency department, explains Dr. Kelley Singer, the system’s director of quality. Those patients then move to a negative-pressure room with decreased air circulation to help prevent airborne virus particles from escaping. Two Tru-D SmartUVC robots use ultraviolet rays to disinfect patient rooms and PPE between patients.
Patients under investigation are monitored until their test results return and stay under careful observation until discharge. The hospital has six ICU beds, with the ability to reach 26 if needed, says AdventHealth spokesperson Victoria Dunkle, and “enough ventilators for each ICU bed.” Dunkle and Singer referred questions about the system’s current number of COVID-19 patients to the Henderson County Department of Health, which does not share hospitalization numbers on its dashboard.
Protocols are similar at Pardee Hospital in Hendersonville. Suspected COVID-19 patients arrive at the emergency department and receive a rapid COVID-19 test, which delivers results within two hours, explains Dr. David Ellis, Pardee’s chief medical officer.
Patients with confirmed COVID-19 are sent to an isolated respiratory care unit, given IV fluids and supplemental oxygen and closely monitored to see if symptoms worsen, Ellis continues. If necessary, patients are taken to the ICU and placed on ventilators.
On June 30, Pardee had five COVID-19 patients in its Hendersonville hospital, two in the ICU and three in the respiratory care unit. Capacity holds strong, Ellis emphasizes: The 16-bed ICU has averaged seven patients since mid-March, inclusive of COVID-19 cases. Pardee has 24 ventilators, and the hospital is licensed for 222 total beds, with 50 additional beds available for surge capacity.
As of July 6, 875 ventilators, or 27% of North Carolina’s stockpile, were in use across the state, according to N.C. Department of Health and Human Services data. Inpatient hospital beds were 72% filled and ICU beds were 74% filled, with 81% of state hospitals reporting.
“With the opening of the state, we’re seeing increased cases and we believe that’s going to continue,” Ellis says. “Some of the models predict the actual peak of this won’t happen until September, so we expect more cases.”
AdventHealth, Pardee and Mission all offer remdesivir, an antiviral medication produced by biotech firm Gilead Sciences that’s being tested as a COVID-19 treatment. At Mission, sicker patients requiring oxygen may also be candidates for dexamethasone, a steroid that has shown early success for improving COVID-19 survival. And Pardee offers immune therapy with tocilizumab for select patients depending on severity of illness.
In May, Pardee Hospital began participating in a Mayo Clinic trial to provide convalescent plasma therapy to COVID-19 patients. Plasma, the liquid part of the blood, is collected from individuals who have tested positive for either COVID-19 or COVID-19 antibodies and transferred to current patients; researchers believe this approach may help those patients fight off the coronavirus.
Patients receiving the therapy get a one-time infusion of donor plasma in the hospital, explains Dr. Chris Parsons, the medical director for Pardee’s Center for Infectious Diseases.
So far, every COVID-19 patient at Pardee recommended for plasma therapy has opted in, he says, and the results have been promising.
Prior to the availability of plasma and tocilizumab treatments, the COVID-19 mortality rate at Pardee Hospital was approximately 40%, Parsons says. Since early May, that rate has dropped to about 2%.
“This is despite having equally sick patients on ventilators, some of whom were from skilled [nursing] facilities, being among those patients admitted since May,” Parsons notes. “In other words, mortality improvement is not explained only by younger-aged or healthier patients — the therapies are making a difference. We do not yet know which combinations of these therapies are optimal.”
The Charles George VA Medical Center is also a participant in the Mayo Clinic plasma study, and AdventHealth and Mission Health offer convalescent plasma when indicated.
Despite the ample capacity and progress in treatment, life has not returned to normal at area hospitals. Pardee only allows visitors in situations involving pediatric patients, labor and delivery, ICU patients without COVID-19 and end-of-life care. AdventHealth and Mission have both loosened visitor restrictions in recent weeks but continue to limit visitors to their COVID-19 units.
“It’s a very challenging situation to be in,” Hathaway says. “But it’s what we felt was in the best interest for a while for our patients and their family members, so they don’t inadvertently get COVID in the hospital, and for our staff, so they could be able to take care of patients safely.”
Hathaway says Mission has made two exceptions to its visitation policy since the rules went into effect in mid-March, with both situations involving a child. However, the family of Daniel Pincu, an older Asheville resident who died of COVID-19 at Mission Hospital on April 27, told Xpress that a relative was permitted to visit Pincu in the COVID-19 unit just before he was removed from life support, in contradiction of Mission’s stated policy. The same episode received coverage in the Citizen Times on May 2.
In response to questions about Pincu’s situation, Mission spokesperson Nancy Lindell gave the following statement: “While there is no visitation allowed on the COVID-19 unit, exceptions are considered on a case-by-case basis for patients at end of life.”
Both AdventHealth and Mission offer tablets to help patients connect with loved ones via video calls. “We immediately took steps to help work around the no visitation policy and make contact with loved ones still available,” says Singer with AdventHealth. “It’s really sweet to be able to have this kind of 21st-century visit.”
Right now, COVID-19 hospitalizations remain steady. But local health experts warn that this could change at any time.
“We’ve been lucky, but we’re on pins and needles the whole time, wondering if this recent surge that we’ve heard about — in Texas, in Florida, in Arizona because they opened up much more quickly — if we’ll also get that wave,” Hathaway says.
The main actions people can take to keep Pardee and other hospitals from filling up are wearing a face covering, washing hands and social distancing, Ellis says.
“Everybody is fatigued, and everyone wants this to be over,” he explains. “But we can’t just make it be over. If everybody wears a mask, it would make a dramatic difference, and we would be much better off.”