Borders, who also serves as an endowed chair in rural health policy for the Foundation for a Healthy Kentucky, said the state’s rural hospitals do not have enough specialist physicians, intensive care unit beds or other equipment that would be necessary to handle a major increase of sick patients.
“I’m pretty concerned about it,” he said. “We don’t have the capacity to handle a large surge in the number of severe cases that require hospitalization.”
Across rural parts of the state, local officials and health departments have spent recent days developing and implementing strategies to contain COVID-19, which has largely been concentrated in an around Lexington and Louisville. They said they feel they are as prepared as possible.
They’ve set up alert systems, coordinated responses by all agencies, encouraged citizens to practice social distancing, declared states of emergency and reinforced policies enacted by Gov. Andy Beshear to try to limit the spread of exposure, including closing county offices to foot traffic.
While officials said rural counties may have some advantages over urban centers like Lexington or Louisville — rural residents are less likely to encounter large crowds, and social distancing may come more easily — some share Borders’ concerns about the ability of rural health care systems to treat patients if there is a major spike in cases of COVID-19.
“Our local hospital, they could be over-ran very quickly,” said Sherwin Corder, the emergency management director in Wayne County.
Health officials said that’s why it is critical to limit the spread of the virus through the techniques officials have stressed, including frequent hand-washing, keeping physical distance from other people, and staying home if you feel sick.
The goal is to spread out the progression of cases over a more manageable period, avoiding a spike, said Shawn Crabtree, head of the 10-county Lake Cumbeland District Health Department.
“We’re gonna overwhelm our medical infrastructure” if there is a wave of cases in a short time, Crabtree said.
How rates of infection will change in the coming months is unclear, but some estimates suggest that half of all Americans could become infected with novel coronavirus over the next 12 months.
Marc Lipsitch, a Harvard professor of epidemiology, has estimated that between 20 and 60 percent of Americans will eventually be infected with the virus.
Low on equipment and cash to fight coronavirus
Even with moderate estimates of infection, experts warn that rural hospitals will have neither the financial nor operational capacity to effectively treat patients, putting more pressure on urban hospitals, such as Baptist Health Lexington or UK Chandler Hospital, to meet the demand.Some rural hospitals may have more open beds than urban hospitals, but will not have the ICU capacity required to take care of patients with the most severe cases of coronavirus.
“Even if we do all these things that we’re trying to do, in terms of social distancing and closing the businesses and schools, many areas will still have need that exceeds capacity,” Borders said. “On the one hand I think that Kentucky is doing more than many places to try to bend the incident curve that the federal government has referred to — that said, if there is an outbreak of severe cases, I don’t think any hospital is prepared, in Kentucky or elsewhere.”
Rural hospitals across the country have already reported shortages of equipment and cash flow necessary to meet the demands of the virus, according to testimonials provided by the National Rural Health Association.
Deaconess Health System, which operates a hospital in Henderson, announced Wednesday that they would ask the public to sew face masks for staff, according to the Courier & Press.
“Overall, this thing is testing our health care infrastructure significantly, and in rural areas, we have a more vulnerable infrastructure and we have a more vulnerable population, so it makes it even harder,” said Brad Gibbens, the deputy director at the Center for Rural Health at the University of North Dakota.
Gibbens warned that many rural hospitals are already operating on tight budgets, and that a large increase in patient volumes could strain hospitals to a breaking point.
Nearly half of all rural hospitals operate at a financial loss, according to the National Rural Health Association.
In Kentucky, the hospital in Pineville declared bankruptcy in 2018, and the Our Lady of Bellefonte Hospital in Ashland announced it would close by the end of September.
“The rural health care safety net was fragile before the national emergency, now rural health care is being crippled by COVID-19,” according to a recent letter from the National Rural Health Association. “Rural hospitals are small businesses that their communities rely upon. Health staff is becoming sick, EMS shortages are extreme, and cash-flow problems are at crisis levels.”
Little known about rural hospital capacity
Borders, the director of UK’s Rural and Underserved Health Research Center, said the public has been largely uninformed about the capacity of Kentucky’s rural hospitals despite growing concern over the virus and its continued spread in the state.“We need better information and statistics from the Kentucky Hospital Association, as an example, and the Kentucky Office of Rural Health about the capacity of these rural hospitals and clinics to really handle these issues,” Borders said. “It’s not as if we have a lot of great information about the urban hospital capacity, but we have even less information about rural hospitals and health care systems.”
A 2019 analysis found that only 1 percent of the intensive-care hospital beds in the country are in places with populations under 10,000, according to a recent report from the Society of Critical Care Medicine.
Rick Neikirk, chief executive officer and administrator at the 25-bed Cumberland County Hospital in Burkesville, said the facility has two isolation rooms with negative air pressure to keep pathogens from escaping. It also has ventilators and has taken precautions to limit exposure to coronavirus, including stopping visitation, increasing screening of potential admissions and taking employees’ temperature as they report to work and leave.
However, the hospital has no intensive-care beds. It transfers patients who need that level of care to hospitals in Bowling Green or Nashville.
“I think we’re prepared as well as can be, but it evolves hourly, so who knows?” Neikirk said.
Pikeville Medical Center, one of the largest health care providers in Eastern Kentucky, has enough negative pressure rooms to treat 40 patients with severe cases of coronavirus, “with the ability to greatly expand that number if needed,” said James Glass, Vice President for Development at Pikeville Medical Center, in an email to the Herald-Leader.
The hospital also has several heart-lung machines known as ECMOs, which could be used in the most severe cases of respiratory failure.
“Having this advanced form of life support is unique for hospitals in rural areas,” Glass said. “Pikeville Medical Center has proactively prepared for this novel coronavirus, and we encourage everyone to take the necessary steps to stay safe and well.”
A spokesperson for Appalachian Regional Healthcare, which operates about a dozen hospitals in Eastern Kentucky, did not reply to a request for comment for this story.
The federal government recently gave critical access hospitals, which are normally limited to 25 beds, permission to add beds if needed to deal with the coronavirus pandemic.
According to a recent report from HealthAffairs.org, if 40 percent of Americans become infected over 12 months, the demand for ICU beds across the country could be 254 percent of current capacity.
“Regardless of where an individual resides, if there is a large outbreak there’s gonna be a severe capacity constraint,” Borders said. “The ICU beds are just not available in many areas to handle an outbreak.”
Rural coronavirus hope is containment
The response from local officials in rural areas has primarily been a policy of containment and education.The need for containment will be especially important in rural parts of Kentucky, including Eastern Kentucky, where higher percentages of the population are elderly and suffer from diseases that could worsen a coronavirus case, such as diabetes and respiratory issues.
“When you look at our health rankings and the rates of chronic disease, we already know that COVID-19 impacts people with compromised immune systems much more severely,” said Scott Lockard, director of the Kentucky River District Health Department, which services much of Eastern Kentucky. “So I have great concerns for our population.”
Lockard said he has been very pleased with how local officials throughout the region have cooperated to educate the public about the importance of social distancing, as well as other measures to protect the most at-risk populations.
In Pike County, virtually every elected public official gathered in the courthouse Tuesday to declare a state of emergency, promote its county-wide alert system, and inform residents of upcoming changes that would be enforced because of the coronavirus spread, including the closure of restaurants to in-person dining.
Tammy Riley, Pike County Health Director, said she was coordinating with local groceries after several complaints from residents that shelves were not stocked with baby formula.
“You can imagine the concern of a young mom with a 3- to 4-month-old baby and there’s no formula on the shelf,” Riley said.
Riley said groceries have committed to implementing new policies that will keep formula in stock.
Jackson County Judge-Executive Shane Gabbard was among several county executives who declared a state of emergency and closed the county courthouse to foot traffic. Gabbard said county employees were still coming in to help people by telephone.
Gabbard said county officials, police, firefighters and health department representatives met this week to coordinate the local response to the coronavirus.
The county has no hospital and there are no coronavirus tests available locally. Those are concerns, Gabbard said, but “I think we’re about as prepared as we can be.”
Crabtree, the director of the Lake Cumberland District Health Department, said his biggest concern is that many people still are not taking the virus seriously and limiting potential exposure.
Crabtree said he is a Christian, but expressed disappointment that many churches continued to hold services last Sunday despite calls to limit gatherings.
At a meeting where Pulaski County Judge-Executive Steve Kelley declared a state of emergency, Crabtree read 1st Corinthians 13:13: “And now these three remain: faith, hope and love. But the greatest of these is love.”
One way to show that love for others these days is responsible social distancing, Crabtree said.
“Because you could be passing something on to them that could kill them, and you don’t even know you have it,” he said.
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