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MAY 02, 2020 -- On March 14, the Saturday before school closed for the year, more than 400 people attended a quinceañera in rural Doniphan, Nebraska — population 829.
Two of the attendees later tested positive for COVID-19. And now, 7 weeks later, Hall County, home to Doniphan, leads the state in COVID-19 incidence. It has over 1000 cases, more than double that of urban Douglas County, where Omaha is located.
Meanwhile, nearby Nuckolls County — along with 33 other rural counties in the state — doesn't have a single case.
Such wide variation from county to county suggests that rural hospitals may need to prepare differently than their big-city counterparts. While cities have been gearing up for or are already in the midst of a patient surge, some rural areas are experiencing micro-outbreaks — such as the one in Hall County — while others anticipate a slower, more sustained outbreaks that could last for months.
Many rural hospitals already suffer from strained finances, leaving them understaffed or on the brink of shuttering. Now these stretched-thin hospitals face the added burden of not knowing which scenario to prepare for.
Medical care in rural America for decades has been challenged by a population that is older, poorer, and sicker than its urban counterparts. There are fewer ICU beds per capita, fewer options for backup staffing, and less access to specialists (outside of Omaha, there are only two infectious disease doctors in the entire state of Nebraska). It all adds up to make the rural areas vulnerable to the pandemic and its course unpredictable, said Angela Hewlett, MD, MS, an infectious disease specialist at the University of Nebraska Medical Center and the medical director for the state's Biocontainment Unit.
Nebraska is 34th in the country in the number of COVID-19 cases, which — at first glance — seems to imply the state is in decent shape. "But break it down by county, and it's a completely different picture," Hewlett said. "It's really alarming what we're seeing in individual counties."
The epidemiology of COVID-19 in Nebraska is similar to that of rural landscapes across the country. Lightly populated counties account for both the lowest and highest per-capita incidence of COVID-19 in the United States. (Lincoln County, Arkansas, tops the list with 6258 cases per 100,000 people. Dozens of counties sit at the bottom, with zero confirmed cases.)
Like Nebraska's Hall County, some have been hit with micro-outbreaks stemming from large gatherings prior to social-distancing orders or crowded conditions at meat-packing plants. Yet other areas anticipate only a slow, prolonged trickle, banking on the natural physical distancing that comes with wide geographic spread, single-family homes, and a lack of mass transit and crowded shopping areas.
"As one of our doctors put it, it feels like we're waiting for a tsunami of molasses," said Kimber Wraalstad, CEO of North Shore Hospital in Grand Marais, Minnesota, population 1351, which hasn't seen any diagnosed COVID-19 patients yet. "We don't know if it's going to be up to our ankles or our knees or over our head. Are we going to be a hot spot? We don't know, so the planning has to be for the worst-case scenario."
Preparing for the Unknown
Without a playbook for rural hospitals to prep for COVID-19, hospital administrators are trying to plan for micro-outbreaks as well as long, sustained transmission. Hospital administrators are trading tips furiously over a national LISTSERV, and have spent countless hours strategizing over video conferencing. And while plans vary from one hospital to the next, most agree on this: Hope for the slow trickle while preparing for the micro-outbreak.
We talked to rural-health experts about how they're preparing and what they view as the biggest challenges.
Every bed and every item of personal protective equipment (PPE) must first be counted; then those numbers can be compared to estimates of how much might be needed in a surge. It's a challenging number to estimate, considering the variation among different epidemiologic models. Plus, those models address surges but not the more sustained scenarios, which could cause healthcare facilities to burn through more PPE and tests, said Jamal Horani, MD, an infectious disease specialist at Dixie Regional Medical Center in St. George, Utah.
With a best guess on PPE in hand, hospitals can then come up with creative solutions to reduce its use and decide whether to create more ICU beds or lock down plans to transfer patients to other facilities with capacity. In many states, health departments are tracking which hospitals have open beds to facilitate transfers.
Advising Potential Hot Spots
One of the reasons experts predict fewer surges in rural areas is because their vast open spaces inhibit spread of the virus. Yet small towns may be more vulnerable to micro-outbreaks, Hewlett said. "Rural communities are often very close-knit communities, and that ... makes them susceptible to the spread of an illness like this."
While stay-at-home orders have curtailed large social gatherings, such as the quinceañera in Nebraska, micro-outbreaks are not unlikely in towns dominated by meat-packing facilities or other factories where employees work in close quarters. That's prompted some state health departments to deploy biocontainment nurses and physicians to meat-packing plants and long-term care facilities to assess social-distancing procedures and share best practices.
Lining Up Staff
Counties experiencing a slow trickle know they're lucky, but a prolonged event comes with its own challenges. "It's very difficult to sustain caring for a large number of cases over a long period of time," Hewlett said, noting that hospitals need to pay particularly close attention to preventing healthcare workers' exhaustion and burnout while doing everything they can to keep staff healthy.
At North Shore Hospital, in Minnesota's Cook County, in the event of a surge employees would be divided into cohorts that could cycle in and out of COVID-19 wards. Although that would mean placing people in areas they don't normally work, it should help ensure that at least a portion of the staff remains healthy. Wraalstad worries about securing additional nurses and is relying on the state's hospital association and department of health to match hard-hit facilities with healthcare workers who have been furloughed.
"[The US doesn't] have a model where we send people to rural areas for disaster relief," said Carrie Henning-Smith, MPH, deputy director of the University of Minnesota Rural Health Research Center. "There aren't always hotels or housing. It's hard to imagine what it would look like — but I can't imagine we can get through this without something like that."
Critical-access hospitals, small facilities with fewer than 25 acute-care beds, must prepare differently than larger, regional hospitals. Adding ICU capacity "is not as easy as buying a ventilator and opening the box and the user's manual," Wraalstad said. A hospital without any ICU beds, such as North Shore Hospital, would most likely have no staff trained on using ventilators. Instead of adding ICU capacity, Wraalstad says Cook County will continue to transport patients needing intensive care 110 miles south, to Duluth.
Hospitals without ICUs can also use telehealth to connect with an infectious disease specialist or pulmonologist, although some rural areas are also constrained by lack of reliable wireless technology.
Many in small towns initially thought they'd avoid the pandemic by dint of their smaller, sparser populations, Hewlett said. "But it can go wherever people are having contact with each other. Rural areas aren't immune to this pandemic."
In fact, experts said, the only thing that seems certain is that the pandemic will hit every town, one way or another.
"There's some degree of certainty it will come to every county — no rural county should feel insulated or safe," Henning-Smith said.
"We're a long time out from being able to do a comprehensive look at how all this will play out," said Henning-Smith. "But I worry a lot that mortality rates in rural areas will be higher.... I certainly hope that coming out of this, we value access to healthcare for all of this."