Hospitals across rural Nevada are where their urban counterparts were a week ago, waiting for the inevitable first case of the novel coronavirus within their communities.
What they’re doing in the meantime, in many ways, parallels preparations hospitals in the state’s two urban counties are making, such as establishing protocols to screen symptomatic patients who show up to the emergency room, figuring out the proper channels to go through to get patients tested for COVID-19 and having a plan in place to prevent their workforce from being exposed to the virus.
In other ways, the challenges they face are quite different. Even a small number of patients showing up in the emergency room all at once could quickly overwhelm tiny rural hospitals. Testing isn’t as simple as running a swab over to a nearby public health lab — a courier has to pick up the samples once a day and drive them hundreds of miles. And if a doctor is accidentally exposed to a patient who tests positive for coronavirus? That could be the one doctor the hospital had.
But the one thing that is often the biggest challenge for the rural areas — their sheer remoteness from the hustle and bustle of urban life — is also what hospitals are counting on to mitigate the spread of the coronavirus in their communities.
“We think because we’re far away, maybe it won’t hit us as severely,” said Joan Hall, president of Nevada Rural Hospital Partners, an alliance of 12 small and rural hospitals across the state. “But maybe we’re thinking about that wrong.”
Hugh Qualls, the administrator of Mt. Grant General Hospital in Hawthorne, is hoping that the town's remoteness will minimize the exposure risk. Hawthorne is about a two-hour drive from Reno and Carson City, or about an hour and 15 minutes from the more developed Fallon.
“It’s an advantage in some ways, because we don’t get a lot of contact other than when folks go on the weekend to go shopping,” Qualls said. “But there is still a risk. When people go shopping in Carson, Reno or Fallon, they’re going to mingle with other folks who have been elsewhere.”
So far, Hall said that there have only been “isolated” instances of people being tested for coronavirus across rural Nevada, including one person in Pahrump whose test came back negative. At least two patients in Elko County have been tested for coronavirus, though their results remain unknown, according to the Elko Daily Free Press.
A spokeswoman for the Department of Health and Human Services, whose Division of Public and Behavioral Health is the public health authority for most of rural Nevada, did not respond to a request for comment Wednesday about the number of rural Nevadans who have been tested for coronavirus.
In the meantime, rural hospitals are continuing to evaluate the plans they have put in place for when the first case does arrive.
For instance, at William Bee Ririe Hospital in Ely, anyone who presents with flu-like symptoms will receive a mask and be asked about their recent travel history. If they meet the criteria for testing, they’ll be taken from the admitting desk into a room where they will wait for a physician to suit up in personal protective equipment to collect a sample.
Patients who are healthy enough to treat their symptoms on their own will be sent home to self-quarantine until the results come back from the Nevada State Public Health Laboratory in Reno. Patients who are sick will either be hospitalized in Ely, if it’s a case the hospital has the capacity to treat, or taken by air ambulance to an urban hospital if they need intensive care.
But hospitals’ plans are also continually adapting and evolving.
“A couple of weeks ago we all sat down and met,” William Bee Ririe Chief Executive Officer Matt Walker, said. “And we’re changing the plan every day according to the CDC's new guidelines.”
Perhaps the biggest concern for rural hospitals is their workforce, particularly in light of reports from around the country and across the globe of health care workers being sent home to self-quarantine for 14 days after exposure patients who test positive for COVID-19. Mt. Grant General has one doctor on staff at the hospital. William Bee Ririe has two.
“If there were to be a staff member or someone came down with a presumptive positive, that would be somewhat catastrophic,” Qualls said. “That would impact our operations. We’re the only health care facility in west-central Nevada — Gabbs, Round Mountain, Fish Lake, Dyer, Tonopah — that would be a terrible situation and we’re doing our best to avert that.”
In the event of an emergency, both Mt. Grant and William Bee Ririe are planning to draw on the doctors who work at their affiliated primary care clinics, and Walker said that some doctors who work with the hospital but live elsewhere have also said they might be able to help.
Hospitals are also making preparations to ensure they have adequate space in which to house patients, including checking with the state to see whether they would be able to convert old surgery rooms or obstetrics departments to add additional bed space if needed. On top of that, not all rural hospitals have negative pressure rooms needed to isolate patients and prevent cross-contamination from room to room.
“Some of our ERs can be converted to negative air pressure, but you take away a room for a person coming in for a laceration or broken bone or a heart attack,” Hall said.
Mt. Grant General, for instance, can’t meet the strict isolation standards put forward by the Centers for Disease Control and Prevention and is planning to transfer any patients who test positive for coronavirus elsewhere. Qualls said that any patient who tests positive for coronavirus would be isolated in one of the hospital's ER rooms until the hospital could arrange transport.
Rural hospitals have also finally smoothed out their testing procedure, with commercial labs Quest and LabCorp agreeing to have their couriers deliver coronavirus samples to the Nevada State Public Health Laboratory in Reno on their daily lab runs, and soon the two companies will begin their own commercial testing.
“It had proven the first couple of weeks a little difficult because people forget we’re a little far away and how were we going to get that lab specimen to the state lab,” Hall said. “(The Division of Public and Behavioral Health) and the state lab have been wonderful working with us.”
But not all rural hospitals even have the materials they need yet to test people. At Mt. Grant General, they have their courier plan in place, but they’re still waiting for kits to collect the samples.
“We’ve got the cart before the horse,” Qualls said.
Rural hospitals that have affiliated long-term care facilities have also had to take extra precautions, including ending visiting hours. Qualls said it’s been particularly hard at Mt. Grant General because most of the patients’ families are in town.
“They’re the population that’s most at risk, not just from the coronavirus but the flu, which has been our biggest challenge this winter,” Qualls said.
In the meantime, rural hospitals are focusing on community education — which they note is, perhaps, an easier endeavor in a small town where everyone already knows everyone than in the state’s urban areas.
“We have good communication with the community,” Walker said. “We’re trying to stress to the community to not panic. If you’re really sick, call ahead and let us know that you’re coming.”
Rural hospitals may also have an additional leg up, Qualls said. Because of their small size, they’re also required to think fast on their feet on a daily basis.
“It’s one more challenge, but rural hospitals have dedicated staff and they love their communities. They’re here to serve,” Qualls said. “What we lack in other resources we make up for in passion and commitment to the community.”
And as far as what will happen when the first coronavirus case arrives?
“I think we’re ready,” Hall said. “As ready as you can be.”