State rules, COVID fears kept many away
Some patients have seen their health suffer in recent months as they delayed medical care due to state restrictions on non-emergency medical procedures, and fear of exposure to the coronavirus.
“I saw a lot of people who came in far sicker than they would have under normal conditions,” said Jennifer Thill, an emergency department physician at Mid-Valley Hospital in Omak.
Patients are slowly beginning to return to community hospitals and associated clinics in Okanogan County as restrictions on medical procedures, imposed throughout Washington to prevent the spread of coronavirus, are gradually lifted. As people regain confidence about visiting medical facilities, more patients are following up on needed medical care, and elective surgeries are beginning to be scheduled again.
“We’re seeing an uptick in patients coming in for care,” said Alan Fisher, Mid-Valley Hospital’s chief executive officer. The hospital is promoting a “don’t delay, get care today” message via social media to the public, Fisher said.
Thill, chief medical officer at Mid-Valley Hospital, said the emergency room has seen patients in recent months who put off coming to the hospital even when they had serious medical symptoms.
“We have had patients who had chest pains that started earlier in the day,” she said. “With a heart attack, the consequences of that are that rather than a small area of heart muscle being damaged, you have a larger amount damaged, which can lead to congestive heart failure or arrhythmia.”
Patients have expressed fear of being exposed to someone with COVID-19 (the disease caused by the coronavirus) if they came to the hospital, Thill said. “There was not a clear understanding of measures the hospital was taking to protect everyone,” she said. “We have infection control and isolation processes in place.”
News reports earlier in the spring of hospitals flooded with COVID-19 patients in places like New York City and Seattle also deterred people from coming to their local hospitals, Thill said. Regional hospitals have not had to deal with a large COVID-19 caseload, but in the early weeks of the pandemic “we didn’t know how many cases we would see, we didn’t know how quickly it would spread,” Thill said.
Routine care
In some cases, patients did not receive routine health care, either because it was temporarily suspended or they were afraid to come to a medical facility. For people who need help managing chronic conditions like diabetes or high blood pressure, for example, “their problem is exacerbating or progressing” without routine care, Thill said. “We recognize in the emergency department the correlation when a patient has access to clinics and providers.”
Doctors and clinics throughout the Okanogan County have turned to telemedicine to enable patients and caregivers to hold appointments virtually via computers and smartphones, but that technology isn’t available to everyone, Thill said. “We’ve made great inroads in rolling out telehealth in remote areas, but people without access are being disproportionately affected.”
In mid-March, Gov. Jay Inslee ordered a ban on all non-emergency medical procedures to ensure that there would be enough hospital beds and adequate protective gear for medical workers in case of a deluge of patients with COVID-19. Most hospitals in Washington have avoided being overwhelmed with COVID-19 patients as “stay home, stay healthy” orders and social distancing measures have slowed the spread of the virus in this state.
Inslee eased restrictions, effective May 18, on the kinds of surgeries and procedures that would be allowed. Mid-Valley Hospital and Three Rivers Hospital in Brewster have been developing procedures to cautiously resume non-emergency surgeries, including testing patients for COVID-19 infection before surgery.
“We’ll pre-screen all patients for COVID-19 before their scheduled procedure, per current recommendations,” said Jennifer Best, business development coordinator for Three Rivers Hospital in Brewster. “Patients will be asked to self-isolate at home in the period of time between their test and their surgery date. This is to ensure they aren’t unknowingly exposed to the virus. If they test positive, their procedure will be postponed, if it’s safe to do so.”
Best said the hospital is “shooting for 48 hours from the time a patient is tested and the procedure.” The hospital has “quite a few rapid tests, with less than a day turnaround time” that are done in-house, she said. But the hospital also sends tests to the University of Washington (UW) in Seattle, which requires about 24 hours. “It’s not a long turnaround like it was in the early days,” Best said.
Best said the hospital currently has about 300 test kits. “We’re working with public health to get more. It’s becoming a little easier to get them,” she said.
Mid-Valley sends tests to UW and LabCorp, and is working to increase its capacity to conduct rapid tests that are done in-house, Thill said.
State guidelines
In order to conduct non-emergency surgeries and medical procedures, hospitals must comply with guidelines issued by the governor, including maintaining at least 20% bed capacity for a potential surge of COVID-19 patients, and 14 days of personal protective equipment for medical staff, such as gowns, masks, and gloves.
The easing of restrictions on elective surgeries means that many general surgical and preventive procedures can once again be scheduled, such as gynecologic and orthopedic (including joint replacement) surgeries, laparoscopies, and colonoscopies.
Since the beginning of the pandemic, hospitals and clinics throughout Washington have developed procedures to protect patients and staff from possible infection, including screening all patients before they enter a facility, doing extra cleanings and sanitizing of exam rooms, physically distancing patients, masking patients and providers, limiting the number of visitors to patients, not having people wait for their appointments in a waiting room.
Thill said these enhanced isolation and infection control practices apply not only to coronavirus, but to other viruses that cause colds and flu, as well as bacterial infections like MRSA (a type of staph bacteria).
“One of the good things that I think has come out of this is we have become more aware and cognizant of the fact that we can do a better job of preventing transmission of lots of different diseases,” Thill said. “I hope that we, as health care professionals and community members, recognize we can really stop of the spread of not only coronavirus but the flu. These are the things we will continue to carry forward. I’m excited for that,” she said.
“It’s almost like we’re reliving the early days of medicine when Florence Nightingale [who cared for British soldiers during the Crimean War in the 1850s]) recognized that if you put cots 6 feet apart, the rate of infection dropped. She was one of the first people to recognize that distance between patients was a good thing,” Thill said.
Community members will adjust to changes in health care that result from the pandemic, Thill said. “You might be taken aback if you come into the emergency room and nurses and doctors are in face masks or shields. There is some shell shock initially. But the resilience of people in our community is amazing … as we get more familiar with what we can do to take care of ourselves.”
Financial challenge
Allowing non-urgent and elective procedures is a critical step toward easing the financial crisis faced by Mid-Valley and Three Rivers hospitals. With dramatic declines in patient volumes and revenues in recent months, Mid-Valley and Three Rivers hospitals have each received more than $3.5 million in emergency funding through the federal CARES Act and the Paycheck Protection Program. But those funds are stopgap measures until hospitals can resume normal operations.
For small rural hospitals, “elective surgery is our bread and butter,” said Mid-Valley’s Fisher.
Reimbursement for surgeries, and ancillary medical services like lab tests and X-rays, account for almost 50% of Mid-Valley’s revenues, he said.
Surgery is a well-reimbursed service and helps us pay for [Three Rivers’] operational costs,” said Best. “We think it’s important for small towns to have access to those services.”
“Opening up for elective surgery is huge for us … for our financial viability, and for the community we serve,” Thill said. As hospitals and clinics resume most health care services, she hopes community members will seek the care they need.
“There are a lot of things we want to be sure we can provide. We want people to take their kids in for well checks and to get immunized. We want women to have screening mammograms. We want people to come in when they are sick, and not super sick,” Thill said. “This is a step toward opening and returning to some semblance of a new normal.”
