Local Hospital Braces for Impact of Increased Demand, Plans for Triage Situations, Staff Shortage and Burnout a Looming Concern

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By Echo Menges

NEMOnews Media Group

The following interview was conducted with Dr. Jeff Davis, DO. Dr. Davis is the Chief Medical Officer at the Scotland County Hospital located in Memphis, MO. He is also the Medical Director at the Edina Medical Services clinic located in Knox County, MO, the Lancaster Medical Services clinic in Schuyler County, MO, and Memphis Medical Services in Scotland County. This interview was conducted over the telephone on Wednesday, November 25, 2020.

What has it been like at the hospital as far as patient load and staffing shortages?

A couple of things have been happening in the last two to three weeks as we have seen a surge in COVID-19 patients in Northeast Missouri and Southeast Iowa.

The hospital really takes care of people that come out of Schuyler County, Scotland County, Knox County, Clark County and some of the southern tier counties in Iowa. We will occasionally have patients that we take care of from Putnam County, and Adair County, and Lewis County as well. We have a fairly large service area, and that area has been particularly hard hit with an increase in COVID cases. There’s multiple places in the health system that we’re seeing stress on our ability to provide services.

Numbers of patients presenting to the emergency department have increased, and the acuity or the severity of their illness has increased (from) what we are normally accustomed to. That puts a burden on the providers that are there, physicians, nurse practitioners, physician assistants, as well as the nurses. These COVID patients are fairly sick. Our respiratory therapy staff, our laboratory technicians, our radiology technicians are all stressed and put through the strain as well.

When we interact with these patients in isolated areas we have to have a complete set of PPE (personal protective equipment) that includes N95 masks and goggles, shoe coverings, gowns. Those get changed in and out as we come in and out of that care area to evaluate so that we reduce the risk of transmission to the caregivers that provide for them.

As we’ve seen those numbers in the emergency department increase, that’s led to more of those people with severe disease being admitted to the hospital or transferred to higher level of care tertiary care centers in the tri-state area, and that’s led to a burden on our inpatient medical wing.

All the way back in March and April, we had our maintenance services put up isolation areas in the inpatient wing and that limits then the non-COVID patients as well as the COVID patients to that area – that we can take.

We have at times reached the level we didn’t have enough beds in the isolation area as well as enough staffing to staff those areas. And that’s primarily because whether it’s in the hospital emergency room department, the clinic or our acute care clinic for respiratory  illnesses at this time of year. They’ve all seen staffing shortages because of the the number of our own employees who have contracted COVID illness related either to transmission from a family member or a social transmission in the community or, you know, getting exposed to it at work from either a fellow employee or a patient encounter and so they’re out for those reasons if they have COVID.

Also, if their children have COVID or if their spouses have COVID, and then they become quarantined because of a close contact with a family member or something like that. Even when they’re not COVID positive. That’s really resulted in a staffing shortage. We’ve been anywhere from 10 to 15 percent of our full-time employees have been out at any one time. Yesterday, we were at 15 percent. Today, I think we’re right at 15 percent, if not just a little bit under that, for staff not being able to report (for) duty, which then puts a strain on our ability to provide for the patients, whether they’re COVID patients or not, who are requiring medical care.

With those staffing shortages and, I know you guys put out an all-call for retirees or people with medical experience to please apply and kind of fill in some of that gap, have you had a response from the communities around to help fill in where it’s needed?

Yes, we definitely have. Within a few hours of that information being put out there, we had some semi-retired or part-time nurses contact us. Initially, the ones that have contacted us were ones that have active licenses because they were either recently retired or part-time and they’ve offered anything. One of the first nurses that reached out to us was from Monroe County in the Monroe City area and reported that they had a job but they had Saturdays free and possibly even some nights. If we could utilize them to show them what we needed and see if they could meet the need.

We’ve had nurses retired from the State of Iowa who know someone in Scotland County or had some relationship with the hospital previously that have also reached out to us. We’ve continued, that’s been about a week now to 10 days ago that we put out that all call, and we’ve continued daily to have people either communicate with us through our Facebook page or through our hospital’s website on the internet or call directly and speak with our staff on showing interest in volunteering, assisting us in whatever way we can.

Going a little deeper into that, just to throw this one in, I noticed you are advertising for custodial and also daycare staff.

Yeah. For both reasons, what we have had happen is we’ve had COVID, either exposure or disease, be contracted or to be exposed by some of our maintenance, housekeeping, and daycare staff as well as other staff.

This has not only affected one type of staff member. We’ve had many nurses, but we’ve also had physicians, physician assistants, nurse practitioners, clinic nurses, hospital nurses, custodial staff, the housekeeping staff, business office workers that have either had to be quarantined or have had to actually be isolated because of illness with COVID as well. We’ve had other volunteers for those things as well.

One thing that happened here recently, Scotland County schools went completely virtual as of last Thursday night. So, Friday, Monday, Tuesday, Wednesday (being) virtual going into the Thanksgiving holiday here. That meant no open school for those kiddos to go (to). Many of our staff members have young children in the elementary school that did not have a daycare arrangement already made.

We’ve even had a daycare in our community temporarily have to close. That was more of a shortage in daycare and so many of those were going to have to stay at home and help their children do their virtual classroom.

We had been discussing it for a while and when we got that call that (virtual) was going to happen, we scrambled and got some volunteers and we actually have now a monitoring service that is offered to our employees’ children, to monitor them in an area where they’re able to socially distance. They wear their masks. They have their tablets or their laptop computers. We give them access to our WI-FI and then they have a (person to) monitor. They’re not tutoring them. They’re not teachers. They’re making sure they’re well, that they’re safe, that they can make it to the bathroom and back, that they stay active on their assignments while their parents are working in the hospital.

Because we have that level of shortage, we need every worker on hand that we can have available.

That’s really amazing. This will be a good way for people to know you don’t need to have medical experience to be able to lend a hand.

That’s right. There have already been some people without medical experience, (that are) not nurses, just contact us when we put out that call for help saying, I’m available, I want to help you, is there anything i can do in one way or another. We’ve found places for those people to volunteer and help us out – one way or the other. You’re right. It does not have to be medical personnel.

Shifting back to patients and about 10 days ago-ish, when you guys did send out the alert messages, about the possible filling up of the hospital, have you had to turn emergency patients away since?

Yes.

We have had situations where we are on diversion. Any time a hospital goes on diversion, if licensed by the state, we have to notify the state that we are on diversion because we don’t have capacity. At the same time, that we’ve been on diversion, other area hospitals like Blessing Hospital in Quincy, Illinois, or Northeast Regional in Kirksville, or Boone County (Hospital) in Columbia, the University of Missouri, Ottumwa, Ft. Madison, Burlington, there have been other hospitals at that same time also on diversion. That’s put a real pinch on our emergency department staff’s ability to transfer, find beds available to transfer patients. This is primarily COVID positive patients who have severe disease and need to be admitted.

It even has happened when we’ve had someone come in with a stroke, or someone come in with a myocardial infarction or an orthopedic injury. Whenever we try to get them transferred to the hospital of their choice, oftentimes that we find out that they don’t have the capability to receive them. We have to go down a list of trying to identify hospitals.

Shortly after that happened, we began preemptively contacting hospitals twice daily finding out what their bed availability was so that, if they weren’t available, we didn’t utilize that time contacting them just to find out that they weren’t going to be able to take our patient transfer anyway.

On a rolling basis, we will have patients discharged from the hospital in the morning that opens up a bed, or two beds, or three beds. Then, basically within hours, and sometimes we even have patients in the emergency department being stabilized needing admission, that wait in the emergency department until a bed is vacated by a discharged patient. We quickly fill those beds right back up.

We have been lucky that we have maintained the staff level that we have.

We also have put into place some things like canceling and postponing non-essential surgical procedures so that we could free up some of our nursing (operating room) staff who are competent and capable to work on the floor so we can increase our bed numbers to be able to accommodate an increased number of these patients.

Yesterday we had seven COVID patients in the hospital, which is very near our capacity of those beds in that isolated area. Today we have six in the hospital. Then, we have other non-COVID beds that are already full. We have six or seven non-COVID patients that are in the hospital as well.

We have a full obstetric department right now (with) three moms, three babies this morning when the day started. There are labor inductions and cesarean sections and all those things that still have to continue to happen because those babies don’t stay in there and wait for the pandemic to (be) over. It just really has put a significant strain on the system and we’re trying to do everything we can to make sure that we meet the community’s needs.

Going back to when you were diverting, do you know where the patients were landing?

We had some go to Iowa City, the University of Iowa at Iowa City. We’ve used them before for regular transfer. There occasionally are patients who have some relationship with a physician up there already, either through the veteran system that they have in Iowa City or the University of Iowa. It’s not foreign to us to transfer someone there. It’s just outside of our normal service range. (We transfer to) Barnes Jewish in St. Louis, and I believe we even had a patient recently end up in Kansas City for transfer as well. So we have been able to place all of those.

The other thing we’re running into right now, and this COVID illness I think the listeners or readers of information need to understand is that you might come down with COVID and not feel too bad when you first get tested positive. A scratchy throat, or a slight cough, some headache, or fullness in your ears but four or five days later you could begin having increased cough and develop some shortness of breath with activity.

That’s when people really need to be evaluated to find out if they have an oxygen requirement. If you need oxygen and you don’t have oxygen, you can’t just go to the grocery store and pick a bottle up. To give you oxygen, that has to be provided to you medically. Someone like that might come into the emergency department, but after their full evaluation, they’re not in the shape that they need admitted, they need oxygen because their symptoms are still just not severe enough and we’re hoping that they turn the corner and they improve.

They get discharged back home. A day or two later their condition may continue to worsen because we find that the COVID patients, on day seven, day eight, day nine, and day ten, those four days of the illness are probably the worst for those that are going to have severe illness.

For those that have mild disease only, by day seven, day eight, they’re feeling almost back to themselves. That’s why a 10 day isolation period is for most people with mild illness and they’re back to work and felt to not be contagious, according to the CDC and infectious disease experts.

What has happened some too is people that came, we didn’t need to admit them here. They didn’t necessarily need to be transferred but were discharged and then a day or two later are sicker and returned to the hospital again for care.

With needing oxygen and things like that, you’re also the Medical Director here at the Edina clinic, Edina Medical Services, are you seeing any kind of hiccups (with) patients coming in the Edina Clinic and not being able to get into the hospital – if that’s where they need to go? Are they being shipped (elsewhere)?

It’s been good so far. Our two busiest outpatient or remote rural health clinics, Lancaster and Edina, both have oxygen capabilities there. We have tanks of oxygen there, and they both have tested patients for COVID. They both have identified positively tested patients that they tested (and) came back with results positive. They’ve diagnosed COVID disease, and they both have taken care of people with COVID that have presented to them because they’re in some kind of trouble.

We run walk-in clinics. We offer walk-in services at both of those places, and our staff has all of the PPE there that we have in our emergency department, from N95’s, to goggles, and face shields, and all of those things. If their oxygen saturations are low, they can have oxygen applied, given to them. If they continue to require that oxygen, and they’re not able to be titrated off of it or their condition doesn’t improve, just in the time that they’re in the clinic, then generally we have to call 9-1-1 like any other clinic, or any other nursing home or setting where someone needs to be then transferred to an emergency department.

None of the emergency departments are on diversion. It doesn’t matter whether it’s Blessing, or Northeast, or ours – they take all comers because emergency departments have to – unless something has happened and they don’t have any doctors available, or they’ve had a facility problem that they’ve had to shut down their emergency department. That’s gone pretty well. Not many hiccups.

What we would ask anybody to do is, either if they’re COVID positive, or they were exposed, they think they have COVID and they’re in that kind of distress, they really need to call the clinic there in Edina or call our COVID hotline at Scotland County Hospital’s COVID hotline because it’s manned 24 hours a day. That number 660-956-6820. They can give guidance on (when) you need to call 9-1-1, you need to go to the nearest emergency department. If you’re not in that much distress, or you haven’t been tested and the clinic is open there in Edina, (saying) why don’t you get a mask on? We’ll let them know you’re coming so they can be in their PPE and you can go in and be tested there. It’s really going pretty well so far.

I was wondering, because you would really know, if these local smaller clinics are helping to ease the pressure on the rural hospitals?

If someone needs emergency medical care and then to be admitted to the hospital, (clinics are) obviously not able to provide those services, but they are able to keep that care close to home for people that just need (to be) evaluated to find out do they need to go to the ER or not, or to find out do they need a test or not, and to receive a test. They’re able to do all of those things.

I haven’t talked to Lori Moots-Clair, the Administrator at your Health Department, but we’ve already begun having influenza-positive patients. We had a positive result on Monday in our acute care clinic for a patient that also tested positive for COVID. We also had an admitted Influenza B patient last week to the hospital who had respiratory illness bad enough that they needed to be admitted to the hospital and receive care.

We are now beginning to see the dual disease of influenza and COVID begin affecting the way that we take care of patients in the outpatient clinic, the emergency department, and the hospital.

That’s concerning.

Yeah, it really is, and that’s why we’ve advocated. I know Lori has too. There’s been a lot of information about how important it is for people to receive their influenza vaccinations, and it’s not too late there’s still influenza vaccines available at pharmacies and clinics. Our Edina clinic has influenza vaccine. We’re giving it here in our acute respiratory care clinic, and we’re giving it in the clinic here at Memphis Medical Services. It’s very important because if your immune system is prepared to help take care of the influenza, and please no one think that if you get influenza that’s going to keep you from getting COVID, either at the same time or at another time. They are two separate viruses. They both will take the opportunity to infect the human body when they get the chance.

I know you guys are busy there and I’m gonna wrap this up pretty quick. I just have a couple more. Are you planning for (the possibility of) more of an influx after the Thanksgiving weekend?

I know you’ve been reading, and if you’ve been reading or other people that are listening have been reading, (you know) everything big happens around ten days to two weeks to three weeks after a big social time. When it was the Fourth of July, our summer surge hit in mid to late July. When it was Labor Day, our next surge began hitting in October. It won’t be the weekend after Thanksgiving that we’re really concerned about the Thanksgiving gatherings causing the numbers. People will get exposed at that time. They’ll begin developing symptoms on Monday or Tuesday. They’ll get tested for COVID somewhere on Tuesday, Wednesday or Thursday. They’ll find out from a family member who was at Thanksgiving that that family member got sick that night or the next day and then they went and got tested on Friday or Saturday and they were positive. They now know they’re an exposure. It’s when all of those people reach that seventh, eighth, ninth, tenth day of their COVID illness. Then, they’ll be in the ER. They’ll need to be admitted to the hospital for this care.

We’re really looking at early to mid-December. It’s being expected everywhere in the Midwest.

I know St. Louis has been out there saying that, at the current increased rates that they’re seeing that has continued to stay high and increase, after a Thanksgiving holiday, if those rates go up, that those hospitals, and we’re no different in our area, just won’t be able to sustain the increased number to care for – the sustained increased number of patients.

The hospital board of directors met last night. We are in a management agreement and affiliation with Blessing Hospital, and so their leadership was on the Zoom call for the hospital board meeting last night as well, and we discussed crisis standards of care. Crisis standards of care for the Health and Human Services, HHS for the federal government, and DHS for the State of Missouri – what that means is that means when a mass casualty happens, some kind of explosion or plane crash or anything like that.

What standard of care are you going to provide when your resources become overwhelmed? How do you decide which patients get which care?

So basically triaging?

Yeah, basically triaging. That’s the crisis standards of care. People don’t really realize that this pandemic is unprecedented in our time. We have not had a pandemic with this type of disease burden ever in the history of Scotland County Hospital because we weren’t here in the influenza pandemic of 1918. This far surpasses MERS or the first SARS that was around, or H1N1. This is way beyond H1N1. We have to plan ahead of time for what will we do, if we don’t have enough – physically enough beds. Where do we begin caring for people?

If we physically don’t have enough oxygen equipment, where will those people get oxygen delivered to them? If we physically don’t have enough ventilators or positive pressure machines to provide for them, where will people get those services?

We’ve ordered more of all this stuff. We’re waiting on all of it to arrive. If it hasn’t arrived yet, we have to have a plan to provide a certain level of care, a standard of care, to help the largest majority of the population the best that we can.

You have to have an ethics committee to help make the decisions like that. You have to have plans put in place so that you can be prepared, so it doesn’t catch you off guard.

What we know happened in New York City – they were caught off guard and it was chaos. It still will be chaos when something like that happens, but if you’ve planned for it, and you’ve made policies, and you’ve trained people on how they’re going to handle it and react – you’re in a better situation than if it just is like a tsunami that you’re not prepared for.

Just the thought of triaging, or the crisis standards of care, is sobering.

Yeah, and I think it should be. We have to realize that we might think we’re a very advanced country, and we are, but we are not that much more advanced than Italy, Germany, France.

New York City, there they were triaging that had to occur where the minimal services that were available were given to those that were most likely to survive, and have the longest survival longevity left. And those are hard things to think about. They’re hard things to talk about, but they’re the kinds of things that we need to think about, or be aware of might happen if we continue to practice our social lives as usual, or our economic lives as usual because there are real things that can happen.

We were locked down in April and May and we had an empty hospital, empty beds, people standing around. We had to furlough people because we didn’t have cases.

I guarantee you can talk to any hospital employee and they know that there is a monumental and significant difference between what we’re seeing right now, and what was happening in May. That happened for a reason. It wasn’t like it was there then and we just didn’t know it. It wasn’t there. It’s here now and we’re dealing with it.

We’re doing a great job. Our healthcare workers are resilient. They show up every day when they’re capable of it, and they’re providing the highest quality of care and the best care that is available. We want it to continue to be that way for every person every time, and not come to a situation where we get into that triaging and crisis standards of care.

That’s a great segue into my last question, which is what is the mood like there? Are there signs of fatigue, depression among the staff? What are you doing to keep morale up?

There’s definitely a lot of stress, a lot of tension, there’s a lot of melancholy seriousness – especially from those that are taking care of the COVID patients. There are many staff members who themselves had some question about whether this would ever really affect us in any way at all, and why are we locking down, and why are we closing schools, and why were we ever doing this, look we haven’t even seen a single COVID positive patient.

Now that they’re taking care of these patients and seeing these patients. They’re their community members and neighbors. It’s shocking to them, and that has a certain emotional toll, for those individuals.

There definitely is fatigue. There definitely is. Actually, we went, a few weeks ago if not several weeks ago, to mandatory overtime. All nurses that worked 12-hour shifts in the hospital work four instead of three, which is the standard because we had shortages in areas, and we were trying to provide for the maximum amount of patients that we could take care of.

At 48-hour weeks every single week, when you’re taking care of these COVID patients, wearing PPE, it starts to wear thin on everyone’s nerves and their stamina. There’s physical fatigue. There’s mental fatigue. We’re watching for signs of burnout.

We have met with our supervisors in every department asking them to keep a close eye on all their employees, to speak with all their employees about coming to them if they have any issues or concerns.

We have, just last night, announced to our board an employee program for mental health. It’s an employee assistance program, an EAP. We’ve had one for forever because it’s a requirement, but we beefed ours up here in the last few weeks really aiming at being there for our staff that are put to the test by this pandemic, and the care that they’re being asked to give to these patients.

It’s very sad to say, but we have had more fatalities that our employees have witnessed in a short period of time than many have seen in their career as a nurse. If they’ve only worked three or four years, because they may have been involved in resuscitation efforts with success or without success only a few times. This is now happening weekly if not daily, or we’ve even had days where it’s happened more than once in one day. That is something that they’re not accustomed to.

Even employees maybe that worked in lab, or radiology, or physical therapy, who maybe have worked at the hospital for 15 years or 20 years, and they haven’t been on duty when one of the patients that they’ve been caring for crashes, and requires intubation, an emergency transfer and those kinds of things. Those are things that they all say when you hear them talk about it. These are things that only happen in big hospitals. These are only things that we thought happened in St. Louis, and Kansas City, in New York City and they’re becoming more commonplace here because of the situation that we’re dealing with. And that takes a mental toll on them.

Scotland County Hospital has this employee assistance program now with robust mental health. They are able to access it themselves, discreetly, privately, 24-7, and they also have their supervisors they can go to, and we have a quality assurance and HR department that’s led by Terry Schmidt, who is an employee that has a background in behavioral health. She’s the one that’s been working the hardest on employee burnout, depression, fatigue, and this employee assistance program. And they all know that they can reach out to her and her staff in that office.

We’re trying to do everything we can to make that as open and available to them as possible, and encourage them to use it. We’re trying as hard as we can to destigmatize any emotional distress or trauma that our employees witness, or have, related to the care of these patients.

What can the community do to help you and the people at the hospital?

Well, you know the things we’ve been talking about forever are still very important. Because we don’t have a vaccine yet, and one is soon on the horizon, hand hygiene, and mask-wearing, and social distancing are about the only things that we can do.

I would also recommend, and we just talked about this at a meeting earlier today, everyone thinking about educating themselves on the disease as much as they can. Anything that is reputable that they can read about the disease. WebMD has things, Mayo Clinic has things, Blessing Hospital has resources you can get online if you can get online.

What we’re seeing a lot of times is people get diagnosed with it and they don’t really still modify their behavior and their family’s that much. The number one way in Northeast Missouri that people are contracting the virus right now is family spread.

People need to really take being diagnosed with it seriously, even if they have mild symptoms or no symptoms, to make sure that they don’t transmit it to another. Really following recommendations on not going to the grocery store, not going to a restaurant, not going to those locations for sure if you’re positive, for sure if you’ve been exposed and you’re asked to quarantine, and for sure if you have a respiratory illness, a cough, runny nose, headache, fever, even diarrhea, abdominal discomfort, body aches. Go ahead and do the right thing. Isolate yourself from possibly spreading it to others.

I really believe that if we all practice just common sense. I’m sick. I don’t feel well. I’ve been told I have a transmissible disease. I’m going to do what I can to make sure I don’t give it to anybody else. I really think what’s happening is there are so many cases of it that are mild, 85 to 90 percent of the cases end up being mild – they don’t go to the ER, they don’t get hospitalized – and that would cause a lot of people to say, well then what’s the big deal?

The big deal is that we’re having these 45, 50, 55, 60-year-olds who aren’t oxygenarians with five or six chronic medical conditions, and they’re getting sick enough that their life is in danger, if not severely compromised for the time period that they’re admitted to the hospital and receiving oxygen.

Everybody just having it in the front of their mind, thinking about when they encounter someone – hey that person might have COVID and not know it. I’m going to keep my distance. I might have COVID and not know it. I’m not going to get in somebody else’s face. If people can make those types of decisions, I think we can help flatten the curve, lower the numbers locally, so that we don’t outstrip our resources in the emergency department and in the hospital here or in the region.