Normally more than 90% full, Rhode Island Hospital’s occupancy rate in late March dipped to about 75%. The 247-bed The Miriam Hospital had more than 100 beds free at the same time.
And in Warwick, at Kent County Memorial Hospital, occupancy was about 20% lower than the usual 190 to 200 hospitalized patients.
This was the calm before the COVID-19 pandemic arrives in full force, and Judith Ann Thorpe wasn’t about to let that time go to waste.
“Every day we get to plan and prepare, we are grateful for. It’s been a very intense time,” Thorpe, Kent Hospital’s chief nursing officer, said recently. “If you were to walk around the hospital, it would feel like there’s an increased sense of urgency and awareness.”
The relative calm inside some of Rhode Island’s largest hospitals, where many surgeries have been postponed as health systems clear the way for a possible flood of coronavirus patients, stood in contrast to preparations for the pandemic in recent weeks outside the hospitals and beyond.
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GRATEFUL: Kent County Memorial Hospital Chief Nursing Officer Judith Ann Thorpe says the hospital is grateful for every day it gets to plan and prepare for a potential surge in COVID-19 patients. / PBN PHOTO/DAVE HANSEN[/caption]
Outside Kent Hospital, the urgency has been inescapable. Ambulances arriving at the emergency department pulled up to a tent where patients were screened for symptoms consistent with COVID-19. Signs directed people to a separate respiratory triage tent near the main emergency room entrance.
A similar scene has been playing out at Rhode Island Hospital, where tents flanked emergency room entrances to screen walk-in patients and those arriving by ambulance.
In separate tents at Kent and Rhode Island hospitals, R.I. Department of Health workers administered coronavirus tests for people who had been approved by state health officials to receive them.
At Kent, about 60 tests have been performed daily by the DOH since March 13, said Shannon R. Sullivan, vice president of operations for both Kent Hospital and its parent Care New England Health System.
For all the activity outside the hospitals, health care providers said they were bracing for much more.
And, they insisted, they were ready for it.
“Our hospitals are completely prepared for people coming to the emergency department and to care for people who are sick,” Dr. Jeremiah Schurr, Lifespan Corp.’s physician-in-chief of emergency medicine, said in late March, as the number of cases in Rhode Island started a steeper climb.
Dr. Mitchell M. Levy, medical director of the intensive care unit at Rhode Island Hospital, said he was confident in both state and hospital preparation, thanks in part to lessons learned from Italy and other European countries hit hard by the coronavirus.
Measures such as banning hospital visitors soon after COVID-19 appeared in Rhode Island have been vital, said Levy, who has also been working closely with state health officials during the crisis as the lead representative for critical-care providers.
“I’ve heard from a number of my [international] colleagues that we have been ahead of the curve in mitigation and preventing the spread,” he said.
Still, things could change quickly.
“I think it’s likely we will get quite full and more than full, we’ll be in surge capacity,” said Dr. John Murphy, Lifespan’s executive vice president for physician affairs and interim president of Rhode Island Hospital.
Gov. Gina M. Raimondo says local hospitals are not ready for the worst-case scenario.
“If we were to have an outbreak right now similar to what you’re seeing in New York City or New Orleans, we are not ready for that. We are not ready for a surge of cases,” she said.
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VITAL STEPS: Dr. Mitchell M. Levy, medical director of the ICU at Rhode Island Hospital, says measures such as banning hospital visitors soon after COVID-19 appeared in Rhode Island have been vital in terms of mitigation and preventing the spread of the coronavirus. / PBN PHOTO/MICHAEL SALERNO[/caption]
HIDDEN PROBLEM
Even with hundreds of confirmed COVID-19 cases in Rhode Island, dozens of people hospitalized and several fatalities, as of April 1, health officials acknowledged they don’t have a grasp on the full scope of the pandemic in Rhode Island.
Limited testing supplies and protective gear for health care workers have forced officials to restrict testing to hospital patients, health care workers, nursing home residents and those who are ill and have been exposed to the virus.
Both Care New England and Lifespan say several of their employees have tested positive for the virus, although neither would give a specific number.
“We know there are other cases out there,” Dr. Nicole Alexander-Scott, Rhode Island health director, said on March 27.
Right now, some emergency room patients at Rhode Island Hospital who arrive with symptoms consistent with COVID-19 are discharged without testing if they are not seriously ill.
Primary care doctors within the health system are regularly speaking to people who are likely positive as well, but who are told to recuperate at home, Murphy said.
Raimondo said the state would be conducting 1,000 tests a day by April 2, a significant jump from the 100-200 tests per day being performed in the weeks after the state’s first positive case.
Raimondo has publicly asked for donations of supplies, appealing to private manufacturers and businesses, as well as health care facilities for nasal swabs and gear.
Once supplies arrive, sites such as a tent set up outside Newport Hospital for the Department of Health to conduct testing can be put to use. Sites at the University of Rhode Island, Community College of Rhode Island and Rhode Island College were scheduled to begin offering drive-thru testing on April 1.
“Depending on how Rhode Island does with access to testing and testing materials, we might see a skyrocketing number of cases,” said Jeffery Bratberg, a clinical professor of pharmacy practice at the University of Rhode Island’s College of Pharmacy. “But we might keep that curve flattened in terms of access to health care for anyone who requires hospitalization for COVID-19.
“And that’s where the goal is here for the next few weeks,” he said.
Dr. Albert Puerini, CEO and president of Rhode Island Primary Care Physicians Corp., a group that includes 150 primary care doctors and 500 specialists, said he has confidence in Rhode Island hospitals’ approach to the crisis.
“I think it’s been enough for now,” he said. “I think everybody knows this could get a lot worse, and they’re anticipating plans in the future that they may have to do. Clearly they’re anticipating the worst and preparing for it.”
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EARLY SCREENING: A health care worker at Kent County Memorial Hospital in Warwick conducts a preliminary examination at a patient’s car to determine if the patient needs a COVID-19 test or some other type of treatment. / PBN PHOTO/DAVE HANSEN[/caption]
SURGE PLANNING
Preparations at Lifespan included assembling “surge plans” and refitting some emergency department rooms into negative-pressure rooms, which don’t allow contaminants to escape. Patients who are potential COVID-19 positives are taken directly to the specialized rooms, Murphy said.
The hospital system also increased its normal count of 113 intensive care unit beds to 183 spread across Miriam, Newport and Rhode Island hospitals.
Lifespan, which has 150 ventilators systemwide, uses about 50 on a typical day under normal circumstances.
The health system “has had and will have” coronavirus patients in its ICUs, but won’t release specific numbers, Murphy said.
Care New England has seen its share of COVID-19 cases as well, although Sullivan noted that keeping exact records is difficult because not all people with suspected cases are admitted to the hospital.
“We see a lot of patients that we are testing, but if they then get discharged home, they may get that information after they’ve left the emergency room,” she said.
As of late March, Kent had been seeing about 15 inpatients a day who were awaiting COVID-19 test results, Sullivan said.
The hospital has 15 ICU beds, and has prepared another unit for use as an ICU if need be.
Under normal circumstances, there are 188 ICU beds and 352 emergency room beds statewide. As of late March, more than 100 ICU beds were occupied, about 10% of them by coronavirus patients, some of whom were on ventilators, according to the Department of Health.
Prior to the crisis, the state had about 200 ventilators on hand. State health officials have been “working very hard” to increase that number to 600, Alexander-Scott said on March 30.
The number of COVID-19 cases continued to climb as March turned to April – as did the number of those hospitalized from the disease – but health care providers indicated that hospitals hadn’t reached a crisis point yet.
“We’re very organized,” Deborah Coppola, Rhode Island Hospital’s vice president and associate chief nursing officer, said in late March. “We’ve been planning since mid-January.”
But Rhode Island, within 200 miles of the more than 47,000 COVID-19 cases in New York City, is uncomfortably close to the national hot spot for the virus, which threatens to overwhelm hospitals there.
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HITTING THE RIGHT NOTE: Providence Public Schools psychologist Natalie Fleming displays one of the thank-you notes she and a co-worker were placing on cars in the employee parking lot at Kent County Memorial Hospital in Warwick on March 27. / PBN PHOTO/DAVE HANSEN[/caption]
To curtail the spread from New York, Raimondo ordered everyone entering Rhode Island to self-quarantine for 14 days, enlisting the state police and National Guard to stop cars with out-of-state plates and go door to door in some communities to tell visitors to self-quarantine.
While doctors such as Levy are confident the state’s hospitals can handle a substantial wave of infected patients, a big surge could come without warning.
“I wake up every day wondering am I going to come in and the number of patients in my hospital with COVID-19 are doubled. I don’t know the answer to that,” Levy said. “I feel like we’re prepared if the worst comes to happen, which is that we see widespread infection and admissions to hospitals across the state.”
FISCAL PAIN
Many in the health care industry predict an enormous financial impact once the crisis is over.
Help is on the way, with $100 billion in a $2 trillion federal stimulus package bound for hospitals nationwide. The aid, signed by President Donald Trump on March 27, includes $1.25 billion to be used across Rhode Island, including at its health care facilities.
Rhode Island, along with other states, is also in line for additional Medicaid funding, according to M. Teresa Paiva Weed, president of the Hospital Association of Rhode Island.
“The hospitals will be seeking some of that funding,” she said.
But as more surgeries and procedures are delayed to free resources and keep hospital occupancy at a minimum, hospitals and health care facilities are facing steep drops in revenue. Those losses, combined with the enormous costs of equipment and materials to deal with the coronavirus outbreak, along with overtime for staff, promise to be staggering.
Murphy, of Lifespan, estimated that the health system, the state’s largest, will rack up dramatic losses.
“It will be hundreds and hundreds of millions. A $350 million cost is not a bad figure to pick, and that might be low,” he said.
Supply and staffing shortages are only going to add to financial woes, Paiva-Weed said.
“Hospitals are experiencing extraordinary financial losses in preparation for a possible surge,” she said.
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AWAITING PATIENTS: An R.I. Department of Health worker waits outside the incoming COVID-19 patient tent set up outside Rhode Island Hospital in Providence. The tent is used by health department workers to administer coronavirus tests for people who have been approved by state health officials to receive them. / COURTESY LIFESPAN CORP.[/caption]
Primary care practices, which are fielding constant calls from patients anxious to be tested or who have developed mild respiratory symptoms, are caught up in the crisis as well. Although some are continuing to see patients in person, most appointments and outpatient procedures aren’t taking place.
Raimondo’s mandate ordering health insurers to pay for telephone or virtual visits during the length of the crisis has helped quite a bit, said Puerini.
At Thundermist Health Center, which provides primary care and other outpatient services throughout the state, patient counts are down but doctors are honing virtual capabilities.
“We are very appreciative of the measures that have been put in place to reimburse and make those available,” said Amanda Barney, Thundermist’s assistant vice president of communications and development. “In the past two weeks we have seen a decline in visits, but we fully expect the needs of our patients are going to evolve through this crisis. We could see a surge in patients who have the coronavirus and need to manage their symptoms,” she said.
Puerini predicted that the increase in technology use will lead to more permanent changes for many doctors and patients.
“I think we’re going to see more digital health,” Puerini said. “That has kind of lingered on the sidelines for to or three years. Providers want to do it, but payers are slow to do it. I think a lot of things to come out of this will be positive. It’s going to make the health care industry look in the mirror and say, ‘What can we do better?’ ”
