Rural hospitals and clinics are "vigorously preparing" for the possibility of an outbreak of intense respiratory disease in their communities as a result of coronavirus, according to Brock Slabach, senior vice president for member services for the National Rural Health Association.

Slabach said because health professionals know the spread of the disease in the U.S. will be uneven and unpredictable, rural providers are preparing for the worst.

"We have to be ready, and I've talked to a number of providers who are taking this very seriously," said Slabach, who was a rural hospital administrator for more than 20 years.

More workforce, supplies and money

Brock Slabach, senior vice president for member services for the National Rural Health Association.
Brock Slabach, senior vice president for member services for the National Rural Health Association.
Rural providers are preparing in a number of ways, Slabach said. The top priorities are making sure they have ample workforce and supplies to treat infected patients, and securing the financing for their facilities to do so.

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"That's going to be a real issue," Slabach said of getting the necessary funding.

He said almost all rural hospitals and clinics have already canceled elective and non-emergency services because of concern of spreading the disease among people coming to their facilities. That creates an economic challenge for providers, he said.

"If a hospital has 60% of its services in the outpatient department, mostly elective and non-emergent, they could be financially at risk because they've depleted most of their volume," Slabach said. "And their cash flow would then suffer."

Brad Gibbens, acting deputy director of the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences in Grand Forks.
Brad Gibbens, acting deputy director of the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences in Grand Forks.
Brad Gibbens, acting deputy director of the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences in Grand Forks, said there are about 50 hospitals in North Dakota; 38 of them are rural, he said, all of which are "almost always dealing with resource issues."

"We have infrastructure issues to begin with, then we put on top of that a massive pandemic," said Gibbens. "It's going to cause a lot of concern and angst about our ability to respond."

Nursing shortages

Nursing personnel is critically important for treating patients with respiratory illness, and Slabach said most rural providers were already facing nursing shortages before the coronavirus outbreak.

Because of a lack of testing capacity for the virus right now, Slabach said employees who are suspected to have come in contact with COVID-19 are required to quarantine for 14 days.

"This takes them out of the workforce," he said. "If we had more rapid testing, then we could just determine if they were positive or not."

Slabach said school cancellations also could put a crunch on nursing personnel as employees juggle caring for children with working.

"This has placed a real burden on much of our health care personnel, in terms of securing child care while they're having to go to work," he said.

What rural providers lack

Of those infected with COVID-19, 15% to 20% will need some kind of intervention, possibly hospitalization, said Slabach, and 2% to 5% will require a form of intensive care.

Rural hospitals will be prepared for the 20% of patients that require hospitalization, but Slabach said those hospitals will have a problem meeting the demand for intensive services, particularly ones that need the assistance of a ventilator for airway maintenance.

"Because it's just not needed, many rural hospitals depend on their tertiary partners to transfer patients that are seriously ill," Slabach said. "Many of them don't have intensive care units."

Slabach predicts those partners that rural providers rely on to transfer seriously ill patients will be full and unable to do so.

"So they're going to have to do the best they can if this develops into an emergency, situation with the number of patients being presented," Slabach said. "This could be real problematic given the lack of intensive services they would have available."

Slabach said as a public health professional, his best is advice during the outbreak is for everyone to pretend they have the virus themselves. He said looking at the outbreak in a unitary perspective can make a big difference in controlling the spread of the disease.

"Meaning if you love the people you live with in your home and your neighbors and friends, if you assume you have the disease, then you'll be more careful about not spreading it," he said. "In turn, you'll be protecting yourself."

Culture shock

Gibbens, who was still trying to get the hang of working from home on Tuesday, March 17, said he's been tapped into the discussion across the country among rural communities that are trying to respond to the outbreak.

"I would characterize it as the whole country is trying to catch up to the crisis," said Gibbens.

He said the concept of social distancing is contrary to the normal way of life for rural communities.

"Our culture is orientated towards very personal type of interactions with people," he said. "We congregate at the restaurant and after church, and definitely associate through our sports programs — so seeing some of those events being called off has been a culture shock."

The best advice that Gibbens, who grew up in rural North Dakota, is to listen to local providers.

"Listen to your local public health agency, and listen to your physicians and nurse practitioners and nurses, and we'll all get through this," he said. "But you're going to have to be patient."

NRHA request

On Wednesday, March 18, the National Rural Health Association released an urgent request to Congress and the White House on behalf of its members in response to the coronavirus outbreak.

"The rural health care safety net was fragile before the national emergency, now rural health care is being crippled by COVID-19," said the first sentence in the request.

The release included a statement from a Wisconsin health care worker, who described how the community health center they work at is "facing a significant issue with supplies", and is nearly out of swabs necessary for testing. The center is also preserving its supply of N-95 masks as much as possible.

"We have not heard anything from HRSA (Health Resources & Services Administration) or NACHC (National Association of Community Health Centers) regarding the National Supply Stockpile or measures for dispersing or expediting supplies to essential health care providers. We have heard our Wisconsin hospitals are facing the same issues," read the statement.

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