FARGO — Deaths from the coronavirus plague started slowly at first in North Dakota.

Thirteen COVID-19 deaths were recorded in March, the first month of the pandemic.

The death toll climbed gradually, reaching an early peak in May of 43 deaths. Through July, North Dakota had mourned 106 lives taken by the virus.

Then cases and deaths began to skyrocket. September brought 116 deaths — but October is on pace to surpass that number, with 67 deaths as of Friday, Oct. 9, as the state continues to produce one of the nation’s highest per-capita infection rates.

Models projecting the pandemic’s trajectory show no signs that infections will taper, at least in the coming weeks — and health system administrators interviewed by The Forum couldn’t point to any concrete signs that anything will change soon.

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North Dakota’s death toll could climb as high as 475 by Nov. 1, according to one projection, and the number could reach 579 by Nov. 15, under the most pessimistic prediction.

Forecasting by both Sanford Health and Essentia Health suggest the surge — which is straining hospital staffing levels around the state — will not ebb, at least over the next several weeks, the most accurate range for prediction models.

“Unfortunately, what I’ve been seeing is we expect to continue,” said Dr. Doug Griffin, vice president and chief medical officer for Sanford Fargo. “It’s a similar level as we are on for the next few weeks. That doesn’t mean things can’t change.”

Just maybe, he said, more people will take heed of the constant pleas from public health officials and health providers to wear masks in public, keep safe distances, avoid large gatherings and wash hands frequently.

Dr. Richard Vetter, chief medical officer of Essentia in Fargo, has a forecast that is no more encouraging.

“At least in the near term it doesn’t look like it’s going to back off, at least in the next few weeks,” he said. “It looks like we’ll be status quo for the next few weeks.”

Similarly, public forecasting models for the pandemic in North Dakota predict infections will continue to climb over the near term.

In spite of the continued surge in COVID-19 cases, enforcement of preventive measures doesn’t appear to be coming from the state. Gov. Doug Burgum has repeatedly rejected the idea of a mandate on facemasks, making the state one of only about 15 not to impose the requirement. Instead, the first-term Republican has encouraged residents to take “personal responsibility” and choose to wear masks and social distance.

When asked what actions his administration has taken to reverse the upward trajectory of COVID-19 deaths and cases, the governor said the state has managed to keep the economy, schools and universities open while maintaining a two-week average rate of positive tests around 7%. The World Health Organization recommends keeping positivity rates below 5% before allowing businesses to reopen.

“We’re managing our way down the path with some very positive results, but we need a little more on the personal responsibility side,” Burgum said, “because that’s what will work. We don’t need more government mandates — we need people to understand that what they do as an individual affects their community.”

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State health officials and hospital administrators are working on collective planning to handle surge capacity, with an eye toward transferring low-risk patients to rural hospitals, where most of the available staffed beds are located as the state’s six major medical centers fill up with patients.

North Dakota currently has 1,854 staffed hospital beds. Administrators stress that maintaining staffing levels is the critical issue, a challenge that becomes greater over time as nurses are working extra shifts.

“There’s no doubt about it, we’re near capacity,” said Tim Blasl, president of the North Dakota Hospital Association.

The entire state has just 16 available intensive care beds and 186 regular, inpatient beds, according to Friday figures from the state health department.

Fargo’s three hospitals have a combined five open ICU beds and zero inpatient beds, while Bismarck’s two hospitals have just one ICU bed and four inpatient beds between them. The lone medical centers in Minot and Dickinson are also feeling the crunch with only a few open beds each.

As hospital administrators continue to coordinate management of the surge in admissions, the priority is to alleviate the pressure on hospitals so they have room for more complicated cases, COVID-19 and other, Blasl said.

“It’s all being managed and balanced by the big facilities currently,” Blasl said.

Administrators from the top medical centers in Fargo, Bismarck, Grand Forks and Minot said they are sharpening their surge plans, which many have had in place since the start of the pandemic.

Trinity Medical Center in Minot already has activated its surge plan, according to a joint statement by Dr. Jeffrey Sather, chief of medical staff, and Vice President Randy Schwan.

“Our surge plan was triggered several weeks ago when the number of COVID-positive patients outgrew our first-level surge capacity,” they said. “We have since expanded our designated COVID unit to include our entire fifth floor medical unit, and have plans to expand beyond that space when needed.

“On any given day, the normal ebb and flow of patient admissions/discharges expands or contracts that bed availability, but we are lately more often near or at capacity based on the level of available staffing.”

Dr. Michael LeBeau, president of Sanford Bismarck, cautioned that patients might notice the effects of the surge on health systems.

Patients in North Dakota may have to live with longer wait times at hospitals, unusual bed arrangements and occasional transfers from one facility to another during the pandemic, he said. Some hospital patients may even have beds in the hallway, LeBeau said.

To handle surging admissions — which administrators attribute to a combination of postponed care, normal illnesses and COVID-19 cases, hospitals are doing their best to hire traveling nurses, having nurses and other care providers work overtime shifts.

Some are postponing elective procedures to keep beds open, while Sanford hospitals in Fargo and Bismarck have added beds.

Essentia and Sanford also have transferred some patients to smaller hospitals to free capacity at their Fargo medical centers.

Construction workers are adding rooms to provide space for 14 additional beds at Sanford Medical Center Fargo, which has been coping with high admissions. Hospital administrators say normal illnesses, delayed care from earlier in the pandemic, and COVID-19 cases have combined to cause admissions to surge throughout North Dakota. Special to The Forum / Sanford Health
Construction workers are adding rooms to provide space for 14 additional beds at Sanford Medical Center Fargo, which has been coping with high admissions. Hospital administrators say normal illnesses, delayed care from earlier in the pandemic, and COVID-19 cases have combined to cause admissions to surge throughout North Dakota. Special to The Forum / Sanford Health

COVID-19 accounts for about 11% of hospital admissions in North Dakota, said Janice Hamscher, chief nursing officer for Altru Health in Grand Forks.

“This number is far less than projections we had at the start of the pandemic,” she said.

“At Altru, our experience with hospitalized patients has been lower, around 7-8%. As the situation evolves, Altru will work with our partners to determine the best path forward.”

Health systems don’t want patients to delay care, something that happened early in the pandemic, when many patients avoided hospitals and clinics for fear of contracting the virus.

“We do not want anyone to miss their screenings or appointments out of fear over Coronavirus,” Hamscher said. “The impact on the health of our communities could be too great.”

CHI St. Alexius President Kurt Schley said COVID-19 patients place such strong constraints on hospital staffing because nurses must be designated as “runners” to get drugs and supplies for other nurses and doctors that are wearing full protective equipment.

Hospital admissions are up, Schley said, but patients with COVID-19 are not as sick as they were earlier in the pandemic because of new treatments like remdesivir and convalescent plasma.

Health system administrators and the governor agree on one point: North Dakota is nowhere near having to mobilize a field hospital to handle overflow patients, action Wisconsin has taken.

One variable that nobody can predict is the severity of influenza season, which is just getting started. Fortunately, administrators said, the southern hemisphere, where influenza outbreaks begin, is having a mild flu season.

Last flu season, 549 patients were hospitalized, including a weekly peak of 90, according to state figures. At Altru, 34 flu patients were hospitalized last flu season.

“Getting a flu shot early is important this year so that people are already vaccinated prior to a COVID vaccine being available,” Altru’s Hamscher said. “There are antivirals for influenza,” which should be taken within 1-2 days of flu symptoms. “It will be important this year to differentiate between influenza and COVID, including testing for both.”

Fargo-Cass Public Health officials said they do not plan any new strategies. They have an education campaign dovetailing with the state's to promote mask wearing and distancing, and will continue with targeted testing of vulnerable and high-priority groups.