Ashland hospital navigates facility, staffing constraints during pandemic
With widespread disruption of medical services due to the pandemic, specialists and hospital staff fill in where needed. Without scheduled surgeries to draw their focus, anesthesiologists with the Asante health care system have shifted to roles working with intensive care patients.
For the past three weeks, anesthesiologist Dr. Amanda Alford’s role has mimicked a physician’s assistant for doctors working with the critically ill.
Professional training and education in the anesthesia specialty includes intensive care, and Dr. Andrew Young, a partner with Anesthesia Associates of Medford who traditionally divided his time between the operating room and ICU, created a reminder course for how to be an intensive care doctor, Alford said.
For now, Alford works six 12-hour shifts per week to cover the need, including some night shifts at Three Rivers Medical Center in Grants Pass.
“I feel like I’ve been in a little bit of a hole for three weeks where I haven’t done anything else, but my family is really supportive of it and all the staff have been really thankful that the anesthesiologists are doing it,” Alford said at Ashland Community Hospital Tuesday. “There’s a good camaraderie here.”
Team strength and support is on nurse manager Amalia Kieley’s mind each day she walks into Ashland hospital’s pandemic-altered environment.
Lately, finding ways to say “thank you” to hospital staff when the words alone aren’t enough to adequately honor the high degree of work they have contributed keeps Kieley awake at night, she said.
As one option for supporting mental health, some staff meetings have been replaced with listening sessions, providing an open space for people to ask questions, bring forward concerns and share thoughts, she said.
Recently, common concerns mentioned in the sessions include staffing, resources and the vaccine — both the mandate for health care workers and unease about how to best “provide positive influence” surrounding the vaccine, ask the right questions and have answers ready for the public, Kieley said.
A resource manager determines daily which patient transfers between Rogue Regional Medical Center, Ashland Community Hospital and Three Rivers Medical Center are warranted and suited to general medical needs, specialty services or intensive care, opening up beds where necessary and balancing patient load across the Asante system, Kieley said.
With capacity maximized in the hospital’s current bed structure, a “surge plan” prepares the facility for overflow scenarios. The wound care center desk sits empty, and the rooms are staged for inpatient occupancy in case of a need to expand the med-surg department.
“Those are more specific to non-COVID patients, with the idea being that if all of the rest of our med-surg was to overflow with COVID patients, then we would move the non-COVID patients down farther to maintain that separation,” she said.
With only seven emergency department beds and two hallway beds at ACH, small influxes of patients impact the hospital significantly. Some days, there’s a wait for infusion services.
The monoclonal antibody infusion clinic at ACH treats COVID-19 patients at high risk of progressing to severe illness from the disease. The U.S. Food and Drug Administration authorized the treatment last November after clinical trials showed reductions in COVID-19-related hospitalizations and emergency visits within a month after infusion in patients at high risk for illness progression.
Incoming infusion patients undergo triage with a nurse to determine if they can be safely alone for a time. If the emergency department is full, and maintaining safe physical distance in the waiting room isn’t possible, the patient may be asked to wait in their car, Kieley said.
Before the pandemic, the hospital’s ICU treated two or three patients per day, with two nurses on each shift. With all five ICU rooms frequently full of COVID-19 patients, core nursing staff on the unit doubled 24/7.
Some staff members picked up roles doing whatever needs done, whether taking out an endless flow of plastic-bagged PPE and supply waste or delivering meals.
Tuesday morning’s hospital census included 19 patients in med-surg — double the norm one year ago — and five ICU patients. COVID-19 patients typically account for more than half of the daily census, Kieley said.
“We’re certainly seeing patients remain in ICU for much longer periods of time than we ever have before,” she said. “The people who get sick get really, really sick.”
One general surgeon now provides care as a hospitalist, and nurse anesthetists staff patient bedsides in the ICU. Nurses from the birth center have volunteered to help, and med-surg staff see patients within their scope. National Guard members provide nonclinical services such as security and housekeeping.
Before the pandemic, the hospital connected to intensivist services at Rogue Regional Medical Center via telehealth, but with intensivists now caring for patients, nurses and patients have access to valuable resources in house, Kieley said.
With the suspension of elective surgeries, four “highly engaged” surgical staff members picked up ICU shifts, and often float to the area of greatest need. Two nurses sent to the Asante system by the state became fully oriented at ACH last week, she said.
“Looking forward, our staffing looks much improved from what it was,” Kieley said.
Still, too few non-contract nurses are taking jobs, and contract nurse positions remain open, she said. On a case-by-case basis, interested staff members can cross train on patient care services.
Any sort of respiratory symptom sends an incoming patient into the “hot zone” — two sealed soft wall areas in med-surg that allow negative air pressure to be maintained across the zone and separate case types in the department’s small space. The majority of incoming patients are placed in isolation until their status is clear, Kieley said.
“Temporary negative pressure rooms help mitigate the transmission of the aerosolized virus to adjacent spaces, containing contaminates and particles,” according to the American Society for Healthcare Engineering.
Kieley said an increase in COVID-19 testing resources in the community has resulted in a greater number of patients checking into the hospital knowing they have been exposed to the virus or who already have a positive test.
One person receiving intensive care at ACH Tuesday was not COVID-positive. Staff maintain strict infection prevention protocols to protect those patients, and transfer them out to med-surg as quickly as possible, she said.
A typical path to intensive care for a COVID-19 patient starts with their arrival at the emergency entrance after being sick for a week, likely not eating, drinking or moving around much, Alford said. The patient finds that when they try to move, they can’t breathe.
By the time they come into the hospital, the patient’s oxygen levels are “impressively low” in the 80% range or lower, Alford said. Normal oxygen levels hover between 95-100%.
After a day or a week — depending on the patient — of receiving oxygen and other preliminary therapies, the treatment becomes insufficient and oxygen levels fall, sending the patient into intensive care.
“By the time you get to needing to have oxygen under pressure, what it means is that there’s so much inflammation in your lungs that your lungs are lacking the ability to absorb the oxygen from the air to such a degree that just giving you more oxygen isn’t getting the oxygen in,” Alford explained. “Now we have to give you more oxygen, but we have to pressurize it to physically try to pressurize it through the swelling to your lung tissue.”
The first stage of oxygen supply comes through a bilevel positive airway pressure machine, with a mask over the face creating a seal as oxygen pushes through at a constant rate of 65-80 liters per minute. It’s an outrageously high amount, but barely enough for these patients, Alford said.
Many patients exhibit signs of malnutrition at this point.
“We’re putting all of that oxygen in, but it’s not getting into their bloodstream. They’re just not absorbing it,” Alford said. “If they take BiPap off to eat for five minutes, their oxygen levels tank.”
Low oxygen worsens existing lung injury, she said. Some patient’s oxygen levels drop below 90% without causing an out-of-breath feeling, which challenges their willingness to keep the BiPap mask on, Alford said, acknowledging the uncomfortable experience of having a sealed mask blow air in with every breath, making loud, ceaseless noise.
If the first stage of intervention fails, a breathing tube is inserted and unconscious life begins on the ventilator. Patients who reach this stage require higher pressures to force oxygen in than can be achieved with the BiPap masks, which don’t always seal properly and patients often remove to talk or take a break from discomfort, she said.
“They need to be sedated on the ventilator and sometimes we have to run an infusion of a paralyzing drug so that they’re paralyzed and sedated, which allows us to push air under higher pressure into their lungs,” Alford said. “Sometimes people need so much pressure for so long that we’re actually damaging their lungs because we’re just pushing the upper limits of how much pressure and oxygen we can give over time.”
For some patients, so much pressure must be forced through the tube that a paralyzed/sedated combination is necessary to allow their muscles to expand and accept the intensity, she said. Sustenance comes through an oral tube to the stomach.
At RRMC, 7,200 gallons of water per day is sprayed on the oxygen tank to mitigate ice buildup due to high usage, according to Asante communications specialist Lauren Van Sickle. Changes are in the works to increase evaporator size and eliminate the need to use water for this purpose, Van Sickle said.
During Alford’s recent shift at Three Rivers, the low oxygen pressure alarm repeatedly sounded because the system couldn’t keep pace with demand — typically the facility goes through one large oxygen tank per month, but last week, a tank was tapped every two days, Alford said.
Based on her observations, the average time for a patient on a ventilator is about two weeks. After two weeks, if the patient’s lungs heal sufficiently for the breathing tube to come out, they experience severe body weakness from lying immobile.
As far as ventilator availability, Alford said ACH has been “on the edge” of what is needed — though a decline in COVID-19 patient admissions over the previous two days temporarily eased a scarcity issue.
Asante’s resource management group analyzes the availability of ventilators, BiPap machines and other special equipment every day across the system, to determine how equipment should be distributed at each facility and what needs to be borrowed from elsewhere, she said.
“It definitely feels like we’re using a lot of resources and we’re not getting a lot of saves,” Alford said. “In the last three weeks, I’ve had four people who have died on my watch because the family has withdrawn care, because moving forward was obviously futile.”
A handful of Alford’s patients in the 25 to 45 age range were otherwise healthy, yet she still witnessed the moments their families had to choose to remove the breathing tube and allow their loved one’s life to end in the ICU.
“It seems like this particular wave is making people really sick, and we’re just trying everything we can, and it’s not working,” she continued. “Once their disease is so bad that they get to me, the likelihood that they will get out of the hospital is very low. If they do get out of the hospital, they have a very long road of rehab before they’re anywhere close to being independent.”
The trend forces a difficult conversation for Alford in the ICU — she encourages patients to call loved ones, share any unsaid words or sentiments, and make sure someone has a copy of important passwords and documents before intubation becomes a reality.
“Maybe that’s unlikely, but your best chance of not getting to me is to get vaccinated,” Alford said. “If you don’t win the lottery, the cost is high.”
Reach reporter Allayana Darrow at firstname.lastname@example.org or 541-776-4497.