During the first outbreak of COVID-19 in the United States, rural hospitals around the country were forced to rapidly adapt to confront the challenges posed by the emerging pandemic. At Stoughton Hospital in rural Wisconsin, Beam Healthcare’s Hospitalist team began to prepare for an influx of critically ill patients. The team knew that resources would be limited, so they would have to work together, communicate, and rely on each team member’s unique experiences and expertise in order to deliver comprehensive and ICU level care to the community
“Everybody really stepped up and leaned on each other. We all bring experiences from other places and that helped everybody work together. It was a learning curve, but we ended up stronger by the end of it,” said Marlise Davidson-Fielder, Hospitalist at Beam Healthcare.
Supporting Critically Ill Patients
The ICU expectations prior to COVID-19 were massively different for critical access hospitals. Between 2018-2019, Stoughton Hospital had a total of two intubated patients and the majority of critically ill patients were transferred to larger medical centers with more robust resources. However, when the pandemic struck, the hospital systems were completely overwhelmed, even those in larger metropolitan areas. This forced critical access hospitals to work with what they had to help patients recover.
The pandemic progressed slightly slower than expected in the Midwest, which allowed the Hospitalist team a little extra time to get more comfortable with managing these patients. “The heat in the frying pan was slowly raised for us until we were finally taking care of these sicker and sicker patients, and we just got more and more comfortable with it. Whenever possible we would hand the patients off, but once those transfers were totally impossible we had increased our abilities to the point that it wasn’t unreasonable for us to care for the patients,” said Mark Menet, VP of Hospitalist at Beam.
Throughout this journey, the team experienced both challenges and successes. Marissa Julseth, a recent graduate and ICU nurse at Stoughton Hospital said, “The first intubated patient we took care of, we saw a lot of complications, and that patient did not make it. That was my only experience – having an intubation not be successful – and it was really hard. The two traveling ICU nurses on our team at the time were saying that this happens more than you think.
Charlie’s COVID Journey
Not long after, another patient, Charlie, was admitted to Stoughton Hospital, severely ill with COVID. The entire staff worked to take care of Charlie but his condition continued to decline each day. Eventually it came to the point where intubation was the only option, but the staff knew that the chances of survival were low. Having gone through the negative experience of losing their last intubated patient, the team had to lean on each other for support. “We had great teamwork,” said Marissa. “We all learned from our first patient and were communicating about what was going on at all times. We kept the family very informed and we tried to be realistic about expectations and the prognosis.”
Prior to COVID, Charlie would have been transferred to a larger hospital once he was intubated, but in this situation hospital systems were totally overwhelmed and beds were impossible to come by, especially for COVID patients. The entire respiratory, nursing, and hospitalist teams came together to continue caring for Charlie, doing everything they could to manage his symptoms. Over the course of the first 3-5 days Charlie was very sick. “His brain wasn’t functioning and he wasn’t following commands,” said Marlise. “It was difficult to know whether or not he was going to make it.”
After around 1 week of intubation the team began to see indications of Charlie’s lungs starting to get better. They continued to manage his symptoms, doing everything they could to give his immune system time to beat the infection and then start healing. The team started to become more optimistic about Charlie’s prognosis, but they also knew that the chances of successful extubation were slim. “Just about the time when the tube was going to start failing, we were able to get it out of him and he weaned very successfully,” said Mark. “He was incredibly weak, but we were able to transition him to BIPAP support and later a nasal cannula to continue supporting his lungs.”
After Charlie’s extubation, the team knew that they still had plenty of work cut out for them to ensure complete recovery. The team was able to get him breathing, but he wasn’t able to safely eat or drink so they placed a PEG tube – a big step in improving Charlie’s nutrition. He surprised the nurses and hospitalists by recovering faster than expected, and within a month he graduated from needing the feeding tube. Eventually Charlie was medically recovered, but he was still too weak to go home.
At larger medical facilities, when patients don’t have an active medical need they are often transferred to a skilled nursing facility where they spend a couple of weeks regaining their strength, building up their muscles, and getting to the point where they can safely return home. However, because Stoughton’s censuses are lower, the hospital is able to transition to swing-bed care. This allows patients to transfer from acute care to continue receiving skilled nursing care services, including physical therapy, occupational therapy, and monitoring of vital signs, among other services. “We took care of Charlie from the beginning, when he was at his worst, until he was ready to return home,” said Marlise. “He was able to stay in the same room, and he had the same nurses and doctors throughout his entire recovery journey.”
Throughout Charlie’s stay at the hospital, he also experienced an outpouring of support from his friends and family. His brother visited the hospital nearly every day for updates on his condition, and Charlie’s girlfriend Tina would come and sit outside the room and talk to him over the phone. Many of Charlie’s good friends also called, and the team would put the phone on speaker so that Charlie could communicate with them. “We like our patients to know that they’re not alone,” said Marissa.
The COVID-19 pandemic has been a learning experience for healthcare systems all across the country, especially rural facilities like Stoughton Hospital. “I think everybody really stepped up and leaned on each other,” said Marlise. “We all brought experiences from other places too and that helped everybody work together. We ended up stronger by the end of it.”
Being in a smaller hospital has presented unique challenges for the Stoughton team, but it has also allowed them to develop closer relationships with the patients and their families. “You spend a lot of time with them, you get close to them, and they almost become your family,” said Marissa. “This experience taught me to never give up on a patient. If that was your loved one you would want their care team to do everything in their power to try and get them back to normal, and that’s what we did for Charlie.”