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Spared a coronavirus surge, hospitals starting to reopen for business

Pardee UNC Health prepared for a surge of Covid patients and got hundreds less than expected. Pardee UNC Health prepared for a surge of Covid patients and got hundreds less than expected.

The atmosphere was somber when Pardee UNC Health CEO Jay Kirby stepped to the microphone at a meeting of the Henderson County Board of Commissioners in the Historic Courthouse the morning of Friday, March 27.

People were spaced six feet apart: county commissioners, county attorney, administrators, school leaders, public health director, emergency services director, sheriff, the press.

Kirby, who possesses a deep Southern-tinged voice and authoritative bearing, told commissioners that he had been tracking the rapidly rising number of Covid-19 cases across the state and had asked the medical team at Pardee for projections on virus-related hospital admissions. The answer: 500. The consequences grew more dire from there.
“Forty-five percent of hospital patients will require ICU level mechanical ventilation,” he said. “Of that, anywhere from 1-15 percent will be a mortality rate.”
Police officers race toward gunfire, he said, and firefighters race toward fire.
“What I’m here asking for is community support of frontline nurses, physicians, caregivers, respiratory therapists, labs, housekeepers and nurses who are going to run to this,” he said. “Pardee will run to this head-on but I need your help, so that when they run to this fire, they’ll have the masks, the goggles, the gloves and the gowns so they can feel safe and secure caring for the most critical.”

Hearing the warning, Commissioner Bill Lapsley, who thinks in a straight line like the civil engineer that he is, said the information presented by science and public health experts seemed to have left the elected leaders with no choice.
“We get input from our medical community that these numbers are going to grow exponentially,” he said. “Yeah, we’re all doing our part by trying to limit large groups but that’s not going to cut this peak down low enough to avoid a serious problem in our medical community with patients. That gets to the third component and that’s the ventilators. If we don’t have enough ventilators to handle the number of people that are in the hospital we’ve got a serious situation here. That puts our medical community in an awkward situation to have to deal with more patients than they have the ability to treat and that raises a red flag for me.”
Commissioners responded almost immediately. They voted unanimously to adopt an emergency order requiring people to stay at home and imposing other restrictions on gatherings and businesses.
The commissioners’ order, one of the first by a county outside the state’s largest metro areas, was made academic four hours later when Gov. Roy Cooper imposed a statewide stay-at-home order. Either the threat was overstated or the order worked as well as public health officials dared to hope. While Henderson County has a high number of cases — the 10th most in the state, according to an analysis by the Hendersonville Lightning on April 19 — its two hospitals have seen only a trickle of patients with Covid-19. Nor has the region’s largest hospital, Mission Health in Asheville, seen a surge.

Admissions fall 484 short of projection

Last Friday, exactly four weeks after the county and statewide orders, Kirby had a new set of numbers on what had actually taken place. In a Zoom meeting of the county’s Post-Covid committee on reopening for business, he praised business owners for taking the threat seriously. “Don’t change anything that you’re doing,” he said, “but don’t be so scared that you become paralyzed because we have people working day in and day out in this hospital who have only seen 16 people come into this hospital with Covid who have been admitted.” Just four employees had contracted the virus.

The Covid landscaping was changing.

The day before, Dr. Teresa Herbert, medical director of AdventHealth, had a similar message during the Land of Sky regional council’s Covid-19 update.
“We’re moving from containment to recovery,” she said. Advent and Pardee UNC Health have been spared a large spike in cases, patients, ICU use and need for ventilators health care professionals had predicted four weeks earlier.
Herbert credited “a really great collaboration with our health department” to hunt for and identify areas of outbreaks and to ensure treatment that does not overwhelm hospitals.
“We’ve been able to manage patients in their homes and keep them in their homes so we can avoid the surge,” she said. “We’re not seeing a lot of community spread. The ICU right now has very few patients.” Pardee is “in the same situation. There is not a lot of community spread right now. That has really saved lives. If you look down at Greenville County, things are very, very different. The hospitals are very busy.”
Someone attending the Land of Sky Zoom meeting asked Herbert how many Covid-19 patients were currently under treatment in the intensive care units of AdventHealth and other hospitals.
“None now,” at Advent, she said. “Pardee has a couple and Mission a handful. Patients in ICU are related to the long-term care facilities. They were known to be infected when they came into the facility.”

Hospitals resume elective surgeries

While no public health official is recommending a broad relaxation of the stay-home orders, the lower number of cases at the county’s two hospitals suggests that the worst-case surge has been avoided.

Pardee has begun scheduling non-essential surgeries, because it has plenty of capacity and the supply line of masks, goggles, gloves and gowns has improved, said Dr. David Ellis, the hospital’s medical director.
“At this point we have an adequate supply of personal protective equipment and the supply chain seems to have stabilized,” he said. “Any surge we were going to see appears to have been significantly pushed out. A month ago, we were looking toward June” for a peak in Covid patients. “That curve doesn’t look as high as it did a month ago
He credits widespread adherence to the stay-at-home order for the near flatline of cases.
“I think these things have worked,” he said. “We’re seeing several (Covid patients) on a daily basis but not anything that can’t be handled. A month ago we didn’t know where we were going to be today and today I don’t think we know what things are going to look like a month from now. I think we all think we’re going to get a bump when people start socializing again.”

Mission Health announced Monday that it, too, would resume nonessential procedures.
The surge of COVID-19 patients initially anticipated when the pandemic first began to spread across the country has not materialized in Asheville, either. Mission had just over 20 inpatients with COVID-19 throughout the entire health system as of late April, the HCA-owned medical facility said in a news release.
“Thankfully the sacrifices we have all made to flatten the curve have helped to slow the spread of the virus,” said Greg Lowe, president of HCA Healthcare NC Division and Mission Health. “This gives us hope as we plan to restart services that we temporarily suspended in March as part of our initial response to COVID-19.”
“We understand that many of our patients have forgone important procedures like cancer therapies and joint replacements due to the pandemic, and we are developing a cautious, comprehensive strategy to allow for the safe return of these patients to our facilities.”

‘We may be on the down side of this’

How did the projection of 500 admission miss the mark by 486 patients? “That’s the magic question,” said Lapsley, the tip of the spear for the local shutdown order.
Commissioners, he said, acted on the information they received on that Friday morning of March 27.
“At that point in time we weren’t sure what the governor was going to do so we felt like based on what we were told by Jay Kirby and his staff and all the information that the commissioners needed to step forward and start asking people to stay at home,” he said in an interview Monday.
“We don’t have any proof that says because we did this stay home deal that we saved X amount of lives,” he said. “I’m confident we did. I don’t have data to prove it was 80 percent effective but we know it had a positive effect on our community. And I’m glad we listened to the medical professionals. But now as we work through that, I would like the commissioners to have the flexibility to decide how we open back up rather than it come from Raleigh.”
Two weeks ago, Lapsley transitioned to a new role. Now he co-chairs the county’s Post-Covid committee to draft guidelines for reopening the local economy. On Friday he told the 22 business owners and factory managers on the committee that he hoped the governor would grant counties flexibility in reopening their local area.
When Cooper spells out conditions needed to ease restrictions, “the implication is he might extend it again until the end of May and I don’t know as a community that we can survive that extended period,” Lapsley said. “I’ve got some frustration with that.” (Cooper ignored the county’s request for the authority to reopen for business.)
“It appeared to us the governor hadn’t decided what he was going to do” when county commissioners formed the post-Covid committee on April 15. “Was he going to stop everything and open the door wide open or he was going to extend his order.”
Seeing the flat numbers at Pardee and Advent, commissioners grew to believe it was time to prepare a plan for life — and commerce — after Covid.
“Pardee Hospital was not seeing 200 people in the hospital as was projected,” he said. “Well, now we have statistics, we have actual facts. The numbers we’re seeing at Pardee were telling us that, ‘Hey, we may be on the down side of this.’”
The panel on reopening for business has one more meeting, on Wednesday.
“So our committee is going to finish its work on Wednesday and we’ll have our things together but we’re not going put them out because at this point it would be confusing to the public,” he said. “It may be in conflict with what the governor does because the governor has control over this.”
Asked whether commissioners would reconvene a meeting of the public health director, hospital administrators and infectious disease experts for an updated projection on cases and the hospital burden, Lapsley said, “It’s a fair question.”
Even with weeks of actual experience, rather than models, to guide them, commissioners know that they can’t be sure the coronavirus won’t roar bigger than it has up to now.
“Cases may spike by 200, I don’t know,” Lapsley said. “But it looks like to me that we’re getting in a better position every day. Thirty people (with known Covid-19 infections outside of nursing homes) in a general population out of 130,000 — that’s pretty small, that’s pretty negligible. It seems to me we’re in pretty decent shape. So I’d like to see us focus our attention where we know the problem exists and ease up the rest.”

Not like flu season


Dr. Ellis, Pardee’s medical director, recommends that people adjust their outlook to the reality of the novel virus.
“I think people need to realize that this isn’t going to be like flu season,” he said. “There’s a part of this that we’re going to have to deal with. There’s not a date that this goes away. We need to realize that this is going to be a somewhat slower recovery than we’re used to and not be panicked by the fact that it’s around for a while.”
At Pardee, beds remained empty when Covid patients failed to show up. Elective surgeries fell to zero, regular business at physician practices and urgent care centers ground to a halt. Some days in the ER, crickets.
“I think every hospital in America financially is suffering from this,” Ellis said.
But in the longer view he sees victory on both fronts — in medicine and the economy.
“The U.S. health care system will eventually conquer Covid,” he said, “and it will eventually conquer the financial problems Covid created.”