Stories From a Rural Hospital During the COVID Pandemic
This is the story, told from multiple perspectives, of one rural hospital’s innovative approach to keeping their hospital beds available for the most critical patients.
The Struggle for Survival
During the COVID pandemic, the struggle for survival affected all who encountered the infection. Hospitals were ground zero for the sickest patients. Primary care offices, emergency rooms and urgent care centers were ground zero for the initial contact.
What happened to patients with COVD-19 after they received their initial diagnosis? This is the story of a new technology born out of necessity to respond to a new pandemic the likes of which the world had not seen since the influenza pandemic of 1918. The COVID Virtual Hospital, hereafter referred to as CVH, was designed to keep emergency rooms from crowding, and hospitals with limited numbers of inpatient beds, ventilators, oxygen, personnel and more from being overwhelmed. This is the story, or stories told from multiple perspectives, of one rural hospital’s efforts to make sense of an environment that changed from day to day. The central theme of these stories is how a community hospital and their primary care physician staff, in real time, were able to adapt to the COVID pandemic surges and, as a result, save lives.
The CVH was a real time innovation created to meet the needs of a rural hospital and the patients they serve in the time of the COVID pandemic. The goal of the CVH was to keep hospital beds available for the patients who most needed them. The nucleus of the CVH was a group of five RNs who also were well versed in care management. They would contact patients on the phone and through a risk assessment tool were able to stratify patients. Through this tool they were able to determine the needs of the patients and escalate care accordingly. After each encounter, a message was sent to the patient’s provider to update them on the patient’s progress or lack thereof.
Dr Gandhari Loomis, DO — Family Medicine Physician, BlueRidge Medical Group Physician Advisory Council Chair and Medical Director of the BRMG COVID Virtual Hospital
As with many advances in medicine, technology arises due to a perceived need in our communities. As we looked at the news coming out of New York City in February 2020, many in our healthcare community wondered when this pandemic would reach our small rural community. Further, what could we do to prevent our hospital and limited resources from becoming overwhelmed by this virus? Burke County’s first confirmed COVID case arrived on March 24, 2020, and urgency for preparedness suddenly escalated.
Early on, our system began weekly ‘All Provider Calls’ to educate and train members of our outpatient medical group and medical staff on the new CVH. Since the COVID diagnosis would be originating with our point of care testing locations, further direct education sessions were completed with Urgent Care and Primary Care Providers.
These All-Provider communication touchpoints were also utilized to give updates on the ever changing landscape of the pandemic, providing guidance on testing supplies, testing algorithms, reporting requirements, isolation/quarantine guidelines, and clinical care recommendations. Knowing that this would be a community-wide effort, we invited all community providers, including independent practices and representatives from the health department to attend.
In conjunction with our local county medical society, the system sponsored a thermometer distribution program with specific targeting of local churches, schools, and the health department. As providers volunteered for hospital disaster privileges, a second initiative, Essential Skills Training, a hands-on workshop for our providers on how to complete IVs, venipunctures, IV pump management, intubation, and suction management, was offered with multiple sessions. These initiatives helped ignite provider engagement and facilitate everyone working toward a common purpose.
In early April 2020, one of our hospitalists asked a simple question after noticing an EMR order set for ‘COVID Virtual Hospital’, “should we be using this order when we discharge COVID patients?”. Upon quick investigation, it was apparent that Atrium, our large hospital system partner in Charlotte at the time, had developed a program using a self-monitoring app, virtual nurses, virtual hospitalists, and paramedicine. Given the inherent differences in patient demographics, resources, and size, it was easy to see that their CVH was not a one size fits all model. But the concept was sound and why couldn’t we create our own CVH that was resourced by our organization and right sized for the needs of our rural community?
The goal was simple: take care of COVID patients at home as long as it is safe to do so, minimize unnecessary presentations to our Emergency Departments, and keep our hospital from becoming overwhelmed. It was imperative that we prevent what was happening in New York City and health care systems in other parts of the world (England, Italy, etc.) from happening here. If the predicted COVID surge was going to happen in our community, we needed to make sure our inpatient beds were reserved for those who needed them the most.
To accomplish this goal, we hypothesized that virtual monitoring through touchpoints based on disease risk stratification would yield less self-escalation to Emergency Departments. Further, if patients were connected to virtual care, including home monitoring equipment, nursing calls and virtual visits with a primary care provider, they would receive the necessary home care and guidance for supportive disease management and hence decrease the likelihood of needing a higher level of care (inpatient). This would require exemplary coordination of care, education, and collaboration across our healthcare system.
With that, the Blue Ridge CVH went live on April 22, 2020. Upon COVID infection confirmation, patients were risk stratified based on an existing pneumonia assessment tool called the DSCRB65, which determined necessity of inpatient or outpatient initial management. Briefly, this tool risk stratified patients based on specific clinical criteria (D-chronic disease, S-O2 saturation<92%, C-confusion, R-RR>22, B-BP<90 and 65-age>65). Those who did not require inpatient level of care were admitted to the Blue Ridge CVH. The initial step required notifying the CVH Team of admission via the EMR, providing the patient with a pulse oximeter and instructions for proper use, notifying the Primary Care Provider of the patient’s COVID diagnosis and scheduling a Virtual Visit appointment with the PCP in 2–3 days. If the patient did not have a PCP, they were assigned a new provider through the CVH Admission Process. Notably, of the first 700 patients enrolled, 255 patients did not have a PCP and were assigned to a medical home.
The keystone of the CVH is our Transitional Care Team Nurses. This team was already well versed in the tasks of direct patient care, nursing triage, coordination of care and quality initiatives for decreasing re-admissions. They were a natural fit for becoming our CVH Nurses. After receiving notification of admission, the nurses contacted the CVH patient within 12–48 hours (depending on their DSCRB risk score). A COVID-19 Nursing Questionnaire (CNQ), a patient symptom triage form, was completed during each patient call and recorded in the patient record. This questionnaire provided an automated risk score which suggested a time frame for the next follow up call. For example, if a patient scored low and was minimally symptomatic, they would receive a check in call in 3 days. If their score was high, they would receive a call back in 12 hours. Having RNs in this role also allowed for use of their clinical judgement in determining each patient’s unique monitoring frequency. To ensure continuity in care, each CNQ was forwarded to the PCP for review.
In addition to the CNQ, the CVH Nurses and PCP’s maintained direct communication via EMR messaging for any patient needs. As to not duplicate services, on days when the patient had a COVID Virtual Visit with their provider, they were not contacted by the CVH Nurse. Creating 3-way communication between patient, nurse and provider yielded a streamlined, coordinated approach for each patient. CVH Nurses also provided extensive education on supportive care, pulse oximeter parameters and warning signs of decompensation. They played a vital role in education regarding quarantine, isolation, return to work guidance, vaccine guidance, Monoclonal Antibody Therapy and addressed social needs (food insecurity, medication assistance, etc). For patients who were non-English speaking, the team utilized language services to assist.
With funding assistance from our hospital foundation, every COVID+ patient was provided with a pulse oximeter at the time of diagnosis, free of charge. If results were received after the patient’s visit, from a send out test, for example, they were instructed to send a healthy friend or family member to a designated location to pick up a free device. We knew that having this device in the home was imperative if we were going to successfully engage with sick patients via a virtual platform.
Upon CVH admission, a PCP Virtual Visit was arranged within 2–3 days, on average. We knew from the NYC surge that if a patient was going to decompensate, this was most likely to happen around day 7–12 of illness. During the virtual visit, the provider was able to obtain real-time objective data from the patient including their resting oxygen level, ambulatory oxygen level and heart rate. Utilizing video platforms added the ability to visualize respiratory effort and calculate a respiratory rate if desired. Having this objective data was critical in making a confident clinical assessment of the COVID patient.
Although the CVH concept was a tall order, we were confident that broad, repetitious, and direct communication with our healthcare teammates could get us there. Communication was critical and our early All Provider Calls and community preparation initiatives would prove themselves to be invaluable as we introduced the concept of CVH. When it was time to roll it out, we already had everyone’s engagement and attention.
Knowing that we may need additional resources and financial support in the future to sustain the CVH, from the beginning, we collected data. As the case counts in the community increased, analysis of the data became enlightening. By tracking demographic information, employer information and other details, we were able to see, like a crystal ball, what was coming. For example, from our data tracking, it was apparent that there was a cluster outbreak at a local meat processing plant before anyone else in the community knew that the outbreak was happening. We were able to share this invaluable information with our hospital leaders and county health department.
The data also proved itself as a predictive model for subsequent surges. As our CVH census would gradually begin to rise, we were able to prepare our outpatient, hospital, and administrative teams. Conversely, as our CVH census decreased, we could advise our hospitalists that numbers should begin falling over the future weeks.
In late October 2020, we began seeing those subtle changes suggesting a new surge. By this time, our CVH nurses were very adept at knowing who was safe to monitor at home and who needed to have inpatient management. However, there was a small subset of patients that the CVH nurses simply didn’t feel comfortable managing at home. “Dr. Loomis, if we could just lay eyes on this patient, give them IV Fluids or oxygen, we could probably keep them from going to the ED.” Was this possible? Could we provide a higher level of care in the field and further avoid an escalation to the ED or inpatient while still safely monitor them at home?
With this in mind, we began preparing for an additional, critical level, of our CVH. Through collaborative efforts with the ED, Infectious Disease, Outpatient and Hospitalist physicians, a clinical matrix for same management was agreed up. Our CVH, Critical Level, involved a mobile health team made up of an EMT-P and RN. The CVH nurses identified patients that needed in home assessments and interventions. Mobile health was deployed to the home and cared for, on average, 4 of the most acutely ill CVH patients each day. After thorough evaluation and implementation of needed interventions, a CVH Attending was contacted to complete a Virtual Visit with the patient and Mobile Health Team. The team together would then determine if the patient was safe to remain at home or if care needed escalated to inpatient management.
On December 23, 2020, I received an emergency call from administration regarding the surge. The hospitals in our surrounding counties had reached capacity and were requesting to transfer patients to our small hospital. At that time, our hospital had a COVID census of 24 while they each had 61 and 104 COVID patients. This was the moment I realized that our CVH was truly working. We had achieved our goal of reserving inpatient hospital beds for the most critically ill who needed them the most.
Our second surge ended on February 14, 2021. Between April 22, 2020, and February 14, 2021, we admitted 3,384 patients to the CVH. Of those, 121 patients had to be escalated to the emergency room or hospital (3.5%). Our peak inpatient census for COVID patients was 36. In the CVH, we had 2 deaths (one of which chose hospice care instead of being admitted to the hospital).
Today our CVH remains strong. We have expanded to a team of 5 CVH Nurses, a more robust CVH MIH Team and providers who are engaged in the process. Our ED and inpatient colleagues have repetitiously thanked us for our outpatient efforts and feel strongly that our hospital would’ve been in a much worse situation without CVH. This program is proof that when hospital administration teams work with engaged providers, amazing things can happen for your patients, hospitals, and community.
Kathy Bailey, FACHE, President and CEO of UNC Blueridge Healthcare located in Morganton, NC:
As we entered the pandemic, we were faced with the same challenges as all facilities. How many COVID patients would be in our community and how many would need hospitalization? Did we have the capacity to effectively care for them?
We watched the news stories about hospitals being full, patients laying in hallways, tents erected for additional beds, and scarce resources of personnel and supplies. With each passing day, we were acutely aware of the challenge facing us and the need for a workable solution.
Our nurse leaders began the development of a medical surge plan so that we could handle large numbers of admissions. But our clinical leaders also began to look at the possibility of preventing the admissions in the first place. If we could keep these COVID+ patients out of the hospital, we would be much better prepared to care for those that truly needed admission.
We began the development of the CVH plan. Dr. Gandhari Loomis stepped up and agreed to lead this plan. The overriding premise was that we could keep the less severe COVID+ patients in their own home, while still monitoring their care and condition. With the provision of pulse oximeters, BP cuffs, and sometimes oxygen, these patients were able to stay at home and have a successful course of treatment and care.
Our transition of care nurses took on the role of doing virtual or telephonic checks on these patients, sometimes one or two times daily. They remained in close contact with the physician supervising the care of the CVH patients. During the initial surge alone, they were caring for 315 patients in the CVH. At that time, our inpatient census never exceeded 36 COVID patients.
Through the implementation of the CVH, we were able to manage our resources effectively at a time when surrounding facilities were struggling to find beds for admitted patients. Our community benefited from the CVH, the patients were able to recover at home, and we now have a program that can transition into caring for other diagnoses effectively through a virtual platform. The CVH is the hidden gem that arose in the midst of the pandemic and positions us well for innovative care delivery going forward.
Anthony Frank, MD, MBA, FACEP, CPE, Chief Medical Officer:
What a year in healthcare. 2020 was the year of the global pandemic and my first year as the CMO of a rural healthcare system. COVID-19 presented numerous challenges and uncertainty in a time of needed significant changes to the way we administer care.
It was fascinating the way we could quickly assemble the best information we had to work with and set a course of action. Early in the pandemic, what was set on a Monday was out of date and possibly even wrong within the week, or even the following day. Establishing a source of truth from valid sources amounted to us using Atrium Health’s policies, and when there was nothing else available, using the CDC and our own experts to formulate a plan and path forward.
Our team was amazing, as they took care of patients in an environment of uncertainty, following us as leaders who didn’t have the right answers let alone sometimes any answers. Focusing on what was right for the team and the patients continued to be the true north for us in the pandemic and led most of our decisions.
I recall our ED medical director asking us about this new order set and idea that had come out of Atrium, the CVH, and were they supposed to participate in it? Asking more questions and discussing with our case management and primary care physician leaders it was decided that we did not want to turn over control of our local patients to a program out of Charlotte that may not understand the rural dynamics of caring for our patients. Also, as dedicated practitioners and members of the community it was our responsibility to care for our population. Thus, we created our own version of the program and began to innovate.
What a fantastic decision and the right answer. Our transitional care nurses elevated to the challenge and became the heroes providing emotional support to our patients, working long hours and days at a time without a break. They became the CARE in healthcare.
From an operational standpoint, the CVH saved us. The CVH was and still is the early warning signal for what we can expect on the inpatient side of COVID. Our inpatient volumes mirrored the VH census throughout the pandemic and helped us make predictions concerning how much extra capacity we would need during our pandemic surges (nursing personnel, respiratory therapists, ventilators, etc.). If we had 300 patients enrolled in the CVH, we knew within about 2 weeks our inpatient census would be 30. The reverse was also true. If we had 100 patients in the CVH, our inpatient census would be 10. This has tracked consistently through each of our pandemic surges. We suspect it would have been much higher without the VH tool. Even an additional 5% hospitalized would likely have overwhelmed our resources.
For all the negatives associated with COVID, the innovation and hopefully lasting change of how to care for patients differently and where they are will hopefully be the legacy of the pandemic.
Patricia Amoako, MD, Medical Director, Blue Ridge Hospitalists
In February of 2020, Blueridge Morganton had our first encounters with COVID-19 Viral infection with a myriad of implications, some born out of fear of this virus which we had heard and voraciously learned about. The impact of this pandemic fully hit our doors in March and April of 2020. Inpatient care of patients transformed. The treatment of hospitalized patients with COVID infections was always a moving target in the beginning. Studies across the world were done “on the fly” and we always processed information and adapted new methods of treatment as the science evolved. Sometimes the science changed weekly. As a small community hospital, we sharpened our skills, changing our culture to do the very best for our neighbors with the firm belief of “neighbors taking care of neighbors.”
This new culture, born out of necessity due to shortage of all bed assignments in the entire state and country forced Incident Command at our facility to allow creative measures for the betterment of patient care. It was quickly recognized that admitting all patients who tested positive to the hospital was not feasible. How would our small community of providers be available to the ever-expanding volume of patients? At the height of our community’s experience with COVID-19 viral infection, our inpatient census was 36 with a persistent daily census of 30 and above: our usual total daily census prior ranged from 90 to 120.
Telemedicine quickly became a reality. We forged an alliance with Emergency medicine, Hospitalists, Critical Care Specialists, Infectious Disease and Primary Care Providers. The CVH of Blueridge Health flourished COVID-19 viral infection in our patient populations, it was noted that symptoms worsened usually after day 5 of initially testing positive. Patients would be seen in the Emergency department, and most would be triaged to the CVH; education was made available to the emergency room physicians, and they referred patients initially not requiring oxygen to be monitored by outpatient providers virtually.
As volume of COVID-19 infected patients increased, the work of obtaining Home Oxygen by social workers was streamlined so that patients requiring less than 4 L of oxygen could be monitored virtually as well. The CVH system continued to grow with inclusion of physical and respiratory therapy to our transitional care team (originally Nursing and Social Workers); providing such education as prone positioning at home to improve oxygenation, home pulse oximetry monitoring, DVT prophylaxis, antipyretics, anti-emetics, IVF, etc. The success of the program is self-evident.
The treatment of COVID-19 and the escalation of the CVH had an immediate impact on the inpatient provider service (hospitalists, intensivists, and subspecialty services) allowing them to focus their time on the sicker COVID patients: those requiring higher oxygen levels and many with severe complications of COVID-19 infections (Acute Strokes, Pulmonary Emboli and Encephalitis). I am forever grateful for hospital leadership that allowed for providers across the continuum to give input and coordinate the best outcomes for our patients and CVH system.
Bill Enslow, DO, Medical Director, Blue Ridge Emergency Department
I am an emergency medicine physician working for UNC Blue Ridge in Morganton, NC and I was the acting chief of the emergency department during the worst of the coronavirus-19 break out that occurred in our county and surrounding area in the late fall and early winter of 2020. It is hard for me to articulate just how great of an impact the Blueridge CVH had on our ability to function as an emergency department and as a hospital.
Working in emergency medicine is a peculiar tension between having an understood immense responsibility to care for the sickest of the sick while being extremely dependent on resources outside of ourselves to be able to perform our mission. The emergency department is the last line of defense, always open, receiving all comers regardless of degree of illness or ability to pay, knowing that when the primary care clinics are closed and even if the hospital is full, we will still be receiving and caring for patients to the best of our ability. That said, we are also the most sensitive to issues that “clog” the flow of patients through that department and the longer patients stay the more difficulty we have in taking care of the newcomers that we know will eventually present and yet cannot control when they come and in what state.
It is always preferable to be able to send a patient home if possible. This may be for comfort’s sake, hospital bed availability, and even for the sake of the impact on the patient’s finances. That said, quite often emergency department physicians are faced with the dilemma that results from knowing that a patient would LIKELY do fine at home, but there is a possibility that they wouldn’t, and this often forces our hand to keep a patient in the hospital though we wish we didn’t have to, and we think they likely won’t need it.
We are also often faced with the difficulty in knowing that a patient we are currently taking care of does not qualify for hospital admission at the time but is at risk for a sudden and precipitous downturn in their health status.
For these reasons there are few things that reassure an emergency medicine physician that a patient can be safely discharged more than knowing that they have good follow up. Usually, we are relying on a patient calling their primary care office the next day or in a couple of days when seeing them on a weekend, but we rarely have established appointment times where we know they will be seen or could contact or email the providers that will see them in the future. This can cause significant difficulty in sending patient’s home.
The COVID surge that occurred in late fall/early winter of 2020 had the potential to significantly compromise our hospital. Not only was the hospital filling rapidly, but we were faced with a dilemma in the inability to transfer patients out. Usually if a community hospital becomes full then ER patients that need admission can be sent to other hospitals in the region, especially the large referral centers. As the COVID surge upticked we found ourselves in the heretofore unknown situation of being full ourselves and every other hospital in the area also being full. We were told at one time that there were no intensive care unit beds to be found in the entire state.
Dr. Gandhari Loomis and the outpatient care team at Blue Ridge Morganton had been planning and implementing a CVH for patients in their primary care network and for those who did not have primary care physicians in Burke County. When the uptick occurred the CVH team quickly engaged and we rapidly worked a process out whereby emergency department patients that were diagnosed with COVID-19 could be placed in the CVH by Emergency Department staff, given a pulse oximeter and discharged with certainty that the patient would be followed up within the next day or two by the CVH staff and would be continually reassessed until it was clear that the patient had passed through the worst of their illness and was well on their way to improvement. The CVH team continually expanded the impact of their care by designing scoring systems to indicate which patients required sooner or more frequent assessment, accomplishing the logistical challenges involved in discharging patients directly from the emergency department with home oxygen, incorporating the emergency department together with the CVH to streamline high risk patients receiving monoclonal antibody infusions and even eventually engaging mobile health teams to assess patients directly in their homes and give supportive care such as intravenous fluids, anti-emetics, etc.
The impact that the initiative and efforts taken by the virtual health team on Blue Ridge Morganton’s ability to function during the COVID surge cannot be understated. Even with maximal effort to expand bed space within the hospital we were still full and often had patients in our emergency department waiting for beds. If we had not been able to safely discharge many patients home and keep many out of the hospital because they were being frequently assessed and even treated at home through the CVH service our hospital would have been overrun. Sadly, this was the state of some of the local county hospitals in our area that unfortunately did not have CVH services that were as effective as ours or had been initiated at all. There was more than one time when I was driving to work thanking God that I had the good fortune to work at Morganton knowing that my work shifts, though already challenging, would have been awful had it not been for the CVH and the work of the administration at Blue Ridge Morganton to make sure that our community was served well. I could take no credit as I had had nothing to do with its inception, I was only benefiting as a worker, while our entire community benefited by its presence.
Carolyn Gordon, MD, Associate Program Director, Internal Medicine Residency Program, Attending, Mobile Health Unit of the CVH
I really enjoyed being an attending for the Mobile Health Unit wing of the CVH. It was an interesting experience because the medical decision making was quite algorithmic and straightforward, but the real value was often in that the patient really needed the face-to-face interaction to be reassured that staying home was okay or to be convinced that going to the hospital was a necessity. I remember one patient who had saturations below 80 on 3 L who had already been told to go to the ER but refused so the team was deployed. I initially thought it was an unnecessary consult because there was nothing I could add to the conversation other than telling her to go to the hospital. But somehow, I think the reality of a team of people coming to her house covered in PPE, doing an exam, and talking to a live doctor via video conferencing made the reality sink in that she indeed was very sick. During my conversation, it became evident that she was paralyzed with fear and admitted that she thought that going to the hospital equated to a death sentence. So, after understanding the reasons for her reluctance I was able to reassure her that hospital care would give her the best chance at recovery and staying home without treatment would be more likely to result in death. She did then agree to go to the hospital where she was placed on high flow oxygen and later intubated. She was in the hospital for several weeks but did finally make it through the ordeal.
I also remember several patients we saw who were dyspneic and maybe had some mild volume depletion or nausea and just needed some oxygen and fluids and a bit of Zofran. The memorable thing about interacting with them was again just feeling how appreciative they were of our team coming into their home during a pandemic. Both the patients as well as the families caring for them were understandably extremely fearful and anxious about staying at home while experiencing significant shortness of breath. Even through the lens of the camera, the relief and comfort they felt in having our team present was palpable. It was fascinating to see the transition from tense faces at the beginning of the visit to relaxed body language and easy smiles after an exam, some oxygen, and clear instructions for follow up care.
I think so much of the focus during COVID from the physician’s perspective has been on trying to figure out the best way to treat this virus, but this experience showed me that perhaps one of the best things we can do for our patients is to remember the importance of showing up and in this case, physically entering their forced isolation. It has been said that people do not care about how much you know until they know how much you care. I think the people we served truly felt cared about and I am grateful to have gotten to be a part of this.
Ed Bujold, MD, Community Physician
The COVID pandemic really hit our area hard. I was fielding questions, bringing patients in for testing, following patients who were already diagnosed with the infection, setting up telemedicine visits, getting people pulse oximeters, and going crazy trying to follow all these patients. I had five to seven interactions every day.
When I learned about the CVH, I was so relieved. I was able to enroll every patient we diagnosed in the CVH and not worry about taking care of them anymore. The patients were monitored closely and, as problems arose, I was called to step in and intervene as needed. It took a tremendous burden off my shoulders, and the patients were getting great care. Patients also felt much better about their treatment plans. Several times patients commented to me if it were not for my care and the care they received in the CVH they really would not have survived.
In the early days of the pandemic, I got a lot of pushback from my staff about taking care of COVID patients, testing COVID patients, catching the COVID infection, dying of the COVID infection, etc. Early in the pandemic, four of my staff of seven contracted the infection, albeit outside of our clinic. One of those employees was out of work for approximately six weeks.
We all had to pivot and make the patients feel comfortable about coming to the clinic and I had to make sure my staff felt quite comfortable seeing patients with potential COVID infections. From day one, no one with any infectious process was allowed into the clinic. All clinic personnel were provided with protective equipment and instructed on their use. There was a learning curve involved in this process and several changes were made so everyone was much more comfortable seeing potential COVID patients.
I still take care of patients in the hospital, and I must admit the first patient I took care of in the hospital was an anxiety-provoking scenario. I was in good health but approaching 70 years of age. The personal protective equipment was just another necessary but added level of frustration. Fortunately, after the first day I settled into a routine, and I felt much more comfortable going into a patient’s room. A negative pressure room and a positive pressure head apparatus certainly helped me feel more secure. The true heroes in this story though are the nurses who were with the patients all day long. My hats off to them.
Jessica Boldridge, MD, Internal Medicine Resident
COVID certainly made this last year interesting. Suddenly, we were dealing with extremely sick patients who were afraid to come to the hospital. Our hospital system was starting to run out of beds and resources in the fall and winter months of the pandemic. The CVH made this experience much more manageable and I’m not sure how we would have gotten through without it. There was a particular patient whom I became close with during the pandemic. She had a prolonged hospitalization for COVID and was discharged from the hospital on oxygen. I followed along with her for a few months in the CVH. I was pleasantly surprised how I was able to build a bond and a connection through what should have been a disconnected platform. During our time “together” I was able speak with her multiple times a week in the earlier stages after being discharged. This was a time of high anxiety for her given that she almost died in the hospital. I was thankful to be able to provide this support even from afar. The CVH changed medicine for the better and I am hopeful to continue to use it in the future.
Stephany Toledo, Patient
One of our worst fears for my parents and boyfriend was me getting sick with COVID-19 because of my asthma history, previous bronchitis, and pneumonia infections. We all knew if I got sick it would be worse for me due to my medical history. So, my family and I made sure we took all precautions possible to stay healthy and free from the virus. In the meantime, we were waiting to hear from Immigration Services for both of my grandparents’ Resident Card renewal. Due to the pandemic, everything had been put on hold and their applications were at a standstill. During all of this, my grandparents were staying in Mexico, and we were all worried because we did not want them to be exposed to Covid-19 but also knew it was important for them not to lose their US residency.
I remember it was late November 2020 when I finally received an email from USCIS stating their fingerprint appointments were scheduled a few days after Christmas. My heart sank down to my stomach because by this time the virus was in full force in our country. Not only would they be exposed, but my mother had to travel to Mexico and be exposed herself to bring them back to the US for this appointment. Despite the risks, my grandparents made the decision to travel on this long journey. As much as I was excited to see them, I was worried sick. It was bittersweet for all of us.
After they arrived in the US, they stopped in Northern California to see some relatives and of course to get some rest. Now this was a plus for them because they got to spend Christmas with my uncle, aunt and all my cousins. A day after Christmas they continued their journey to North Carolina, and we were all elated to have them and my mother back home safely. That same week they arrived here they had their fingerprint appointments at USCIS in Charlotte, North Carolina. It was very quick, and all precautions were taken to keep them safe from the virus.
A couple of days after their appointment on a Saturday night my mother called me to tell me my grandparents were complaining of a bitter taste in their mouth. That immediately concerned me because in the back of my mind this is what we all had been worried about. They were not complaining of any other symptoms, just that “bitter taste” as they both described. I made appointments for both at Table Rock Family Medicine on Monday, which is also where I work. That same day on Monday I woke up feeling strange, I was congested and had a weird feeling in the back of my throat. I made the wise decision to go to employee health to get tested. I was told I would get my results late that evening, so in the meantime I took my grandparents to their appointment and my grandmother tested positive. I could not believe it! Our worst fear had come true and to make things worse I received a call later that evening telling me I was positive as well. We were all so afraid and did not know what to expect after this.
It felt almost immediate when my grandmother and I developed high fevers and we both had terrible headaches. All we could do at this point was to quarantine away from everyone else in the household as much as we could, but it was not long before everyone else got sick. Everyone else started developing fevers, cough, headaches, and fatigue. We knew we had all become infected with the virus and the only thing we could do was try to stay positive and have faith we would all pull through.
Despite all of us feeling terrible, we knew we had to help each other stay strong to help our bodies fight this awful virus. My mother and grandmother were constantly in the kitchen cooking homemade soups and making tea for all of us. My job was to handle all calls because I was my grandparents’ interpreter, therefore I was constantly on the phone with the CVH and with the doctors during their Virtual Visits. It almost felt as if I could not afford to let this virus bring me down. I was constantly running all over the house making sure everyone was stable.
We were given pulse oximeters from our doctor to take home with us to monitor our heart rate and oxygen levels. I feel that checking these vitals constantly throughout the day gave us some peace of mind. While checking my grandfather’s oxygen we noticed his was in the low 90’s, which caused some concern for us. One of the nurses from the CVH told us to keep an eye on it and immediately contact the provider on call or take him to the hospital if it dropped any lower. The next day when checking his oxygen level, it showed eighty-seven and this had me worried. I contacted the provider on call, and they suggested that he be put on oxygen, which was quickly arranged to be delivered.
My grandfather did not seem in distress nor was he short of breath, but even with the oxygen machine his levels kept dropping to low 80s. Being given all the medical advice from the providers and nurses from the CVH my family and I made the decision to take my grandfather to the hospital. I remember him being so afraid, thinking he would not be able to come back home. I cannot imagine what he felt, especially not being able to understand the English language. I made sure he understood he was in good hands and the providers in our community would do everything in their power to get him better. His chest x-ray showed pneumonia and he was given antibiotics via his IV fluids. The doctor at the emergency room said everything else looked good and gave us the okay to bring him home. Even though he was glad to be able to come home, he did not feel good. We could tell he was extremely sick, and this virus and pneumonia were taking a toll on him.
I just remember thinking how could this happen; they travelled this long way to make it to their Immigration appointment for them just to get sick and possibly die? We were all so heartbroken and, in a way, felt guilty. We just wanted them to get better!
About a week and half after we got sick, we felt like we were finally making progress and started to feel somewhat better. But just as we thought that, my grandmother started having mid-upper back pain that was radiating to her chest. I called her doctor’s office at Table Rock Family Medicine and made her an appointment with her primary doctor. Right away her doctor noticed something was off with her heartbeat and suspected she was in Atrial Fibrillation. We did not know if this was something Covid-19 caused, or maybe she had this for a long time and went undetected. He put her on a couple of different medications and made her a referral to be seen by a Cardiologist. A couple of weeks went by, and my grandmother was already feeling better with the medication she was prescribed. She was able to get in to see the Cardiologist and did confirm she had Atrial Fibrillation. She had multiple studies done to rule out the possibility of any other heart disease and made sure she was on the correct medication. Which turned out she was, and her studies came back normal, we were all so grateful.
Although I truly hated that this happened to my family, at the same time I can honestly say I am glad it happened here and not somewhere else. It almost feels like this was meant to happen; it may sound weird, but I really believe we were all meant to get sick together. While we were all so worried for my health, I almost had no time to just lay or sit around and be sick. I was too busy worrying about everyone, and this is what kept me going. I certainly thought I would end up developing pneumonia but the way everything was set up, as far as the CVH calls, and Virtual Visits kept me active and may have helped stir away serious complications. Luckily, everyone in my family recovered from this scary virus. Not only did the providers help all of us get better, but they also discovered my grandmother’s possible life-threatening heart disease. We are beyond blessed to have had all the support from the providers and nurses at Table Rock Family Medicine, Carolina’s Blue Ridge Hospital in Morganton and Valdese and the staff at the CVH. Everyone involved played a huge role in our recovery and were there every step of the way.
Closing
The impact of the COVID Virtual Hospital in our community has been immeasurable. First and foremost, early intervention with low-cost technology (pulse oximeters, a risk assessment, communications between the nurse care managers running the VH and primary care physicians), allowed for early intervention (oxygen, IV fluids, assessment by a rapid response team all at home) before patients became critically ill. It is the authors opinion the two most significant tools the CVH used were the risk assessment tool and a pulse oximeter. Anecdotally, we have heard from our colleagues about many patients who would sit at home without monitoring with low oxygen saturations levels and present to the emergency room in dire distress.
Early intervention with low-cost technology is cost effective. Our chief financial officer estimates the care of a patient on an inpatient unit (not intensive care) costs our hospital system $3,000 per day with an average hospital stay of 5 days. The cost of our CVH is $5 per day with an average length of stay of 8 days.
Our CVH kept patients out of the emergency room and decreased our COVID hospital admissions giving us much needed capacity to take care of our usual mix of patients with an added benefit of taking COVID patients from surrounding hospitals in our service area due to our available bed capacity.
We have read over these stories many times prior to publication. As health care providers (whether doctors, mid-level providers, nurses, respiratory therapist, etc.), we tend to do the job in front of us and push our emotions to somewhere in the background to be process and dealt with later. Publishing and writing these stories have brought these emotions back to front and center. One of us recalls the fear and uncertainty of confronting this pandemic. How much personal protective equipment enough? How many times should we wash our clothes? Were surfaces we worked on contagious? How many hours could we work in a week and still maintain our physical and mental wellbeing? Were we going to contract the infection, and would we survive? What happens when our significant others, parents, children get infected? Stepping into abyss of the unknown was what we did because that was our job. Fortunately, most of us survived (1) and most of our patients did too. We are now much better prepared to deal with the pandemic. We know a lot more about what treatments work and what treatments don’t. Hopefully, we will be much better prepared for the next pandemic. It has been an honor to serve our patients, our hospitals, and our communities. Working together we can solve the most difficult problems.
1. Physician deaths from corona virus (COVID-19) disease
E B Ing,1 Q (A) Xu,2 A Salimi,3 and N Torun4,
Occup Med (Lond). 2020 May 15 : kqaa088.
Published online 2020 May
By Ed Bujold, MD, FAAFP; Golnosh Sharafsaleh, MD; Gandhari Loomis, DO; Regina Rhodes, MSN, RN; Ellen Collett, MD; Stephany Toledo; Jack Westfall, MD; Patricia Amoako, MD; Kathy Bailey, FACHE; Anthony Frank, MD, MBA, FACEP, CPE; Bill Enslow, DO; Carolyn Gordon, MD; Jessica Boldridge, MD.
