They were pretty good questions, I thought, for the folks at Monument Health.
First, why would COVID patients from a tiny hospital on the Cheyenne River Reservation be transferred for care to a hospital in Minnesota rather than one in, say, Rapid City?
And second, why in the heck was it so hard, as my wife and I found out, to get scheduled for a COVID-19 test through Monument?
Dan Daly, a former colleague in the Rapid City Journal newsroom now working for Monument Health in Rapid City, helped me get lined up to talk about the first question with Dr. Brad Archer, chief medical officer for Monument, and the second with Dr. Stephanie Lahr, the system’s chief information officer.
The first question pestered me after I read an AP story last week noting that the 8-bed Cheyenne River Health Center, an Indian Health Service facility in Eagle Butte, sent two COVID patients to a hospital in Burnsville, Minn. because they were turned away — diverted — by a succession of hospitals in South Dakota.
Why not go to Pierre? Why not Bismarck? And why not Monument Health here in Rapid City?
These transfer questions can be critically important to any patient, but especially to tribal members across western South Dakota who often have limited access to quality health care and must travel long distances to find it. A native of Lake Andes, Archer is familiar with the health-care challenges faced by Native people in the state, and how Monument can help.
Without focusing on the two patients mentioned in the news story, Archer said that from the first of September to the end of last week, Monument Health turned away 12 patients from Cheyenne River. But during that time Monument accepted 55 patients from Cheyenne River, Archer said.
While we were on numbers, we talked about patients being referred to Monument from facilities on the Pine Ridge and Rosebud reservations during the same period. Archer said Monument diverted 30 patients from Pine Ridge but accepted 109. It diverted nine patients from Rosebud but accepted 44.
Some of those patents were COVID-19 patients. Most were not, Archer said.
Choosing the option that fits the patient and the hospital
As you might imagine, it’s all a bit more complicated than simply whether there are beds available at a larger hospital like Monument. Archer said hospitals are legally bound to care for patients in need, even from distant locations.
“When we get a call from anywhere, even areas getting more remote than Eagle Butte, if we have the right care for the patient and the room to accept the patient, we will,” Archer said.
The ideal situation is to take a patient from the system’s service area in the Black Hills, where Monument has access to the patient’s medical history and providers have a scheduled-care relationship. Transfers from beyond the region are more complicated but part of the mission, Archer said.
Monument has a transfer center that is busy all the time taking calls and making decisions on the placement of patients. But the center has been busier than normal not just because of COVID patients but especially because of the many regular patients who have put off health care visits and procedures because of their fears of contracting COVID.
That stresses the system and adds to an already complex process of determining whether to accept or refer on a patient from another hospital who needs care.
“The decision is made on where the best place is for that patient. So there might be more discussion on patient’s needs and conditions, and perhaps we’re not the right place,” Archer said.
It could be the availability of beds or staff or proximity or the specialty care needs of the patient and whether they are available at a given hospital.
“We’re pretty full service, but we don’t have everything,” Archer said. “Just to assume we automatically accept whoever calls is not correct. We strive to take care of the patients at the right place at the right time with the best medical care. And if that’s us, we take that patient. If not, we try to seek to get that patient to the right location.”
Last spring regular call-in meetings with other facilities focused on COVID-related issues. The call-ins were suspended during the summer but resumed last week. Archer said part of the discussion will be ways to improve the transfer-diversion system and better explain why certain patients are accepted while others are not.
“We have great communication through the transfer center but we all agreed we can probably do a better job as administrators ahead of time,” Archer said.
Trying to fix the backlog in calls for COVID tests
Monument is also working to do a better job with its COVID testing. After my wife and I were exposed to someone with COVID almost three weeks ago, we self-quarantined for two weeks. And early on in the quarantine, we both tried to get tested through a Monument’s drive-up.
It was more important for my wife, Mary, since she was having cold-like symptoms. Neither of us ran a fever. And I was having some symptoms but not inconsistent with age and arthritis and autumn sinus issues and probably magnified by worry.
Mary called the Monument triage line three times over two days. Twice she gave up after more than half an hour of waiting. And a third time she lost her call due to heavy pressure on the line. Finally, she went to an urgent care clinic for another health system, saw a physician’s assistant, and got a test. It was negative. I didn’t want to sit in a clinic to get a test, since my symptoms were so mild and questionable.
When I mentioned the experience on Facebook, Daly contacted me and got me set up with Dr. Lahr. She oversees information systems and telemedicine, including a triage-nurse line set up last spring for scheduling COVID tests and providing medical guidance to callers based on symptoms.
The triage nurses could help determine whether callers needed to see a provider or do self-care at home. They also could get a test scheduled for the caller. The nurses in the triage program also stayed in touch with COVID patients treating themselves at home to monitor their progress and provide guidance.
And it all worked together for months before it was overwhelmed with calls.
Then came the rally, the motorcycles, and the virus
The Sturgis Motorcycle Rally arrived in early August, and so did hundreds of thousands of visitors on motorcycles. That was followed by a return to school to one degree or another and more businesses adding services and putting more employees back to work.
COVID cases that had held steady for months began to rise, a trend that has continued.
“A good part of the summer even through early in the rally we were seeing on average 200-300 calls a day during the week, with call volumes dropping to 75 to 150 calls a day on weekends,” Lahr said. “About the second week in August and the third week, we started to see volumes rise to 500 or more calls a day during the week and 150 to 250 on weekends. So, it was nearly doubling since about mid-August. And that has remained relatively consistent.”
The planning and implementation of the nurse-triage line included staffing for about 250 calls a day. As you might expect, the system didn’t work well at 500 calls.
“So it has obviously been challenging and frustrating for the community and frustrating for our team as well, to feel like we barely hit 50 percent of the mark,” Lahr said.
But Monument this week announced a revised program that will allow callers with COVID-like symptoms to schedule their own tests at Monument drive-up locations in Rapid City, Custer, Lead-Deadwood, Sturgis, and Spearfish. The online scheduler will free up the triage nurses to work directly with callers on more complicated cases.
The new program can be found on the Monument Health website at https://monument.health. A small yellow tab on the lower-right corner of the page will lead to a series of questions followed by options for scheduling a test.
The new scheduling option will mean Monument won’t have to look for additional nurses for the triage line, which is a difficult thing during an ongoing nurse shortage.
“Because this is an automated process, it eliminates the need for us to staff up,” Lahr said. “The reality is, there is absolutely a nursing staff shortage. We had a shortage before we had COVID, let alone now. We can’t really bring nurses in to help with calls because there aren’t nurses to do that.
“If a person just needs a test, you don’t need a nurse for that,” she said. “We want nurses available to answer clinical questions.”
With COVID on the rise and flu on the horizon, a new system is essential
With the rising number of COVID cases, the new scheduling-triage options will help avoid the jammed-up phone lines and delays in testing. And the improvement comes at the right time because more complications will be coming this fall as the COVID surge continues and the flu season arrives.
“It’s a very very busy time in our health-care system now, related to COVID but not related to COVID directly,” Lahr said. “People ignored or put off accessing health care. People just didn’t want to come in. We’re seeing a lot more of people now. And we’re moving into influenza season. “
Lahr and Archer are rightly concerned about the increase in COVID-19 patients and the number that require hospitalization. Statewide the number of COVID patients in the hospital varied from between 50 and 100 for months. But Wednesday there were more than 300 patients in hospitals across the state being treated for COVID.
Monument is feeling the increase, although when I talked to Archer on Monday there were three COVID-19 patients on ventilators at Monument. A state report Wednesday said there were five. The hospital has about 30 critical-care beds with ventilators but can “flex up” to double that if needed.
There are enough available beds, including critical-care beds, at this point. But the rise in COVID cases is a concern, especially when mixed with the overall increase in non-COVID patients.
“Right now, any potential threat to that capacity we take very seriously,” Archer said. “As we look at the large numbers of new positive cases every day, we are concerned. We try to watch the age category very carefully to try to predict the number of hospitalizations because in most instances it’s very clearly an age-related phenomenon.”
Care providers have learned a great deal about the best treatment plans for COVID patients since last spring, which will help those needing advanced care.
“The treatment protocol is getting more clear across the country and world and our survival rate has gone up significantly from what it was for those patients that require ventilatory care, Archer said. “It’s still obviously a very serious situation.”
Like other health-care systems, Monument has worst-case scenario plans that Archer and others hope won’t be needed.
“Last spring in response to what we saw happening in New York, we created a large surge-capacity plan that takes us through various phases, all the way through to if we had to set up a National Guard facility to care for people,” Archer said. “Clearly we’re hoping we don’t have to do that. But we do have that plan in place.”
