An increase in novel coronavirus COVID-19 cases in the Appalachian Highlands has prompted Ballad Health to postpone all elective and non-emergent surgeries, including already-scheduled procedures, effective Thursday.

Ballad Health’s hospitals are at their limit and their ICU’s are at full capacity, according to Ballad’s Chief Operating Officer Eric Deaton. As a result Ballad has begun converting post surgical recovery rooms into rooms that can house patients, in an effort to create the ability to handle more patients. Patients are also being held in emergency rooms and cared for there. This has led to protracted wait times in emergency departments.

And the health care system is preparing for the possibility of implementing a “scarce resource plan” that could determine who receives care.

On Wednesday, the census of patients being treated as inpatients at Ballad Health for COVID-19 reached 281, with nine of those being children at Niswonger Children’s Hospital. The volume trends are exceeding what had been modeled as a most hopeful scenario, with the census growing nearly 29% since Friday. Based on current modeling, it is now likely that, without any changes to the trends, Ballad Health could be serving as many as 400 COVID-19 patients within two weeks.

Forty-three percent of positive cases tested at Ballad Health are under the age of 18.

Seventy-one COVID-19 patients are in Intensive Care Units, and 49 are on ventilators.

Ninety-three percent of those COVID-19 patients hospitalized are unvaccinated, and 98% of those in ICUs or on ventilators are unvaccinated.

Ballad is also caring for 258 COVID-19 patients through its “Safer At Home” program which utilizes telemedicine.

Ballad is having to face this surge alone, without the help of other hospitals in the Southeast.

“We have to be able to manage the population here on our own. Normally if you have spikes and peaks in volume, you can lean on other hospitals, but because of what’s going on all over Tennessee with other hospitals reaching their capacity, we cannot do that right now,” Ballad Health CEO Alan Levine said.

If the current hospitalization trend continues, Deaton believes that the system could surpass its COVID-19 inpatient record of 361 by next week.

“If you refuse to get a vaccine, you are putting yourself at risk and your family at risk. At the least please wear a mask,” Deaton pleaded.

LIMITING SERVICES

“As we continue to urge mitigation steps in the community, such as vaccinations and wearing masks indoors, we must also take the unfortunate step of further limiting our services,” said Eric Deaton, Ballad Health’s chief operating officer and incident commander of its Corporate Emergency Operations Center (CEOC). “To prepare for a higher volume than we originally anticipated as our best-case scenario, we must now begin planning for a worst-case scenario.

“Ballad Health’s highest priority is to provide care that is safe for patients and for team members. Given the limitations on available staffing, it has been necessary to take these steps to ensure the safest possible environment,” Deaton said. “We are grateful for everyone’s ongoing cooperation and input; unfortunately, as the volumes appear to be growing even more, the strain on the system is such that additional steps are important to safely optimize our capacity to absorb the anticipated volumes.”

This is a necessary move to preserve much-needed space and staffing. Ballad Health is not furloughing team members at this time, but may ask affected team members to provide support in various areas throughout the facility in which they work. This will enable Ballad Health to prioritize the most critical and highest-acuity patients.

The decision to postpone these procedures follows Ballad Health’s earlier announcement that it would defer elective procedures that required an overnight stay, which went into effect Aug. 16. The steps previously taken to limit overnight, non-emergent/elective surgical procedures helped mitigate the impact on Ballad Health’s capacity as volumes have shifted from surgical to COVID-19 and other urgent medical admissions.

To determine which procedures are classified as non-emergent, Ballad Health will continue to follow the Elective Surgery Acuity Scale (ESAS), which was developed by St. Louis University and is recommended by the American College of Surgeons as hospitals and health systems respond to challenges posed by COVID-19.

As examples, postponed procedures will include low-acuity surgeries for healthy and unhealthy patients, including, but not limited to, hernia repair, cholecystectomy, cardiac and interventional radiology procedures, aesthetic and plastic surgeries, podiatric procedures, vasectomies, bariatrics, joint replacements, screening endoscopies and non-essential spine surgery.

In coordination with the respective chairs of the medical staff, and surgery and anesthesiology leaders, to seek input and assistance on this pause, Ballad Health will reevaluate this decision on an ongoing basis, with the goal of returning to full service as soon as possible. This decision will rely upon information about the spread of the COVID-19 virus and projected volumes, patient demand for urgent and emergent services requiring medical or surgical admission, and available staffing.

Deferring procedures needed by patients is the last possible effort to ensure a safe environment for patients who have urgent or emergent medical or surgical needs, health care system officials said. In making this decision, Ballad Health relied upon guidance from the American College of Surgeons, American Society of Anesthesiologists, Association of Perioperative Registered Nurses, and the American Hospital Association, all of whom issued a joint statement in November that stressed the importance of regional cooperation to address hospital capacity and patient needs, as well as case prioritization and scheduling.

“This was not an easy decision to make; however, it is necessary if we’re to effectively fight the COVID-19 pandemic in our hospitals,” said Dr. Clay Runnels, Ballad Health’s chief physician executive. “The people who need these procedures are not experiencing their best quality of life, and it deeply troubles us that we have to put them on hold to handle this COVID-19 surge – one that could have been prevented or at least mitigated with more widespread prevention measures and a higher uptake of vaccines.”

REDUCED VISITATION

Effective Thursday, visitation will not be permitted in rooms with COVID-19-positive patients, or in adult units in behavioral health centers.

Previously, the health system had permitted two visitors for each patient for a two-hour period, and it screened visitors for potential signs of illness. However, the continued spread of COVID-19 necessitated an expansion of this policy to restrict all public guests in these critical areas, health system officials said.

No one under 18 will be permitted to visit any patients in Ballad facilities, and any adult visitor must wear a mask.

Exceptions to this policy include patients positive for COVID-19 on a Ballad Health labor and delivery unit, who will be allowed one visitor during the entirety of the hospital stay. Patients who are positive for COVID-19 in the neonatal intensive care unit at Niswonger Children’s Hospital, and in pediatric rooms, will be allowed two visitors, but they must be parents or guardians.

Concessions for end-of-life and extenuating circumstances will be made on a case-by-case basis. Ballad Health will ensure the patient/family has been offered a virtual visit, through a daily video conference, to provide for interpersonal communication and connect the family to the patient.

These limitations will remain in place until further notice. Ballad Health will issue communication when the restrictions are lifted or modified.

PREPARING FOR SHORTAGES

As witnessed in multiple states and regions, such as Texas, Arkansas, Mississippi and Middle Tennessee – where, for example, ICU bed space is limited – the spike in patients can result in situations where patient needs exceed a health system’s ability to provide certain equipment, supplies or therapeutics, Ballad officials said.

Ballad Health leaders say that after having taken measures to maintain open beds and boost resources, including the deferral of elective procedures and welcoming 20 National Guard personnel to Johnson City Medical Center this week, they may have to make decisions about who gets care if further overwhelmed. The system’s board of directors has an established ethics committee, composed of composed of medical professionals, clergy and other individuals with the requisite backgrounds “for the purpose of advising management or the Board on issues of medical ethics,” the health care system said in a statement.

“Beginning last spring, and regularly since, Ballad Health has clearly articulated concerns about limitations in staffing due to the national shortage of nurses, and potentially shortages in supplies or equipment, depending upon the volume of patients impacted by the virus. Since the beginning of the current surge, Ballad Health has been warning of the impact of these limitations on service levels, including in the emergency departments, where patients are assessed and treated based on their severity of illness. With the deferral of elective procedures, this is another example of prioritization of limited resources, with resources being redirected to those who are most severely ill with medical conditions or conditions that require emergent surgery. With intensive care unit bed space now at a premium, similar assessments are made to ensure the most severely ill patients may access the service,” Ballad said in the statement.

Given the further strain on limited resources, the ethics committee has approved a “scarce resource plan” and guidance for implementing it in the coming weeks, if necessary.

“Our capacity to care for patients is finite. We don’t have endless resources,” Runnels said. “At some point, we have to decide how to allocate those resources.”

While the health system is not yet at the stage to implement these guidelines, Ballad Health is working to ensure team members and clinical providers are aware of and educated on the policy and its practices.

To fully mitigate the situation and bring the COVID-19 pandemic under control, Ballad Health continues advocating for wearing masks in public and COVID-19 vaccinations for everyone 12 and over.