Margaret Mary Health, a 25-bed hospital in Batesville, Indiana, was hit by COVID-19 in mid-March, before even the larger cities nearby like Cincinnati got a major influx of patients.
"It's a new disease, and all of a sudden it's just flooding us," said Tim Putnam, president and CEO of Margaret Mary Health. "People are struggling to breathe."
The hospital that normally has 15 patients at a time had as many as 28 patients at one point and went from being 80% outpatient to 80% inpatient, Putnam said. They had to purchase seven more ventilators to double their capacity to intubate patients.
"We were trying to learn from each other," he said. "It was just people stepping up all over the place."
In rural hospitals, staff often have a broad scope of responsibilities and deal with a lot of different illnesses, Putnam said. Caregivers aren't separated by departments in the same way that they are in urban settings. That experience helped prepare them to respond to COVID-19.
"I think a lot of innovative patterns and staffing begin in a rural context out of necessity," National Rural Health Association CEO Alan Morgan said. "It's just the lack of boots on the ground in many rural health clinics that ends up driving this."
A study by the University of Minnesota School of Public Health, the Urban Institute and Athenahealth found that nurse practitioners in primary care clinics in rural environments have more autonomy than those in urban settings.
"Our findings are striking," said University of Minnesota School of Public Assistant Professor Hannah Neprash, the leader of the study. "Along every dimension we can measure, nurse practitioners have greater practice autonomy in rural areas."
At Margaret Mary Health, when elective surgeries were postponed, the anesthesiologist team provided around-the-clock support for intubated patients, Putnam said. Whereas before the pandemic, the hospital would maybe have one person on a ventilator for 12 hours or so, now there were six to seven on ventilators at a time.
"It's a teamwork environment. You have to lean on each other a little bit more," Putnam said of his 800-person staff.
Community hospitals banded together, too. Putnam reached out to the Suburban Hospital Organization, a group of 12 Indiana hospitals, for support when half of his system's four-person OBGYN team was exposed to COVID-19. The group agreed to share staff as needed as the hospitals dealt with outbreaks in their communities.
"Having that partnership set up was a big deal. We were all calling in favors." Putnam said.
For many rural health systems, responding the pandemic was a major financial strain, Morgan said. About 80% of the income for rural hospitals comes from outpatient services, which have not yet recovered, he said.
Through April 15, 14 rural hospitals in the U.S. permanently shut their doors, which is on pace to the be the largest number of closures yet, Morgan said.
The CARES Act's Provider Relief Fund brought relief and staved off more closures, he said. But he worries more closures will be on the horizon. Bluefield Regional Medical Center in West Virginia closed July 30, and others could follow.
"We're going to see rural hospital closures going into the fall," Morgan said. "Rural hospitals are probably in a more precarious situation than they were at the front of this year."