As the calendar turned to the year 2020, the respective medical staffs at Brattleboro Memorial Hospital and at Grace Cottage Hospital in Townshend could see the gathering storm that would be the COVID-19 pandemic coming straight toward them.
“Yes, we were watching the situation very closely, as most health care organizations were at the time,” said Grace Cottage President and CEO Douglas DiVello. “I think we all realized at the time [in January 2020] that it was eventually going to get here.”
“All the physicians and most of the nurses spent a lot of time reading and talking about the evolving science of COVID-19,” said Dr. George Terwilliger, Grace Cottage's chief medical officer. “Unfortunately, early on, there was very little known about it. So we were scared.”
With so much still not known about COVID-19 by last March, other than it was deadly and spreading rapidly around the globe, both Grace Cottage and BMH focused on what they could control - namely, preparation and prevention.
At BMH, personnel quickly went into what they call “Incident Command” status. President and CEO Steve Gordon described it as “a military structure for rapid decision-making. We put together an executive council made up of administrators and clinicians, who would guide all of our decisions through this pandemic.”
Normally, Gordon said that Incident Command is used for a short-term event, such as a big accident on Interstate 91 or a fire or chemical spill that causes numerous casualties. The practice was never really designed to be used over a period of months.
At BMH, Incident Command remained in effect from March until August last year, with meetings nearly every day to make decisions about what needed to be done.
“We looked at all of the things that we needed to do, from limiting access to two entrances at the hospital, freeing up our screeners by consolidating medical practices, looking at policies, and procedures related to the use of personal protective equipment, or PPE.
“The amount of decisions being made on a rapid basis was pretty phenomenal,” Gordon said. “And that's what this incident command structure allows you to do, rather than the typical structure where decisions have to be made through different layers and different avenues. This is much more streamlined.”
Being streamlined and nimble is a daily reality at Grace Cottage, the smallest hospital in Vermont. Terwilliger said that he and his colleagues quickly developed and implemented a screening system where every employee is evaluated daily for fever and other COVID-19 symptoms, as well as tested regularly for the virus.
“We have to check temperatures and sign in every morning,” he said. “That is actually required to this day. We started that very early. We had been wearing masks for a long, long time and, when we didn't have enough manufactured medical masks, we were constructing cloth masks.”
Gordon said BMH implemented a similar policy for employee and client screening that also continues to this day.
Masks and protective gowns were tough to come by last March and April, but all over Windham County, community members stepped up to fill the gaps.
“They were delivering hundreds of masks to our doorstep every week,” said Grace Cottage Director of Development and Community Relations Andrea Seaton.
“We had people calling us saying they had some extra K-95 masks in their shops, while others were sewing cloth masks for us,” she said. “WW Building Supply down the road made about a thousand face shields for us.”
“It was really, really heartwarming to see how the community helped us out,” Seaton said. “They wanted us to survive and not get knocked offline by an epidemic.”
Gordon said BMH had a good supply of PPE gear as the pandemic began, but community members were generous about supplying homemade masks and gowns for the hospital to use. The hospital also made the PPE supply last longer by cutting back on elective surgeries.
The Grace Cottage engineering team sprang into action, building negative-pressure isolation rooms where contaminated air is sucked out of the space where COVID-19 patients are being treated.
That measure was just one of the many improvisations from a hospital staff who creatively prepared for a surge that, thankfully, never happened.
“They're very talented, and they do a lot with a little,” Terwilliger said of the GCH engineers.
“We explored ways to [set up] critical care for a large number of people in our hospital,” he recalled. The engineers found old oxygen concentrators, “still functional, that were left over from the days when there wasn't bottled oxygen delivered through the wall sockets.”
“We had them dusted off, and now we actually have 10 or 12 of those so we [could] provide oxygen for a large number of people if that [need] came to pass,” he said. “Fortunately, it didn't.”
“We were able to cobble together three ventilators,” Terwilliger said. “We still have those three, and we are able to eventually procure more from the federal government.”
Telemedicine is here to stay
Gordon said that telemedicine - medical visits by phone or online for non-urgent care - used to be about 5 percent of BMH's patient consultations. With the pandemic, more than 20 percent of consultations are now done remotely, and Gordon believes that percentage will keep increasing.
“The challenge with that, as you're well aware of in Vermont, is that connectivity to the internet is still a problem in many places,” he said. “So it does have limitations in an area like like ours. But it is here.”
“Telemedicine has been a real boon for some patients who have great difficulty and mobility issues and can't get in very easily,” Terwilliger said. “It really makes sense for them.”
He said that many patients have continued to do some of those remote calls even after getting the all-clear for in-person visits.
“We always feel like we get a better product if you're face-to-face, and it's still not ideal,” he cautioned. “It's better to be in person. We just wish our internet would improve here.”
However, telemedicine doesn't take care of a real problem for hospitals: the drastic decrease in patient volume that every hospital in Vermont has experienced.
“We have suffered volume decreases of anywhere between 10 to 20 percent,” said Gordon. “Every hospital in the state has pretty much suffered volume decreases of anywhere from 10 to 20 percent.”
“Now, we see volumes are increasing and folks are now going back to getting elective procedures done,” he continued, noting that BMH expects community use of the facility to bounce back - “but that's going to take some time.”
In the meantime, state and federal governments have picked up some of the slack. Gordon said that BMH has received about $11.2 million in assistance.
“And if we hadn't gotten that money, we would have had an $11 million loss for this past fiscal year,” he said. “That is substantial. But we did not lay off employees during this process. We did furlough some employees, but we brought back pretty much everyone. If we hadn't gotten that level of funding, I think we would have been in a serious, serious situation financially.”
Grace Cottage remains one of the larger employers in Windham County, with about 200 employees, but DiVello said it was small enough to qualify for federal Paycheck Protection Program (PPP) funding.
Thanks to PPP, DiVello said the hospital wasn't “in a position where we had to lay people off or furlough people. We did no layoffs, we did no furloughs.”
“Everybody continued to work and get a paycheck, which was very, very important to me,” he said.
A hat tip to the community
Health care providers all around the state have acknowledged that their jobs were made easier through the pandemic because nearly all Vermonters adhered to the mantra popularized by state Health Commissioner Dr. Mark Levine - “masks on faces, 6-foot spaces, uncrowded places.”
“We were able to communicate to our population about things to do, and I think that they trust us,” DiVello said. “I think it had some bearing on the behavior of the community.”
He spoke of looking at the weekly travel maps that the state put out during the summer “with amazement” at how Vermont “was like an island, in the middle of the Northeast, where states all around us were in a different place in terms of how many cases they had within their state boundaries. And it kind of stayed that way for the last year.”
DiVello credited what he called “the Vermont culture, the way people pull together and listen to one another and respect one another and care about one another. I think that we're just so very fortunate to be living in a state like this.”
“People were respectful of the guidelines and the restrictions that were issued by the state and supported by the hospitals,” Gordon said. “And I think that got us through this challenge over the last year.”
Terwilliger said he appreciated that, unlike other states, “politics does not come between policy and good care” and that Vermont Gov. Phil Scott and his administration have been successful “mostly just by doing that simple thing of listening to the science.”
Gordon said that the good level of communication between the state and its hospitals was one factor in Vermont avoiding the worst of the pandemic.
“As we went through this pandemic, other states didn't have that type of communication and coordination among the hospitals, or between the hospitals and state government,” he said. “I think it goes back to what Vermont's all about.”
A change in attitude
Grace Cottage was as prepared as it possibly could be for a surge in hospital cases, Terwilliger said.
“We were able to give all of our doctors and nurse practitioners emergency privileges in the Emergency Department and in the hospital, in case we had that surge. And we have a call system. So in case the worst-case scenarios came, we would be ready.”
The hospital remains ready, he said, but “we never really had to do any of that, as we only had very few people who were critically ill with Covid. And they were rapidly transferred.”
As a rural hospital, GCH's role in recent years has been to take in patients, stabilize them, and then send them off to a bigger hospital for advanced care. However, over the past year, DiVello said, GCH discovered that it could do much more than that.
“We kind of assumed that patients need to go to a hospital with an [intensive-care unit], a respiratory therapy department, etc. We've now discovered that there really is a role for us and, much to my surprise, there was actually enthusiasm among the physicians and the nurses here that we can take patients who no longer need an acute care bed, and we can help them recuperate and get home safely.
“And we can be part of that, and our team here at the hospital was willing and ready to step up after the fear subsided.”
But Terwilliger said the fear is not far away from the minds of anyone involved in health care. A couple of hundred miles away, New York City was hit early and hit hard. By mid-April, more than 1,000 people were dying of complications from COVID-19 in hospitals that were understaffed, underequipped, and traumatized from the fight against a new and deadly disease.
In southern Vermont, “we've been spared so much from the trauma,” he said. “I would say most hospitals in the country have been traumatized by Covid.”
“But the reality is we have not had a bad experience physically from Covid on this hospital,” Terwilliger continued. “We've been cautious, so the fear probably is a good thing, because it keeps us doing safe practices.”
DiVello said the hospital is counting its blessings because the one thing they feared the most did not happen. West River Valley Senior Housing assisted living, the long-term care facility next door to GCH, did not have a single case of COVID-19.
But he said that doesn't mean there is no longer anything to worry about.
“I think that people aren't going to die in large numbers. I don't really have that big fear right now,” he said.
But, DiVello warned, “We're going to see probably this thing dribbling on for a long, long time with new variants coming along.” He predicted that the current vaccines will require booster shots, and that “we'll be giving those boosters for a good long time.”
“I think we're going to live with this,” he predicted. “We'll be living pretty normal lives here soon, and I think everyone's feeling a little better because of the vaccines.”
Ending the isolation that people have been feeling has been the biggest thing that DiVello hopes to see happen soon.
“We're social animals - we need to be around people. And hopefully this summer, we'll be able to have barbecues and go to the movies.”