Fall 2021 COVID-19 Surge Hits Remote Island Community in Alaska: Local Critical Access Hospital Responds Under Challenging Circumstances

What Happened

In mid-summer 2021, the Delta variant (SARS-CoV-2 B.1.617) became the dominant strain of the COVID-19 virus in Alaska. By October, uncontrolled spread of the virus had made Alaska the state with the highest infection rate in the U.S. The state's hospitalization rate at the time was nearly twice the national average and, at the height of the surge, the number of COVID-related deaths in the state would be higher than at any other point in the course of the pandemic up to September 2022. This wave of infection strained Alaska's hospital system in ways that it had not experienced before, with the possible exception of the 1918 influenza pandemic.

In the earlier days of the pandemic, the combination of geographic isolation, strict lockdown and quarantine measures, and early adoption of testing and vaccination strategies had largely protected Alaska from the worst outbreaks of the disease that had affected other areas of the country. But by mid-2021, many of these mitigation efforts began to wane for various reasons, leaving the state more vulnerable than it had been previously. So just as the wave of Delta variant infections was beginning to recede in the lower 48 states, it was surging throughout Alaska.

As a consequence of Alaska's geographic size and relatively sparse population, its healthcare system is comprised of a network of small community clinics, regional medical centers, and several larger hospitals in the cities of Anchorage and Fairbanks. This system relies heavily on the ability to transfer patients requiring higher levels of care to its larger hospitals or even, in some cases, to healthcare facilities in Oregon or Washington. This structure can pose challenges even when operating under normal circumstances, especially in remote areas of the state that, in some cases, may not be accessible by road and where the nearest healthcare facility may be located several hours away. Thus, in a situation where the large city-based hospitals reach their capacity and have limited ability to accept patients from other areas, it has a ripple effect across the entire healthcare system.

This is exactly the situation the state faced in the fall of 2021. In mid-September, the hospitals in Anchorage and Fairbanks began implementing crisis standards of care (CSC) at their facilities to cope with the influx of COVID patients. This was followed just a few weeks later, on October 2, by the state activating crisis standard of care guidelines for 20 medical facilities in the state. The CSC protocols adopted by the state are designed to help guide decision-making at facilities when resources become scarce due to a disaster or emergency event. The protocols focus primarily on strategies to substitute, adapt, conserve, and re-allocate necessary resources. In some cases, facilities may need to prioritize which patients will receive treatment ahead of others. In the worst-case scenarios, they may have to make determinations about who will receive care and who will not.

One of the main functions of the CSC declaration, therefore, is to provide some measure of legal liability protection for the healthcare facilities in the event someone is harmed or even dies as a result of a decision the facility makes regarding treatment. With many facilities in Alaska operating at or over capacity during the COVID surge, decisions to ration care were made in some places. These decisions did not only affect COVID-related cases. Many facilities postponed most non-emergency surgeries and treatments for less severe conditions. For patients with life-threatening non-COVID illnesses, treatments could be delayed, putting them at increased risk. In some tragic cases, patients who had to forego care ended up losing their lives.

Petersburg Medical Center (PMC), a Critical Access Hospital (CAH) in Petersburg, Alaska, was among the 20 facilities included in the October 2, 2021, CSC declaration. The Borough of Petersburg is located on Mitkof Island, which lies along the southeastern arm of the state, along the coast stretching down into Canada. There are no bridges connecting the island to the mainland; it is only accessible by sea or air transportation. PMC is a 27-bed CAH and is the only healthcare facility on the island, serving a total population of around 3,200 residents. Like much of the state, they would also experience their worst surge of COVID cases of the pandemic between the middle of October to the beginning of December in 2021.

Through the summer of 2021, the leadership team at PMC, now well accustomed to tracking the progression of COVID outbreaks, were closely monitoring the wave of Delta variant infections as it progressed across the country and eventually made its way to Alaska. Based on their experience with patterns of transmission from previous COVID surges and from maintaining regular contact with facilities in the major cities, the hospital had a very good understanding both of when Petersburg would be affected and how severe the surge might be. In one respect, their remote location benefited Petersburg's response to the surge. Their distance from the major population centers in the state meant that Petersburg would hit the peak of the surge at least a couple of weeks after the peak in Anchorage and Fairbanks. Also, because of their position at the far southern end of the state, transferring patients to facilities in Washington State was a common practice. These combined factors made it much easier for PMC to locate beds and transfer patients than it was for many facilities in Alaska at the time. As a result, PMC fortunately was not faced with some of the more difficult decisions regarding what treatments were available in the face of very limited resources, like in other parts of the state.

This awareness of the progression of the disease was an important factor in Petersburg Medical Center's ability to prepare for the oncoming surge of COVID cases. In this time period, PMC was working closely with the state health department to secure any additional resources that were needed, focusing especially on supplies of testing kits, vaccines, and monoclonal antibody treatments. As anticipated, the hospital began to see an uptick of cases at the beginning of September, which receded briefly before climbing again to a rate of over 800 new weekly cases per 100,000 residents at the beginning of October, according to Tracking Coronavirus in Petersburg Borough, Alaska: Latest Map and Case Count from the New York Times. The surge would ultimately peak in mid-to-late November at a weekly rate of well over 2,000 new cases per 100,000 residents, and the rate would not fall below 200 cases per 100,000 residents again until the middle of December. The severity and duration of this surge caused considerable strain on hospital staff and resources. As Petersburg Medical Center's Chief Executive Officer (CEO) and administrator Phil Hofstetter recalled, “Addressing Delta or whatever that surge was at that time was major for us. It was all hands on deck, and it was exhausting. It was absolutely exhausting during that time.”

As the number of cases began to rise, PMC took a number of important steps to bolster hospital operations, enhance care for patients, and mitigate harm to the community. Among the first steps they took was to expand their testing program. In order to reduce barriers and facilitate access to testing, vaccination, and treatment to the furthest degree possible, PMC made a determined decision about how they would use emergency COVID relief funding. As Hofstetter explained:

“We took our COVID funds that we were able to get, and we just directly extended it out to our services in the community. We made it free; we made it available. We just said if we're going to address this pandemic, we've got to be able to appropriately allocate those [funds] and make it as available as possible…We made it a big point that we were going to remove all barriers. We're going to take any COVID funding that we get, we're going to allocate directly right out into the community in the form of services and availability.”

This approach was crucial to expanding community access to testing, vaccination, and other services as widely as possible, and it was one factor that made it easier for PMC to build trust and overcome resistance or reluctance toward some of these measures that existed in the Petersburg community.

From the outset, the hospital — as the only healthcare provider on the island — was one of the leaders in directing the response to the pandemic, which was highly integrated with the state, Petersburg Borough, and other partners. PMC was a member of the borough's incident command team, a PMC physician served as Petersburg's public health officer, and the state public health nurse for the community worked out of PMC's facility. They therefore played a central role in developing and implementing Petersburg's testing strategies. They directly administered or provided guidance for testing processes at the schools, at the airport, for ferry and cruise ship operators, and in the community at large. With vaccination rates that were still well under 70% at the time for the adult population, identifying positive cases as early as possible and getting those testing positive and their close contacts into quarantine or isolation right away remained the best tool to prevent the spread of the disease in the community.

Where it could be implemented to a greater degree, the testing program had a strong record of success. Perhaps the biggest example of this was the testing done by the school district. With guidance from the hospital, the school has been able to administer a high number of tests on a daily basis over the course of the pandemic. As a result, students have been able to continue in-person instruction for the majority of the time. After the initial lockdown period at the beginning of the pandemic, it only became necessary for the school to close down in-person instruction for a period of no more than two weeks.

Another step PMC took that strengthened their response to the surge in COVID cases was the rapid adoption and deployment of monoclonal antibody treatment for COVID-19. Hofstetter described this treatment as a “game changer” in terms of their ability to prevent some of the worst outcomes as the number of cases climbed. Use of the monoclonal treatment was most effective when working in tandem with the testing program. In the case of the monoclonal antibodies, the sooner the treatment could be administered, the greater its efficacy would be. Lab technicians at the hospital, therefore, worked long hours (well past midnight at times) processing tests. By doing this, they were able to reduce the amount of time between when a COVID-positive case eligible for the treatment could be first identified and when treatment for that person could be initiated.

This combination of rapid testing with the use of monoclonal antibody therapy was instrumental in decreasing the number of cases of severe COVID in the hospital. Limiting the severity of the disease provided better outcomes for patients and also contributed to better operating conditions at PMC, which helped relieve some of the pressure on hospital staff. Over the course of the fall 2021 surge, PMC had relatively few patient transfers, which meant staff and administrators did not need to spend as much time locating available beds in other facilities and processing those transfers. The amount of time the hospital spent operating at or over capacity was also minimized. For the majority of the surge, they were able to stay below capacity and keep beds available. All of this contributed to saving lives, as the number of COVID-related deaths in Petersburg was also kept comparatively low.

Another critical component of Petersburg Medical Center's COVID-19 response was their ability to reach people outside of the hospital setting. Alongside and often in conjunction with testing programs and vaccination drives, PMC found multiple ways to engage the community where they lived and worked. Central to this effort was PMC's home health team. While the volume of long-term, inpatient, and outpatient services performed at the hospital was greatly reduced during the pandemic, the number of people receiving home health services increased drastically. This utilization of home healthcare was another way PMC was able to reduce inpatient COVID admissions and keep the hospital operating below capacity as cases spiked. Hofstetter described the process this way:

“So, if someone had COVID, instead of having them in inpatient, they were discharged safely. And then our home health nurses were able to do some checks on them in their home, which was really great. Like with O2 Sat [oxygen saturation levels], if we had O2 monitors, we gave them to patients, and they were able to check and keep in touch with the home health nurse.”

Through this interaction, PMC could better monitor these patients and more quickly connect them to higher levels of care if their conditions worsened. In this way, the team of home health nurses provided essential follow-up care and served as an ongoing point of contact with the hospital for patients with COVID-19, making it less likely that anyone in need of additional care fell through the cracks of the health system. These in-home services also gave providers another opportunity to provide testing and vaccination for household members and to reinforce the importance of following public health guidance related to masking, social distancing, hand-washing, and other measures that could help prevent the spread of the disease.

Another important way Petersburg Medical Center engaged with the community was by serving as a reliable source of health information on matters related to the pandemic. These efforts only became more urgent as cases surged in 2021. While PMC utilized various formats to communicate with the public — including the local newspaper, press releases, in-person events, online and social media platforms — one of the most effective ways to reach the community was through the local radio.

As the situation on the ground evolved rapidly through the fall, PMC staff and leadership along with representatives from the schools and borough were on the radio daily with important updates, information, and clarifications about the spread of the virus and the community response. The radio format allowed PMC to keep Petersburg residents informed of the latest developments in a more immediate and relatable way. Providing a clearer understanding of the situation and its risks and how to best respond, both collectively and individually, to the surge through local radio became a critical tool in dispelling much of the distrust, skepticism, and fear that existed in the community around many of these issues.

Along with their use of local radio, PMC held several town hall events, and they were also a constant presence at borough assembly meetings. These venues provided opportunities to communicate directly with residents in person and to advocate for the best policies and measures to protect the community and individuals from the COVID outbreak. In all their communication efforts, PMC was fortunate to have strong support from experts and leaders at the state health department. Whenever needed, they could call on officials such as Alaska's chief medical officer, director of public health, and state epidemiologist to join them, whether on the radio or at in-person meetings, to give people the best up-to-date information and to further their awareness of the disease, its progression, and its effects as well as their understanding of local, state, and national policies, programs, and guidelines being implemented to help communities respond to the pandemic.

The access that small communities like Petersburg had to state-level health officials, who had expertise and the best available information related to the pandemic, was essential to their pandemic response efforts. This open communication went a long way toward building trust with residents and strengthening the relationship between healthcare providers, public officials, and the wider community as they worked together during one of the most difficult periods in the borough's history.

Taken together, both the internal and external steps Petersburg Medical Center took to respond to the worst surge of COVID-19 their community had seen as of September 2022 were effective in providing the people of Petersburg with essential care and services, avoiding the worst outcomes of the surge of COVID infection, and ultimately saving lives.

By the end of 2021, the number of weekly cases in Petersburg had fallen to well under 200 per 100,000 residents. The community would go on to see cases of COVID-19 surge again a couple more times in the beginning of 2022, though not with the same intensity and duration as in the fall of 2021. With the knowledge and experience gained from that previous wave and with vaccination rates now approaching 80%, Petersburg was in a stronger position to respond to these surges, even as those same waves of infection had caused or were causing some of the worst outcomes of the entire pandemic elsewhere in the country.

Success Factors

State Partnership and Support

The role of the state and the state department of health is one of the biggest factors that contributed to the success of the COVID response in Petersburg. Petersburg Medical Center CEO Hofstetter summed up this relationship as follows:

“Our state agency was just very available, and I don't know how other states were, but that was something that made a big difference. I felt like they backed us up incredibly with our community…So, there were very good responses, and they were very consistent. They were the same people from the start of the pandemic to the end and they stayed on, and that's a big deal when it comes to some of the consistency with messaging.”

Some of the ways the state department of health provided support to PMC's response efforts included:

• Supplying necessary resources, such as polymerase chain reaction (PCR) test kits and doses of COVID vaccine
• Regulatory flexibility, granting PMC more leeway to respond how they saw fit to events on the ground
• Daily briefings and meetings to coordinate state and local efforts and provide high-level, evidence-based information and expertise
• State public health nurse and other public health personnel working in the community
• Health department officials and experts made available locally to help disseminate information, clarify policies, and reinforce public health messaging about the pandemic

Aligning Incident Command Systems

Another element that contributed to success was the importance of aligning incident command systems (ICS) across organizations and agencies that were working together to respond to the COVID-19 outbreak. These independent agencies and organizations, such as the borough, law enforcement, first responders, and the state, adopted similar ICSs, which facilitated collaboration and coordination between them throughout the course of the pandemic. Much of this comes down to simply using consistent language and terminology across systems to keep everyone on the same page. By speaking the same ICS language, communication and coordination between these groups were much more efficient and therefore more effective in addressing the crisis at hand.

Barriers

Emergency Funding and Disproportionate Burden on Small Hospitals

One challenge Petersburg Medical Center faced in responding to the COVID crisis was the difficulty in processing the amount of paperwork necessary to receive reimbursement through certain federal programs. While having this funding available during an emergency is essential to small, rural facilities like PMC, they are often at a disadvantage in attempting to access it. This can put these facilities into a kind of negative financial feedback loop: because rural facilities are often more financially insecure than larger providers, they are often the places most in need of funding in an emergency, yet because of their limited resources, they often have the most difficulty in securing the funding that is available. Hofstetter emphasized the volume of work this created for PMC: “We were spending so much staff time putting this stuff together. And it's not like we can hire staff out of our rural back pocket. We were asking our healthcare providers to do and file reimbursement paperwork…it was enormously frustrating for us as a facility. We just didn't have the depth for that.”

In addition to this, some of the reimbursement mechanisms available during the pandemic, which were critical to ensuring that the hospital had the financial means to respond comprehensively and aggressively to COVID-19, created financial challenges for PMC after the worst COVID surges had subsided. Financial recovery, in this case, is another area that can be more of a challenge for rural hospitals, with smaller budgets and operating margins, as they try to balance repaying some of the COVID funds they received upfront while still maintaining their current operations at adequate levels. Knowing they may face financial hardship on the back end of a disaster could serve as a disincentive to rural hospitals spending the money to do all they can to respond to the emergency in the first place. Finding solutions to ease these disproportionate burdens on rural providers and healthcare systems is therefore one factor that can enhance emergency response to future large-scale disasters in rural areas.

Patient Privacy, HIPAA Compliance in Small Communities During Disaster

As the number of cases, hospitalizations, transfers, and deaths from COVID-19 increased in the fall of 2021, maintaining patient privacy on individual cases became another challenge for Petersburg Medical Center. This is especially true for PMC as they were serving a significant public health role for the community. As they worked hard to communicate effectively with the public and keep residents informed of the latest developments as to the progression of the disease, it also resulted in situations where patient privacy might be compromised.

While Health Insurance Portability and Accountability Act (HIPAA) compliance is a concern for any healthcare provider, this challenge can be amplified in a small town. In small, close-knit communities such as Petersburg where residents are more familiar with the ins-and-outs of each other's daily lives, even little details could be enough to violate the privacy of individuals who had received or were receiving care. Hofstetter pointed out this situation and the care that had to accompany their communication efforts in Petersburg:

“The other big thing in the small town was HIPAA protection. Making sure that we had those strong protections in place. There's a lot of demand [for information] on medevacs and severity of illness and how many inpatient stays, and in a small town, people can figure that out. So, maintaining patient privacy during all that was certainly a big balance and a big challenge in a small hospital and a small community.”

Maintaining Community Relations

Among the biggest challenges for Petersburg Medical Center during the pandemic was managing their relationship with the community, especially as many of the public health measures being implemented or advocated for were met with significant amounts of resistance among the residents of Petersburg. As in many places, the fear and doubt that accompanied the emergence of a dangerous novel respiratory disease and a global pandemic could lead to distrust, skepticism, criticism, and anger within populations, which was then often directed at healthcare providers as they worked to respond to the emergency.

Again, in Petersburg, where PMC was at the center of the community public health response, they also faced this distrust and criticism from the public around measures such as masking, lockdowns, vaccination, and social distancing. Because PMC leadership and clinicians were often front and center at town halls, assembly meetings, school board meetings and other events, they were affected acutely by these interactions. Furthermore, the lack of trust in the health measures meant to prevent transmission and protect Petersburg residents from the disease could lead to fewer people adopting and adhering to these practices, which then threatened to make the outbreak of the disease more severe and put more people at risk.

In response to this situation, PMC adopted a position of providing the community with as much open, honest, and positive communication as they could regarding these issues. Hofstetter explained the importance of transparency in their public communications and how it could build trust with the community:

“I felt like it was important that they [the community] heard from us. And I remember our school administrator said, ‘Let's get on the radio and just talk to the people.’ Because, again, when you're dealing with information and so many changes, the big thing is expressing that we don't really know what's going on, but this is the best information we have to date. And we kept saying that over and over again. I felt like that made a big difference when we had to make changes or when things were just so fluid.”

The ability of healthcare providers to be open and transparent about gaps in knowledge and the uncertainties involved with the pandemic and its response gave residents reason to trust these providers and officials when they did put forward policies and measures that could be unpopular with some of the population. Even though this approach was often difficult and could not succeed in changing every negative perception of the public health response in Petersburg, it was essential to building trust and maintaining a constructive relationship in order to address the challenges of the pandemic in a more unified and effective way as a community.

Lessons Learned

Emergency Planning for Pandemics

While Petersburg Medical Center had a strong emergency preparedness plan in place prior to the pandemic, one critical gap exposed by the COVID-19 emergency was a lack of a specific plan and training for a pandemic. Much of their planning and regular training was oriented toward relatively more common emergencies, such as accidents or mass casualty events. Because they were more likely to encounter these types of emergencies, it was easier to give a comparatively rare emergency, such as a pandemic, less time and attention in an already busy schedule for their facility.

Despite this gap in their preparedness plan, PMC relied on their strong incident command system and the benefit of having a relatively high number of long-term medical and nursing staff at the hospital who were able to provide a level of experience, continuity, and cohesiveness to their pandemic response that they would not have had otherwise. Yet, it would have been valuable to have a specific plan and training geared toward emergency response for a pandemic situation, not least because the unique characteristics of Petersburg itself presented PMC with challenges not faced by most other communities.

For instance, because they are situated on an island, they had to assess the risk and decide what measures needed to be in place related to travel on and off the island by ferry, boat, or plane. Since restrictions and policies around these modes of travel — which is a necessity for island residents — could be more cumbersome than those for car travel, it could be a factor that contributed to heightened tensions between healthcare providers and the public. An emergency plan and training that incorporated pandemic response specifically could have helped PMC prepare for some of these unique contingencies before the COVID-19 emergency struck their community and could have helped to further strengthen the response of their already capable and dedicated team.

Person(s) Interviewed

Phil Hofstetter, Chief Executive Officer (CEO) and Administrator
Petersburg Medical Center