Stemming the COVID Tide in a Rural Hot Spot

The CEO of a health center in central Nebraska needed all hands on deck when the global pandemic hit close to home.  

The city of Lexington, Nebraska sits just north of a pair of mighty east-west thoroughfares, U.S. Route 30 and Interstate 80, more or less equidistant from the highways’ twin termini on the Atlantic and Pacific Oceans – but the word “city” might be a bit of a misnomer, as the jurisdiction of barely more than 10,000 residents is surrounded as far as the eye can see in every direction by a grid of nearly identical squares of lonely county roads.

Locals no doubt hardly expected to see the city’s name appear in the pages of the New York Times, for any reason. Yet in late May, that’s precisely what happened.

“Lexington … became a hot spot for COVID-19,” explained Leslie Marsh, CEO of Lexington Regional Medical Center for about the last decade and a fierce, nationally renowned advocate for rural healthcare. “The largest employer in the community is a meatpacking plant, and as you now likely have heard, the actual workspace lends itself to viral spread.”

Tyson Fresh Meats, the pork and beef unit of Tyson Foods, Inc., reportedly employs a workforce of about 2,700 in Dawson County, of which Lexington is the county seat – that’s nearly eight times as many workers as any other employer there. The massive meatpacking plant on Plum Creek Parkway in Lexington employs more than half of those workers, about 1,400.

During the worst of Nebraska’s COVID-19 experience, one in six of those with a positive diagnosis reportedly worked in a meatpacking plant. But while this particular plant was a root cause in a considerable hospitalization spike that began in the second week of April, it was also a trusted ally of Lexington Regional in helping fight back against the virus.

“Fortunately, our plant has always been a good partner, and as more information became available, through credible governmental and public health agencies, the plant did implement engineering and process designs that helped reduce transmission of infection. They were also doing all they could to ensure that their team members followed CDC recommendations in terms of quarantine, isolation, use of PPE (once they were able to secure PPE), and ongoing monitoring,” Marsh said. “They began travel restrictions and quarantine post-travel, earlier than anyone else in the county, and erected screening tents for temp monitoring twice a day in early March. So, while that industry has been identified as being particularly hard hit by the virus, their efforts did mitigate risk and spread.”

Still, Marsh added, there were other reasons for the surge, which resulted in hospital care management of 45 patients, at its peak – a big number for a small county (the population of Dawson County is barely two and a half times that of Lexington alone, around 25,000).

“We saw at least an equal number of our positive cases come from a lack of adherence to social distancing and other directed health measures,” Marsh explained. “We are a diverse community, and we have roughly 63 percent Latinos living in Lexington. Some of cultural values we have always seen in this population in our community include a strong tie to extended family – gatherings are common, and celebrations like quinceaneras, Easter, Mother’s Day, and other rites of passage are important. So large group gatherings … continued.”

Marsh, who in 2018 was named a “CEO to Know” by Becker’s Hospital Review, added that language barriers and health literacy of patients and their families factored into the challenges being faced by hospital staff. But in the face of such challenges, the staff at Lexington proved as dedicated and tenacious as they were resourceful and imaginative.

“The talented people who took care of our community were nothing short of spectacular,” Marsh said. “There were supply chain interruptions, but we were able to secure some PPE through the state and through Hearts for Heroes’ Project Cure. We had to think through maintaining the health and safety of our health team, so processes changed to enhance use of engineering devices and the construction of additional barriers for intubating and caring for all patients in a high-quality, safe way. Innovation, identifying and addressing throughput, and using medical screening outside the ER, as CMS enabled us to do through waivers, using incident command and communicating regularly, were staples of our approach.”

During the busiest times, the hospital’s leadership team worked night shifts and provided weekend support to help as needed, bringing meals and snacks to fortify the frontline workers.

“In the long run, it was a unifying and clarifying experience,” Marsh said. “People came together and we did what we always do – take care of one another and of our community.”

COVID-19 has now sickened nearly 2.5 million and killed nearly 125,000 in the U.S., and while deaths and hospitalizations have generally seen mild declines, new cases are up, in the short term – especially in several large states such as Arizona, Texas, and Florida, which have set new records in all the wrong metrics.­­ The 33,000-plus new cases recorded nationally on June 23 were the most in a single day since more than 34,000 were recorded nearly two months prior, on April 25.

Yet, in Nebraska, as in many states, restrictions are slowly being lifted.

“We continue to use social media and other media communication channels to talk about how to mitigate the risk of transmission by using tried-and-true infection control practices, wearing masks, continuing to practice social distancing, and moving forward slowly as we begin to interact with our environment in a more traditional, pre-COVID way,” Marsh said. “We don’t want to generate ­­fear and/or panic; we want people to know that there are ways they can alter their behavior to keep them as healthy as possible. Of course, there is a tradeoff in mitigating health risks – you cannot eliminate all risk and expect to have a quality life – but you can alter your behaviors in ways that show a clear benefit without significant costs.”

Marsh said she also hopes that lessons learned at her hospital and other rural facilities that have experienced a surge in cases can benefit those dealing with similar circumstances down the road – whether amid a “second wave,” or amid continued peaks of the first.

“Incident command is critical, and communication, a foundational underpinning, multi-disciplinary planning, and leveraging the teams’ unique strengths helps to empower and generates innovation and coordinated care management,” Marsh said when asked about what best practices she’d share with such providers. “Take time to practice gratitude. Celebrate your team of heroes and the wins just as often as you talk about what could be done differently or better. Thank your team in small and larger ways – let them know how much you value them, and be there for and with them. We all signed up for this purpose-driven, incredibly rewarding life, but we also need to take time to maintain our own mental and physical health. So help one another stay healthy.”

“Culture really does trump strategy, because it either impedes or enhances execution of strategy,” she added. “It is a team sport, and we are only as good as our lowest performer, so make sure you have the culture you want before you have to rely on it to operate.”