When doctors and administrators at St. Joseph Mercy Ann Arbor in Ypsilanti, Mich., began seeing cases of fungal meningitis in early October, they were ready with a disaster preparedness plan. What they couldn't foresee was the size of the outbreak, its length and the complications that would force many patients to return to the hospital.
"The patients keep coming. We see more and more of them every day," said Robert Casalou, St. Joseph's chief executive and president. "We get ready for the sprint, and what happened here is the marathon."
As of Nov. 26, the Centers for Disease Control and Prevention had counted 510 people in 19 states who had been stricken with fungal infections traced to spinal injections of tainted steroids distributed by the New England Compounding Center in Framingham, Mass. The disease can be deadly, but it is not contagious. With 178 patients, Michigan has, by far, the largest concentration in the nation. St. Joseph has taken care of 146 of those patients. As Catholic Health World went to press, the national death toll stood at 36, with 10 deaths in Michigan, seven of those at St. Joseph.
Some patients have been hospitalized since early October. "The best way to treat them is to 'cohort them,' bring them all together in a group, instead of caring for them at multiple locations," Casalou said.
His hospital, part of Livonia, Mich.-based Trinity Health, quickly opened 16 patient beds that had been approved but were not online and won fast-track approval from the state to bring in a portable MRI machine, open another operating room and bring in nurses from Ohio.
Slow to manifest
"The main challenge has been how this outbreak has evolved," said Dr. Lakshmi Halasyamani, the hospital's chief medical officer and vice president of quality and systems improvement.
Early on, patients developed fungal meningitis, an inflammation of the lining of the brain. Now some patients who had meningitis and others who did not are developing abscesses, primarily at the sites of the original injections with the contaminated steroids.
"I don't think we understood how indolent, or slow-growing, this fungus is," Halasyamani said. "Some of it took three months to manifest. It's not clear when the exposure period will end." Meningitis is treated with drugs, but the abscesses require drugs and surgery.
The abscesses are diagnosed with MRIs, and at the hospital's request, the state granted permission to bring in the additional portable MRI machine just before Thanksgiving. "Here at St. Joe's, we're proactively reaching out to patients," Halasyamani said. They are examining everyone in their area who received the tainted injections, not just those who are showing symptoms. As a result, doctors are finding and treating abscesses that some patients didn't realize they had.
Physical, financial reckoning
The influx of patients has filled the hospital to capacity, Casalou said in an interview in late November. "We had 32 beds that were off-line, and we opened half of those," he said. "We opened that unit within a week. We're considering opening the remaining 16, although it would take a little longer," he said, explaining that the hospital would need to acquire additional equipment.
"The cost of caring for these patients is extraordinarily high," he said. "The drug cost is high. It's a big issue for the patients, and that's one of our greatest worries." The out-of-pocket cost for the medications can reach $8,000 a month. "The greatest fear of patients is sometimes the finances," Casalou said. "We're giving patients that can't afford their medications supplies of the medications. We're incurring costs here as well. That's part of our mission."
For now, St. Joseph is focusing on treating the patients. The hospital will try to lessen the financial burden later. "We have faith that the insurers and the government will work with us," he said.
Potential shortages of the antifungal drugs are another concern, as are the drugs' side effects, which can include kidney failure and hallucinations. "One of the difficult parts of managing this is that each patient has different tolerances for these drugs," Casalou said.
Floating nurses
To help deal with the influx of patients, Trinity Health sent more than 20 nurses from its other facilities. Those out-of-state nurses needed licenses to practice in Michigan, which the state granted in 24 hours. "The state of Michigan has really partnered with us in extraordinary ways," Casalou said.
Stacey Yates is a registered nurse who works for Mount Carmel Health System in Columbus, Ohio. Like the other visiting nurses, she said, her regular job is to float as needed among the intensive care unit, the emergency room, oncology unit and work as a behavioral health nurse.
Trinity Health sent a mass email to its floating nurses with the subject line "urgent need." "It explained the situation and asked if any of us were willing to come up here and help take the load off of those who have been dealing with this for so long," Yates said.
"The staff who have been here forever are doing such a good job. They deserve credit."
Yates is staying in housing provided by the hospital during her four-day work week, then making the three-and-a-half-hour drive home to Columbus to be with her husband and 3-year-old son on her days off. "I plan on working here four days a week until this whole thing winds down," she said.
She noted that some patients are in great pain, while others are comfortable and question why they need to be hospitalized. "Fear, frustration, hopelessness, they don't feel in control of their lives right now," Yates said.
Comfort in numbers
To address that, the hospital outfitted a resource room in the wing that houses many of the patients and formed a support group that meets each afternoon, said the Rev. William E. Foster, an American Baptist minister who serves St. Joseph as director of pastoral care.
"This special patient population is our highest priority," he said. "We include the family members and loved ones as part of our patient care."
He said that participating in the support group helps patients feel less alone. "We realized a few patients were already starting to meet on their own," he said. "They had been finding comfort in hearing one another's stories."
The resource room is always open and stocked with books, games, movies and snacks. "Being cooped up in their rooms is miserable," Foster said. "This helps them get out a bit, and still be safely in the unit.
"This is one reason I love being part of Catholic health care," he said. "Catholic health care really appreciates the spiritual dimension as part of the health care process."