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Health care providers were optimistic for the first time in about a year early this spring.

They had made it through two major surges in the COVID-19 pandemic and vaccinations were rolling out.

Building on a "mid-response assessment" of hospitals it published in September 2020, the Missouri Hospital Association (MHA) began gathering data about the pandemic's next phases. It began work on "Missouri's COVID-19 Response: A Clinical and Operational Reflection for Missouri Hospitals," which published Aug. 19.

However, within the next couple of months, the COVID-19 delta variant began to rapidly spread across the state and the nation.

Local health crises are typically contained within about two weeks, not 18 months, said Jackie Gatz, MHA vice president of safety and preparedness.

"We thought once vaccines were rolled out we would see the end of the pandemic," said Gatz, who authored the report. "We elected to move forward with publication this summer because we were still in the fight."

Shelving it until next spring or late in the fall wouldn't benefit hospitals who could take away best practices from the report.

Hospitals can use information provided through the report and look at what long-term challenges to them came about as a result of the pandemic, said Dave Dillon, MHA spokesman.

"We created these tools and have been hosting webinars. Safety leaders are discussing what we've found and what we're learning," Gatz said. "We're already thinking about the third iteration (of the report)."

The delta variant surge in the pandemic created unprecedented challenges for health care organizations, the August report says.

"No level of planning or preparation could fully inform the scale, longevity or level of impact the virus would have on our organizations, communities and nation," its executive summary says. "As case levels stabilized in spring 2021, hospital operations shifted to monitoring and managing COVID-19 in the long term, to include outbreaks."

The report shares best practices, assists member organizations with assessments and improvements, and records hospitals' accomplishments.

About 91 percent of MHA hospitals surveyed said they activated emergency operations plans at the onset of the pandemic, according to the report. Eighty-four percent remained activated in April, when the information was collected.

Documentation, the report states, supports hospitals' use of waivers intended to streamline health care operations and expand patient care capacity during the pandemic. And, the report finds, it was evident that executive, clinical and operational leaders must remain engaged in emergency preparedness and operations planning.

Leadership of Missouri Delta Medical Center in Sikeston, realized early after activating its incident command system (ICS) that the pandemic would challenge the traditional ICS responses, the report said.

"This event would last much longer than traditional emergency response events and require daily engagement with external partners," the center said. "This event had the potential to not only push our facility's capacity to the limits, but every facility in the region and throughout the country."

The center decided to implement a COVID Task Force, which met daily. It brought in emergency medical services and county health departments to participate in planning and response. It later expanded to include air evacuation, city and county law enforcement, courts, clinics and management of major area employers.

Later additions included school leadership and the MU Outreach Program, which coordinated with area nursing homes. As vaccines became available, the task force invited vaccinators to join.

The task force remained flexible and began to scale down this spring. However, with a significant surge of the delta variant in July, it fully reactivated.

The MHA also engaged in the Fusion Cell, a statewide whole-of-government structure in which public and private partners participated in daily briefings.

"As we look forward, opportunities remain to strengthen data interoperability within Missouri and across the nation," the report found. "Limitations in the various data sources used to guide the state and federal response, and the lack of interoperability underlying these systems, became apparent early on and have persisted throughout the response."

Strengthening interoperability between electronic medical record systems and public health systems would streamline reporting and inform accurately targeted responses, the report finds.

Clinicians were learning on the fly about specific patient treatments and outcomes early on during the pandemic. Guidelines changed constantly. Remdesivir received limited approval for treatment of hospitalized patients in May 2020.

Hospitals had to keep up with changing guidelines concerning treatments, and had to "navigate the allocation process" for treatments (which were controlled by the state).

"Many hospitals in Missouri developed innovative strategies and redesigned spaces to deliver outpatient intravenous monoclonal antibody treatments," the report found.

In a later development, clinicians began dealing with the emergence of "COVID-19 long-haul patients" who recover from the acute disease, but continue to experience chronic symptoms for long periods of time.

In anticipation of surges, Missouri hospitals added 156 emergency department beds early in the pandemic. They also added 471 intensive care beds and 657 medical surge beds.

They added 215 negative pressure rooms (those whose air pressure is kept lower than surrounding rooms, so when the door opens, potentially contaminated air remains in the room) within emergency departments. Air within the room is filtered before being pumped outside the facility. They added 1,650 outside emergency departments.

About 700 of the new negative pressure rooms are expected to be permanent additions to hospitals.

While admitting Missouri and the rest of the United States aren't ready to rip the bandage off the pandemic, signs of it showing appear every day, Dillon said.

"All indications are that delta is at least headed in the right direction. I think we're getting close to where we can begin to talk about this being in the rear-view mirror," he said.

He repeated the state is not done with the disease, and pointed to January and February this year, when the country seemed to be on the downside of the "spike."

"The second report is truly about lessons learned," Dillon said.

And, Gatz said, hospitals are cognizant of flu season beginning, and how that might play out as the pandemic begins the second half of its second year.

"We still have a young population that is unvaccinated. They are susceptible to the flu and being hospitalized for the flu. All of our hospitals are sensitive to what that could look like," she said. "It's really just the next concern because it's a little bit unknown."

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