Rural hospital expansions may be small, despite federal action

By: - March 18, 2020 2:30 pm

Boone County Hospital in Boone, Iowa, is one of Iowa’s larger rural hospitals. (Photo by Clark Kauffman/Iowa Capital Dispatch)

Despite federal action allowing Iowa’s rural hospitals to expand their patient capacity due to the coronavirus, hospital officials say they’re not likely to grow very much.

Iowa has 82 critical access hospitals that are relatively small and located in rural areas of the state. They supplement the care provided by 40 larger, acute care hospitals located in more densely populated areas of Iowa.

Because the critical access hospitals typically have a very low patient census, they receive significantly more federal funding for patient care. The extra money enables them to remain open and serve rural areas that otherwise would have no inpatient hospital services.

To remain eligible for the higher level of funding, however, the hospitals have been capped in size at 25 beds, and patient stays have been limited to 96 hours or less.

To deal with the expected increase in demand for hospital services, the federal government has temporarily waived the caps on beds and patient stays. But removing the bureaucratic hurdles to expansion may have little overall effect.

“Most smaller hospitals, you know, they might be able to bump up immediately by, say, 10, 15 or 20 percent, and that’s if we’re lucky,” said Joe Smith, CEO of Boone County Hospital, one of Iowa’s larger critical access hospitals. “Anything beyond that and, well, we’d just be taking care of people the best we could.”

Iowa’s critical access hospitals have a total capacity of roughly 2,000 patients, while the acute care hospitals can handle a total of 9,500 patients. Gov. Kim Reynolds recently signed a proclamation that waives the lengthy certificate-of-need process by which acute care hospitals can increase their capacity during the COVID-19 outbreak.

The Boone County Hospital was originally designed and built as a large, acute care hospital, so it has far more physical space than many of Iowa’s other rural hospitals and — in theory at least — more capacity to grow.

In the 1960s and 1970s, the average patient census was often around 150. But by 2005, after multiple renovations, the hospital downsized to 25 beds to meet the federal standards for critical access care.

Although there are still areas of the hospital dotted with repurposed rooms once used for patient care, converting them back to patient rooms wouldn’t be easy.

“We have three or four additional beds in our basement that are under lock and key because that was always a requirement of the Iowa Department of Inspections and Appeals,” Smith said. “So those beds could be immediately made available, and we have also, over time, converted some rooms that we could make available almost immediately. These are rooms that already have the oxygen and other medical gases that are required to get a room up and going.

Boone County Hospital is one of 82 critical access hospitals in Iowa. (Photo by Clark Kauffman, Iowa Capital Dispatch.)

“We figure we could go from 25 beds to 29 or 30, so the bump in capacity isn’t real impressive. Now, for a real emergency situation, we also have, I think, about 15 cots that we could use — but I think these are just slightly better than an Army cot.”

Iowa’s critical access hospitals also aren’t equipped to deal with multiple cases of viral infections that require patient ventilators.

“If this got to the point where we were trying to care for critically ill patients who need a ventilator — well, we have two ventilators and that‘s it,” Smith said. “Now, in a pinch we have anesthesia machines that could act as ventilators. So, in that situation we’d have five.”

In addition to beds, equipment and rooms, the hospital also has a limited number of staff, he said. “If we’ve got six or seven nurses available during a particular shift, you have to look at how many people they can safely take care of,” Smith said.

Although Iowa’s nursing shortage isn’t considered as severe as it was in 2016, there are still shortages in some areas of the state.

According to a recent survey by, Iowa has the nation’s third lowest rate of pay for registered nurses, behind only South Dakota and Alabama. The median annual pay for a registered nurse in Iowa is $56,710, or $2 an hour less than neighboring Nebraska.

Iowa is allowing former nurses with licenses that have lapsed or expired within the past five years to treat coronavirus patients, but Smith said that idea has its drawbacks.

“Do you want to bring in 70-year-old nurses? Well, in terms of their expertise and their ability to work, absolutely. But in terms of their own safety, well, I’m not really sure that makes the most sense.”

Sen. Chuck Grassley, R-Ia., said Tuesday he hopes Congress can provide some form of additional assistance to critical access hospitals.

“It’s important to me that rural hospitals, which are already facing staff and resource shortages, receive the help they need,” Grassley said. “Rural America can’t be left behind, even as we combat the virus in more densely populated hot spots.”

Our stories may be republished online or in print under Creative Commons license CC BY-NC-ND 4.0. We ask that you edit only for style or to shorten, provide proper attribution and link to our web site.

Clark Kauffman
Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing. His 2004 series on prosecutorial misconduct in Iowa was named a finalist for the Pulitzer Prize for Investigative Reporting. From October 2018 through November 2019, Kauffman was an assistant ombudsman for the Iowa Office of Ombudsman, an agency that investigates citizens’ complaints of wrongdoing within state and local government agencies.