When it comes to caring for patients with coronavirus in Coeur d'Alene, Idaho, and surrounding rural areas, Kootenai Health is the only game in town.
"We're pretty much it," said Andrea Nagel, a spokesperson at the hospital, in the northern part of the state near the border with Washington. Critical access hospitals in nearby areas transfer patients they can't handle to Kootenai, and as Idaho's daily COVID-19 cases tick upward space at the hospital is dwindling.
While the number of free beds fluctuates, medical surgical units were 96% full on Friday, according to Nagel, and staff have been calling out-of-state hospitals in Spokane, Seattle, Portland and Salt Lake City to see if they have extra beds should Kootenai become overrun.
Nagel was careful to add that the emergency room at Kootenai is open and anyone who needs emergency care, COVID-related or otherwise, still can get it.
"We're hanging in there," she said of the staff, who are starting to feel the pandemic fatigue health care workers in New York and New Jersey described during the spring. Despite the rising cases, however, the regional health department board voted to end Kootenai County's mask mandate earlier this week, according to The Associated Press.
The anti-science backlash from some community members, including comments on social media, taken an additional toll on the hospital workers.
"It's definitely difficult for them," Nagel said. "I know a lot of our medical staff are struggling with that."
On Thursday, the state health department reported 950 new COVID-19 cases, bringing cumulative infections to 56,000 since the outbreak began.
In addition to rising cases and hospitalizations, an average of 34% of tests were positive every day in the past week in Idaho, as of Thursday, according to an ABC analysis of data from The COVID Tracking Project. That's nearly seven times the rate that health experts recommend staying below.
A high positivity rate can be a sign that a state is only testing its sickest patients and failing to cast a net wide enough to accurately capture community transmission, according to Johns Hopkins University. The World Health Organization recommends that governments get their positivity testing threshold below 5%.
At least 553 people in Idaho have died of the virus so far, according to the health department.
Unlike the cities and metro areas that got hit hard earlier this year, Idaho is decidedly rural. The state's population of less than 1.8 million means there are about 18 people living on each square mile, compared to the national average of 87, according to Census data Idaho's outbreak is also part of a larger pattern. With just three counties left in the United States with zero COVID-19 cases, rural areas are increasing becoming hotspots.
The trend is especially concerning given that so many rural communities that used to have hospitals recently lost them -- 95 rural hospitals closed between January 2010 and January 2019, according to the Department of Health and Human Services's Federal Office of Rural Health Policy. Of those facilities, 32 were critical access hospitals.
Beyond access to health services, rural populations tend to be older and to have morbidities, like smoking, hypertension and obesity, which can be risk factors for severe and fatal cases of COVID-19, Courtney Gidengil, a senior physician policy researcher at RAND, previously told ABC News.
As it stands, 1 in 5 Americans live in rural America.
ABC News' Soorin Kim, Brian Hartman, Benjamin Bell and Arielle Mitropoulos contributed to this report.
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