Idaho enters grim ‘crisis’ period. Hospitals statewide on verge of rationing.

Idaho on Monday moved into “crisis standards of care” for the first time in the state’s history.

The Idaho Department of Health and Welfare announced the decision Tuesday morning. It applies to North Idaho, based on a recommendation from a large committee of health care and patient-advocacy stakeholders from around the state.

All of Idaho is teetering on the edge of crisis standards, an official said. That’s mainly because Idaho hospitals are running out of capacity, so are hospitals all over the U.S., and the state’s COVID-19 case counts are still rising.

“I will say what I have said for the last couple of weeks, which is for the rest of the state, we remain dangerously close to crisis standards of care,” said Idaho Health and Welfare Director Dave Jeppesen.

The announcement came as Idaho hospitals see the largest surge of coronavirus cases since the pandemic began. More than half of Idaho’s ICU beds on Monday were filled with COVID-19 patients, according to federal data released Tuesday.

Staffing is a major issue in Idaho hospitals, which struggled before the pandemic to hire enough specialized nurses with experience in emergency and intensive care units — two areas now being hit hardest by patients with COVID-19. In addition, many health care workers have left their jobs in Idaho and across the country during the pandemic.

Idaho Gov. Brad Little attempted to stave off “crisis standards” by activating the Idaho National Guard to help hospitals manage the flood of patients. Many patients have life-threatening or critical illnesses and injuries that aren’t related to COVID-19, but the coronavirus disease has now crowded Idaho’s ICU beds beyond capacity.

The crisis affects everyone, not just COVID-19 patients.

“What it means is if you go to the hospital, you should expect a longer wait time,” Jeppesen said. “You may not be seen in a traditional space; in fact, you may be seen in a classroom or a hallway, or you may be sent to a different hospital that has more capacity.”

Jeppesen advised Idahoans to get a COVID-19 vaccine, which significantly reduces the risk of hospitalization. Idahoans who are vaccinated also should “just be a little more careful,” he said.

“Wear a seat belt. Take medications as prescribed. Reconsider high risk activities that could land you in the hospital, because that’s where we are … at this point,” he said.

Crisis standards will apply to North Idaho hospitals in the Panhandle Health District and the North Central Health District “because of a severe shortage of staffing and available beds in the northern area of the state caused by a massive increase in patients with COVID-19 who require hospitalization,” the department said in a news release Tuesday.

Hospitals in the Treasure Valley, Magic Valley and East Idaho are now being stretched to their limits, as well. Saint Alphonsus and St. Luke’s health systems have warned that they are being pushed to the brink of crisis standards.

For example, St. Luke’s Magic Valley serves a sprawling region with low COVID-19 vaccination rates. It had 63 patients with COVID-19 on Sunday. That was 45% of its total patients at the time, and the largest number of coronavirus patients the hospital has ever reported.

With COVID-19 on top of other ailments, injuries and emergencies, St. Luke’s Health System hospitals are now more full than they’ve been since at least April 2020.

What’s happening in North Idaho?

Kootenai Health in Coeur d’Alene has been preparing to enter “crisis standards” and recently turned a classroom into a patient care unit.

“This week, within a 36-hour period, four COVID-19 patients at Kootenai Health passed away,” said a hospital news release on Aug. 25. “Three of them were 45 or younger. Yesterday Kootenai installed a new, higher-capacity oxygen tank because the hospitalized COVID-19 patients they are seeing now have a much greater need for oxygen.”

The hospital has remained maxed out on patients it can take who need intensive care. There were 108 patients with COVID-19 at Kootenai Health on Tuesday morning, up from 93 on Friday. Of those, 39 were in the ICU.

They’re not hospitalized because of getting a COVID-19 vaccine. They are hospitalized because they didn’t get a vaccine before they were exposed to the virus.

“Since the beginning of our most recent surge, we have found 97% of patients hospitalized for COVID-19 are unvaccinated,” Kootenai Health says on its website. “Kootenai Health has not admitted a single patient for adverse reactions to the COVID-19 vaccine.”

What does “crisis standards” mean for Idaho?

Hospitals have been preparing for this scenario and doing everything they can to avoid it.

When patients outnumber the available health care staff, equipment or medication supplies, it forces health care providers to shift from the normal “standard” of care they provide to the community.

Some of that is already happening outside North Idaho, to various degrees. In the Treasure Valley and Magic Valley alone, St. Luke’s and Saint Alphonsus health systems have downshifted their operations in some areas — postponing things like non-emergency heart surgeries and tumor removals — to free up resources for patients who need life-saving and life-sustaining care immediately.

The official declaration that Idaho is at “crisis standards” helps to protect doctors, nurses and hospitals from liability when they can’t respond as well to patients or have to make tough decisions about which patient is most likely to survive.

It allows them to follow guidelines to determine how to most effectively use scarce resources.

A state committee last year developed an in-depth plan for health care providers to follow.

“As a public health emergency moves along the continuum of care (i.e., from conventional, to contingency, to crisis), normal operating conditions will give way to extreme operating conditions,” the plan says, explaining how Idaho would arrive at crisis standards. “Health care resources, including space, staff, and supplies, will become increasingly scarce. The indicators listed in Table 1 may serve as general assumptions or indicators for health care facilities during the transition from one level of care to another along the continuum of care.”

The plan also explains what happens to force health care providers to move into “crisis standards” instead of staying at conventional or contingency standards.

“The indicators listed in Table 2 may be used by the DHW Director and other state policy makers to determine the need for (crisis standards of care),” the plan says. “The precise trigger point for transitioning from contingency to crisis will be determined by the Director in consultation with the Governor’s Office, (state health care operations and crisis standards committees), the Idaho Office of Emergency Management (IOEM), local health officials, and health care system stakeholders.”

The plan and accompanying guides and checklists help hospitals navigate the crisis. They are intended to help doctors and nurses — who want to give all patients the highest level of care possible — determine how to triage patients and allocate resources to save as many lives as they can. For example, if there are two ventilators but five patients who seem likely to need a ventilator, the guides offer a way to decide who should be intubated first.

The guidance is lengthy and complicated, with multiple tiers. But the “primary triage” guide offers some insight into what would happen if 100 patients are waiting in an emergency department, which only has enough nurses to safely care for 50 of them. Some patients would be in the “red” category, while others may be in a “yellow,” “green” or “black” category.

Editor’s note: The crisis standards of care activation timeline has been corrected.