Idaho is now in statewide mass-casualty triage mode, due to COVID surge

Halting procedures that put someone at significant risk of permanent disability or chronic health problems.

Idahoans with low oxygen levels waiting four or more hours to be seen.

Nurses with less time to monitor vital signs and paralysis. 

Health care workers using basic ventilation devices with no monitoring or sensing functions. Patients awaiting an intensive care unit bed who must be physically ventilated with a bag for up to two hours. Patients receiving care only by stretcher in new overflow areas because hospital beds are entirely full.

These are just some of the eroding standards of care St. Luke’s Health System’s top health care executives cited that pushed them to apply for permission from the state to implement crisis standards of care.

Now, the week after North Idaho hospitals reached a breaking point and were forced to enter “crisis standards of care,” Idaho has activated the care-rationing protocol for the entire state.

How we got here

St. Luke’s, Idaho’s largest health care provider, requested the standards be activated, according to an Idaho Department of Health and Welfare press release. Officials from the health system joined hospital CEOs and doctors from around the state during a Thursday media call hosted by the Idaho Hospital Association to explain the need to implement the standards statewide.

Treasure Valley and Magic Valley hospitals are overburdened to a point where they must now begin to triage patients. East Idaho hospitals are similarly buckling under the strain from COVID-19 patients.

Idaho’s largest hospitals take patients from small community hospitals. They also have traditionally taken in patients from other states.

Idaho Health and Welfare Director Dave Jeppesen said in a telephone town hall, just before 1 p.m. Wednesday, he believed a request for crisis standards was “imminent” from Treasure Valley and Magic Valley hospitals.

Such a request requires documentation that hospitals are using every possible resource — even their “contingency” resources — and still cannot manage all the patients coming through their doors.

“We will wait to see if and when a hospital makes that request,” Jeppesen said during the town hall.

That day, Idaho’s crisis standards of care committee convened, reviewed all the information and recommended to Jeppesen that he activate crisis standards.

This will have a ripple effect, because smaller hospitals may be unable to transfer critically ill or injured patients to larger medical centers in Idaho.

There is no step beyond crisis standards of care — just degrees of crisis. Hospitals may have to ration or delay certain types of medical care; or if the crisis worsens, they may have to triage patients according to their likelihood of survival.

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 state has provided guides and checklists to help hospitals, doctors and nurses — who want to give all patients the best care possible — most effectively use the resources they have, to help as many people as they can.

What can Idahoans do now, to keep ourselves safe?

Idaho officials have urged Idahoans to get vaccinated for the past nine months.

It is rare for a vaccinated person to need hospital care if they get infected with the coronavirus, and even more rare for them to end up in the ICU.

But even vaccinated people may now be at risk of not getting life-saving medical care. If hospitals have just one ICU bed, and two critically ill patients arrive, the person deemed more likely to survive will get that bed. (The other patient would likely still receive some medical care, or at least medication to keep them comfortable, until an ICU bed opens for them.)

Jeppesen and other public health officials have urged all Idahoans to be careful, avoid risky activities and take medications as prescribed.

During an AARP Idaho town hall meeting with Gov. Brad Little and Jeppesen on Wednesday, a resident asked how hospitals will determine who receives care, especially those from outlying rural areas. 

“If you have a medical emergency, do what you would normally do,” Idaho Health and Welfare Director Dave Jeppesen told the caller. “If it was something you would normally go into the emergency room for, you should do that. Some of those wait times and even locations where you may be seen will be different, but the hospitals haven’t locked their doors. If you have a true need for medical care, seek medical care.”

Jeppesen added anyone who needs a COVID test and is not in immediate need of medical care should not go to the emergency room for a test. A list of testing sites can be found on the Idaho Department of Health and Welfare website.

Another individual asked whether vaccination status could be a factor when hospitals using crisis standards are determining who receives care. Jeppesen said just like if someone is in a car crash and not wearing a seatbelt, they wouldn’t receive a different standard of care than someone who was wearing a seatbelt.

“The hospital will make a holistic decision for each person and then act accordingly,” Jeppesen said. “… While we strongly encourage people to get vaccinated, it is not a determining factor in how care is given.”

Idaho’s health leaders explain what crisis standards mean for their hospitals

While officials with the Idaho Department of Health and Welfare made the decision to permit crisis standards for hospitals throughout Idaho, it doesn’t mean care rationing is already underway for every hospital. Two hospitals in North Idaho have been using crisis standards for the past week, according to Idaho Hospital Association President and CEO Brian Whitlock, but Saint Alphonsus Regional Medical Center hasn’t reached that point yet. 

During the media call Thursday, Jordan Herget, CEO of Pocatello’s Portneuf Medical Center, said the hospital has not yet implemented crisis standards either, but will clearly communicate if and when it becomes necessary.  

Jim Souza, chief medical officer at St. Luke’s Health System, said in North Idaho hospitals, the rationing meant that for a time only individuals who were in immediate danger of dying were receiving surgeries, including open heart and brain surgeries.

“We’re not there yet, and we don’t want to go there,” Souza said during the media call. “Some of those things would be contemplated in the next phases of a surgical rollback. We don’t want to go there.”

Sandee Gehrke, St. Luke’s senior vice president and chief operating officer, added that staffing has been stretched thin to accommodate the influx of COVID patients in addition to standard patient care. While one intensive care unit nurse would typically be assigned to one patient, right now the ratio is one nurse for every three critical care patients.

“We’ve been able to supplement that with other (health care workers), but that’s still a stretch, especially when these patients are ventilated and prone and on so many different medications,” Gehrke said.

Boise’s St. Luke’s hospital had three patient overflow units as of Thursday, and Gehrke said they were working to set up a fourth. Meridian, Nampa and the Magic Valley also have overflow units.

“We’ve opened overflow emergency treatment spaces in our Nampa hospital. We’re caring for patients within our imaging suites, so where you might typically have an X-ray done, we are treating and diagnosing emergency department patients,” Gehrke said.

The organization is also consolidating outpatient diagnostic lab procedures from Nampa’s hospital to Meridian so that the recovery area in Nampa’s hospital can be used as a second emergency department treatment space.

With overflow areas for patients has come the need for overflow areas for the bodies of those who have died. Gehrke said each hospital in the St. Luke’s system has an additional morgue space, and they are partnering with local coroners’ offices to increase capacity. This week, an additional morgue overflow space will be set up for St. Luke’s Boise.

Souza said the crisis standards declaration doesn’t mean any resources have been deallocated.

“What it actually means for us is acknowledging, number one, that the usual standard of care has been breached,” he said. “And number two, it frees us to continue further innovation to stretch, to expand, to get more creative, use telehealth more aggressively, further expand teams to do our darndest to optimize the standard of care.”

Hospital officials said the best thing for Idahoans to do to help is to wear a mask, avoid crowds, and, above all, get vaccinated as soon as possible.

“The only thing that could make things worse is to act like this is not happening, because it most definitely is happening,” Souza said. “And we know how to stop it. If you went out and got a vaccine today, it’s not going to help us for weeks, but it’d be a start. And until then, wearing a mask when you’re in public … could help very quickly.”