Each day Kenneth Krell is working at Eastern Idaho Regional Medical Center’s intensive care unit, he and a respiratory therapist will check on the patients who are on high-flow oxygen.
They’ll decide who is “most at risk to crash” and admit them into the ICU, “anticipating” who will need to go on a ventilator.
“Some of them, we may watch for a while,” said Krell, who directs the region’s largest ICU. “In the best of all worlds, more of them would be in the (ICU). But I’ve only got so many beds, so many ventilators.”
Last Friday, EIRMC was treating 50 COVID-19 patients. Twice, over Thanksgiving, Krell and others had to rush people that they thought could hold out for longer onto ventilators. “If we had better resources, those patients would have been transferred earlier,” Krell said.
In all, hospitals in the area were treating 70 virus patients on Tuesday. Statewide, COVID-19 admissions into ICUs continues to rise. And the resource strain, particularly acute with some hospitals reporting staffing shortages, bring questions about when Idaho hospitals could become so overwhelmed that they have to triage limited resources.
Hospitals can’t make the official call.
To move to a formal designation, Gov. Brad Little would have to institute Crisis Standards of Care, a process that outlines how to decide who gets care. Those standards are largely focused on getting care to people who have the highest chance of living.
The state committee that developed that plan, called the State of Idaho Disaster Medical Advisory Committee, hasn’t recommended Little institute the disaster planning measures. Krell serves on that committee.
But informally, he said EIRMC is already rationing care.
“We would never do that under regular circumstances,” Krell said of the hospital’s decisions on when to decide who gets a ventilator. “So, yeah, we’re rationing care.”
A large hospital in Boise had to make similar decisions Monday after its ICU filled up, the Idaho Press reported. An administrator for St. Luke’s Hospital system said Tuesday that “we kept people who needed an (ICU) bed in the emergency room overnight.”
People who need ventilators at EIRMC are still accessing ventilators, Krell said, despite the stressful rise of COVID-19 patients whom require more resources. It’s just not as soon in Idaho, which had one of the nation’s lowest number of ICU beds per capita before the pandemic.
“Where we place a patient is a judgement both on how sick they are and what kind of slack have we got in our resources that I can put them on a higher level of care if I think maybe they’re gonna go south. That’s how we’re having to see that now,” Krell said. “Now, that’s different of getting to a point with the Crisis Standard of Care where you essentially have a scoring system to decide who gets a nurse, who gets a ventilator. ... We’re not at that point now. We’re intubating anybody who needs it. I don’t see that changed. Where we ration is how closely you monitor people and where you place them.”
For months, eastern Idaho hospitals have told regional health officials that they’re stressed but managing. Those capacity reports supplement publicly reported COVID-19 hospitalization figures and ICU bed availability, which have shown increasing strain but never past capacity. However, health care leaders have stressed that metrics on bed availability aren’t entirely telling — patients require beds and nurses.
Krell said staff shortages are driving the strain, not “stuff,” such as ICU beds. Lately, Krell said ICU nurses at EIRMC have gone from closely monitoring two patients up to three. The head nurse, who typically only manages staff, has begun caring for a patient, too, he said.
Dr. Kenneth Newhouse, Chief Medical Officer at Bingham Memorial Hospital in Blackfoot, said the 25-bed rural critical access hospital isn’t in the same stressful position. Smaller hospitals rely on larger hospitals to transfer patients who need advanced levels of care — and larger medical centers across the state, from Boise to Twin Falls to Idaho Falls, are seeing alarmingly high levels of COVID-19 patients.
A member of the state hospital disaster planning group, Newhouse said stress in larger hospitals fluctuates. But, he said, “our hospital systems are extremely busy with COVID … in addition to that, trying to take care of the (typical patients) coming into the hospital.”
“Both Portneuf (Medical Center) and EIRMC have gone on divert transiently for short periods of time,” for around 12 to 18 hours usually, Newhouse said. “We definitely have seen an increase in the amount of time those places have been on divert, with respect to their ICU, but it hasn’t been they’re on divert for a week or to.”
Newhouse didn’t want to sound alarmist. Things are clearly bad, he said. Health care workers are calling in sick, they’re burned out and showing more signs of distress. Managing staff resources is a “shift-by-shift decision,” he said, because “every 12 hours is a different world.”
“We’ve bumped up against the hard limit of divert a couple of times, and we’ve gone back. That’s kind of where we’ve been for the past month,” Newhouse said.
It’s not the worst-case scenario, he said. But he and others are predicting that the coming weeks and months will bring waves of more infections and hospitalizations, after many people ignored pleas from health officials to avoid large gatherings during Thanksgiving, as the virus continued to spread rapidly.
SIDMAC met once six weeks ago and again two weeks ago. It planned to meet again Tuesday; that meeting was postponed until next week. Newhouse said the committee meeting more frequently signals “there’s probably more of a sense of urgency.”