The Idaho Board of Health and Welfare on Friday voted to finalize how Idaho would set in motion the “crisis standards of care,” otherwise known as health care rationing or triage.
The new rule authorizes Idaho Department of Health and Welfare Director Dave Jeppesen to activate the crisis standards, if Idaho’s health care system becomes fully overwhelmed as the pandemic rages out of control.
“It’s our hope, and my hope, that we never have to activate crisis standards of care,” Jeppesen said Friday. “But in the unfortunate circumstance that we did, we want to be prepared with a legally solid process of how to do that.”
About 80% of Idaho hospitals are operating at “contingency” status, he said. That is one level before crisis.
What does ‘crisis standards of care’ mean?
The COVID-19 surge is straining Idaho’s hospitals — both small, rural hospitals and larger, regional medical centers. The state is now in the midst of influenza season and starting to experience a surge in infections following the Thanksgiving holiday. Health care leaders and Idaho Gov. Brad Little warn that more people are going to need medical care, at the same time as nurses and other health care workers themselves are out sick or in quarantine.
There is a limited supply of health care resources. A committee of medical stakeholders put together a set of standards this year, giving health care providers a set of directions, flow charts, tables and scoring systems to help them determine how to allocate scarce resources. The state is also creating guidelines for other areas of health care, such as nursing homes.
Crisis standards won’t just apply to people with COVID-19. They will apply to patients who need medical care for any reason, such as car crashes, heart attacks, strokes or influenza.
“The goal … is to save as many lives as possible, even when the odds are stacked against us,” Gov. Brad Little explained at a press conference Thursday.
How long until Idaho reaches crisis standards of care?
Idaho is not there yet, as of Friday. Hospitals still have the ability to either take patients or send them to other hospitals in the region. But options to send patients elsewhere, especially to other states, are dwindling. States including Utah, Montana and Nevada are battling their own surges in hospitalizations.
Idaho’s most likely path to crisis standards is when too many patients need to be hospitalized, there aren’t enough health care workers to staff hospitals, and Idaho’s hospitals that fill up can no longer find anywhere else to send patients.
St. Luke’s and Saint Alphonsus health systems — who take a large share of the critically ill and injured patients in Idaho — estimate that Idaho may hit that point around Christmas or New Year’s Day. But it may be earlier, and it may be inevitable at this point, two Idaho health care leaders told the Idaho Statesman.
“We could easily be a week, 10 days away from crisis standards of care,” Dr. David Pate, retired CEO of St. Luke’s Health System and a member of Gov. Brad Little’s coronavirus working group, told the Statesman on Thursday. “The governor didn’t want to put a date on it, and he was right not to. … I look at, what are the hospitals doing right now? What I see is they’re checking off almost everything on my list, which means they’re running out of options.”
Idaho is likely at a point of no return, according to Dr. Ted Epperly, a physician who runs Idaho’s largest medical residency and serves on the Central District Health board.
He believes that Idaho will reach crisis standards of care this winter due to a “toxic combination” of COVID-19 mixed with flu season, and the holidays. People taking risks from Thanksgiving through the New Year’s holiday season will “propagate a cycle” through the next couple of months, he predicts, pushing the health care system beyond its limits and into crisis standards.
“That is going to happen,” he said. “Things will only get worse.”
Epperly said that, while he believes the coronavirus is too far out of control to prevent crisis standards, anything Idahoans do to avoid catching and spreading the virus will lessen the harm to Idaho.
Does this mean Idaho hospitals will send away patients with nothing?
That is very unlikely, for three reasons:
- Crisis standards could apply to just one category of health care resource — such as staffing, oxygen or ventilators. They also could apply to only one region, although Jeppesen said Friday that in the pandemic they likely would be activated statewide after Idaho hospitals ran out of resources they could share.
- Hospitals have repeatedly said they will provide as much care as they can, even if they must deny resources to a patient. For example, if a patient is too likely to die, they may not receive a ventilator immediately but could receive medication to keep them comfortable.
- The health care system would stay in communication with patients and their families or caregivers — so that even if they can’t be treated right away, they could be brought back for medical care when resources free up or if their health condition improves enough that they become eligible for limited resources.
Has Idaho ever done this before?
No. Idaho hospitals have been able to either admit patients who need medical attention or transfer them to other hospitals nearby. Crisis standards have been activated in the U.S. just once, in Arizona during the summer surge.
“I may be the only health care CEO (in Idaho) who ever operated under these kinds of conditions,” Pate told the Statesman on Thursday.
He was in Houston, running a hospital, when a tropical storm hit and caused significant flooding, he said. One hospital in the area couldn’t take any new patients, another was at limited capacity, and Pate’s hospital was the “last one standing. For 10 days, we operated without power. We couldn’t even flush our toilets,” he said.
They had trouble getting staff to the hospital during the emergency. The hospital filled up and couldn’t take any more patients, he said.
“I had families calling me,” he said. “I still have PTSD about this — families calling me, begging, pleading, crying with me to take their family member, because their family member wasn’t going to survive. … I had to tell those people, ‘I don’t have beds, I don’t have staff. Even if you were here, I couldn’t provide care.’ It is horrendous. It will keep you up at night. It will psychologically damage you.”
The situation then “wasn’t as bad as what we’re talking about” with the pandemic, he added.
It was a disaster that affected the greater Houston area, but they could still fly patients to Dallas/Fort Worth, Texas, or to Louisiana, he said. “So some people did survive,” he said.
Still, he said, “I have no doubt people died because of this.”
Will people who didn’t follow COVID-19 guidelines be denied care?
No, they will be prioritized the same way as people who faithfully followed the guidelines.
It would be against the law and against medical ethics for Idaho’s health care system to triage patients based on things like where they live or whether they obeyed mask mandates.
Who will be first in line? Who will be last?
Idaho’s crisis standards of care plan is 48 pages long, with an additional 41-page guide and a 42-page set of checklists. You can download them by visiting the Idaho Department of Health and Welfare’s Emergency Preparedness page.
“The goal of providing care quickly and efficiently must be guided by fairness, equality and compassion,” one of the documents says. “As such, (this) is grounded in ethical obligations that include the duty to care, duty to steward resources, distributive and procedural justice, and transparency. Its guiding principle is that all lives have value and that no patients will be discriminated against on the basis of disability, race, color, national origin, age, sex, gender, or exercise of conscience and religion.”
Basically, the guidelines give priority to people who are more likely than others to survive, based on their health status at the time. People who are “actively dying or certain to die” are last in line for life-saving care.
For example, one part of the guidelines related to ventilators says, “In the event that there are more patients in a priority category than there are critical care resources/ventilators, several ‘tiebreakers’ should be used.”
Priority would go in order of:
- Children up through 17 years old.
- Pregnant women with a viable pregnancy, at more than 28 weeks of gestation.
- Adults by age, from younger age groups to older: age 18-40, age 41-60, age 61-75 and older than 75.
- Patients who “perform tasks that are vital to the public health response of the crisis at hand, including, but not limited to, those whose work directly supports the provision of acute care to others.”
- A lottery, or “random allocation,” if there is still a tie after going through the first four priority criteria.
The crisis standards of care may give Idaho hospitals a defense in lawsuits against them over patient care during the pandemic, Jeppesen said.
They could point to the crisis standards of care activation and say, “we essentially were operating under unique circumstances that required us to depart from the usual standard of care, given the level of resources that were in the community,” Jeppesen said.