What Does a Crisis Standard of Care Activation Mean?

This past week, our state implemented crisis standards of care for all of our healthcare facilities. I mentioned a bit about this in my last writer's workshop post, but let me provide this explanation from a nurse friend of mine: Crisis standards means the minimum standard has changed. Patients will be treated in areas they never previously were (hallways, conference rooms, etc), they are pulling more clinic doctors into the hospital to help out, cancelling non critical surgeries and procedures, team based nursing (1 nurse lead and several medical assistants or certified nurses aides to do the care when usually it is just the nurse), they have a triage team to determine where resources are used when there becomes a shortage (IV solution, medications, beds, vents etc), some non critical patients are being discharged to lower acuity hospitals, patients are being discharged early and followed by Remote Patient Monitoring. It is more of a level indicator of care. Hopefully not much will change between yesterday when we weren't in Crisis mode and today when we are but there is a plan in place if resources (staff, equipment and beds) are at a premium. It is more like what happens after a natural disaster."

This post will include a video explaining it from a bunch of local healthcare leaders as well as the actual letter of request for the activation of crisis standards of care. If yo think this doesn't matter to you, think again. If you are sick, you are looking at less access to urgent cares (staff is being relocated to the hospital where they are urgently needed). This means if your surgery isn't absolutely, life-threateningly important, you won't get it. At some point in time (I am thinking when not if anymore) they are going to have to decide who gets the ventilator based on who has the best chance for survival. This is real and this is happening. Please pray for your healthcare workers (both those on the frontlines and those who have to watch this sh** show from the sidelines. 

Anyway, here are the details you have maybe been reading this for. 

This is a press conference with many of the leaders of all the local hospitals. I feel it explains what this means in very clear language. 

I am sharing this letter that my work (St Luke's Health System) sent to the director of public health requesting that the crisis standards of care be activated for all of Idaho. 

CRISIS STANDARDS OF CARE ACTIVATION REQUEST

September 15, 2021

Dear Director Jeppesen,

St. Luke’s Health System submits this letter and exhibits in support of its request for activation of Crisis Standards of Care. The healthcare system is being overwhelmed by a patient surge that has resulted in a substantial change in usual health care operations and in the level of care it is possible to deliver. 

St. Luke’s Health System has exhausted its ability to provide contingency standards of care and is formally requesting the activation of Crisis Standards of Care. 

Over the past seven weeks, St. Luke’s Health System’s eight hospitals have seen a rapid increase in patients requiring hospitalization for COVID-19, on top of non-COVID volumes running higher than average compared with seasonal norms. On July 24, 2021, St.Luke’s had 33 COVID-positive inpatients across all our hospitals. (All census counts indicate the number at 11:59 p.m., midnight census, unless otherwise noted.) On September 12, we had 270 COVID-positive inpatients at 11:59p.m.and as many as 281the following day. This number represents greater than 50% of our 475 total staffed traditional adult inpatient beds across the system and approximately 35% of all St. Luke’s hospitalizations. This past Friday, Sept. 10, the most recent day for which the total statewide COVID hospitalizations were available on the state’s dashboard as of this accounting, 626 COVID-positive patients were hospitalized across Idaho; 40% of them were in a St. Luke’s hospital.

A high percentage of COVID patients require intensive care unit resources and, when in the ICU, require ventilatory support at a higher rate than typical critical care patients. On September 13, St. Luke’s intensive care units were caring for 58 COVID patients out of 71 total occupied critical care beds. Of the 71 critical care patients in our hospitals, 63 were on ventilators due to respiratory failure. Typically in September, our ICUs have 10to 23 ventilated patients on any given day.

Across the state on September 13, only 14 ICU beds were available. Given the capacity constraints in our ICUs, St. Luke’s is now caring for some patients in our general medical/surgical units who would ordinarily be in the ICU, including patients on BPAP (bilevel positive airway pressure) machines.

Worryingly, we are now also seeing children hospitalized with COVID. On September 11, five children were hospitalized at St. Luke’s Children’s Hospital, three of them in the pediatric intensive care unit. That night, we reached our capacity for care within our pediatric unit. Last night, we had four COVID-positive children in our pediatric intensive care unit. 

For several days now, St. Luke’s has consistently been at physical and staffed capacity for critical care, medical/surgical and telemetry beds across its hospitals in Boise, Meridian, Nampa and Twin Falls. With all critical care beds consistently filled, and approximately 80% of them occupied by COVID patients for several weeks, St. Luke’s has implemented and continues to implement strategies to expand our staffing and physical resources by opening surge units, redeploying nurses from other areas (including non-clinical areas) to support and augment staffing and adjusting documentation requirements to handle the surge. 

We have opened and filled three overflow units in Boise, four in Twin Falls and one in Meridian, and we have been transferring patients to critical access hospitals to make room in those of our hospitals that provide higher levels of care. Patient ratios for nurses and respiratory therapists have been extended by 25% to 100%. 

We have also implemented virtual care teams for nursing, hospital care and palliative care to augment staff at the bedside and further extend our resources. In addition, we have been using remote patient monitoring to care for patients in their homes so as to keep them out of hospital settings; we are currently at the limits of our remote monitoring resources and have 27 patients on the waiting list of for this service. Of the 346 patients using this service, 243 are COVID discharges from hospitals.

In addition, St.Luke’s has been caring for patients in areas of our facilities in Boise, Meridian, Nampa and Twin Falls where we have not traditionally provided care. For example, patients have been routinely boarding for more than six hours, and some for longer than23 hours, in our emergency departments. Some of these boarding patients require critical care beds; some require ventilators. At times, our teams have had to discharge inpatients from the emergency departments as we have been unable to find an inpatient bed in our typical units for the duration of a patient’s stay. 

Patients have been treated in our emergency room lobbies, for example, receiving administration of pressors and IV antibiotics in the lobby of the St. Luke’s Nampa emergency department. Patients on BPAP, high oxygen requirements and complicated titrated medications are waiting for critical care beds on our med/surg units, occasionally requiring the support of bag ventilation and floor unit nursing for prolonged periods due to lack of local ICU capacity while awaiting transfer to another site. At this point, we have so many ventilators and BPAPs in use that we are running low, and that we could run out of available devices in the near future. We have ordered additional devices and expect some to arrive next week. 

In response to these unprecedented volumes, St. Luke’s has worked to load-level patients across the system and within the state to the extent that we have been able to obtain patients’ consent to the transfers, including optimizing our critical access hospitals; expanded physical capacity for care in both traditional and nontraditional patient care locations; and stretched our caregiver ratios while also bringing non-direct patient care teams to the bedside.

In addition to having reassigned approximately 300 staff from surgical, ambulatory and administrative roles into direct patient care roles and implementing team-based nursing to further expand nursing capacity, we have continued to add employees to our workforce. We have added 802 external hires in the past 60 days, 480 of whom are clinical staff; we have more employees now than we did before the summer. We also now have approximately 430 clinical travelers working in our facilities, compared with 79 travelers in September 2020.We will soon be receiving169 personnel secured by the State of Idaho in response to our request for assistance. 

Even with a larger workforce than we had prior to this surge, our staffing is not sufficient to continue providing contingency care with the very high volume of patients we are seeing and with the level of need in this patient population. We have also seen rising numbers of employees off work for COVID, with 391 out earlier this week. Two months ago, on July 14, only 141 employees were off work for COVID. 

We have had a pause on “green” elective surgeries and procedures for weeks. “Green” procedures are those that can be safely delayed. Beginning today, Sept. 15, we will be pausing “yellow” surgeries and procedures in all our facilities. “Yellow” surgeries are those that have a “theoretical risk of permanent disability or pathology,” and include such procedures as removal of low-risk cancers, correction of fractures with pain and hernia repairs. We are pausing these procedures to be able to overflow patients into these areas of our facilities and to redeploy the surgical and anesthesia staff into critical care and telemetry to address the current needs. 

Today, September 15, we are opening additional overflow inpatient units in Boise and Nampa; we are also adding beds within our over flow space in the Magic Valley. After that, we will be completely out of hospital beds and will need to convert to stretchers. We have 58 beds en route, but do not know with any certainty when we will take delivery. We have opened “discharge lounges” in our Boise and Nampa hospitals and will open one in Meridian this week, to allow us to turnover inpatient beds before the discharged patient has left the building. 

Our tactical projections indicate we could have as many as 425 COVID-positive inpatients by September 27; that number would be89% of our traditional adult inpatient staffed beds. Our projections from September 1 indicated we could have 250 COVID-positive inpatients by September 13, which turned out to be less than the actual number we had on that date. 

Additionally, we have continued to collaborate closely with the state and our health care partners to load level beyond St. Luke’s Health System. We would note in particular our participation in the Idaho Medical Operations Coordination Cell, which has helped to facilitate movement of patients and supplies to help balance care capacity, and our participation in Region 10 Office of Emergency Management efforts to balance care capacity across the region. 

In summary, and as described in this letter and further detailed in the attached Crisis Standards of Care Facility Checklist, St. Luke’s has implemented many contingency standards to meet patient needs during the current surge in COVID-19 hospitalizations. These efforts have allowed us to meet the needs of the communities we serve up to this point, but we are now out of options to maintain the staffing and physical space necessary to continue the provision of contingency-level care for the ever-increasing numbers of patients needing our help. We must now request activation of Crisis Standards of Care to ensure we can provide the greatest good to the greatest number of patients, and save the most lives possible, while healthcare resources are overwhelmed by this sustained patient surge. 

We would appreciate your prompt consideration of our request for Crisis Standards of Care activation. 

Respectfully,

Chris Roth President and CEO

Sandee Gehrke SVP, Chief Operating Officer

James Souza, MDSVP, Chief Physician Executive

Elizabeth Steger, RN, NEA-BC, FACHESVP, Clinical Practice Integration, Chief Nurse Executive