In COVID-Stressed Idaho Hospitals, the `What If?` Has Arrived

The Idaho Statesman

Idaho hospitals large and small, hours away from each other, have the same problem: They're running out of space for patients as COVID-19 tears through their communities.

The virus is filling up hundreds of beds and taking out doctors, nurses, respiratory therapists and other health care workers. As cases surge in Idaho, health care leaders plead with residents and officials to stop the inertia before the COVID-19 wave overwhelms the health care system.

There is little time left for Idahoans to change their behaviors, or for government leaders to implement stricter COVID-19 prevention measures, they said.

"We've all prepared and talked about the what-ifs. And the what-if, it's here today," said Tom Murphy, CEO of Minidoka Memorial Hospital in the small agricultural town of Rupert.

"We've been unsuccessful at getting mandates, whether that be from the state level, the city level or the health district level," he said. "If nobody's willing to do that, where does that leave the trigger point for a change in behavior? Is it when I put a sign out that you'll be triaged before you even enter the facility, and you may be turned away and not treated?"

Idaho hospitals have reported at least 251 patients hospitalized with COVID-19 every day since Oct. 20, with a record-breaking 296 hospitalizations Monday. The state also has a higher-than-ever number of ICU patients with COVID-19, with numbers in the 70s.

The Rupert hospital — which can take about 17 patients when it's fully staffed — admitted four COVID-19 patients in a single day in late October. More than 10% of its staff was out sick that week.

The coronavirus also is tearing through the tiny hunting-and-fishing town of Salmon and its county. Data from the Idaho Department of Health and Welfare show Lemhi County's rate of new COVID-19 infections per capita tripled in the last week of October and is now the highest in the state.

"I had maybe one or two staff members out with COVID up until a few weeks ago, and then it just kind of all exploded, and we're down almost 40% of our workers right now, and it's really difficult," said Jeanie Gentry, CEO of Steele Memorial Medical Center in Salmon. "And we're at our capacity with inpatients that have COVID."

And Idaho is competing with other states for a limited supply of temporary nursing staff. One travel nursing agency that staffs COVID-19 hot spots listed nearly 50 openings in Idaho hospitals as of Wednesday.

"I can't emphasize enough right now how ... in the beginning, we were all talking about our health care heroes, and now we won't even put on a mask to help our health care heroes stay safe," said Toni Lawson, vice president of government relations for the Idaho Hospital Association. "If people really want to honor their health care heroes, it's a pretty simple action to do that."

At least 4,040 health care workers have been infected, according to state data.

In the Big Cities

The same is happening in Idaho's larger cities, where the coronavirus is sometimes better controlled but beds are filling up with patients — including patients from those smaller hospitals that aren't equipped to care for them. Other hospitals in the Northwest and Mountain West region that usually take critically ill patients are filling up, too.

"We in Saint Alphonsus can't divert to St. Luke's, if they have no capacity. St. Luke's can't divert to us. And we can't divert out of state because Utah, for instance, is experiencing a surge and it's no longer accepting patients," Dr. Steven Nemerson, chief clinical officer for Saint Alphonsus Health System, said during a media availability in late October.

Saint Alphonsus had 49 patients admitted with COVID-19 on Tuesday — about 13% of all the patients in its hospitals — according to its publicly shared coronavirus data.

As more people get infected, more people are developing serious complications that require nursing care in a hospital. That leaves less room for other patients.

Almost 17% of the patients hospitalized in Idaho on Oct. 28 had COVID-19, and almost one-third of the state's ICU patients had the disease, according to data from the Idaho Hospital Association.

Patients with COVID-19 can spend days or even weeks in the hospital.

Last month, St. Luke's Health System patients with COVID-19 were hospitalized an average of about five days. Those who needed ICU care spent an average of seven days in the hospital, while those who didn't need intensive care were discharged in about three days.

Hospitalizations for COVID-19 statewide increased by about 45% in the second half of October, surging by more than 80% in the Panhandle and Southwest health districts, according to the hospital association's data.

"We're in a closing window of opportunity here to intervene. Action is required now," said Dr. James Souza, a pulmonologist and the chief medical officer for St. Luke's Health System.

The St. Luke's system had 100 patients with COVID-19 in its hospitals as of Tuesday. Nearly half of those were in its Twin Falls hospital, which has been inundated with cases from around the Magic Valley. On a Sunday in late October, the Twin Falls hospital had 56 patients with COVID-19, about 45% of all its patients.

St. Luke's hospitals in the Treasure Valley have taken on some patients in the past month because the Magic Valley hospital was too full due to COVID-19. Two weeks ago, St. Luke's was forced send pediatric patients who normally would have been admitted to Magic Valley to its children's hospital in Boise. That freed up nursing staff to manage the COVID-19 surge.

"The day after it was announced that Magic Valley would be diverting most pediatric patients to St. Luke's Children's Hospital in Boise, our children's hospital nearly filled," said Anita Kissée, public relations manager for the health system.

Luckily, enough patients were well enough to go home the next day that beds were available again, she said.

"We appreciate the action the governor took, and appreciate his call for individual responsibility. The message here is very simple," Souza said. "We do not need to shut down large segments of our economy. But when you're with other people bedsides your own family, put a covering on your face and watch your space. Period."

Idaho health care leaders have called for local public health districts to put in place stricter measures to curb the spread of COVID-19. But the boards governing those health districts include elected political leaders. Some of those leaders don't want to pass mandates in their communities, or say they don't believe COVID-19 is the reason for increasing sickness, hospitalizations and deaths.

That frustrates Murphy, who sees people in the Magic Valley continuing to spread the virus.

"When we call in to give updates of how the hospitals are doing, and some of those representatives on that board that are county commissioners as well, say, 'If I vote for a mask mandate, I'm going to have a lot of (backlash from constituents),' they're making a political decision and not a health-science based decision," he said. "It's going to put more people's lives in unnecessary risk."

Murphy understands that residents of some communities, like Boise or Blaine County, may have been more receptive to the mask mandates imposed by their local governments. But even if a mask mandate in the Magic Valley area or statewide increased the use of face coverings by a factor of two, that would help, he argued.

It used to take a half hour for Minidoka physicians to find a hospital that could take patients who'd been in a car crash, for example. Now, it takes them two or three hours, Murphy said.

"At what point do you take action?" Murphy said. "Is it when I have people dying in my ER because I can't admit them?"

Rationed Care?

The looming fear for hospitals is this: COVID-19 surges will get bad enough that Idaho must use "crisis standards of care," when not every patient can receive life-saving care because of a lack of resources to care for all of them.

That is a worst-case scenario for hospitals and their health care providers.

"We are, at Saint Alphonsus, within a couple of weeks of having to make decisions about ramping down what we call medically necessary, time-sensitive care ... the need to remove a tumor if it's cancerous, the need to intervene operatively to prevent internal bleeding, these sorts of things," said Nemerson. "And we have not, at this point in time, needed to ramp down that care. But as I said, we are very, very close. We look at that every day. We look at our ICU census, which is full. We look at our inpatient census, which is nearly full. ... That is the tragedy of the situation we are in."

Nemerson and other health care leaders have hammered the point that the situation can be reversed — if Idahoans immediately stop going out in public without masks, stop gathering with people from other households, wash their hands and keep physical distance.

While it is possible to create new beds for seriously ill patients — field hospitals or surge units, for example — those beds would need enough nurses and doctors. Hospital leaders are struggling to staff the beds they already have.

If Idaho's COVID-19 surge does not abate, will the state be able to avoid "crisis standards of care," or rationing?

"I really want to say yes," said Lawson, of the Idaho Hospital Association. "My gut tells me we will, and perhaps it may be in large part just because different communities will peak at different times, so we will be able to move patients, transfer patients."

Even in the worst-case scenario, it's possible that "crisis standards of care" would be necessary for 24-hour periods instead of for days or weeks.

"Our hospitals are doing everything they can to avoid it, and I trust they will do everything they can to avoid it. But suddenly, if there's no place to send patients, we're going to be left with some very difficult decisions," she said.

Some hospitals are already making tough decisions.

The Magic Valley hospital had to cancel elective surgeries last month to free up beds and staff for COVID-19 patients. The hospitals in Rupert and Salmon have had to pare back on their services or prepare to do so, their CEOs said.

"In certain departments, we're just trying to have to kind of triage our workload and reduce what kind of services we're offering, just down to the basics and most urgent and important," Gentry said. "Of course, we're keeping the ER and walk-in clinic open, but some of the appointments that can be scheduled out a few weeks, we're doing that."

Murphy said one department — surgery — had no physicians from Oct. 28 through Nov. 2. One surgeon was out of town when the other came down with COVID-19, he said.

Four other departments were close to their tipping point, he said: the medical floor, respiratory department, laboratory and extended care facility.

"If we lose one more person (in those departments), we're at risk of not being able to provide all services," he said.

That scenario already played out at one rural Idaho hospital this spring. St. Luke's Wood River Valley in Ketchum ceased normal operations for about two weeks in March as Blaine County became the state's first COVID-19 hot spot. Deborah Robertson, medical director for the hospital's emergency department, told the Statesman in a phone interview that the hospital saw a surge in patients at the same time a large swath of staff fell ill with COVID-19 or had to quarantine because of possible exposure. As Blaine County's sole hospital, the facility became rapidly became overwhelmed.

"It was this domino effect very quickly as the positive tests came back," Robertson said. "We were quarantining employees and then quickly realized, 'We're running out of people.'"

St. Luke's Wood River Valley has the ability to care for patients in critical condition, but typically transfers those patients to the health care system's Boise or Twin Falls facilities when possible. When Blaine County was hit hard in March, other St. Luke's facilities still had plenty of capacity, and the Wood River Valley hospital was transferring so many patients it was difficult to find ambulances to transport them all.

Robertson said that network of other hospitals was critical to the Wood River Valley facility resuming its normal operations as quickly as it did.

"I found myself numerous times back in March being so thankful that I had a phone number to call with someone at the other end in Twin Falls or Boise who could help me problem-solve," Robertson said. "Had we been an isolated hospital during that time, maybe we could have done some maneuvering to keep our emergency department open at that time, but it would've been tough. ... My heart goes out to any isolated hospital that doesn't have those resources."

The Edge of Capacity

The surge illustrates how much hospitals throughout Idaho and its neighboring states rely on each other.

Idaho hospitals are tied closely to Utah, Oregon, Washington and Montana hospitals and send patients there. That may no longer be an option, if other regional hospitals in places like Utah are unable to take in Idaho patients because they're straining under their own local COVID-19 outbreaks.

Gentry's hospital would usually send patients with serious injuries or illnesses to hospitals in Missoula or Idaho Falls, she said. Increasingly, she's had to transfer patients to any hospital with room: Rexburg, Pocatello or Hamilton, Montana.

"This whole side of the state has been on the edge of our capacity," Gentry said.

There were 60 patients with COVID-19 in six hospitals in the eastern part of the state as of Tuesday, with 14 in ICU beds, according to coronavirus hospitalization data gathered by EastIdahoNews.com.

Some health care providers at smaller hospitals are concerned about what will happen to their patients as larger Idaho hospitals approach capacity. St. Luke's McCall Medical Center can care for up to 15 patients. It does not have an ICU, and it regularly transfers patients to other St. Luke's hospitals in the Treasure Valley.

"One of the things we've learned about these patients is their health status can deteriorate quickly, so we like to send them down to Boise so they have resources available," said Amber Green, chief operations officer and chief nursing officer at the McCall hospital.

Green said McCall also transfers patients with common non-COVID-19 related health issues like heart attacks, strokes or major trauma. Those patients would have to be rerouted if the Boise hospital hits capacity.

"We anticipate a day in which we no longer will be able to transfer those patients," Green said.

The McCall hospital does have surgery capacity and access to some ventilators, she said. It also has telemedicine channels to consult with doctors in the Treasure Valley. And though it cares for patients from Riggins to Council to Yellow Pine, it has not yet approached capacity during the pandemic, which Green attributed to high mask compliance in Valley County. She said face masks and social distancing will be crucial as the area heads into its winter tourist season.

"Heart attacks, strokes, appendectomies ... those things will still happen regardless of COVID," Green said. "And we still have to take care of those patients."

Gentry also said she has noticed an unusual number of tourists coming to Salmon — trying, she assumes, to briefly escape life in a city during a pandemic. But the coronavirus doesn't stop at the city limits.

Some of those visitors are taking a vacation from their COVID-19 precautions, walking around in the grocery store without masks, she said. She wonders if that may have played a role in seeding the current outbreaks in Salmon.

"We had been unnaturally low for a long time, and I think it lulled people into a faux sense of security that 'we don't need no stinkin' masks, and we're not going to get COVID,'" Gentry said. "But now a lot of people have it. ... Now I'm getting a lot of questions from the community about what happened, and I say, 'Well, it came here like it did everywhere else.'"