Crisis Standards Activated in Idaho as Hospitals Overflow

An overwhelming number of hospitalizations primarily due to COVID-19 has led Idaho to invoke its crisis standards of care (CSC) for two regions, the state’s health department reported earlier this week.

“Crisis standards of care is a last resort. It means we have exhausted our resources to the point that our healthcare systems are unable to provide the treatment and care we expect,” said Dave Jeppesen, director of the Idaho Department of Health and Welfare (DHW) in a news release. “This is a decision I was fervently hoping to avoid.”

Idaho adopted the standards by applying elements from the Institute of Medicine (IOM) Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response, published in 2012. “The plan is based on the five key elements of CSC planning identified by the IOM. They include Emergency Management and Public Safety, EMS, Hospital, Public Health, and Out of Hospital Care,” the Idaho CSC document states.

So what does that mean for healthcare professionals working at the ten centers in Idaho’s Panhandle and the city of Coeur d’Alene? MedPage Today examined the CSC document, as well as other recently updated guidelines.

The standards were designed to maximize care at the population health level, and it is recommended that medical centers use them as guideposts to help devise their own game plans, though they stop short of making many detailed stipulations. “The goal of [the] crisis standards of care is to extend care to as many patients as possible and save as many lives as possible,” the DHW news release stated. “Hospitals will implement as needed and according to their own [crisis] policies.”

But the CSC document does offer several specific suggestions, including:

• “Continue efforts to increase surge capacity through changes in care practices, e.g., further changes in documentation, nurse-patient ratios, [and] active recruitment for alternative care providers”
• “Defer non-life-sustaining outpatient services, including physical and occupational therapy”
• “Adapt services and venue for cardiac/stroke rehab and cancer therapy (in pandemic setting) to minimize risk of exposure to severe transmissible illness and free staff for other duties”
• “Cancel all job duties considered non-essential and reassign personnel as appropriate”
• “Move patients who cannot be discharged but who are stable to alternate facilities experiencing less surge”
• “Defer surgeries not essential to preserve life and limb or not needed to facilitate discharge from hospital”
• “In mass trauma settings, pull staff with surgical experience from other areas of hospital to support trauma response capacity”

In addition, the document notes that “the EMS Physician Commission will need to create specific guidance for EMS providers that corresponds with the care continuum … In the case of COVID-19 … EMS staff must stringently adhere to infection control and decontamination procedures.”

EMS dispatchers should “utilize non-certified dispatch personnel to handle incoming emergent calls … [and] decline response to calls without evident potential threat to life.” The document also suggests “allowing an experienced critical care Paramedic or RN be the sole provider versus a three-person team if they are comfortable providing that care based on patient needs.”

The DHW may also ask for support from HHS and the CDC, it noted.

From Writing to Activating Standards

The state has activated these standards “because of a severe shortage of staffing and available beds in the northern area of the state caused by a massive increase in patients with COVID-19 who require hospitalization,” according to the DHW release.

The CSC document was signed off on in June 2020 by the state’s public health administrator, to prepare for a potential pandemic-fueled problem. The DHW solicited feedback from nearly four dozen contributors, including two dozen medical doctors and three registered nurses.

The state has also produced the Strategies for Scarce Resource Situations. This document, updated in January, echoes the CSC: “When applying these scarce resource allocation protocols, decisions regarding candidacy for treatment should be based on individualized assessments using the best available objective medical evidence. In all phases of evaluation and treatment, communication assistance should be provided to all patients and families/designees who request such assistance.”

Idaho does not appear to be triaging care based on specific COVID-19 criteria — including vaccination status — and MedPage Today could not find any mention of the impact of the dire situation on malpractice, among other issues that concern clinicians during hospital surges. It is also unclear if other states have yet adopted crisis or similar guidelines in any of their hot spots.

In Idaho, the standards “will remain in effect until there are sufficient resources to provide the usual standard of care to all patients.”

“We have reached an unprecedented and unwanted point in the history of our state. We have taken so many steps to avoid getting here, but yet again we need to ask more Idahoans to choose to receive the COVID-19 vaccine,” Gov. Brad Little (R) said via the news release. “More Idahoans need to choose to receive the vaccine so we can minimize the spread of the disease and reduce the number of COVID-19 hospitalizations.”

‘They Just Save Different Lives’

The standards are not likely to be very effective, said Joel Zivot, MD, of Emory University School of Medicine in Atlanta. “These crisis models don’t actually save more lives, they just save different lives,” he noted. “The only way to really do this is first-come, first-serve.”

Zivot is “troubled” by the idea that a healthcare workforce can consistently decide which patients to treat and when in an ethical manner. “We are talking about letting people die; let’s not be so quick to decide,” he said. “All patients — COVID, non-COVID — are equally valuable and they’re due equal access to care.”

“It feels like the state is trying to push this onto doctors” to make the key decisions, he added.

The Idaho DHW did not return a call by press time.