More hospitals forced to ration care amid delta surge

Coronavirus patients are flooding and straining hospitals across the U.S., particularly in Western states, where administrators are put in positions of needing to ration care as their facilities are pushed to their breaking points by the delta variant.

Alaska this past week joined Idaho in adopting statewide crisis standards of care that provide guidance to health care providers making difficult decisions on how to allocate limited resources. Several hospitals in Montana have either activated crisis standards of care or are considering it as the state is pummeled by COVID-19.

Under the guidelines, providers can prioritize treating patients based on their chances of recovery, impacting anyone seeking emergency care, not just those with COVID-19.

“Ultimately it’s a decision about, at that point in time, who we feel is most likely to benefit from what may be a limited resource,” said Michael Bernstein, regional chief medical officer in Alaska for the health care company Providence.

Typically, crisis standards of care involve a scoring system to determine the patient’s survivability, sometimes including their estimated “life years” and how well their organs are working. Such guidelines do not call for factoring in vaccination status, much like emergency rooms don’t prioritize certain car crash victims based on whether a driver was drinking.

Still, the vast majority of COVID-19 patients overwhelming hospitals are unvaccinated, months after the vaccine became widely available to U.S. adults.

As of Friday, the ICUs in Alabama, Georgia, Idaho, Kentucky and Texas all exceeded 90 percent capacity. The ICUs in Alaska and Montana, meanwhile, were 84 percent and 77 percent full, respectively, according to federal data.

With Alaska seeing its highest rate of COVID-19 hospitalizations since the pandemic started, the Providence Alaska Medical Center in Anchorage decided to start crisis standards of care earlier this month so doctors wouldn’t be forced to make determinations about patients themselves.

“That also ensures that it is equitable [and follows] principles of justice, fairness because we all want to do the right thing,” Bernstein said. “And those types of choices can cause moral pain for health care providers.”

While emergency rooms commonly require physicians to triage and treat patients with the most urgent needs first, the practice is not common when making decisions about “more critical” treatments.

The medical center, particularly the intensive care units, have been “very full,” which Bernstein said is “largely because many COVID patients will progress to needing that level of care.”

At Providence Alaska Medical Center, the surge of COVID-19 patients make up about 24 percent of inpatients, with about 87 to 90 percent of all patients being unvaccinated.

Nationwide, a quarter of the eligible population, or about 70 million people, has not gotten any dose of the COVID-19 vaccine. Health officials have repeatedly referred to recent outbreaks as “a pandemic of the unvaccinated,” which President Biden reiterated in a speech on Friday.

“In a country as large as ours, that 25 percent minority can cause an awful lot of damage,” Biden said. “And they are causing a lot of damage.”

Idaho is another state where hospitals are enduring high stress, with officials instituting crisis standards of care statewide earlier this month. This past week, there was a record number of COVID-19 hospitalizations, said Toni Lawson, vice president for government relations at the Idaho Hospital Association.

“It’s just across the board pretty serious, but crisis standards of care has really allowed our hospitals the flexibility to provide care to as many patients as possible,” she said.

Hospitals are participating in statewide calls to organize where patients go, as noncritical patients are sometimes transferred to smaller hospitals to make room in larger hospitals for severe cases.

“Right now, when you go to the hospital, you may not end up” receiving care at the same facility, Lawson said. “You may need to be transferred to another hospital because of capacity issues.”

In several hospitals, providers are adding beds to deal with the surge in new patients.

Gabe Kelen, director of the Johns Hopkins Office of Critical Event Preparedness and Response, said health care providers can consider other options like increasing the number of patients each nurse manages, shutting down services such as elective surgeries and assessing the risk of releasing bed occupants to make room for other patients.

But delaying care by months for some patients, for example those with cancer, could jeopardize their health.

“The vaccine deniers obviously in many of our minds are like really, really, really hurting like the whole system, whereas someone who has a heart attack is only attacking their own heart — they’re not attacking everybody else’s,” Kelen added.

But Kelen, who is also an American College of Emergency Physicians board member, said people have to look at it through a medical lens.

“We’ll do our best to save your life, whether you’re vaccinated or not, because that’s the oath that we took,” he said.

Meanwhile, the health care industry is taking a hit of a different kind, with many hospitals across the country experiencing staffing shortages amid burnout. Compared to earlier in the pandemic, there’s more demand on staff to also conduct testing and vaccinations, Kelen said.

Kristina Orfali, a professor of bioethics at Columbia University, said it’s important for hospitals to communicate the crisis standards of care with patients at admission.

“It’s sad, but it’s important that we know about it, and … there’s more transparency to what it is, and I think we should sort of be better in communicating all this,” she said.

Other states have taken steps to revamp their crisis standards of care amid the pandemic, with Hawaii releasing a plan earlier this month. A spokesperson for the Arkansas Department of Health said the state is working on finalizing its standards.

Tennessee declared last week that it is restricting the use of monoclonal antibody treatments to those unvaccinated against COVID-19, following National Institutes of Health guidance to prioritize those who are not fully vaccinated and are at high risk of developing serious COVID-19.