With new coronavirus cases shattering records on a daily basis, Utah’s hospitals are expected to begin rationing care in a week or two.
That’s the prediction of Greg Bell, president of the Utah Hospital Association, who said administrators of the state’s hospitals confronted Gov. Gary Herbert on Thursday with a grim list: Criteria they propose doctors should use if they are forced to decide which patients can stay in overcrowded intensive care units.
Under the criteria, which would require Herbert’s approval, patients who are getting worse despite receiving intensive care would be moved out first. In the event that two patients' conditions are equal, the young get priority over the old, since older patients are more likely to die.
‘We told him, ‘It looks like we’re going to have to request those be activated if this trend continues,’" Bell recounted, “'and we see no reason why it won’t.'"
Hospitalizations normally rise after the number of new cases increases, and Utah repeatedly set new records for daily case totals last week. At least two Utah hospitals have opened overflow ICUs this month.
The state’s hospitals can shift patients around to free up bed space, Bell said, and the state has long planned to open a field hospital at the Mountain America Expo Center in Sandy if necessary.
But one of the defining features of intensive care is access to doctors and nurses with specialty training — and opening new beds does not mean those health care workers can staff them.
Bell said it’s now all but inevitable that hospitals will need to enact their triage protocols, known as “crisis standards of care.”
“I haven’t said, ‘It’s gonna happen’ — until [Thursday] night,” Bell said. “I told the governor, ‘It’s gonna happen. We’re going to be back here asking for crisis standards.’ ”
State officials confirmed they are bracing for ICU overload this week, based on Thursday night’s meeting.
“The chief medical officers were very clear: They were asking us to be prepared for that,” said Joe Dougherty, spokesman for Utah’s Division of Emergency Management. A spokesperson for Herbert said Friday, “We are not there yet, but we are too close, uncomfortably close.”
When University of Utah Hospital opened an overflow ICU two weeks ago, hospital officials warned that it would be staffed by doctors and nurses working overtime — at a time when health care workers already routinely break down into tears describing hospital conditions during the pandemic. Dr. Russell Vinik, chief medical operations officer at the U., warned that simply opening new beds would not be sustainable in the long run.
Meanwhile, Bell said, the coronavirus has left Utah’s hospitals desperately understaffed.
“We’re down 20% to 30%. Hundreds and hundreds of nurses are not able to work as they were [before] because of their own disease or infection in the family, or they’re moms and dads with school issues,” Bell said. “Some are worn out, some are on leave because they’ve been doing this for seven months.”
Adding ICU beds without adding staff doesn’t address the needs of the sickest coronavirus cases, he said; even for non-COVID-19 patients, care is not “intensive” if doctors and nurses have too many patients — or if patients don’t have access to the specialists they need.
“Frankly, our [hospital administrators] have reacted in a similar way about the surge facility at Mountain America Expo Center,” Bell said. "While we appreciate the state’s efforts, we’ve said to them numerous times — and they understand — look, if we’re fighting to staff our existing facilities, how does it help us to try to take somebody out of that and take them down to Sandy?
“You can put water in your gravy to a certain point,” Bell said. “Then it’s just water with gravy in it.”
‘False sense of security’
According to state data, Utah’s ICUs have been about 75% occupied in recent days. But that number can be misleading. “It gives a false sense of security," Bell explained, “because ... we can’t operate to the max.”
Not only do staffing levels shift over time, but also different patients require different levels of time and attention. And coronavirus patients, who made up about 20% of ICU patients last week, can be particularly time intensive to care for, said Dr. Lindsay Leither, director of Intermountain Medical Center’s respiratory ICU.
“A lot of our COVID patients tend to be really sick and they do tend to stay in the ICU longer,” Leither said in an online news briefing. And, she added, there’s a heightened “busyness” in coronavirus units. “Nurses, all the different therapists that are there, in and out of patients' rooms all day long, putting on and off their [personal protective equipment] and cleaning it.”
Meanwhile, as ICU beds become more scarce, the logistics of moving patients around takes more and more time and effort.
“It can be very hard when we’re moving patients out and in throughout the day nonstop, and you’re telling nurses, ‘OK, I know you’ve already had three different patients today but we have more coming and we need to get more out,’ ” said Dani Beebe, a nurse in an Intermountain Medical Center ICU. "It’s constant.”
Just arranging the transfers adds to the workload.
"Every one of those calls takes time, whether it’s for somebody having a heart attack down in Delta or whether it’s for somebody who needs COVID care at [Intermountain Medical Center] or a child that has a complex congenital disease down in Utah County that needs to go to Primary Children’s [Hospital]. It does take time away from direct patient care,” said Dr. Mark Ott, medical director for Intermountain Medical Center.
That all means operating at 100% capacity is generally unrealistic, Bell said. “If you’re a manager of an ICU, you might say, ‘We really can only open three more beds this afternoon,’ even if [the normal ICU capacity] says ‘six.'"
Under new state guidelines, statewide ICU occupancy of 72% is considered a mark of “high” virus transmission levels.
While Utahns may see that figure and believe it means there’s still room for patients in 28% of ICU beds, health officials chose that “conservative” number precisely because it’s understood that hospitals cannot actually staff every ICU bed all the time, Dougherty said.
“If we are at 85%," he said, “we are basically at 100%.”
The difference between the number of beds and the number of patients an ICU can realistically care for is not the only reason the state’s capacity figure may be overly optimistic.
In calculating ICU capacity, Utah health officials estimate there are about 590 beds statewide, Dougherty said; as of Friday, about 76% of those were occupied, the Utah Department of Health reported.
But for the purposes of pandemic planning, the Utah Hospital Association assesses ICU capacity looking only at the large, “referral” hospitals that take nearly all of the coronavirus patients who need intensive care. Smaller hospitals typically transfer their seriously ill coronavirus patients, Bell said.
That means there are only about 460 ICU beds that are fully equipped to care for coronavirus patients, Bell said, and as of Friday, 80% of those were full. And while smaller hospitals can provide intensive care to a number of patients with other injuries or illnesses, those aren’t the patients whose numbers are skyrocketing.
‘It’s unsustainable, it’s rampant’
The most grim indicator of a possible crisis in the next week is the explosive rise in cases last week.
Hospitalizations typically rise seven to 10 days after diagnoses do, Bell said. Even as Utah hospitals struggled to care for the 300 or so COVID-19 patients who were concurrently hospitalized each day in the past week, that pressure generally did not come from the record-breaking volume of new cases. That pressure was created the week or two before, when there were about 160 fewer new cases each day.
Now daily case counts are not just rising to new heights every day; they’re obliterating past records. Friday’s increase of 1,960 new cases was more than 27% higher than the previous record of 1,543. The weeklong average of 1,355 new cases per day was nearly 130 higher than the average a week ago.
That means hospital pressure is likely to rise more this week than it did last week.
Not only that, there is even more likelihood now that hospitalizations could rise out of proportion to the number of known cases. That’s because the percentage of tests coming back positive has risen sharply in the past 10 days, from 13.9% to 15.8%.
When the percentage of tests with positive results is low — 3% to 5%, as Utah saw in the early months of the pandemic — it suggests nearly everyone who’s infected is getting tested and the daily case counts accurately reflect the number of people who have the virus.
But the higher the percentage of tests with positive results, the likelier it is that large numbers of infected people aren’t being tested. And that means there’s greater risk that some of those people — or the people they unwittingly infect — will not be identified until they turn up in a hospital. The ceiling for a surprisingly large increase in hospital admissions is even higher.
On Friday, more than 20% of the new test results reported by the state were positive.
“Even at 15%, 16% ...” Bell trailed off warningly. “When we say it’s ‘unsustainable’ — it’s rampant. We’re going to overwhelm the hospitals. Now it’s not a question of ‘if,’ it’s a question of how do we handle it?”
Going elsewhere for care
Even away from the front-line ICUs, medical staffers are feeling the pinch. At Huntsman Cancer Institute, health care workers are taking overflow patients from nearby University Hospital, said Don Milligan, executive director of the institute’s cancer hospital.
Milligan couldn’t say exactly how many patients have been transferred from University Hospital to Huntsman in recent weeks, as COVID-19 cases have spiked across the state, adding it was “not very many — but we stand ready to help.”
Huntsman won’t take COVID-19 patients, and if cancer patients test positive for COVID-19, they are transferred to University Hospital to be treated there. Huntsman at first banned visitors, and now allows them on a limited basis.
“We do everything we possibly can to keep Huntsman Cancer Hospital COVID-free,” Milligan said, adding that with the limit on visitors, “Our patients have been deeply impacted, not having their loved ones at their side."
The institute takes University’s non-COVID patients, to free up space and staff there to treat more people with COVID-19.
“It depends on their surgery schedule, and our surgery schedule, and our list of patients to be admitted to either institution,” Milligan said. “There’s not a cut-and-dry rule. … It’s communication that happens many, many, many times a day between our medical staff and our nursing staff.”
Medical workers at Huntsman, Milligan said, “are very resilient, and are doing a wonderful job of meeting the needs of our patients. That’s not to say they’re not tired. Some are exhausted. They spend long hours taking care of patients, and, of course, everyone is impacted by this pandemic personally at home.”
Staffers and patients also now wear more personal protective gear. “Everything," Milligan said, “takes a little more time, a little bit more attention, and costs a little bit more money.”
Sara Johnston, who has visited hospitals multiple times since she developed multiple symptoms of COVID-19 in March, has personally seen the recent effort to ease the burden on University Hospital.
Although she was not immediately tested — with access to tests severely limited in March — the Cottonwood Heights resident said four doctors have since diagnosed her with the coronavirus. And since then, she said, she’s been beset by health problems that still haven’t abated: Short-term memory loss, fatigue, chest pain and recurring headaches.
When chest pain began radiating down her arm Thursday night, she said, she visited an Intermountain InstaCare in Holladay. When a doctor advised her to go to a hospital, she mentioned she’d go to University Hospital, which her insurance would cover.
The doctor immediately waved her off, she said. “They told me the U. would be full," the 36-year-old said, “and I should go to St. Mark’s [Hospital] instead.”
She said that advice wasn’t unexpected. Earlier this month, she visited University’s emergency room after a severe headache left her temporarily unable to see out of one eye. The hospital was so busy she was treated on a gurney in the hallway.
“I wasn’t surprised at all, with everything that’s been in the news about capacity issues,” said Johnston, a research coordinator who previously worked for Intermountain. “That’s why I went to the InstaCare [on Thursday] rather than the U.”
‘The greatest good for the greatest number’
So looms the once-unthinkable possibility of kicking the very sickest Utahns out of intensive care units.
The protocols for deciding who gets priority are outlined in a document, first created for natural disasters but later modified for the coronavirus, called “Utah Crisis Standards of Care Guidelines.” It addresses both ICU space and ventilators, though state data shows only 16.5% of Utah’s available ventilators were in use at week’s end.
The guidelines provide a four-step process to decide who gets ICU space or ventilators when they are close to running out. The goal, the plan states, is to “stay ahead by one” — or, if that’s not possible, to “do the greatest good for the greatest number.”
The first order of business is to make sure the patients currently using those resources actually want them.
“Engage in a shared decision-making discussion,” the guidelines advise: Explain the pluses and minuses of staying under intensive care, and the likelihood of recovery. Make sure do-not-resuscitate orders are clearly communicated. Don’t involve hospital administrators in the discussion, and don’t pressure patients to voluntarily give up their ICU bed or make end-of-life decisions they otherwise wouldn’t make.
“These discussions on goals of care need to occur independently from triage decisions,” the guidelines state. “Providers must be careful not to coerce patients or their families.”
The second step is to consider, and ask patients to consider, a transfer to a regular hospital bed if they aren’t improving with intensive care. Their condition is rated with a score that measures oxygen levels, jaundice, blood pressure, kidney function and responsiveness. The worse their condition, the higher the score.
If ICU space or ventilators run out, it’s time for step three. It calls for looking at patients' condition scores but also considering individual factors; in general, those with high and worsening scores are the first to be transferred out of an ICU. If shortages worsen, hospitals should then consider transferring patients with high or worsening scores. Pregnant patients get priority for intensive care, and if two patients are equally eligible for a spot in the ICU, it generally goes to the younger patient.
Step four: Evaluate ICU demand every day, and change the “cutoff” condition score as possible. Stop using the guidelines when “all hospitals have been load leveled out” of using any cutoff score.
While perhaps morbid, the guidelines should compel Utahns to try harder to minimize the spread of the virus, Dougherty said. Each case prevented could determine whether some other person is able to get needed hospital care in coming weeks.
“Right now, it feels very close to being under the crisis standards of care. The [hospital administrators] were very clear about the level of stress that they’re under,” Dougherty said. “We can have a public health order ... but even with that in place, we still need people to choose to limit their gatherings.”
Editor’s note • Paul Huntsman, who is chairman of the board that oversees the nonprofit Salt Lake Tribune, and his family are major donors to the Huntsman Cancer Institute.