Utah hospitals have begun informal rationing of care, doctors say, as they cope with surge of COVID-19 patients - Salt Lake Tribune

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With a combination of luck, new hires and creative reorganizing of staff and patients, Utah’s hospitals haven’t had to eject anyone from intensive care units due to the coronavirus.

But several doctors say the solutions still amount to rationing, with the quality of care deteriorating as hospitals are stretched thinner and thinner.

And with record numbers of new patients being admitted every day, they say the breaking point is all but inevitable. Utah reported 3,395 new cases on Saturday and set a new record with 551 patients hospitalized — and those mostly are from diagnoses a week or two ago, when cases were lower.

“What keeps me awake at night is that we have not felt the admissions of the 4,000-patient-a-day caseloads. We’re going to feel that in the next week or so. But our hospital already is at 100% capacity,” said Dr. Sean Callahan, a University of Utah pulmonologist and critical care physician who oversees the hospital’s respiratory therapists.

‘Health care is changing’

As of Thursday, there was room for about 45 more ICU patients statewide, said Greg Bell, president of the Utah Hospital Association.

But past data shows how quickly those beds are likely to be filled by new COVID-19 patients alone. As of Thursday, Utah’s ICUs had been caring for an average 192 coronavirus patients each day for the past week. That reflects a gain of about 45 patients in just two weeks — and that’s excluding the 60 to 70 percent of ICU patients who are there for some other illness or injury.

It also reflects much lower case counts, since those new ICU patients likely were infected a week or two earlier — when the state was averaging 1,500 to 2,500 new cases per day.

On Saturday, the state was averaging more than 3,200 new cases per day. In total, 7,458 patients have been hospitalized in Utah for COVID-19, 782 of them in the past week.

But while cases and hospitalizations rose as expected, Bell said, hospitals expanded capacity just enough, by adding staff, shifting some doctors and nurses to ICUs from other departments, and repurposing beds.

“The water is lapping at the top of the dam,” he said. “I keep thinking it’s going to go over, and it somehow doesn’t.”

But doctors say the solutions have their own costs.

“Standard ICUs are full. Period. We’re now talking about ‘extended access’ ICU. So the care is different,” said Dr. Eddie Stenehjem, an infectious disease physician at Intermountain Medical Center in Murray. “We’re having to ask providers to do things that they aren’t comfortable with.”

ICUs usually are staffed by doctors and nurses who have training and experience specific to intensive care. But to staff the overflow ICUs that have opened around Utah, hospitals are moving doctors and nurses from other departments. And Intermountain Healthcare has hired about 200 nurses from out of state.

“We’re asking them, ‘Take care of the most complex patients that you’ve ever had, in a health care environment that you’ve never been in.’ And so the health care is changing.”

Meanwhile, the patients who are in the ICUs, particularly the ones with COVID-19, are likely to be in precarious condition, with multiple organs at risk of failure, Stenehjem said.

“The margin of error is really low,” he said. “...You’re potentially going to have more errors, and you’re potentially not going to have as good of care that you would have if you had the [regular] ICU team that works together as a cohesive unit ... every day.”

At the U., a coronavirus-only overflow ICU has doubled the number of patients per nurse in order to expand intensive care to patients who do need it, but who are on the more stable end of the ICU spectrum, Callahan said. Treating only patients with coronavirus does save time, Callahan said; the tasks are more consistent from patient to patient, and providers don’t have to change personal protective equipment every time they cross a threshold, as they do in the standard ICU.

But coronavirus patients are just like any others requiring intensive care: monitoring is constant, alerts are frequent, and patients don’t have minutes or seconds to spare. The lower staffing ratios mean nurses are sometimes facing more urgent tasks than they have hands for, Callahan said. And when patients in the overflow unit unexpectedly destabilize, setting off more alarms than the staff can respond to, they have to be moved back to the regular ICU — a time-consuming task in its own right, Callahan said.

“We are still providing good care, I’m proud of our care. But it’s not what we would normally offer,” Callahan said. “We’re doing quite a few different things than I thought we were going to be doing: opening up more ICU spaces for patients, canceling even more surgeries that are even more urgent.”

‘He came home with tubes’

University Hospital has been delaying two surgeries a day on average, for the past two weeks — but that has reached up to 10 delayed procedures in one day, said Kathy Wilets, hospital spokeswoman.

“Each patient is assessed based on the time sensitivity of the procedure, with those deemed least time-sensitive being delayed first,” she wrote in a response to The Salt Lake Tribune’s inquiry.

There also may be delays in particular units that are full. With the coronavirus absorbing so many resources, hospital patients have been diverted even to other facilities, such as the Huntsman Cancer Institute.

Dimitrius Maritsas, 21, arrived at the Huntsman Cancer Institute on Thursday for a five-day inpatient course of chemotherapy, his second since he was diagnosed in October with a fast-growing form of lymphoma.

Staff initially said they thought they could secure a bed for him and began the infusion, said Maritsas’ sister and family spokesperson, Xenia Maritsas.

But after the first round of treatment, the staff unhooked him and told him they didn’t have a bed after all. Nurses sent him home with instructions to drink as much water as possible, since he wasn’t going to receive a saline drip that night.

“He came home with tubes in his chest,” Xenia Maritsas said. “They said, ‘Unfortunately, somebody came in that needs urgent care.’”

The family doesn’t know whether the last remaining bed was filled due to hospital overflow; Dr. John Ward, physician-in-chief for the institute, said the cancer center has occasionally taken overflow patients from the university’s hospital, but he didn’t know if any were there on Thursday. While it’s “not a common occurrence” for a patient to be delayed for a rescheduled procedure, Ward said, the cancer center is frequently full midweek.

“I don’t think it’s indicative of a trend,” Ward said.

Xenia Maritsas said her family wouldn’t fault the cancer center for delaying chemotherapy in order to take other, more critical patients. Dimitrius Maritsas was called back to continue his treatment late Friday.

But if the capacity margins are that small, Xenia Maritsas said, and the hospital is getting fuller and fuller, Utahns need to realize that being careless about spreading COVID-19 could mean displacing very sick patients.

“I wish people would realize the severity of the situation,” she said.

When overcrowding affects the quality of care across the board, Callahan said, it still amounts to rationing — even without the formal shift to “crisis standards of care,” which require authorization from the governor and give priority to the ICU patients who are likeliest to survive when there aren’t enough beds to go around.

“It is a continuum,” agreed Dr. Andy Pavia, chief of pediatric infectious disease at the U. “There are things going on right now that wouldn’t normally happen. Patients from Idaho are not being accepted. People are staying in small community hospitals rather than coming to referral hospitals, where the greater [technical] sophistication is. It’s just not the point where people are stacked up in the hallways with no bed.”

‘It’s going to be heartbreaking’

Utah’s death toll from the coronavirus stood at 787 on Saturday, with 14 fatalities reported since Friday:

Three Salt Lake County women, ages 25 to 44, 65 to 84, and older than 85.
Four Salt Lake County men, ages 65 to 84.
Two Weber County men, one age 65 to 84 and one older than 85.
A Utah County man older than 85.
A Wasatch County man, age 65 to 84.
An Emery County man, age 65 to 84.
A Washington County man, age 45 to 64.
A Sevier County man, age 65 to 84.

The highest rates of new cases per capita were in Sevier, Garfield, Utah and Cache counties, where more than one in every 65 people has tested positive for the virus in the past two weeks — meaning their cases are considered “active.” And Wasatch, Salt Lake, Morgan and Washington counties each are reporting more than one in every 75 residents have tested positive in the past two weeks.

There were 16,270 new test results reported on Saturday, above the weeklong average of about 13,900 new tests per day.

And for the past week, 23.7% of all tests have come back positive — a rate that indicates a large number of infected people are not being tested, state officials have said.

With case counts in recent days making further crowding inevitable, Callahan wasn’t sure that Utah would eventually be willing to take the difficult steps to limit ICU admissions before hospitals start losing patients whose lives could have been saved — the ones who would get priority under more formal rationing.

“I worry that while we’re dragging our feet, trying to make do with everything, some of these younger or more-well people are going to get hurt,” Callahan said.

It’s going to be even harder, Callahan said, to let hospitals move the very sickest patients out of their ICUs, even if “crisis standards” are necessary to save the most people.

“It’s going to be heartbreaking — and it’s going to be a political disaster,” Callahan said. “I don’t think there’s the will to implement them when they will likely be needed.”