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'Dangerously close': Hospitals warn of need for crisis care if COVID cases don't slow

Citing units of the hospital at and above capacity, Bozeman Health on Wednesday warned it is readying a surge unit for the first time, may have to start using unlicensed beds and is preparing to implement crisis standards of care if the COVID-19 situation does not change.

The hospital in one of Montana’s largest communities was the second to announce the possibility of adopting crisis care standards, following Billings Clinic, one of the state’s biggest facilities in its most-populated community.

In addition to overflowing capacity and an acute lack of staffing, Bozeman Health’s COVID-19 incident command leader Kallie Kujawa said another factor in preparations is the frequency with which other area hospitals are going on “divert,” meaning they cannot accept any new patients like those who come in from a car crash or other medical emergency.

Over the last 24 hours, the Bozeman hospital has also not been able to accept critically ill patients, Kujawa said, though it has been requested to.

“We are experiencing that domino effect right now. We are still caring for people who have heart attacks, strokes or traumas and other health care and medical needs. We do not want to be in the position of our other communities where other decisions are being made ... we are dangerously close to being there.”

The 20-bed critical care unit at Bozeman Deaconess was fully occupied Wednesday, Kujawa said. The medical unit was at 95% capacity and the surgical unit was at 114%.

The surge and staffing redistribution plan can include hiring emergency crisis staffing, though hospitals have said they struggle to find workers. Kujawa said Bozeman Health has more than 400 open jobs, and it has already hired between 30-40 emergency staff. The hospital is also considering asking for assistance from the National Guard. Billings Clinic received 10 Guard volunteers earlier this week.

Though the surge plans were not implemented by Wednesday afternoon, Kujawa said “we are preparing them to be used in the coming hours as we anticipate that we will see continued increases in patients with an inability to transfer them to other hospitals.”

Weekday emails sent out by the state recently show more than a thousand new COVID-19 cases tallied since the previous day's report. Over the weekend Missoula broke its record for new daily cases added and one hospital is using ambulance bays for triage. Statewide hospitalization numbers are up 46% over the last two weeks, nearing previous peaks of late last year.

The Bozeman surge plan could include implementing crisis standards of care to manage those spikes, Kujawa said, but emphasized the hospital is not yet at that point. The state last week announced an update to those crisis standards, first crafted in 2020 in response to the pandemic. Bozeman Health said it has adapted the state’s standards some to fit their facility.

A recent press release from the state Department of Public Health and Human Services said the most recent version of the standards has “minimal changes” from the original version. The release said the update was done at the direction of Republican Gov. Greg Gianforte “to ensure the information remains relevant and current.”

The documents contain guidance about when to consider moving to crisis standards of care, though both Kujawa and Dr. Nathan Allen, an emergency medicine physician, department chair of Emergency Medicine for Billings Clinic and a medical ethicist, said the decision to use those standards would be made locally by individual hospitals.

In the press release last Friday, Adam Meier, director of the state health department, said the document was meant to give “consistent guidance for medical providers and staff in situations where certain medical resources become scarce, and prioritization of care may need to be considered.”

“The hope is we never get to this point, but we must be prepared,” Meier said in the release.

Crisis care is the inability to follow normal standards of care with the resources available, Allen said, and having a framework means a hospital can “do as much good for the whole community and save as many lives as possible” if a hospital needed to adopt those standards. He helped create the guidance along with groups from around the state including the health department, Montana Hospital Association, disability advocates and more.

The document provides outlines for managing scarce resources, as well as triage protocols for reviewing patients based on scores developed by assigning points based on their likely health outcomes. There's a strong ethical backing to the algorithm that’s meant to be easy for health care professionals to follow, Allen said. Each hospital can make their own adaptations like Bozeman did, but it’s good to have a shared state framework as a base, he said.

“I think the challenge of doing something like this is the moral weight of being involved in doing it and trying to take these very complex ideas and get them down on paper in a manner that a huge number of people can pick them up and put them into effect quickly,” Allen said.

The document also includes considerations for if patients are “tied” in their priority rankings, such as “Among adults, there is value in allowing individuals to experience as many life-cycle periods as possible. When there are large age differences between patients (for example, >30 years age difference), resources should be allocated to significantly younger patients.”

While hospitals like Billings Clinic develop plans and practice frequently for unexpected disasters like earthquakes or tornadoes, the crisis standards of care guidelines are the first time Allen said Montana has developed such a framework.

“The move toward crisis care is us wanting to be transparent with the community about where we think things are now across our region and where they are headed and it’s about putting in place the processes and teams to make these very difficult decisions in a manner consistent with that statewide guidance," Allen said.

Both Allen and Kujawa said staffing is a massive challenge leading to capacity issues.

“The one that we’re seeing the most critical shortage of are the highly trained and dedicated health care workers, particularly nurses who are essential to providing care to patients in the hospital,” Allen said.

The Montana Department of Labor and Industry this week sent out an email to request physicians, physicians assistants, registered nurses, licensed practical nurses, emergency care providers or respiratory care practitioner whose license was terminated for non-disciplinary reasons renew their licenses amid the labor shortage.

“With COVID-related hospitalizations increasing statewide, at the governor’s direction the department is looking at ways to mitigate the health care worker shortage and ensure there are no unnecessary delays in the licensure process for individuals qualified to provide medical services,” Jessica Nelson, a spokesperson for the department, said in an email Wednesday.

Nelson did not directly respond to a question asking whether the email had garnered any response.

Allen and Kujawa strongly urged people to get vaccinated to help ease the stress on hospitals.

“We need to see decreasing numbers of COVID-19 cases. Vaccination is the best tool we have to help accomplish that,” Allen said.

Kujawa also urged the use of other prevention measures such as masking, distancing, hand hygiene, staying home when sick and getting tested. The state does not have any mandates on masking, distancing or capacity in place, and local health powers to implement those were reduced in the most recent legislative session. She the situation is "scary and it's challenging."

“When you speak to our caregivers and you speak to our clinicians and all of our support team, they're here to care for the community in the best way that they know how. And if they aren't able to do that with the resources, the equipment and the personnel that they need to do that … it’s going to make a huge, huge impact on all of them as people and all of them professionally. … No amount of time can mentally prepare you for what we're about to experience, or what we're anticipating experiencing.”

— Reporter Seaborn Larson contributed to this story.

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