Following weeks of rising COVID-19 case counts and a tide of hospitalizations that have strained hospitals around the state, 20 health care facilities in Alaska are now operating under crisis standards of care.
The shift to crisis standards is often seen as a worst-case scenario. They’re meant to provide both guidance and liability protection for health care workers operating with extremely scarce resources.
The 20 hospitals that requested crisis standards make up a majority of Alaska’s 31 health care facilities (a total that includes hospitals and nursing homes), and they cover nearly every region of the state — on the road system and off, from Southeast to Northwest Alaska to Bristol Bay and all along the Railbelt.
Heidi Hedberg, director of the state Division of Public Health, said in an interview Saturday that the move to crisis standards is a sign that hospitals are getting closer to having to make extremely difficult decisions about patient care, calling the changes at Alaska hospitals in recent weeks “a slow progression.”
These hospitals “really are toggling further and further into the space where … they’re having to pull in that triage team to make a clinical decision, which didn’t happen before.”
The application of crisis standards of care varies widely by each facility and doesn’t always mean they’re rationing care. In many cases, activating crisis standards is seen as a pre-emptive measure, Hedberg said.
Some of the hospitals now under crisis standards had said, “We want to know that we have that liability, so at 2 a.m. in the morning, if we have to pull our triage team together and use the state document, we have that” in place, according to Hedberg.
Alaskans should know that the move doesn’t mean that care is no longer available at hospitals — and they shouldn’t delay seeking important medical care when they need it.
“Alaskans are going to receive care, but it may not be the care that they need,” she said. “It may be that the resources that they need may not be there.”
‘A heavy psychological burden’
Alaska’s hospitals have been operating under high levels of stress for months. In the midst of the sharpest coronavirus surge in the nation, the state’s limited health care system is particularly vulnerable due to its isolation and large rural population.
“Right now, we have five times the national average in cases, which reflects in our hospitalizations, but we have one of the most limited health care systems” in the country, Hedberg said.
In recent weeks, some impacts to care have included limited kidney dialysis therapy, a shortage of oxygen supplies, staffing shortages and difficulty transferring patients from rural communities, as Anchorage hospitals have been particularly full with critically ill patients in recent months.
Triage teams at hospitals are made of clinical ethicists, medical ethicists and, sometimes, pastors. They exist to help physicians make difficult decisions.
“There’s a heavy psychological burden to these physicians that are treating patients at the bedside when they don’t have enough resources,” Hedberg said.
“If a physician says, ‘I have two patients, and I have one resource. What do I do?’ They have to go to this triage committee, and that triage committee will review the information and help make a decision, so it’s not on the shoulders of that bedside physician,” she said.
Hedberg said she has heard of just three examples so far in recent weeks of an Alaska doctor having to make a difficult decision about resource allocation.
The 20 affected facilities include: Alaska Native Medical Center; Alaska Regional Hospital; Bartlett Regional Hospital; Bristol Bay Area Health Corp./Kanakanak Hospital; Central Peninsula Hospital; Cordova Community Medical Center; Fairbanks Memorial Hospital; Maniilaq Health Center; Mat-Su Regional Medical Center; Norton Sound Health Corp.; Petersburg Medical Center; Providence Alaska Medical Center; Providence Kodiak Island Medical Center; Providence Seward Medical Center; Providence Valdez Medical Center; SEARHC/Mt. Edgecumbe; South Peninsula Hospital; Elias Specialty Hospital; Wrangell Medical Center; and Yukon Kuskokwim Health Corp.
Flexibility and a push for resources
Several of those health care facilities had previously enacted crisis standards of care unique to their facility.
At Providence, “crisis care” has meant an occasional rationing of treatment, and using state guidelines and an internal triage team to make difficult care decisions when necessary. At Alaska Native Medical Center, the decision to move to crisis standards was mainly made to allow for more flexibility for providers.
For these 20 facilities, crisis standards of care “will remain in effect until there are sufficient resources to provide the usual standard of care to all patients,” the state health department said in a statement.
To address the staffing crunch at many of Alaska’s hospitals, the state has signed a federal contract to bring in about 470 health care workers from Outside. They started arriving this week.
The state also recently ordered five dialysis machines from the national stockpile plus more oxygen, and continues to do everything it can to prevent further crisis, Hedberg said.
At the beginning of the pandemic, Alaska’s hospitals worked together to draft the crisis standards of care guidelines, which break down specific topic areas around resources including oxygen, staffing, nutritional support and medication administration.
It wasn’t until last month, when rising COVID-19 hospitalizations caused the state’s health care system to be overwhelmed, that the document came into play. The state enabled crisis standards in an addendum to a public health emergency order.
When health care facilities reach a point of extreme stress, they now have the ability to appeal to Alaska’s health commissioner and the state’s crisis care committee, which is made up 15 physicians and health officials from both tribal and non-tribal hospitals around the state. The state can than approve the hospitals’ requests to activate crisis standards.
“That’s what happened yesterday,” Hedberg said.
A ‘highly fluid’ situation and ‘very serious surge’ in Fairbanks
Foundation Health Partners, which operates Fairbanks Memorial Hospital, said Friday that it activated crisis standards of care because of a “critical shortage of resources,” including staffing, available beds and transfer options to other facilities.
“The move to Crisis Standards of Care is not something we take lightly,” said Dr. Angelique Ramirez, chief medical officer for Foundation Health Partners, which also operates Tanana Valley Clinic and the Denali Center. “This is in response to a very serious surge of COVID in our community.”
The Fairbanks health organization also referenced a shortage of monoclonal antibody treatment, which health officials say is a highly effective treatment for high-risk individuals with COVID-19 early on in their illness, though they’ve stressed that it’s not a substitute for getting vaccinated.
Other factors involved in the decision, according to Ramirez, include “community spread driven by low vaccination rates and low mask utilization,” high patient numbers and inpatient acuity.
As of Friday, about one in three inpatients at Fairbanks Memorial Hospital were COVID-positive.
The shift to crisis standards “impacts all patient care, those with broken bones, traumas, heart attacks, strokes, COVID, anyone needing medical care could be impacted,” Ramirez said. “The care we are able to provide is highly fluid and can change day-by-day and even hour-by-hour depending on the availability of resources within our system and statewide.”
The Fairbanks North Star Borough is one of the least vaccinated regions of the state, with about 52% of residents fully vaccinated. University of Alaska interim president Pat Pitney said in a letter Friday that the chancellor of the University of Alaska Fairbanks asked her to consider approving a vaccine requirement for staff and in-person students at its Fairbanks locations. An update is expected within two weeks.
Health officials continue to encourage people to wear a mask in public, receive a vaccination if possible and get tested if COVID-19 symptoms develop.