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Crisis Standards Of Care Activated In North Idaho: 'Almost All Of This Was Avoidable' Says Doctor

Three photo collage separated with white lines. First photo has a background of a snowy mountain scene surrounding a lake, with the title 'Patient Care: Strategies for Scarce Resource Situations' overlaid in a navy blue text box with white and light blue font. A white Idaho Department of Health and Welfare logo is centered at the bottom of the photo. Second photo is a group of five health care workers dressed in personal protective equipment surrounding a patient's bed.  Third photo is an image of the COVID-19 virus in red and gray on a gray background.

Crisis Standards Of Care—a term we've heard many times in the shadow of the pandemic. These guidelines help health care providers decide who should get life-saving care—like ventilators, ICU beds and staff time. Up until now, it was a worst-case-scenario in hospitals dealing with COVID-19.

Now, it's a reality.

Tuesday morning, the Idaho Department of Health and Welfare announced it had activated Crisis Standards of Care in two public health districts in North Idaho. This comes after Kootenai Health in Coeur d'Alene requested the guidelines be activated two weeks ago. Health care providers will not be in the position of deciding who gets care based on criteria established by the state.

Morning Edition host George Prentice recently spoke with Dr. David Pate, former President and CEO of St. Luke's Health System and member of the Idaho Coronavirus Task Force, about what this means for Idaho doctors and nurses.

“Almost all of this was avoidable; but we have made a mess of this.”
Dr. David Pate

Read full transcript below:

GEORGE PRENTICE: It is Morning Edition on Boise State Public Radio News. Good morning. I'm George Prentice. Crisis Standards of Care: a term we've heard on several occasions in the shadow of the pandemic; and it’s something we do need to know more about. Dr. David Pate is here, former president and CEO of St. Luke's Health Systems, a member of the Idaho Coronavirus Task Force. Dr. Pate, good morning.

DR. DAVID PATE: Good morning.

PRENTICE: I know that you can bring some straight talk on Crisis Standards of Care; and I'm looking at a definition from the Idaho Department of Health and Welfare, and it reads that it is a “substantial change in the usual health care operations and the level of care it is possible to deliver, which is made necessary” by what they call “a pervasive disaster.” Could you break that down for us and give a layperson idea of what that might mean?

PATE: I think it is a good definition. What it really means is that we have such a crisis that it is overwhelming our hospitals. It may mean that we just have too many patients and not enough beds. It could be that we have the beds, but we don't have enough staff. It could mean we're out of ventilators or we're out of whatever it is that we need. But for some reason, a public health crisis or a natural disaster is overwhelming our hospitals. Normally, of course, our hospitals take care of everybody and we give everybody all the care that they need. This contemplates a situation where we cannot take care of everybody and we cannot give everybody the care that we would if we had our normal resources.

PRENTICE: So does that mean it's a shift of focus from the patient to the general public?

PATE: Well, that's a good way of thinking about it, George. So, ordinarily when I was practicing and I was taking care of a patient, I did whatever that patient needed because we had those resources. What this situation of Crisis Standards means is we no longer can give every patient what they need. Therefore, we must look at them not as individual patients, but as the collective. And now we have to somehow differentiate among patients - who will get the resources and who can we simply not do that. And so your description is a good one. It means that we have to now evaluate what is the likelihood that if we do give these precious resources that are in short supply to a specific patient, that they're likely to survive, and those who are not likely to survive, we can't afford to give them the resources. We have to give them to somebody who is more likely to survive.

PRENTICE: Is there any precedence for something like this? Have you ever seen something like this?

PATE: I've seen something like this. There is no precedent for what we are getting ready to do, but there is something like it. There is a recent example in Texas where a veteran, I believe in his early 40s, showed up to a hospital emergency room with a condition, not COVID, a condition that is very serious, life-threatening, but one that we can treat. But this hospital was a smaller hospital, and couldn't because other hospitals in Texas were so overwhelmed with COVID patients, it was difficult for the hospital to find another hospital to transfer the patient to. It took them more than seven hours. And by the time they found the hospital and could fly the patient to it, unfortunately, he could no longer be helped; and that person died. So, we have some very limited experiences, but nothing on the scale of what we are facing right now.

PRENTICE: Gosh, it sounds almost like a combat situation… like triage or a MASH unit.

PATE: Well, George, that's exactly the analogy. This is like triage. This is going through, in the military, the wounded, in this case, the ill and infirm, and trying to triage them. Who can we help? Who can't we help? In normal times, we could probably help all of these patients. But in this crisis situation, there are people who would have survived if we were in normal resource situations, but won't survive under these circumstances.

PRENTICE: Could a CSC be declared for one… or a group of hospitals? Or would it be statewide because our systems of care depend on each other?

PATE: Technically, it can be declared for a region. So it wouldn't be for a specific hospital. Because, let's take for example, if St. Al’s was overwhelmed, they would merely shift patients to St. Luke's, because we're very close together. It's a whole different matter if St. Luke's in St. Al’s are both overwhelmed. Then where are we going to send those patients? We could send them certainly up to Kootenai in the Panhandle. But right now, Kootenai’s getting overwhelmed. They may actually be the first area to go to Crisis Standards, or we could look at flying people to eastern Idaho. But one has to understand that other than local disasters like an earthquake, a forest fire, something local, what we're talking about with a pandemic is something that's really not only impacting our whole state, but until recently, we've been getting transfers from states as far away as Oklahoma, and Georgia, because there's no other hospital to transfer to. So while CSC can be declared for a region, one of the three regions of Idaho, in practicality, if one region goes to CSC, it will not be long before another does.

PRENTICE: Are we talking about a reallocation… or a shift in resources? I'm wondering how it impacts most of us - for instance, our physical therapy or maybe a class or counseling that we would get at a clinic or hospital

PATE: Our hospitals in Idaho right now aren't operating normally. What you're seeing is that we're creating additional capacity. It might be that we've taken a classroom. And converted it for hospital beds. George, you saw this a year ago in New York City when they opened up the convention center. Those kinds of things. Those are contingency standards where it's not our normal operations, but we're trying to shift things around, shift resources around. And currently, for example, somebody that we might have kept in the hospital for another couple days so that they could go home. We can't afford those couple of days now. So, we are looking at is: are there other hospitals we might be able to send that are the smaller hospitals? They don't need as much care. We could send them there so we can offload the hospitals that can provide the highest level care. Or maybe we're sending them to a long-term care facility, a nursing home, that kind of thing, just so that we can unload the pressure on the hospitals. So, yes, right now we are shifting resources around. We can only do that for so long.

“Regardless of our ideological differences, regardless of our political differences, regardless of where we're getting our sources of information, what you cannot argue with is our hospitals and our health care professionals are being strained.”
Dr. David Pate

PRENTICE: I'm looking at the Idaho Department of Health and Welfare’s a white paper on Crisis Standards of Care. And I see that… and I want to get this right. It says, quoting here, “Generally, party seeking resources will be directed to their local public health district that will work with the hospitals and health care entities to fulfill resource requests”. And I guess the reason that jumps out so much is that public health districts are under a new scrutiny and pressure that we've never seen before. In particular, I'm thinking of Central District Health, which has a board of health which is embroiled in, quite frankly, a political divide. And Dr. Pate. I guess the greatest fear here is that this is no time for politics.

PATE:. Actually, none of this pandemic has been the time for politics. We see what has happened when we're facing a public health threat, which is not political, when it becomes political. And it's unfortunate and is frankly the reason why we are dealing with this crisis situation now. Almost all of this was avoidable; but we have made a mess of this. And certainly, I think we have to think forward. I understand there are people who don't believe COVID is a big deal, don't believe that there are any particular risk. But we have to understand the next pandemic we deal with could be completely different. And I could tell you viruses that I would be worried about for a potential next pandemic that will kill our children, that will have 30-, 40-, 50-times higher fatality rate than what we're dealing with now. So, we shouldn't be thinking that all pandemics are like what we're going through now. As bad as this has been, it can be worse. And we don't have the time for those politics. Now, fortunately for this part, where our hospitals would turn to the public health districts for help. Fortunately, we deal with the staff. We don't deal with the boards for that. And the people in these public health districts, the professionals that work there every day, are outstanding. What I fear is the biggest fallout from the nonsense that we have seen with some of these boards is that unfortunately, a lot of these very skilled public health workers that you never see or hear from, but are behind the scenes are being very helpful to us. They're leaving because they don't want to be part of a joke. They don't want to be part of something that's not science based. They don't want to be part of this politics. That is my absolute greatest concern.

PRENTICE: Before I let you go, I'm going to ask you to remind us about face coverings. The use of face coverings is absolutely based on science, correct?

PATE: It is. It is, George. And, you know, this has been a real tragic part of this, that we're not relying on science. And people are coming up with poorly designed or conducted studies to try to refute very well-done studies, or we have people, sometimes doctors, unfortunately, promoting very untrue things. Masks do work. Masks are not perfect. You should not rely solely on the mask, but masks are important. And I think what is called for is, at this point where we're talking about the potential for people that don't even have COVID. They have a heart attack. They have a stroke. They're in a car accident. They fall and break a bone. We may not be able to take care of all of those people. So regardless of our ideological differences, regardless of our political differences, regardless of where we're getting our sources of information, what you cannot argue with is our hospitals and our health care professionals are being strained. So, what I would ask of Idahoans, because we have in the past, we've always come together to help our neighbors. That's been the great thing about Idaho. What we need to do is: I'm just asking people for a few weeks, maybe it's going to be a month or two. I don't know, but it's not going to be long. First of all, if you are listening and you're thinking about getting vaccine, if you're open to that, find someone to ask whatever the remaining questions you have that can give you good information. And please get vaccinated right away. For all of us, let's take care of our hospitals and our health care professionals. Just for a matter of weeks, could we all please be careful as not have large gatherings wear our masks when we're out in public? Whether you're vaccinated or not, let's just protect our hospitals and our health care professionals. Just till we get through this surge, then if we want to go back to fighting and arguing and all that stuff… but let's come together for the next few weeks.

PRENTICE: He is Dr. David Pate… this day and every day, a prime source of information and straight talk. Dr. Pate. Thank you so much.

PATE: Thank you, George.

Find reporter George Prentice on Twitter @georgepren

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