How would crisis standards of care be enacted in Washington — and at what point?

While Washington’s hospitals are severely strained, we are not yet at the point of having to enact crisis standards of care like Idaho has done.

Idaho’s medical crisis is ‘becoming our problem’ in Washington

However, health leaders warn we are getting dangerously close.

“Crisis standards of care” is a medical designation primarily used in the context of a disaster — such as an earthquake, volcano, or a pandemic like COVID-19. It means that a catastrophe has caused so many medical problems and overwhelmed the health care infrastructure to such an extent, that difficult triage decisions will have to be made by medical professionals in order to best use the limited resources available to save lives.

“It is a term that is very much meant to be a last resort, when life-saving medications or therapeutics or ventilators, you just don’t have enough of them, and you get to this point where you have to ration the care,” explained Washington State Health Secretary Dr. Umair Shah at the Washington State Department of Health’s Wednesday briefing.

While some of Washington’s hospitals have seen people with serious conditions like strokes and appendicitis having to wait for care, we are not quite at the point of officially declaring crisis standards.

“Today in our system, we’re seeing care that’s being provided in a crisis, … but it’s not enacting what this specific term of crisis standards of care would mean,” Shah said.

It is the state’s Disaster Medical Advisory Committee that would meet and decide if and when to designate crisis standards. Shah explained that they would look at two main factors when making their decision.

“One is the saturation within the actual health care system,” he said. “The other is the inability for resources to be moved back and forth, or patients to be moved back and forth, … if you can no longer transfer patients across the state, or you can no longer get resources into a hospital that is severely stressed.”

If the committee felt that it was necessary to make that move, it would make the recommendation to the state Department of Health. The department, along with other health partners and Governor Inslee, would make the final decision.

Dr. Shah said that if this were to happen, it would likely be as a state, rather than by one region as Idaho implemented at the beginning.

So how close is Washington really getting to crisis standards of care?

Shah compared it to stretching a rubber band to its breaking point over and over again.

“I’m really concerned that we have stretched this rubber band, and at some point that rubber band is going to break if we do not continue to keep up with what we can to prevent people getting into that health care system,” he said. “Plus, we have an issue of staff shortages.”

He said the state had put in a request for 1,200 personnel to help fill those gaps.

Earlier this week, the Washington State Hospital Association announced at its briefing that it had requested staffing help from the National Guard and other federal resources, but was not counting on getting much aid because of the immense demand around the country from COVID and the hurricanes.

“Along with providing assistance for the COVID-19 response, the civil unrest last summer and again in January, the wildfire seasons last summer and currently, we have more than 1,000 men and women deployed overseas,” the National Guard told KIRO Radio in a statement.

Meanwhile, medical centers are relying on the state’s emergency volunteer databank, as well as community volunteers at individual hospitals.

And as the rubber band continues to stretch, Dr. Steve Mitchell, medical director of Harborview’s Emergency Department, said they are especially having trouble with the second factor in the Disaster Medical Advisory Committee’s decision. Mitchell founded the Washington Medical Coordination Center, which helps hospitals move patients around the state to get care — for example, from small, rural facilities to larger, more urban ones where they can have access to a greater variety of procedures.

There are 39 designated critical access hospitals in rural areas of Washington, which are hospitals of 25 beds or fewer that typically care for a patient in an emergency, and then send them to a bigger regional facility for further treatment. Lately, however, hospitals have been running into challenges finding other facilities to take their patients.

State’s hospitals warn stroke, appendicitis patients seeing delayed care

“Since July 1, my team at the Washington Medical Coordination Center has dealt with over 1,000 requests from hospitals that have been unable to place their patients from these small, rural critical access hospitals, where they can stabilize patients, to the locations that can actually intervene and fix those patients,” he said.

Those resource hospitals are taking dramatic steps to fit those patients in.

“They are doing things like turning areas not meant to be taking care of critical care patients into ICUs,” Mitchell said. “They are also taking staff who normally don’t work in intensive care units and extending the staff who normally work in critical care units, trying to increase their reach so they can care for yet still more and more patients, putting increasing strain on all of our staff.”

Even though new cases appear to be starting to flatten statewide, that does not mean the stress will immediately begin to lift for our hospitals, which are still at all-time highs. Shah said that hospitalization trends typically take a couple of weeks to follow case rates, so the hospitals will still be inundated for some time. He compared it to taking your foot off the accelerator when you are going at a fast speed down the freeway.

“It does not mean that the car immediately stops,” he said. “Your car will continue at a certain speed for a while coming, and that’s going to be a real issue that we’ll have in our health care system is that we’re going to continue to see whatever input, whatever patients that are coming that will continue to stress that system for some time, moving forward.”

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