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SALT LAKE CITY — The president of Utah's hospital association warns that Utah may soon reach its maximum occupancy for intensive care unit beds based on the worsening trends reported at hospitals already and the growing number of COVID-19 cases.
"We just know that hospitalizations follow (the) disease, and so we have to think in the next week or two that we're going to be at the maximum of even our contingency planning for ICU beds," said Greg Bell, president of the Utah Hospital Association, in an interview with KSL on Sunday.
It's why Bell met with Gov. Gary Herbert and state health department officials last week to discuss the Crisis Standards of Care Guidelines — a list of procedures for medical providers to follow in the case of an emergency that overwhelms medical facilities — and when hospitals might need to implement it.
If enacted, it's a plan for determining when some patients might be denied care or moved out of ICU beds to make room for others who might have better outcomes.
"(It's) guidance for hospitals to help them make very thoughtful, ethical, moral decisions in the most extreme circumstances," said Joe Dougherty, spokesperson for the Utah Division of Emergency Management, in an interview with KSL NewsRadio's "Dave and Dujanovic" on Monday morning.
He said the hospital association provided the governor's office and some members of the state's Unified Response a briefing on the document during a meeting Thursday.
The meeting over possibly having to use it happened at a time that the Utah Department of Health reports not only its highest number of new cases to date but also some of its highest COVID-19-related ICU bed occupancies since the coronavirus was first reported in the state back in March.
"We are not there yet," Doughtery added. "What they did is they said, 'Here is what the Crisis Standards of Care are and it's possible that if we don't get out of this trajectory, that we will be asking the governor to invoke the Crisis Standards of Care plan, which does go into very serious decision making."
Utah's growing hospitalization and ICU needs
Utah entered this week with a running seven-day average of 1,493.6 new cases per day — an all-time high. The seven-day running percentage of positive tests per test administered reached 17% through Oct. 20, which was also an all-time high.
The latter figure is backdated to account for the results of all tests conducted for the date. It's also an important statistic because it provides an indication of how many cases could still be out there underreported.
"When you have a spread rate that exceeds 15% — some days 20% — you know that's a proxy for many other cases beyond those who have been tested," Bell said. "We truly have a pandemic loose in our community, and in our state, and we just know where it's going."
It's resulted in the highest number of active COVID-19 cases the state has reported since March. There were an estimated 27,298 active COVID-19 cases — cases reported over the past three weeks without fatalities — as of Monday. That's about one-fourth of the state's cumulative total over the past 7½ months.
It's also leading to an uptick in hospitalizations. Ongoing COVID-19 hospitalizations reached 300 in a day for the first time earlier this month. It was 299 as of Sunday, per state health department data released Monday. The department reported ICU bed occupancy at 76% full on Sunday, which is above the state's targeted goal of below 72%. The figure fell to 69% on Monday.
Not all ICU beds used right now are occupied by COVID-19 patients. That said, the number of COVID-19-related ICU utilizations is slowly growing. It reached at least an eight-week high Saturday, with 120 COVID-19 ICU hospitalizations that day. The figure dropped back down to 112 on Sunday, according to health department data released Monday.
The state had reported 47 ICU beds were used because of COVID-19 on Sept. 1. That number held steady through early September before climbing at the end of that month and into October. It reached 100 on Oct. 14, and then 120 on Sunday. The state also exceeded its COVID-19 ICU occupation target — set at 15% — during the week of Oct. 11 for the first time since July.
Dougherty called the number of case counts and hospitalizations piling up "unsustainable."
People are so worried about the government imposing a lockdown; but at some point, the disease is bad enough that people lock themselves down. We can (avoid) this through masking and social distancing. We know how to do it. ... We just need to do it.
–Greg Bell, president of the Utah Hospital Association
The state has kept additional hospital beds available at the Mountain America Exposition Center in Sandy should hospitals need more bed space, especially for non-ICU cases; however, additional beds only solve one of two large problems hospitals face if they are overrun.
"We have more beds than we have skilled medical teams in our hospitals, so how can we take those teams and put them in another facility? It doesn't make sense," Bell said. "So you have to generate other teams to deal with people in the expo center. That means you have to bring people from outside, or somehow you've got to have people working around the clock."
Some of the state's largest hospitals have reported reaching maximum occupancy this month, or other major issues as this has unfolded. The state's data reflects Utah hospital beds as a whole but not individual hospitals or staff situations. That's why some hospitals are maxing out beds above the state's total rate.
For example, University of Utah Health's chief medical officer announced earlier this month the organization had created additional ICU space after its capacity reached 104%, according to an Associated Press report. Intermountain Healthcare also released a new advertisement campaign last week to address how COVID-19 creates constraints for Utah hospitals.
"As the spread of COVID-19 has accelerated in Utah, our hospitals are experiencing mounting pressure. I know most have not personally experienced the harrowing reality in our ICUs, but it takes all of us to reverse the trends," Herbert tweeted on Monday.
The growing hospitalizations and shrinking ICU bed capacity are where the state's Crisis Standards of Care plan comes into play. It's a document nobody wants to use. The document's protocol even acknowledges this in the first sentence, which states: "Every effort should be made to avoid Crisis Standards."
The emergency plan
There were fears COVID-19 could lead to this plan being used during the first few weeks of the pandemic in Utah. Those worries subsided as COVID-19 cases plateaued early on. A revised plan was crafted in August but wasn't publicly discussed much as something that would be enacted even after a summer uptick led to more and more hospitalizations.
The guidelines become a possibility after a public health emergency is declared, which Herbert did on Oct. 13.
The state's contingency plan first calls on hospital staff to absorb extra shifts, but Bell explained that can only last for so long. The guidelines specify who should or shouldn't receive treatment as well as what priority one patient has over another.
The plan after that mostly follows the traditional procedure for critical care triage, which is known as Modified Sequential Organ Failure Assessment, or MSOFA. It's a system with a calculated score based on several factors that determine the likelihood of mortality. In the end, those more likely to survive are typically given priority.
"ICU/ventilator care needs to be increasingly focused on those that are more likely to benefit from it, to meet the goal of 'the greatest good for the greatest number,'" the authors of the state document wrote. "Additionally, non-ICU care, including comfort care, needs to be made available to those that are critically ill but unlikely to benefit from ICU care."
The protocol follows different stages if the hospitalization situation worsens. If an ICU or ventilator patient isn't improving they might be removed from the ICU and the bed or ventilator is given to the next person in need. The state's goal, the document points out, is to ensure that it is "ahead by at least one" when it comes to ICU beds, staffing and equipment.
Those with do not resuscitate or Physician Orders for Life-Sustaining Treatment orders are near the top of what will move someone out of an ICU bed for another patient, as are cases of cardiac arrest "without an identifiable and reversible cause."
Should the need for ICU beds or ventilators exceed the capacity of equipment, MSOFA score calculations would determine how the equipment is distributed to patients.
There are some tie-breaking situations. Patients who are pregnant would be favored because they may represent multiple lives. Age is another possible tiebreaker because younger individuals "generally have better short-term mortality outcomes than older persons with the same clinical condition," the document states.
Disability advocates have pushed back against contingency plans that would not provide equal medical access since March. The document does state there are protections in place to ensure people with pre-existing disabilities "have an opportunity for equitable treatment" at any time the demand for ICU beds or ventilators exceeds the supply.
Bell said it's not an option hospitals want to take, but it's an option they might be forced to address in the coming weeks. He said there is still a way to avoid the worst-case scenario, which is finding ways to curb new COVID-19 cases.
He urges people to continue to stay home if they are sick; when people are outside their home, they should wear masks in public places and physically distance themselves from other households.
"People are so worried about the government imposing a lockdown; but at some point, the disease is bad enough that people lock themselves down," he said. "We can (avoid) this through masking and social distancing. We know how to do it. We can knock it down. We just need to do it."
Dr. Angela Dunn, the state' epidemiologist, tweeted that Utah's situation was "not OK," especially because it had gotten to this point.
"It is maddening that we are planning to ration care in Utah," she tweeted. "Unacceptable. We must do EVERYTHING we can to slow #COVID spread. No excuses."
Contributing: Emerson Oligschlaeger, KSL; Dave Noriega and Debbie Dujanovic, KSL NewsRadio
