Hospital “crisis” care already happening amid Colorado’s omicron surge, ER doctors warn Polis

Colorado’s emergency rooms are essentially already rationing health care amid COVID-19’s omicron surge, but without the legal protection that would come if the state authorized crisis standards, a physician group told Gov. Jared Polis’ staff late last week.

The Colorado chapter of the American College of Emergency Physicians told the governor’s office in a five-page letter that doctors are having to triage which patients will receive the limited hospital beds available, and some people who would be deemed sick enough to admit under normal circumstances are being sent home.

Anyone having symptoms that suggest a life-threatening illness — something like difficulty breathing, chest pain or extreme weakness — should still go to an emergency room, said Dr. Ramnik Dhaliwal, president of the Colorado chapter.

But, he said, staffing shortages in hospitals and public confusion about where to go for care or COVID-19 testing have contributed to a squeeze in emergency departments that impacts all patients, not just those being admitted for treatment of the virus.

A statewide activation of the crisis standards of care for as short as one or two weeks would help hospitals get through the current surge, he said.

“We’re operating in that (crisis) framework without the liability protections,” Dhaliwal said in an interview Monday.

The hospital crisis standards address two problems: sorting out which patients are most likely to recover even if they don’t get a general hospital bed, and deciding which are so sick that they’re unlikely to survive if they don’t get the highest level of care. These would apply to all patients, not just people hospitalized with COVID-19.

Colorado has had crisis standards for staffing in place since early November, giving hospitals legal protection if they stretch their workforce in less-than ideal ways. In early January, the state reactivated crisis standards for emergency medical services, allowing ambulance workers to not transport some patients, and to not attempt resuscitation if the odds of success are low.

The state has never activated the hospital care-rationing standards.

COVID test positivity dropping

The number of people hospitalized with COVID-19 in Colorado remained roughly level over the weekend following a 68% increase since Christmas Day. As of Monday afternoon, 1,655 patients statewide had confirmed cases of the virus. About 93% of general hospital beds and 92% of intensive-care beds were full.

Estimates of the number of people primarily hospitalized for COVID-19 have varied considerably amid the surge fueled by the virus’s fast-spreading omicron variant. It remains unclear what effect COVID-19 is having on the patients not being treated primarily for the virus — how many needed care for something completely unrelated to an asymptomatic infection, and how many had a chronic condition exacerbated by the virus.

Some signs pointed to possible relief for Colorado in the near future. Following a nearly month-long surge, the percentage of tests coming back positive has been dropping for about a week, though, at 27%, it’s still well above levels that would indicate the state has a good handle on the size of the surge. Generally, when the positivity rate drops, cases and hospitalizations follow in the coming weeks.

COVID-19 deaths in Colorado have continued to drop following their last peak, amid the fall surge of the delta variant, but people are still dying, with the statewide total recently exceeding 11,000 deaths due to the virus.

At this point, it’s too early to be certain if the omicron peak has passed, though, said Beth Carlton, an associate professor of environmental and occupational health at the Colorado School of Public Health. And even when cases stop rising, it will take time for hospitalizations to fall, and many people still will be contagious, she said.

“We remain at unprecedented levels of cases and very high levels of hospitalizations,” she said. “We aren’t out of the woods yet.”

Staffing shortage causes backup

The emergency physicians group presented their letter, first reported by Colorado Public Radio, to a member of Polis’ staff during a virtual meeting last week.

It also asked the state to:

  • Explain to the public who is eligible for certain COVID-19 treatments and how to get them
  • Offer incentives for nurses to take permanent jobs in Colorado, or to stay in their current jobs
  • Set clear rules on when staff infected with COVID-19 can work
  • Bring in more nurses from the National Guard or the Federal Emergency Management Agency
  • Improve the statewide transfer center, which doesn’t always have the staff to answer when hospitals call looking for available beds
  • Reimburse ambulance providers for time spent transferring patients between hospitals

Polis’s office didn’t respond to questions about the letter from The Denver Post on Monday.

Hospitals have a staffing shortage, so they’ve had to stop using some of their beds, Dhaliwal said. That means patients who need a hospital bed are sometimes spending hours in the emergency department, waiting for one to become available, and occupying rooms that then aren’t available to treat others coming in behind them. Those who don’t have life-threatening conditions then have to get basic care in the waiting room until space becomes available.

“The shortage isn’t just in medical staff. It’s even in people to clean beds,” he said.

One of the simplest ways to ease some of the strain in emergency departments would be to increase access to testing, and to explain to the public where they can get care if they don’t have a life-threatening condition, Dhaliwal said. People come to hospitals when they don’t know where to get tested or can’t get an appointment, but that clogs up the system — and many emergency departments don’t even have tests available for people who don’t need to be admitted, he said.

“The state can do small things to help us decompress,” he said.

Some hospitals have essentially declared their own crisis standards, limiting non-emergency surgeries or setting their own rules about when sick employees need to come back to work, Dhaliwal said. The state could require hospitals to be transparent about their practices, to ensure that some aren’t handling the brunt of emergency patients because others keep doing surgeries that could be postponed, he said.

The hospital crisis standards, updated in late November, call for the state to halt non-emergency surgeries before allowing any rationing of care.

For the patients deemed lowest-risk, crisis standards could mean being sent home with oxygen and instructions to monitor their symptoms, or being discharged from the hospital earlier than normal. The standards instruct emergency room doctors to consider special circumstances, such as whether a patient is homeless. That takes time, though, which further exacerbates the emergency room backup, Dhaliwal said.

The standards for the sickest patients focus on their odds of surviving for the next year. Patients would be assigned a score based on how well their organs are functioning, with additional points added for age and conditions that might kill them in the near future, such as cancer or advanced liver disease. A hospital then sets a cutoff number of points, based on how many patients they currently have that need a particular resource, and how many more patients they expect to come in that day. Patients whose point totals are above that cutoff would receive a lower level of care: a general bed instead of an ICU bed, for example.

The biggest things that members of the public can do to help improve the situation are to go to a primary care doctor or urgent care if they don’t think their symptoms are life-threatening; wear masks, to reduce the virus’ spread; and get vaccinated, which makes it less likely they’ll become severely ill, Dhaliwal said. Though omicron causes more breakthrough infections among vaccinated people, most of those who are hospitalized with the virus are unvaccinated, he said.

“This is not a political thing,” he said. “This is life and death.”

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