In Alaska, which has been enduring what is reportedly one of the worst surges of COVID-19 in the country, the state's largest health care provider and hospital group said it is in the unfortunate position of showing the country what an emergency response plan to COVID-19's fourth surge looks like in an isolated region with few quick fixes. Many U.S. states developed health care crisis standards of care during the coronavirus pandemic, but allocating critical patients among neighboring cities and hospitals -- called load bearing -- was often the first way to ease the crisis and avoid rationing health care.
Several times in a recent two week-period, patients with COVID-19 -- including patients who are infectious and patients who are considered COVID-recovery patients -- accounted for 24% of the inpatients at Providence Alaska Medical Center in Anchorage, according to Dr. Michael Bernstein, the hospital's chief medical officer.
Providence Medical is often the hospital that takes in transferred patients from rural and other communities across Alaska, but due to the delta variant surge and limited resources, equipment and staff, the hospital formally implemented crisis standards of care Sept. 11.
"Crisis standards of care provide a framework to make difficult decisions under difficult circumstances. Care may be prioritized, delayed or provided at alternate sites by allocating limited resources for those who will most benefit instead of those who are the sickest," Bernstein told Catholic News Service Oct. 7 in written responses to questions.
"We began to use a triage committee to relieve the burden of providers tasked with difficult decisions about care and ensure the most equitable allocation of limited resources," he added.
Providence Alaska Medical Center is part of Providence Health & Services, founded by the Sisters of Providence. The not-for-profit Catholic health care system, with headquarters in Renton, Washington, operates multiple hospitals across seven states and has more than 100,000 employees.
Providence Medical is Alaska's largest private employer and has publicly supported a citywide mask mandate to address what Alaska's state epidemiologist recently called one of the sharpest surges of COVID-19 in the country.
But a moderate to low vaccination rate in Alaska along with the state's geographic challenges have added to its pandemic response crisis.
Hospital census capacity is something that changes from day to day and is influenced by a variety of factors: Providence Medical might have 200 beds available for adult patients. But not all of those rooms have the ability to be converted to the negative-pressure rooms needed for patients with COVID-19 or other infectious diseases, according to Bernstein.
"Additionally, staffing can impact the number of patients we can treat at the hospital. During the pandemic, at times we have had more than 50 caregivers out due to exposure to COVID-19 in the community or because they have the symptoms of COVID-19 and need to quarantine," he said.
"Currently we are experiencing the highest number of patients who need treatment for COVID-19. It is hard to predict whether this will be the last time we experience a surge," he added.
The Philadelphia-based National Catholic Bioethics Center -- www.ncbcenter.org -- has issued detailed guidelines for what it calls triage principles and limited resource allocation protocols and applications for Catholic health care organizations navigating situations such as a global pandemic.
The NCBC's guidelines deal with foundational moral principles and consistency, accountability, transparency, and regular review of process and triage implementation as a framework for health care providers, including what remains unacceptable for Catholic health care providers at all times -- including euthanasia and physician-assisted suicide.
In addition, a Sept. 20 online forum hosted by the National Academy of Medicine pointed out that the pandemic's fourth wave underscored for many clinicians and patients the necessity of crisis standards of care.
But there isn't always the political will to formally activate crisis standards of care when they may be necessary.
And when these standards are implemented, they often are not uniformly activated from state to state and across hospital systems and among competitor health care providers, according to the University of Colorado's Dr. Matthew Wynia, who spoke at the online forum. He is director of the Center for Bioethics and Humanities at the university's Anschutz Medical Campus near Denver.
Besides Alaska, states with hospitals where crisis standards of care or something similar were enacted during the pandemic include Idaho, Montana, Washington, and earlier in the pandemic, Arizona and New Mexico formally declared crisis health care rationing plans.
Many Southern states announced they were approaching full capacities in their intensive care units last summer.
Crisis standards of care are now active for 20 health care facilities across Alaska.
Providence Medical's Bernstein said crisis standards of care do not necessarily have an impact on every single patient in his system's care even as the Alaska surge seems to be topping out.
"It is more about utilizing a triage team to assist with the decision-making in situations where multiple patients need access to a resource that is limited," he said.
"If we have three patients who need 24-hour dialysis but only two dialysis units available -- which of these three patients will benefit the most from receiving this care?"
One of the measures the hospital has implemented as a response to an increase in hospital census and continued staffing challenges is to postpone some elective surgeries that require hospitalization.
An elective, nonurgent procedure is one that will not cause harm to a patient if postponed for a period of time. "Postponing these types of procedures is a standard practice when warranted," Bernstein said.
And even before the onset of the coronavirus pandemic, a national nursing shortage served as an underlying difficulty to U.S. health care, sparking an added reliance on recruiting traveling nurses from out of state, and some regions of the country have been looking at ways to "up skill" existing nursing and medical staff to assist with more demanding and specialized intensive care unit duties.
Like the rest of the United States, hospitals in Alaska have been impacted by the national nursing shortage and have long recruited traveling nurses during the summer months, according to Bernstein.
"The pandemic has increased the demand for travel nurses everywhere, and it has been harder to fill these openings," he said.
Recently the state of Alaska provided the funding to hire caregivers to come to Alaska and help address the staffing challenges in hospitals throughout the state. Over 100 nurses, respiratory therapists and others have already started working at Providence Alaska ministries, he added.
And the three main hospitals in Anchorage -- Providence Alaska Medical Center, Alaska Native Medical Center and Alaska Regional Hospital -- coordinate patient flow to some degree when emergency departments and intensive care units are full.
"This is particularly the case for patient transfers from communities outside Anchorage; if Providence cannot accept a patient due to hospital census being high (no rooms available), that patient may be transferred to one of the other two hospitals.
"However, Providence Alaska Medical Center provides the highest level of care in the state, so the patients with the most severe injuries and illnesses are sent to (us)," Bernstein said.
In addition, Providence Medical's caregivers must be vaccinated or submit an approved exemption for vaccination request by Oct. 18 to remain in compliance with the hospital's vaccination policy.
Caregivers who are not compliant with the COVID-19 vaccination policy by this deadline will be removed from the schedule and may be subject to termination.
Though deadlines may vary, all health care workers across the country must adhere to such a vaccine mandate from their employer or, in most case, face being fired. However, The New York Times reported Oct. 7 that "only a fraction of U.S. health care workers are risking their jobs over vaccinations."
"The best things community members can do to alleviate the stress on our hospitals is to wear a mask in public, practice social distancing, continue washing your hands and get vaccinated," Bernstein said.
"Wearing a mask is important even for people who have been vaccinated. As we have seen with the delta variant, being vaccinated alone does not guarantee a person will not get COVID-19."
The pandemic continues to challenge caregivers like never before, Bernstein added. "This has resulted in a need to make changes so we can meet current challenges and are ready for what may come. One thing that has not changed is our commitment to our mission."