‘What if I need the ER?’: Full hospitals, holidays, and Crisis Standards of Care

State & Regional

AMARILLO, Texas (KAMR/KCIT) – Even though local health leaders said the High Plains has not yet seen the full impact of the Thanksgiving holiday’s gatherings, crowded emergency rooms and overflowing rural hospitals have presented the community with “ominous circumstances” headed to Christmas.

With the concerns of local healthcare leaders in mind, how are hospitals on the High Plains handling patients? If a person in the area needs an emergency room in the coming weeks, what might their experience look like?

Part I | This week on the High Plains

During the Dec. 1 COVID-19 briefing from Amarillo health leaders, Northwest Texas (NWTH) and BSA Chief Medical Officers Dr. Brian Weis and Dr. Michael Lamanteer both described critical staffing shortages and a lack of space for patients no matter their needs. Many people, they said, have been left waiting long hours for the first available spot in either hospital.

“Some days we have upwards of 25 people holding our emergency room waiting for beds,” Dr. Weis said in the Wednesday briefing, “I know today we have 17 people out in the region waiting to be transferred into a higher level of care, but we certainly can’t accept it because of our staffing limitations.”

Dr. Lamanteer also said 18 patients were held in BSA’s ER Wednesday morning, as there were no staffed beds available.

“With increasing pressures from the smaller facilities that are in our Panhandle that need to transfer us patients that we want to accept, that we’ve been accepting, there’s only so much we can do when our beds are full and our staffing limitations are taxed,” Dr. Lamanteer said.  “That’s the point that we’re at again.” 

Even though the raw number of hospitalized COVID-19 patients has not reached historic highs from last year, such as in November 2020, healthcare leaders observed that the stress level and difficulties are similar. After all, during the worst of 2020, Amarillo-area hospitals like NWTH and BSA were supported with far more state and regional resources than are currently available. RAC staff from the state were slated to leave the area entirely by the beginning of December; even though many who did not have other assignments already scheduled have been allowed to stay for the time being, the loss was significant.

“Without those staff we hired as travelers independently and those supplied by the state and the RAC,” commented Lamanteer, “we would be having a lot of difficulty right now covering all of these patients.”

Alongside the absence of RAC nurses and other state resources, a growing number of regular hospital staff have needed to quarantine as cases have risen in the last few weeks. Weis reported that NWTH had 32 staff in quarantine on Wednesday, and Lamanteer reported BSA had 33 in quarantine at that time.

“If you’re coming to the hospital, don’t expect a rapid turnaround,” said Weis, “You may be holding for a while as you try to take care of your needs. But so that’s why the concern is any further surge is even going to put us further behind the eight ball in that sense.”

Smaller hospitals that serve the vast stretches of rural areas in the High Plains have been faring even worse, according to their leaders.

Deaf Smith County Hospital District CEO Jeff Barnhart, the district being the entity that oversees the Hereford Regional Medical Center, said his hospital has also recently been full with COVID-19 patients. 

“Probably a couple of weeks ago, we started back up, spiking again,” Barnhart said, “…We’ve had, you know, as high as 13 or 14 patients and 100% COVID. Interestingly enough, 100% unvaccinated as well. And then, of course, we’ve got a two-bed ICU and that’s been full as well.” 

Chief Nursing Officer of the Moore County Hospital District Ronda Crow said that as of Thursday, they had nine COVID-19 patients and two of that group on ventilators.

Rural hospitals often contact nearby larger hospitals to accept transfers in order to give patients access to the staff and resources they may need for a higher level of care. Heart attacks, car accidents, gunshot wounds, strokes, and other traumatic injuries or critical illnesses can call for specialized surgeries or dedicated wards that rural hospitals cannot offer.

However, as Crow described, lately it has taken multiple hours, multiple phone calls and multiple people to find a place to transfer both COVID and non-COVID patients to hospitals that provide that vital care. 

“It’s very difficult to transfer a patient, COVID or non COVID for that matter,” she said. “This weekend, we had to go all the way to Santa Fe, New Mexico with a patient on a ventilator and then we had to fly someone to Dallas Methodist for a surgery that we can’t do here on Monday. Nothing was available in Amarillo, Lubbock, Oklahoma City, any of those places.” 

Part II | “Wait – aren’t New Mexico’s hospitals full, too?”

The New Mexico Department of Health (NMDOH) announced that the state’s healthcare system would begin working through Crisis Standard of Care (CSC) guidelines in September. At least six hospitals in New Mexico, including larger facilities in Albuquerque like the University of New Mexico Hospital and the Presbyterian Hospitals in both Albuquerque and Santa Fe, have entered that legal designation.

Under the CSC designation, hospitals are allowed to use a “standardized, equitable procedure for making decisions on who receives medical care.”

Patients may initially be categorized using Immediate, Delayed, Minimal, Expectant (IDME) systems:

Other ways patients might be prioritized in a hospital include using a Sequential Organ Failure Assessment (SOFA) score in order to decide who has priority for ICU care.

More detailed information and a general walkthrough of New Mexico’s Crisis Standards of Care policies can be found here.

Part III | How do Crisis Standards of Care work in Texas?

The State of Texas is split into 22 different Trauma Service Areas, labeled A through V. Similar to New Mexico’s Crisis Standard of Care guideline book, the Southwest Texas Regional Advisory Council (RAC) published a book of guidelines in January 2021.

According to officials with the Panhandle RAC, it adopted the policy guidelines as published by the Southwest RAC. These guidelines, according to Southwest RAC, were intended to support healthcare systems “by providing a clinically and ethically sound triage protocol for allocating healthcare resources (e.g. hospital care, ICU care, ventilators) during a crisis when resources are critical scarce (such as a pandemic respiratory crisis).”

The full eight pages of the Southwest RAC publication can be seen here.

Also similar to New Mexico’s guidelines, the Southwest RAC offered examples of what crisis levels in a hospital may look like. There is also an algorithm map included regarding how a hospital may decide which patients to admit to a hospital during a crisis, let alone an ICU, according to a SOFA “survival score” and specific patient goals. For example, a patient with a low chance of survival even with hospital admission may be considered a low priority when compared to a patient who has a high chance of survival with admission, in that case making them a high priority.

via pg. 4 of January 2021 STRAC Crisis Guidelines

However, while the Panhandle RAC adopted this set of guidelines, the Regional Advisory Council said that it does not have regulatory power over hospitals. While the RAC can strongly recommend certain guidelines and systems, each individual hospital is able to work with its own leadership staff to establish the Crisis Standard of Care policy it would follow.

MyHighPlains.com reached out to the BSA Healthcare System, Northwest Texas Healthcare System, the Deaf Smith County Hospital District, and the Moore County Hospital District for a glimpse at how local hospitals have handled Crisis Standards of Care policy.

“The BSA Scarce Resource Allocation Policy outlines Crisis Care Standards to provide guidance for patient care in times of crisis,” said BSA Healthcare System officials, “This policy was drafted in collaboration with other hospitals and healthcare organizations and was reviewed and approved by the BSA Medical Executive Committee made up of physicians who practice at BSA Health System.”

While BSA has not been recently operating under that policy, officials said it is structured “for use in future situations that might require invoking Crisis Care Standards due to a rapid influx of critically ill patients and a shortage of available resources or personnel.”

MyHighPlains.com asked whether or not the BSA policy is available for the public to read, and as of Dec. 7 was waiting for further response.

After reaching out to the Northwest Texas Healthcare System regarding Crisis Standards of Care policy, as of Dec. 7, MyHighPlains.com was waiting for a response.

While it was not specifically clear whether or not the district had written crisis policy, Deaf Smith County Hospital District described once again its efforts to focus on transferring critical patients to their needed specialized resources. Within the last week, many patients from the hospital district had been sent to the Dallas area for broader access to resources and specialized care.

Moore County Hospital District, which had also recently discussed its efforts to care for its patients and transfer those in critical need to other facilities, said that it did not have such a policy.

Even if an individual hospital had written its own Crisis Standard of Care policy, it has remained unclear who at a higher level would look over and approve that policy, or how.

MyHighPlains.com reached out to several offices across the Texas Department of State Health Services, as well as the United States Federal Office for Civil Rights, regarding crisis policy oversight in Texas. However, as of Dec. 6, there had been few answers to phone calls and no definitive clarification on how hospital crisis policy is overseen at a Texas state level.

Part IV | “Okay, so what does that mean? What if I need an ER?”

Unfortunately, the lack of clarity about how Texas hospitals have been planning to respond to crises, and the lack of official oversight from the state, means that there is no concrete answer as to what might happen if a person needs critical medical care in the next few weeks around the High Plains.

“It’s sure not a good time right now to have a heart attack or, you know, an accident or any other medical condition,” said Deaf Smith County Hospital District CEO Jeff Barnhart, “simply because of the fact that we’re having a hard time, you know, finding hospitals to transfer to.”

Despite the fact that it might not be a good time to have an emergency – they are not generally voluntary. However, multiple medical articles and healthcare blogs have discussed preparing for medical crises with family members and loved ones. With that in mind, a few things that might be done to prepare for an emergency in the next few weeks include:

  • Prepare a list of emergency contacts.
    • This should have a current list of phone numbers for family members, physicians, and other significant personnel that are connected to your and your family’s day-to-day care.
  • Keep important information easy to access.
    • Important documents and records handy in a waterproof and portable container, including a personal ID, insurance cards, Medical Orders for Life-Sustaining Treatment, DNR forms, and/or advance directives.
    • A current list of medication you and your loved ones are taking, pharmacy numbers, and doctors’ names and phone numbers.
  • Pack a hospital overnight bag.
    • This could include nightclothes, toiletries, books, personal care supplies, and any other items that might help you or your loved ones keep a routine if required to stay the night in a hospital – make sure this bag has enough supplies for at least two to three days.
  • Educate yourself about emergency response.
    • You may want to take classes for first aid and CPR. Prepare first aid kits and home and for traveling, such as making a kit for your vehicle. This could include bandages, scissors, tweezers, gloves, cotton swabs, a thermometer, cold compress, hand sanitizer, and blanket.
      • Healthcare providers might determine you should have specialty items such as a blood sugar monitor, blood pressure monitor, automated external defibrilator, or other devices.
  • Plan caregiving responsibilities and communication strategies.
    • A medical emergency for yourself or a loved one can mean time-consuming and emotionally taxing caregiving responsibilities; especially if there is the extra need to communicate with many relatives, in the event that a person is transferred to multiple healthcare facilities or sent to a facility a long distance away. Prepare a communication network for loved ones, and have an idea of who may need to take care of children or pets if a person is hospitalized or with a hospitalized person for an extended period of time.

With all of those planning considerations settled, a few things a person might expect in the coming weeks if needing emergency medical care include:

  • Long wait times in the ER, or for a hospital transfer.
    • Last Wednesday, Northwest Texas Healthcare System reported to have 17 regional patients waiting for care, and at times around 25 people waiting in the ER for beds. BSA reported around 18 patients waiting in the ER, and “numerous” regional patients on hold. Because of the high number of patients needing care in recent weeks, wait times in even the larger healthcare facilities in the area have extended.
  • A hospital transfer falling through, or changing unexpectedly.
    • Particularly with more rural facilities such as the Deaf Smith or Moore County Hospital Districts, many hospitals being full throughout the Panhandle and its neighboring areas have led to uncertainty when trying to transfer patients to different facilities. Some patients have been sent as far as Santa Fe, New Mexico or the Dallas-Fort Worth area for care.
  • Long-distance hospital transfers.
    • Because of the reaching healthcare systems have had to do in order to find space for patients that need transfers, some have been sent through regional partners multiple hours away from community facilities. Some patients have been sent as far as Oklahoma City or Kansas City, over the past year and a half. Patients and loved ones should prepare for the possibility of a long-distance transfer, possibly across state lines, in order to access critical care.
  • Healthcare professionals doing their best to provide care.
    • Despite strains on resources and a severe staffing shortage, healthcare professionals across the board – from larger Amarillo hospitals to rural facilities across the High Plains – have insisted upon their commitment to doing everything possible in order to help ensure care is given to all in need.

With virus prevention such as COVID-19 and the flu at the forefront of their minds, healthcare professionals and leaders across the High Plains have continued to urge community members to be vaccinated. Those professionals have stated that flu vaccination, and especially COVID-19 vaccines and booster shots, remain the best way to keep beds and resources available in hospitals for patients who suffer from other critical conditions or traumatic situations.

This story is developing. Check with MyHighPlains.com for updates.

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