CASPER — Four Wyoming hospitals have recently utilized crisis standards of care, and more than half a dozen have sought information on those standards from the state health department, though no hospital was actively in crisis care as of Tuesday afternoon, health department spokesperson Kim Deti said via email.
Twelve hospitals Tuesday reported a critical staffing shortage to the U.S. Department of Health and Human Services. Thirteen anticipate such a shortage within the week. Tens of thousands of traveling nurse positions are vacant nationwide, making it more difficult for hospitals to attract those workers to Wyoming.
More than 220 COVID-19 patients are hospitalized across Wyoming. The state’s virus hospitalizations have hovered at or above 200 patients since early September, creating a sustained burden unlike the last surge. Hospitals including the state’s largest are caring for the highest number of patients, virus-related and otherwise, they’ve seen in years.
State and local officials say this surge — driven almost entirely by the unvaccinated — is pushing hospitals to the brink.
Crisis standards of care, or crisis care, is used when hospitals don’t have what they need to serve every patient as well as they normally would. The standards dictate how a hospital uses scarce resources.
In extreme situations, this can mean hospitals having to decide who gets a life-saving treatment and who doesn’t.
The Wyoming Department of Health has guidelines for hospitals that utilize crisis standards, but transitioning to crisis care is up to each hospital’s leadership.
When a facility is under crisis care, they must notify the department of health, which is involved in trying to get the hospital back to a less severe position. On Tuesday, Deti said four facilities had at some point this surge been under crisis care but none were actively in that position Tuesday afternoon.
“It is something that is extremely fluid,” Deti said via email. “Hospital status is highly situational and dependent on several factors such as the ability to transfer or obtain resources quickly within the community.”
The health department’s guidelines outline in detail when a hospital can engage crisis care and how to decide which patients receive certain treatments. Crisis care could be necessary in the case of natural disasters or a mass casualty event like a plane crash, or in the case of a pandemic.
“In an important ethical sense, entering a crisis standard of care mode is not optional — it is a forced choice, based on the emerging situation,” reads the state guidelines.
Those guidelines provide detailed criteria for when a facility would shift into crisis care, but stresses the final decision is up to leaders of individual facilities. The state guidelines also stress that choosing not to shift into crisis care if a situation calls for it “is very likely to result in greater death, injury or illness.”
In severe situations, the guidelines provide a point system for determining what patients get certain care. They also outline the ethics behind these decisions, focusing on “doing the greatest good for the greatest number.”
Officials at Wyoming Medical Center, the largest hospital in the state, said they are not at the point of needing crisis standards. That hospital does, however, have a record patient load, with 196 people admitted as of Tuesday. Sixty-four of those patients are being treated for COVID-19 or virus-related illness, Dr. Mark Dowell said in a video message Tuesday — more than 30 percent of all admitted patients.
So many beds are occupied that the hospital is keeping would-be patients in the emergency room until space opens up for them, Dowell said, adding that some elective procedures at the hospital may have been halted.
Dowell said this is the highest patient total at Casper’s hospital at least since he arrived in the early 1990s.
Wyoming Medical Center officials have declined to answer questions about the facility’s needs with specific details. When asked how many patients an ICU nurse is treating now versus what is typical, spokesperson Mandy Cepeda demurred.
When asked how many patient transfer requests Wyoming’s largest facility has declined in recent weeks, she demurred again, confirming only that the number of denials is on the rise.
Twice last week the facility reported zero available intensive care unit beds.
In Casper and all other Wyoming hospitals, staffing has been a primary problem.
“We hear overwhelmingly staffing is an issue across all our facilities,” Josh Hannes, vice president of the Wyoming Hospital Association, said. “Not even just clinical staff, which is certainly the biggest part of it. But the housekeeping, environmental services staff, dietary staff, food service staff ... I mean all positions. They’re really struggling to have enough people to do the work they need to do.”
The hospital association is coordinating two different efforts to address the staffing problem, but they each have their own challenges.
First, the association is coordinating the release of $20 million, allocated by Gov. Mark Gordon, to help hospitals and other facilities keep existing staff and recruit people to vacant positions. That money can also be used for vaccine incentive programs for hospital employees.
The other project has $10 million to hire traveling nurses. But having that money does not guarantee Wyoming will get those professionals.
“It’s been more difficult now than when we did the same thing in the November to March time frame,” Hannes said. “One is because people are just leaving the industry.”
During the last surge, Wyoming worked with the traveling nurse contractor Medical Solutions and brought in about 300 temporary workers to Wyoming facilities.
That company today lists more than 50 unfilled temporary positions across the state. In surrounding areas, the need is even greater. Idaho and Montana both have openings for more than 100 hospital positions.
Another firm contracting traveling nurses, Aya, lists more than 59,000 openings nationwide.
“Part of the problem now is just the need versus the number of bodies that exist out there to fill spots. They’re just not out there,” Hannes said.
Those who are out there cost a lot more than they used to. In August, the average traveling ICU nurse coming to Wyoming would make $85 an hour. In September, they were paid $150 per hour.
That difference is being felt across all nursing positions. With so many openings at such competitive rates nationwide, Hannes said it’s unlikely Wyoming will have the same success filling positions as it did in November.