Spokane hospitals are preparing to meet the demands of an expected surge in COVID-19 patients in the coming weeks, but officials warn that resources are finite and how taxed the system becomes depends on how well citizens follow social distancing and masking guidelines.

At both regional and statewide levels, hospital leaders are coordinating about surges already happening as winter approaches. Among initial solutions to reaching capacity: stopping elective procedures and expanding to serve more patients.

Washington hospitals have made a statewide commitment to ensure no hospital is overwhelmed as long as there is capacity elsewhere. This effort is coordinated by the new Washington Medical Coordination Center, a three-person team at Harborview Medical Center in Seattle that took on the effort when the Department of Health asked them to do so this summer.

Dr. Steven Mitchell, emergency department medical director at Harborview, and two nurses are coordinating care for some COVID and non-COVID patients statewide, as the need arises. If a hospital needs to transfer a patient who is critically ill but cannot find space through usual transfer partners, they can call the WMCC.

“Our goal is to keep people as close as we can and match them to the right hospital, and we have to expand out based on the occupancy at the hospitals we know are available,” Mitchell said.

Mitchell and his team have access to live data from all the state’s hospitals, large and small, about their bed and staffing abilities, occupancy and availability. If Mitchell or someone at WMCC gets a call for a placement, they use the data to assist a hospital in placing a patient. Additionally, the data system, called WA Health, can be updated by hospitals that are surging or making plans or arrangements to add beds or capacity.

“We’ve done a ton of work, really incredible cooperation, I think, with the Washington State Hospital Association and the Department of Health to try and make sure that what’s being reported in WA Health reflects reality to make sure everyone is talking about things in the same way,” Mitchell said.

The statewide coordination has become even more important in recent weeks with coronavirus cases surging in all parts of the state. Mitchell estimates that nearly 60% of the patients they are transferring for care are COVID patients.

Patient transfers have become tighter due to the burden of treating COVID-19 patients regionally, and larger facilities, including those in Spokane, have had challenges accepting as many transfers as they normally would this fall, Mitchell said. WMCC has worked with several rural hospitals with 25 bed or less to look elsewhere for transferring patients since Spokane has been slammed.

This fall surge in COVID-19 cases differs greatly from earlier in the pandemic. Initially, the Seattle area, then Yakima and the Tri-Cities, then Spokane surged which strained the system in a methodical way, unlike what is forecasted for the weeks to come. Hospital occupancy and capacity are fluid.

There are about 9,400 staffed hospital beds for adults as of Nov. 26, and currently 73% of them are occupied.

The goal of WMCC is to help Washington hospitals avoid what other states saw earlier in the pandemic: one hospital overwhelmed with patients just a few blocks away from a hospital with room to spare.

“I think the thing that’s set us apart from other states seeing similar surges is that commitment,” said Jacqueline Barton True, vice president of rural health programs at the Washington State Hospital Association. “We have 100% commitment from our hospitals that no one individual hospital will be overwhelmed so long as there’s capacity in other hospitals.”

Prepared in the Inland Northwest

In Eastern Washington, the Regional Emergency and Disaster Health Care Coalition has coordinated COVID-19 planning for capacity at hospitals throughout the region.

Adam Richards, director of emergency services at Providence in Spokane, said the coalition and health care partners have also had coordinated regional plans, much like what WMCC is doing now, early on in the pandemic. After seeing the surge in Yakima, Richards said hospitals in Eastern Washington began to look at certain locations to take on additional patients.

“We worked together to establish some pop-off valves so people could do what the WMCC is doing,” Richards said.

In the coalition’s preparedness plans, hospitals throughout Eastern Washington are separated into different regions. Larger hospitals serve as disaster medical coordination centers in six different regions throughout Eastern Washington.

MultiCare Deaconess serves as the regional disaster medical coordination center for the Inland Northwest, while Providence Sacred Heart Medical Center serves as one of two state disaster medical coordination centers in these plans.

The coalition’s regions also include hospitals along Oregon and Idaho state borders, including Kootenai Health.

Patient transfer coordination, as well as transferring resources like personal protective equipment or ventilators, has continued throughout the pandemic. From March to September, Regional Emergency and Disaster Health Care Coalition staff processed 321 resource requests from counties and tribes in Eastern Washington.

The coalition can connect hospitals in order for them to share resources, a case study published in September shows.

“For example, one hospital indicated that they were in a critical need of ventilators after the weekly survey had been distributed,” the study says. “Their request was not included in the survey. Fortunately, the week previous, another partner had indicated that they had a backup ventilator available and the connection was made within an hour.”

Understanding capacity

Spokane is the epicenter for health care in northeastern Washington, and the four Spokane hospitals – Deaconess, Sacred Heart, Providence Holy Family and Multicare Valley – will take on the brunt of the coming increases in COVID-19 hospitalizations in the Inland Northwest.

The surrounding rural hospitals with up to 25 beds also could play a role in helping with surge capacity if things get tighter. These include hospitals in Newport, Davenport, Colville and Chewelah.

“We’re beginning a lot of work also in trying to even offload and use those smaller critical access hospitals to say, OK, if a patient doesn’t need one of the big hospitals in Spokane, and they can or are in the recovery phase of their illness, we might transfer them closer to home in a smaller hospital,” Mitchell said.

It could be that rural hospitals and critical access hospitals, needing to transfer a patient with acute needs, could trade their patient for a person who could recover in a setting that doesn’t require intensive care. However, in these instances, the puzzle remains complicated.

The first thing hospitals likely will do as capacity tightens is reschedule or postpone elective surgeries and procedures.

Both MultiCare and Providence hospitals in Spokane still have capacity now to do those procedures, in addition to treating emergent and urgent medical needs.

On Nov. 25, hospital executives from the two systems said they are evaluating elective surgeries on a daily basis.

“We haven’t had to cancel a significant number of surgeries, and we’ll just take it on a day-by-day basis,” said Dr. David O’Brien, chief executive at MultiCare in Spokane.

Other hospitals, including Swedish First Hill, the largest in Washington, reduced in-patient elective surgeries to expand their urgent and emergent beds for COVID-19 patients in mid-November.

Unlike during the spring, state health officials do not seem keen on shutting down elective surgeries.

“We’ve had a lot of discussions with the hospital systems about this,” State Health Officer Kathy Lofy told reporters last week. “We think they know how to run their hospitals best and know when to cut back on procedures.”

Ultimately, canceling elective surgeries can only help with capacity so much. As Richards notes, many elective surgeries do not require patients to take up an inpatient bed. More complicated surgeries that take up staff and bed resources are often times emergent, lifesaving care that hospitals cannot stop.

“The meat, unfortunately, is a cardiac surgery or bypass. (A patient) having a heart attack and needs a bypass – that takes a lot of staff, and they get an inpatient bed, can we put that off? No, that’s lifesaving and has to be done,” Richards said.

Lofy identified intensive care units as the initial pinch point for hospitals treating COVID-19 and other patients statewide in the coming weeks.

Patients needing intensive care for COVID-19 require much more staff and attention than other patients, which can strain resources easily. ICU staff also are trained to handle patients with more serious complications than other health care workers. Hospitals statewide are paying close attention to the trends they are seeing, with a keen awareness that they could need to free up more space soon.

“They know they have to free up more capacity, so anything that will have a long hospital stay after it or potentially have complications that would result in an ICU stay, those are the kinds of things that would be delayed if they can be delayed, to free up some extra capacity because of COVID,” Beth Zborowski, senior vice president of membership engagement at WSHA, said in an interview.

Space, staff, stuff

Richards, with Providence, is no stranger to the world of emergency preparedness. He explains hospital capacity as a combination and availability of the “Three S’s”: space, staff and stuff.

Space is less a challenge in Spokane hospitals, where there are about 1,400 licensed beds, although those numbers do not tell the full story. Some of those are neonatal intensive care unit beds or psychiatric or adolescent beds, for example, making some inaccessible to care for adult COVID-19 patients.

Capacity is difficult to nail down because staff and bed availability change on an almost hourly basis, making it difficult for hospital officials to give an exact number of beds or space day to day.

Richards and his team look at myriad factors that influence capacity regularly to ensure they have the appropriate number of staff scheduled to take care of the estimated number of patients on a given shift.

The Department of Health updated its COVID-19 risk assessment dashboard this week to assess bed occupancy in different regions throughout Washington, and those numbers, including the number of staffed beds, change regularly to reflect actual capacity at hospitals.

The “East” region is made up of nine counties – Ferry, Stevens, Pend Oreille, Spokane, Lincoln, Whitman, Adams, Garfield and Asotin – with 12 smaller hospitals and four larger hospitals.

According to the DOH dashboard, 1,167 staffed acute care beds are available in the East region as of Thursday, and 59% of those beds were occupied. There are 135 COVID-19 patients receiving treatment in hospitals in the East region, who make up about 10% of the total acute care bed count.

ICU beds in the eastern region are more limited. The DOH dashboard shows 131 available adult ICU staffed beds in Eastern Washington, which are about half full with 71 patients. As of Nov. 26, 12 of those 71 patients are being treated in intensive care units for COVID-19.

Ultimately, capacity for the majority of hospitals will not be a space issue but a staffing issue. Rural hospitals, which struggle to recruit staff in normal times, feel the need for additional staff members acutely, but staffing shortages also are present in Spokane.

Typically, hospitals can hire traveling or locum nurses and health care workers to help meet those staffing challenges, but with cases surging not only statewide but nationwide, the pool of available health care workers has shrunk.

“The number of travelers and locums available is not sufficient to meet all the requests happening across the nation,” Susan Stacey, chief operating officer at Sacred Heart, told reporters last week. “We continue to have them and continue to work towards it, but it is not going to be the solve we’re looking for.”

There are a series of actions hospitals can take to improve or make room for more patients. Richards said MultiCare and Providence leaders are meeting regularly and talking with other community care providers, like the Mann-Grandstaff VA Medical Center and St. Luke’s Rehabilitation, to discuss potential expansion when it comes to space for patients.

Currently, there are 105 COVID-19 patients in all four Spokane hospitals, and 85 of them are Spokane County residents.

While this distribution helps keep levels balanced throughout the community, Richards said the hospitals do not have much control over where a patient initially seeks care. It is only when a patient needs acute or specialty care that certain hospitals become the necessary destination for that patient.

Hospitals are the ideal care setting, but expanding to other medical facilities in the region could be possible. Beefing up staffing levels with doctors and nurses from other parts of the health care system, like primary care clinics, could be possible as well.

“What can urgent care do to offload the balance and what can primary care offices do? If our primary care offices close, can they free up staff?” Richards said. “Possibly, but what effect does that have on the patients that still want to go to their doctor and get sick? So we look at what we have to do down the line and create the capacity.”

In the spring, hospital capacity nationwide and statewide was predominantly challenged by personal protective equipment shortages.

As of Nov. 23, Washington had more than 139 million pieces of personal protective equipment, including N95 and surgical masks, gloves and gowns in its inventory that can be distributed as needed.

While Richards said levels are not as dire as they were in the spring, it’s still a vital resource he and his team tracks regularly.

Ultimately, the Washington hospital system is more prepared this fall than in spring to take care of COVID-19 patients. However, there are only so many nurses, doctors and beds to go around.

Taking care of routine emergencies, like heart attacks, strokes and trauma injuries from accidents, must continue, and faced with an increasing number of COVID-19 patients, hospitals could be forced to prioritize.

There are crisis standards of care, which dictate whose life is prioritized and whose life is not, a nightmare position for a provider.

The agreement among hospitals in the state and the coordination work of the WMCC are ideally in place in hopes of preventing any hospital from needing to use crisis standards of care.

“What it allows is an open and transparent and equitable way of making sure as many patients as absolutely possible get the community standard of care that all of us hope for and deserve when we go to the hospital,” Mitchell said of the statewide approach to hospitals sharing the load.

While the goal is not to get there, the hospitals are at the mercy of people’s behavior.

Or as Dr. Stephen Malkoski, who will work in the Sacred Heart ICU the last two weeks of December, wrote in a guest op-ed in The Spokesman-Review, “(I) will witness firsthand the consequences of people’s Thanksgiving decisions.”

Even with preparedness plans and the regional and WMCC efforts, hospital and public health officials continue to plead with the public.

“The best organizational efforts in the world cannot replace good decision-making at your dinner table, and we are absolutely looking at projections of where things could go. Purely based on behaviors and a million little decisions people are making, we could still easily be overwhelmed,” Mitchell said. “… You can only move the deck chairs around so many ways.”