If you’re going to an emergency room in North Idaho, expect a longer wait, treatment in the hallway or to be sent elsewhere – if there’s even a bed available.

COVID patients are filling North Idaho hospitals, impacting access and treatment for everyone needing medical care, and now, setting up potentially dire scenarios for hospital staff who must ration care with an eye toward saving the most lives.

These are the conditions under crisis standards of care, which the state enacted Tuesday in 10 North Idaho hospitals as COVID patients continue to fill hospitals in the region and staffing and space are stretched to their limit.

“We’re beyond the point where we can continue to offer care at a normal level or in a normal setting,” said Jeremy Evans, COVID-19 incident commander at Kootenai Health, the largest hospital in North Idaho. “We hoped this day would not come.”

Kootenai Health was treating 113 COVID-19 patients on Labor Day, a new record-high daily census at the hospital.

Of those patients, 39 were in the critical care unit.

As of Tuesday afternoon, there were 110 patients with COVID-19 being treated at Kootenai Health, and those numbers are projected to increase in the coming week.

The hospital asked the Idaho Department of Health and Welfare to declare “crisis standards of care” in North Idaho as a result of the surge, and the decision gives hospitals the authority to lower their usual standards and ration care.

At Kootenai Health, some lower-level patients are now being admitted to a 22-bed COVID treatment unit, a large conference room in the hospital’s resource center. Providers have brought in oxygen, beds and dividers for what’s essentially a large COVID ward operating in a space not intended for medical use.

Staffing ratios have changed as well, meaning each nurse is being stretched further. Team nursing, with one nurse in charge of several caregivers, is being utilized due to a shortage of staff.

The Department of Defense and a federal contractor are expected to send staff that will be used throughout Kootenai Health this week, but hospital leaders say even that support might not be enough to avoid crisis standards of care.

Kootenai Health officials project that there could be as many as 140 COVID-19 patients hospitalized on any given day in the coming weeks.

In the meantime, critical access hospitals in North Idaho are fending for themselves.

Kootenai Health cannot take transfer patients at this time, and Evans said they have had to decline 300 patients in the past three months, while in a normal three-month period that number would be closer to 15.

There are 10 hospitals, including many smaller critical access hospitals, included in the crisis standards of care area impacted by the Idaho Department of Health and Welfare’s announcement.

The affected hospitals in the Panhandle Health District are Kootenai Health, Benewah Community Hospital in St. Maries, Bonner General Hospital in Sandpoint, Shoshone Medical Center in Kellogg and Boundary Community Hospital in Bonners Ferry. In the North Central Health District, crisis standards of care are now in effect at Clearwater Hospitals and Clinics based in Orofino, Gritman Medical Center in Moscow, St. Joseph Regional Medical Center in Lewiston, St. Mary’s Hospitals and Clinics in Cottonwood and surrounding areas, and Syringa Hospital and Clinics based in Grangeville.

Crisis standards of care are, in essence, the last resort of every health care system struggling to meet the demand for services.

Currently, the emergency department remains open at Kootenai Health, but all elective and urgent surgeries are being canceled. Only emergency operations are being performed, as staff, including physicians, have been re-allocated throughout the hospital to treat patients.

“The concern is always that we’ll get to the point where we don’t have resources to care for the next patient that comes through the door, and if we’re unable to transfer that patient, which we haven’t been able to do in the past few weeks, we may have to make some decisions in those cases,” Dr. Robert Scoggins, medical director of the Kootenai Health ICU, told reporters Tuesday.

Crisis standards of care could also mean that care will be allocated to save the most lives possible. This might mean deciding which patient gets the last ventilator or critical care unit bed. Those decisions are made on a case-by-case basis with the consultation of an ethics committee and several hospital staff, hospital administrators said Tuesday.

“When we get short on certain supplies like oxygen or ventilators, that may require us to make tough decisions about who gets what when,” Evans said.

All of this strain on the North Idaho hospital system could have been avoided, hospital leaders said, if more people had been vaccinated.

North Idaho has the lowest vaccination rates in the state, according to data from the Idaho Department of Health and Welfare.

Just under 45% of the eligible population in the five-county Idaho Panhandle region has received at least one dose. The percentage of fully vaccinated people living in North Idaho is even lower.

The Panhandle Health District has seen a slight increase in the vaccination rate, said Don Duffy, interim director of the district, likely due to the delta surge, as well as the Food and Drug Administration fully approving the Pfizer vaccine.

“We’re seeing an increase in vaccinations; we wish it was much higher,” Duffy said. “We continue to fall behind the rest of the state in terms of vaccination rates.”

The vast majority of patients in Idaho hospitals from May to September – 91.6% – were unvaccinated. Scoggins said patients are younger and much sicker than in previous COVID waves, and he said he’s seen young people, some with no underlying health conditions, die from the virus.

There is no mask mandate anywhere in North Idaho, nor in any school district in the region.

State health officials asked residents to wear masks anyway to help curb the surge.

Duffy said he expects an increase in COVID-19 cases now that schools opened Tuesday. Duffy, who has a standing meeting with superintendents of school districts throughout the region, said he does not know of a school district with a mask or testing mandate in place.

With no mask mandate and low vaccination rates, Kootenai Health is bracing for things to get even worse.

And while North Idaho’s hospitals are operating under crisis standards of care, the rest of the state could follow suit soon if the surge continues.

“For the rest of the state, we remain dangerously close to crisis standards of care,” Dave Jeppesen, director of the Idaho Department of Health and Welfare, told reporters Tuesday.

The state, as well as hospital officials at Kootenai Health, will evaluate whether crisis standards of care need to be in place on a daily if not hourly basis going forward.

“I expect we’ll have our number of patients continue to grow in the next week or so, as there’s not a lot of mitigation strategies up here in North Idaho,” Scoggins said.

Here’s a look at local numbersThe Spokane Regional Health District reported 300 new COVID-19 cases on Tuesday and 20 additional deaths. Over the long holiday weekend, the district reported 962 additional cases.

There have been 768 deaths due to COVID-19 in Spokane County residents.

There are 212 people hospitalized with COVID-19 in Spokane.

The Panhandle Health District reported 321 new COVID-19 cases over the long holiday weekend and on Tuesday and seven additional deaths.

There have been 381 deaths due to COVID-19 in Panhandle residents.

There are 119 Panhandle residents hospitalized with the virus.