Care rationing at Providence impacts staff, forces hard patient care decisions

ANCHORAGE, Alaska (KTUU) - The crisis standard of care implemented at Alaska’s largest hospital last week could continue for another two to three weeks, optimistically, according to the head of the hospital’s medical executive committee, and it’s already impacting care for patients.

Dr. Kristen Solana Walkinshaw told a group of Alaska reporters Monday that one person had died because the dialysis treatment they needed was not available, and that a rural cardiac patient died after Providence hospital couldn’t accept them and perform a cardiac procedure unavailable in the patient’s area.

While caring for very ill patients who don’t always survive is part of the job in a hospital, Solana Walkinshaw said, the fact that doctors and nurses are having to decide who gets care is emotionally straining, especially when adding those decisions on top of a politically divisive medical landscape.

“ER doctors and ICU doctors and nurses and respiratory therapists are around people who have incredibly severe illness, all the time,” Solana Walkinshaw said. “I think we’re experiencing this differently because we’re having to make these decisions about the rationing of care. And I think it’s also that health care has become politicized and our entire country is polarized.”

She said one doctor was recently spit at while leaving the hospital. Some patients will deny that they have COVID-19 as they’re being intubated. Family members on a video call saying final goodbyes will deny that their loved one has the disease, even as they’re being taken off of life support, she said.

“These are the stories that the caregivers are telling me that are weighing so heavily,” Solana Walkinshaw said.

While dealing with politicization outside the hospital, health care professionals are making difficult decisions within, she said. The hospital has a triage team, which is called when there are more needs for a resource than are available. The team includes ethicists and physicians who are on call 24 hours a day, seven days a week.

Since officially declaring the “crisis standards of care” a week ago, the triage team has made decisions on which two out of four patients were able to receive kidney dialysis — one of the patients who did not receive it died. The team has decided whether an organ donor could be left on life support long enough to donate organs, or to open up the intensive care unit bed to an incoming patient who needed it.

Intubated patients need to be monitored in an Intensive Care Unit bed, which are also in short supply. Some are instead being held in the emergency department as an ICU patient, or doctors are deciding whether they can try leaving a patient on a lower level of oxygen assistance.

“These are really rough decisions our caregivers are making,” Solana Walkinshaw said. “If they think that intubation would save their life and they can’t be intubated.”

BiPAP machines, a step below a ventilator, are in short supply in the hospital as well, she said. The state was able to procure 10 more ventilators during the pandemic.

The lack of ICU beds is also leaving patients in need of heart surgery in stand-by mode. Cardiothoracic surgery requires an ICU bed for recovery, Solana Walkinshaw said, and when those beds are full of ill patients, heart surgeries, while they may fall under the “elective” category in the moment, are being postponed.

“We’re talking about ‘elective’ surgery, which means can we put it off for a day or a week, or are they going to bleed out if we don’t do the surgery,” she said. “They’re life-saving and people are being maintained (without surgery) for longer than we’d like.”

The lack of resources is a combination of equipment and staffing, she said. For the dialysis equipment, there is a limited number of machines, and a nurse must monitor the patient 24 hours a day. On one weekend, the COVID-19 unit was short nine staff members. The team was able to pull nurses, patient care technicians and transporters from other parts of the hospital to fill most, but not all of the gaps.

“We’re all pulling together,” Solana Walkinshaw said. “We have a lot of caregivers out themselves with either symptoms or COVID positive right now.”

Some staff in parts of the hospital usually dedicated to life’s happier moments, like births, are dealing with difficult patient experiences with COVID-19, according to Solana Walkinshaw.

“They’re having a really, really rough go — pregnant women with COVID — having terrible outcomes,” Solana Walkinshaw said.

One mother had to go to the Intensive Care Unit with COVID-19 shortly after delivery, and another died. Those outcomes were due to the severity of the women’s infection, and not resources at the hospital, she said.

After the hospital made a call to Alaskans to utilize other forms of medical care, like urgent care, or family physicians, instead of the emergency room, Solana Walkinshaw says the influx of patients to the emergency department for those less urgent issues has slowed.

One thing that is not affecting the staffing shortage right now is the hospital’s vaccination policy, administrators say. The hospital will require all patient caregivers to be fully vaccinated by Oct. 18 or have an approved medical or religious exemptions.

A spokesperson for the hospital said Monday that they are not aware of any resignations due to the policy.

“We are focused on providing education and access to vaccine for those caregivers yet to be fully vaccinated,” he wrote in a statement.

Over the weekend, a town hall-style listening session was hosted by two members of the Anchorage Assembly. Mayor Dave Bronson, who has said he personally won’t get vaccinated after having already had COVID-19, and does not encourage Anchorage residents to get vaccinated either, attended the session. Many speakers at the event were health care workers who said they would likely lose their jobs over the vaccine mandate. Some questioned why they should get them, given that vaccine breakthrough cases occur.

In June, when the delta variant of the SARS-CoV-2 virus became dominant in Alaska, 22% of Alaska’s reported COVID-19 cases were found to be in people considered fully vaccinated. That number jumped to 29 percent of cases in Alaska in July. Despite that leap in the proportion of vaccine breakthrough cases, among those hospitalized, only 19.4% in July were fully vaccinated. When adjusted for age, region, and calendar day, state health officials say unvaccinated individuals with COVID-19 are 8.8 times more likely to end up hospitalized than fully vaccinated people.

Alaskans over 60 years old see the highest rates of vaccine breakthrough cases overall, according to the state’s latest update, with 46% of COVID-19 cases in those 60-69 and 57% of cases in those 70 and older being among fully vaccinated people.

Solana Walkinshaw said employees at Providence, the state’s largest employer, represent a large swath of the community.

“So I am not surprised that some employees are having a very difficult time deciding about their own vaccination status,” she said.

The Alaska Nurse Practitioner Association responded to Saturday’s meeting more boldly.

“We believe that it is the duty and the responsibility of all Alaskan healthcare providers to encourage their clients to receive the vaccine, and to disseminate evidence-based information to each and every individual. It is contrary to the Code of Ethics for Nurses to deliberately contribute to the spread of misinformation,” the statement read, in part. “Both vaccines and the use of masks have already proven, empirically, to reduce morbidity, mortality, and the incredible burden on an already taxed hospital system; a system where emergencies are being turned away for lack of resources, and our colleagues are having to make the unthinkable decision to whom the few remaining resources will go. We are on a trajectory rapidly heading towards healthcare collapse if we do not do something now.”

The association decried the politicization of the pandemic. Solana Walkinshaw said she simply doesn’t understand it.

“This is a very divisive issue and it’s really tragic that it’s so divisive, and I don’t really fully understand why it’s so divisive,” she said.

Even in critical care standards, Walkinshaw says unvaccinated patients will not be denied care.

“We’re going to care equally for Mayor Bronson, if he comes in, and needs to be intubated,” she said. “We’re going to care for him, and pour our hearts into caring for him, and sacrifice our own well-being to care for him, as we continue to do.”