Last fall, Idaho was one of a handful of states that went into emergency “crisis standards of care” to deal with the COVID-19 pandemic. The federal government-backed designation allowed hard-hit states to limit the number of patients in its overwhelmed hospitals and, in some extreme cases, ration care based on how sick people were.

Idaho operated under crisis standards for weeks, with the northern Panhandle region staying there for more than 100 days. Several states have formally instituted crisis standards during the pandemic, including Alaska, Colorado and Hawaii, while many others have informally limited the number of patients they take or have taken other measures to deal with surges.

A new analysis of state data from the Documenting COVID-19 project and the Idaho Capital Sun shows the impact of those crisis standards: As they filled up, Idaho hospitals were forced to transfer patients at least 6,300 times, making unusual moves as they scrambled to find open beds.

During this period, Washington Gov. Jay Inslee criticized Idaho’s leadership for “clogging up” his state’s hospitals. Data from Idaho’s and Washington’s health departments back up this criticism, showing high numbers of Idaho patients treated in Washington throughout 2021.

Major findings from the data include:

• More than 1 in 3 transfers went to hospitals in neighboring states, with the highest numbers going to Eastern Washington;

• About 16% of cases transferred during the crisis period were COVID-19 patients, compared with fewer than 10% in earlier months of 2021;

• Idaho hospitals sent out nearly 1,500 patients each month between May and October 2021, compared with 1,200 patients a month in the prior six-month period;

• A significant share of cases transferred to other states went to children’s hospitals, in part due to an unexpected wave of RSV, a respiratory virus that typically impacts children in the winter months;

• In an unprecedented move, Idaho relied on Veterans Administration hospitals as civilian hospitals filled up;

• When compared with data from the Washington state health department, the Idaho data likely undercount transfer numbers, as Idaho’s figures rely on data from local emergency response agencies which may be inconsistent or incomplete.

This map shows patient transfers from Idaho hospitals to hospitals elsewhere in Idaho or out of state, between April and November 2021. (To minimize the layer panel, click on the arrow on the upper-right of the panel.)

The COVID-19 pandemic has shown the cracks in hospitals’ abilities to respond to a prolonged crisis, as well as the challenges that come with a decentralized system for transferring patients from one place to another – especially across state lines.

Idaho was particularly vulnerable to these challenges, as it has a low vaccination rate and among the most limited capacity for intensive care in the U.S. Health care workers described the hunt for an open bed as a Tetris-like maze of hospital transfers.

In fact, Idaho hospitals were already transferring high numbers of patients in the months leading up to September’s crisis standards declaration, possibly due to the pandemic’s impact on staffing and bed space.

“Even before the pandemic, we’d take patients from Montana, from Oregon, from Alaska,” said Dr. Dave Chen, chief medical officer at MultiCare Deaconess Hospital in Spokane – one Washington hospital that took in a high number of Idaho patients during the delta surge.

But during the pandemic, this process has “become escalated due to stresses in staffing and bed needs,” Chen said.

The way Idaho’s hospitals scrambled to find open beds suggests a lack of preparedness, not only for disease outbreaks but also for natural disasters that may overwhelm hospitals.

In the future, better coordination between hospitals and health care networks could improve crisis response in Idaho and other parts of the country, experts say. Some other states’ approaches to transferring patients during the COVID-19 pandemic may offer possible solutions.

Idaho patient transfers strained hospitals in neighboring states

In a widely-reported MSNBC appearance last September, Inslee, the Washington governor, described how residents of his state couldn’t get needed heart and cancer surgeries because “we are having to take too many people of unvaccinated nature and unmasked, many of whom come from Idaho.”

He called the Idaho transfers “maddening.”

Idaho Gov. Brad Little responded to the criticism, saying in a tweet that Inslee “blames Idaho, yet Spokane County and the surrounding area on his side of the border continue to be hot spots for virus activity with the lowest vaccination rates in Washington, despite Governor Inslee issuing vaccine and mask mandates.”

Indeed, data from both states’ health departments show how hospitals in Idaho often send their patients to large facilities in Washington – taking up resources that would normally be utilized by those states’ own rural hospitals.

Between August and November, 2,109 patients from Idaho were admitted to Washington hospitals, according to data from the Washington State Department of Health.

Even before the pandemic, Idaho often sent patients across the border, mainly to Washington and Utah, and took in patients from other states when necessary. Out-of-state care is the only option for some specialized services Idaho lacks, such as organ transplants, or has limited capacity, such as burn care.

The Washington data suggests that Idaho may be undercounting its transfers. Idaho’s data is collected by emergency medical service providers, which do not have comprehensive health records systems, while Washington’s data is collected directly from hospital emergency departments, in a process that’s required by state law.

Additionally, to preserve patient privacy, the Idaho system only publicly releases data with “suppressed” values any time the number of patient transfers from one facility to another in a given month is fewer than 10. This suppression system makes it difficult to accurately estimate total transfers.

For example, in October 2021, data from Idaho’s system suggest that anywhere between 76 and 308 patient transfers went from Idaho to Washington. Data from Washington put the actual number at 608.

The discrepancy between these two sources is “very understandable considering how ‘muddy’ this [data collection] has been,” said Wayne Denny of Idaho’s Bureau of Emergency Medical Services.

An additional cause for the discrepancy may be that the Washington data count all Idaho residents who are admitted to Washington hospitals, including those who may go directly to an emergency room across state lines. Still, by looking at both Idaho and Washington’s data, it’s clear how hospital transfers between states are used to help reduce the strain on Idaho’s facilities.

In the same August to November period, at least 200 patients were transferred to Utah, per Idaho state data; Smaller numbers were transferred to Oregon and Montana, and a few patients were sent as far as California and Nevada.

MultiCare Deaconess Hospital, in Spokane — just across the Idaho border from Coeur d’Alene’s Kootenai Health — took on more Idaho patients than almost any other Washington facility: 44 patients between August and November 2021, according to hospital statistics. The hospital also consulted with Idaho health care workers on 17 patients who weren’t able to be transferred, said Chen, chief medical officer at MultiCare Deaconess.

With more than 400 beds and specialized services such as neonatal intensive care, MultiCare Deaconess serves as a major hub for medical care in Eastern Washington. The facility often accepts patients from nearby critical access hospitals, similar in size and capacity to those in northern Idaho.

MultiCare Deaconess was still able to treat anyone who came directly to its emergency department during Idaho’s surge, Chen said. But taking on Idaho patients “impacted the outlying facilities” outside of Spokane.

“I hate to use the word, but all the facilities outside of [this city], in the Northwest, are ‘competing’ for the same beds and resources,” he said.

Gov. Inslee’s office said it was unsurprised by the Idaho-to-Washington transfer data because the pandemic “knows no boundaries,” wrote Mike Faulk, deputy communications director for the governor, in a statement. “The decisions of one person – or one state – can have profound ripple effects on entire communities.”

Washington’s medical transport service providers have also faced similar capacity issues to those in Idaho. After a drop in trips during 2020 lockdowns, some Washington transport providers went out of business at the same time the state faced severe labor shortages and increased need for medical transport in 2021, the Washington State Health Care Authority said in a statement.

During the fall 2021 delta surge, children in Idaho and surrounding states also faced a wave of RSV — a respiratory virus that causes more than 200,000 hospitalizations in the U.S. in an average year, according to the U.S. Centers for Disease Control and Prevention. It further strained a very limited number of pediatric facilities and added to patient transfer numbers.

Idaho only has one children’s hospital: St. Luke’s Children’s Hospital in Boise, with 13 beds for pediatric intensive care patients. Fewer than 10 children were transferred to this hospital between August and November 2021, according to state data, while about 220 patients from Idaho went to Primary Children’s Hospital in Salt Lake City, according to the hospital.

This number of patients from Idaho is not unique to a COVID-19 surge, said Dr. Jeffrey Schunk, associate chief medical officer at Primary Children’s Hospital – which itself is the only children’s hospital in Utah. The hospital considers Idaho part of its regular coverage area, along with sections of Montana, Wyoming and Nevada.

As record numbers of adults in Idaho got sick with COVID-19, children’s hospitals throughout the U.S. faced an “unprecedented, never-seen-before RSV surge,” Schunk said. Facilities typically plan for an influx of this virus in the winter, but it arrived in the summer in 2021 – placing an additional burden on the ambulance crews, as well as on families who faced limited visitation hours after traveling to visit their children in the hospital.

While children are significantly less likely to face severe COVID-19 cases than adults, the highly consolidated nature of the Northwest region’s pediatric health care system may lead to a heavy burden in future health crises that impact younger patients.

“In some of the other states, they have a choice of children’s hospitals, sometimes in a very small geographical area,” Schunk said. But if St. Luke’s Children’s Hospital in Boise needed to transfer a pediatric patient, its best option might be Primary Children’s Hospital, more than 300 miles away.

Crisis standards were not designed for months-long surges

Kootenai Health, the largest major hospital in North Idaho, is the best hope for seriously ill or injured patients who live in the surrounding rural counties. But in the three months leading up to the crisis declaration, the hospital got so full, it had to refuse 392 patient transfer requests.

Then, when Idaho went into crisis standards, Kootenai Health was one of the hospitals that sent the most patients to other facilities: more than 140 patients between August and November, according to state data.

Smaller, rural hospitals were in an even worse position. As delta patients filled beds, facilities were less equipped to treat patients who came in with non-COVID conditions, such as car accidents or heart attacks.

“Generally speaking, those [small, rural] providers are not used to holding on to critically ill or injured patients for any period of time,” said John Hick, professor of emergency medicine at the University of Minnesota and author of a report on crisis standards during COVID-19. “They just don’t have the nursing or physician resources”

This lack of resources led to Idaho’s Panhandle region spending over 100 days in crisis standards of care. Hospitals use these standards when they “don’t have enough resources to meet the demand,” Hick said. In other words, these standards are used when a hospital can’t treat everybody who needs treatment to the point that patients are at risk as they await care.

These standards were first developed for natural disasters, like wildfires or hurricanes, that impacted a specific county or region for a short period of time. Early standards also included disease outbreaks, such as a particularly bad flu season, but did not envision hospitals remaining in crisis mode for weeks or months at a time.

“Pandemics are a very different kind of disaster,” Hick said. “There’s no cavalry coming.”

Crisis standards don’t just refer to a shortage of beds. Facilities may also go into crisis for other reasons. For example, a facility may not have enough ventilators available for patients who need respiratory support, enough dialysis machines for patients who have kidney failure, enough blood for transfusions, or enough nurses to check on patients and carry out treatments.

Most hospitals across the country have gone into some kind of crisis standards during the pandemic, according to polling by Hick and other researchers. Even if state officials have not made official declarations – as states have different policies for going into these standards, if they exist at all – all facilities have dealt with shortages at one point, particularly of staff.

In Idaho, overwhelmed hospitals left nurses and doctors traumatized. Some told the Sun they worked on critically-ill patients — called “triage” — in hospital waiting rooms. A doctor in a rural critical access hospital described to the Sun how he waited hours to transfer a patient from his local ER to an ICU bed in Boise only to have the patient die shortly after making the trip.

“There’s a chance that your bed is going to be made available by somebody else dying,” Dr. Patrick “Paddy” Kinney told his critically ill COVID-19 patient in St. Luke’s McCall’s small emergency room. The patient was transferred to Boise but declined rapidly and died soon after, “making room for someone else,” Kinney said.

Dr. Robert Scoggins, Kootenai Health’s critical care medical director, said the pandemic’s toll on his staff would have “long-lasting effects.”

“We are already seeing some people leave the profession,” Scoggins said, citing workers’ frustration at witnessing “unnecessary death.”

Doubling up in ambulances, scrambling to find beds

The delta surge in Idaho persisted for months: Hospitals approached crisis levels in August, and some didn’t emerge from that red zone until December.

Idaho averages about 3,000 staffed beds statewide; Most are not equipped to take COVID-19 patients. St. Luke’s Magic Valley hospital, for example, has about 20 ICU beds. But it serves a multi-county region with several small hospitals. Those hospitals rely on being able to transfer patients to St. Luke’s Magic Valley for critical care.

The Magic Valley hospital was one of the facilities sending out the highest number of patients during the crisis period, according to data from the Idaho health department: at least 240 patients between August and November 2021.

Patients from this hospital were transferred as far as the University of Utah Hospital in Salt Lake City (a roughly one-hour flight) and University of Washington facilities in Seattle (about two hours by air).

During winter, flying is sometimes the only option to move a patient. During the worst peaks of the pandemic, health care workers told the Sun they feared what could happen if weather conditions grounded the air ambulances, too.

St. Luke’s Wood River – a small, critical access hospital in the ski-resort town of Ketchum, which often transfers patients to or from the Magic Valley hospital – has no ICU at all and only 25 total inpatient beds.

St. Luke’s Magic Valley and Wood River are more than two hours from Boise, the state’s largest metro area and hub for hospital care.

Medical transport became “a huge part” of the health system’s operations, said Dr. Charles Burtis, an emergency physician at St. Luke’s Magic Valley in Twin Falls, the regional medical center for South Central Idaho, who also co-leads the medical transport network for the region.

“We may have the patient in Magic Valley for a day or two, and then we’re doubling them up,” Burtis said in a September interview. “We’re actually putting two non-COVID patients together in an ambulance to send them up there (to the small Ketchum hospital) to get a bed.”

That helped keep ICU beds open in the larger Magic Valley hospital; the Ketchum hospital had no ICU beds, but it had space for the stable patients. Those transfers may have helped patients, but they also took out of commission the ambulance crews — paramedics and emergency medical technicians — whose primary job is responding to 911 calls in the Magic Valley.

Going to Boise is “a four-hour commitment,” Burtis said. As a result, when one ambulance crew makes the journey, other crews “have to take more emergency calls.” The crisis has pushed Magic Valley to increase its staffing.

At the most frenzied time in the surge, Burtis said his staff became “sort of the lifeblood of the hospital system.”

The hospital system’s management scrambled to find new ways to solve a cascade of problems caused by COVID-19.

But without a structured network, hospitals had to hunt for beds on the fly.

A critical care nurse from East Idaho, who worked during the surge in a hospital and for an air ambulance company, told the Sun that air ambulances had to fly past hospitals in southern Idaho and northern Utah to find open beds.

Those hospitals normally admitted patients from East Idaho, but they were too full. So the patients would have to go farther into Utah, or up to Montana.

“One of my (coworkers) has been told on at least two occasions when we’ve dropped a patient off that ‘you’ve taken the last bed in our entire facility,’” he said.

The Boise VA Medical Center and the Mann-Grandstaff VA Medical Center in Spokane offered to start taking civilian patients, to help ease the strain on hospitals. The VA usually only takes patients who served in the military.

But as hospitals struggled, the VA authorized its medical centers to do “what they called ‘fourth mission,’ to be a resource for our nation to help in an emergency,” said Josh Callihan, the Boise VA Medical Center’s spokesperson.

The transfer data from Idaho Department of Health and Welfare show the Boise VA hospital took patients from small community hospitals in remote communities across the state: St. Maries, Malad, Cascade, Rupert, Salmon and Weiser.

“We were taking patients from way outside of the geographic area we normally serve … as far away as Montana, Spokane,” Callihan said.

Washington set up a statewide transfer center, while Idaho scrambled with AlertSense

When a critical access hospital in Washington needs to transfer a patient beyond its local region, health care workers at the facility can call a statewide center that will quickly redirect them to a place with available resources to care for that patient.

This center, called the Washington Medical Coordination Center, was set up early in the pandemic. When physicians at the University of Washington’s Harborview Medical Center watched the nursing home outbreak in Kirkland overwhelm local hospitals, they saw the need for better coordination, said Dr. Steve Mitchell, the medical director of Harborview’s emergency department.

“We just knew that we were going to have to think completely differently for this upcoming pandemic,” Mitchell said. Since the statewide center was started, it has facilitated more than 3,500 patient transfers, with the vast majority occurring between summer 2021 and early 2022. Washington has avoided going into crisis standards of care throughout the last two years.

The center is funded by the Washington state health department, with about $1.3 million allocated for operations between 2021 and 2023. As a result, it can only address transfer requests from Washington hospitals, Mitchell said: “We refer patients from out of state back to hospitals within their state.”

A similar statewide transfer center in Colorado, run by the Colorado Hospital Association, was also restricted to patients from state hospitals. The center became active twice during the pandemic, in the delta and omicron waves, then was “powered down” this month.

Harborview Medical Center itself accepted more than 30 patients transferred from Idaho during the delta surge, according to state data. But those transfer requests had to go through the medical center directly rather than Washington’s statewide coordination system.

Meanwhile, Idaho hospitals had no centralized way for finding beds for patients they couldn’t treat. Early in the pandemic, the best option was transfer centers housed in individual health systems, and staffed by people such as registered nurses, who monitor traffic and patient loads to figure out where and when patients can or can’t be admitted.

But more than half of Idaho’s hospitals are small and remote. Many aren’t attached to larger health systems with transfer centers.

Idaho did attempt to make transferring patients easier, through an app, but it had a limited impact.

The week Idaho moved into statewide crisis standards, the state launched a new program for hospitals to use to make it easier to transfer patients.

In theory, the AlertSense Patient Transfer Coordination Tool would allow hospital transfer centers and discharge planners to communicate right away with each other.

“The program is designed to eliminate the need to call each hospital to determine if a transfer can be accommodated,” the Idaho Hospital Association said in a newsletter. “Through the system, a description of the patient and their needs or condition is sent out.”

That dispatch could go out via text, email or through the AlertSense app itself. The sender could direct the message to specific hospitals, or all of them. The hospitals would then respond to indicate if they had a bed open.

Idaho hospitals made 68 patient transfer requests through the app from mid-September through January, including 35 in the month of October, according to data provided by the Idaho Department of Health and Welfare.

But that’s a small fraction of the total patients transferred out of Idaho hospitals in October: More than 1,600, according to state data.

To help, some VA hospitals called smaller hospitals directly to alert them to open beds.

“We would be on these statewide COVID conference calls, (and administrators of small hospitals) were pulling their hair out, trying to figure out where they could transfer patients,” said Callihan of the Boise Veterans Affairs hospital.

Better coordination is needed for future crises

COVID-19 has no concept of state lines. Wildfires, snowstorms, hurricanes and other natural disasters similarly tear through communities with no regard for which hospitals can talk to each other and work together to help the public during a crisis.

As a result, hospitals in different regions, states, and health care networks – as well as the state and federal systems that oversee them – must improve their coordination before future crises hit, experts say.

For instance, instead of a statewide transfer center that’s siloed in Washington, a regional center with visibility into several Northwest states would help, said Hick, the University of Minnesota expert. Some hospital systems with facilities in multiple states already coordinate this way, but a federal agency such as the Department of Health and Human Services could organize such centers on a larger level.

At the same time, better coordination of data across facilities and states could help hospitals with patients in need of a transfer quickly see where beds are available. Currently, different hospital networks have different electronic systems for medical records, and the systems are not always able to communicate with each other.

This lack of communication is “an enormous data challenge” that becomes more complicated outside the realm of COVID-19 data, said Matthew Wynia, director of the University of Colorado’s Center for Bioethics and Humanities and a leading expert on crisis standards.

Hospitals are “businesses, some for-profit, and they are not that interested in sharing resources with a competitor,” Wynia said. The pandemic inspired more collaboration among facilities, which he hopes can continue when COVID-19 is no longer a pressing crisis.

New Jersey is one state with a system for data sharing and communication: Even the public can see when a hospital is so full, ambulances have to take patients elsewhere. The state shows that information on the New Jersey Emergency Department Status dashboard, operated by the company Juvare.

In addition, hospitals could better integrate their planning with ambulance teams and other medical transport companies who travel long hours to bring patients across rural terrain. Angie Coulter, executive director of the Community Transportation Association of the Northwest, recommended standardizing credentials for transport service providers in different states and fostering more open communication between hospitals, providers and state policymakers.

When hospitals are crowded, care suffers. One report from the National Institutes of Health, published in September 2021, found that among 150,000 COVID-19 patients between March and August 2020, nearly 1 in 4 deaths may have been directly tied to hospital strain during a surge.

The Sept. 11 attacks revealed the need for better communication between law enforcement and other first-responder agencies, Callihan at the Boise VA said. Those attacks prompted efforts to make it easier for those agencies to work together in an emergency, and “we all saw this happen, big time,” he said.

“This pandemic has kind of taught us a similar thing.”

Correction: A reference to burn care in Idaho has been edited. There is a burn unit in East Idaho.