‘We’re in a tough spot:’ Idaho discusses crisis standards as children’s hospital fills

Influenza arrived in the household of Dr. Kenny Bramwell this month. The flu symptoms were still lingering in his family on Wednesday morning, when he talked with the Idaho Capital Sun in a video call about what this year’s unusual virus season has done to Idaho’s health care system.

Flu season seems to have returned to old patterns in Idaho – hitting around the holidays. But what’s different this year is that RSV and the COVID-19 virus are surging, too, causing a “triple-demic” that strains the nation’s children’s hospitals and has a ripple effect on overall health care capacity.

St. Luke’s Health System operates the only children’s hospital in the state and has most of Idaho’s pediatric hospital beds. Bramwell oversees those services.

For the first time in Bramwell’s memory, St. Luke’s leaders are now meeting twice a day to talk about capacity for Idaho’s youngest patients – and, just like when Idaho’s adults poured into hospitals with COVID-19 last year, St. Luke’s now must “board” patients in emergency rooms instead of checking them into the hospital right away. Only, this time, those patients are kids.

“Let’s say you’re a 6-year-old, and you have pneumonia, and we are totally full in the hospital but we think we’re going to be able to get you into a bed in the next six to seven hours,” Bramwell said. “We will keep you in the ER, waiting for your bed to open up upstairs. We almost always have a handful of patients who are boarding right now.”

In the interview Wednesday, Bramwell told the Sun that St. Luke’s administrators “start to worry” when 80% of beds are filled in a department like pediatrics.

Federal data this week showed all hospital beds for children and teens were taken, and then some. Nearly every day this month, hospitals were pushed beyond 100% capacity for young patients, including in pediatric intensive care units (PICU).

If the surges worsen, Idaho could implement “crisis standards of care” – a way of prioritizing only the most serious cases to keep from overstretching the system.

Bramwell said he and other St. Luke’s pediatric leaders met with Idaho’s crisis standards committee on Monday.

But for now, he said, St. Luke’s is getting creative to help Idaho weather the triple-demic storm without reaching that crisis point.

“We are in a tough spot already. We are, in fact, nearing full capacity every day,” he said. “We have done a number of things this year that we have done before; we’ve also done a number of things that we’ve never done before.”

Idaho Capital Sun: Last year, when hospitals were overwhelmed by COVID-19, we went into “crisis standards of care” – a protocol for hospitals to use when, for example, they have two patients who can’t breathe but only one ventilator. The state’s crisis standards committee created a kind of rating system to decide who gets care, based on which patient is more likely to survive. Is it possible Idaho would have to resort to that, this winter, for children?

Dr. Kenny Bramwell: There was a lot of work that was done to establish rules and criteria for crisis standards of care in adults.

We are now starting to have those discussions about crisis standards of care for pediatric patients. Right now, there aren’t criteria for being in crisis standards of care (for babies, children and teens). We’re hoping to get those developed over the next few weeks … but we can’t declare that we’re in crisis standards of care because we don’t have the rules.

We’re in something (right now) that we haven’t defined. That’s the strange spot, where we find ourselves right now.

Sun: What are some of the actions St. Luke’s Children’s has already taken to make room for more patients?

Bramwell: We start to admit some of the youngest patients – say, zero to three months of age – to the NICU where normally we wouldn’t. Even before COVID and even before this year’s RSV, the NICU was always the place where we are exceptionally careful about exposures (to infectious disease). So, in normal operations, we don’t admit a 1-month-old with RSV to the NICU because, heaven forbid, RSV travels through NICU patients to those little, tiny tots. But we do that when we are at an extreme capacity.

The other thing we do is we admit older kids to adult floors. So, let’s say you’re a 16-year-old and you have pneumonia. When we’re chock full, we can admit a handful of those larger or older teens to other parts of the hospital.

Sometimes, even in normal circumstances, we have to transfer kids to other states. Usually that has to do with either the complexity of the illness that the patient has – their expected needs over the next few days – or sometimes it has to do with the capacity that we don’t have here locally.

We have to send kids out of state. That’s happening to a degree. I don’t know numbers as far as how often that’s happening, but it feels like there’s been an uptick there.

We have done all sorts of things to expand capacity with these other pop-off valves. We’ve got the NICU, we’ve got the adult floors.

We have opened up a suction clinic, and we have looked at opening up other parts of the hospital or changing their primary purpose to being pediatric beds – we have prepared to do that, but we have not yet done that last option. What we’re looking at doing (there) is, like, in antepartum – you know, where the pregnant women go when they are not yet laboring but they are needing to be admitted for another reason – we’re looking at pivoting some of those beds to being pediatric beds.

Sun: What is the suction clinic?

Bramwell: That is a project that we’ve talked about for some time, but that we put into place in the last month, and it’s fantastic.

RSV for me, as a 56-year-old guy, if I get RSV – and I probably get it routinely – it causes a cough. It causes some nasal dripping. Maybe I sneeze a little bit. Maybe I’m sore, or tired for a day or two. It’s a cold; it’s not a big deal.

If, however, it infects a 1-month-old child, it has a dramatically different set of symptoms.

The biggest thing that happens in the youngest kids is their nasal passages can almost swell shut. They can’t breathe through their nose, which means they can’t eat. They cannot suckle off of a breast or a bottle, because there’s no way to breathe through a totally obstructed nose. If that goes on for a period of time, they can get very dehydrated, quickly, over the course of 12 to 24 hours.

The other thing that happens farther along in RSV is it starts to become difficult for the infant to breathe because of the inflammation that happens inside the lungs. They work really, really hard to breathe, and you can kind of see the muscles between the ribs. Or sometimes you will see their lungs move abnormally. Or they will just start head-bobbing as a way to help move air.

For many of those kids, if those things become severe, they need to be admitted to the hospital, but for many of them it’s mild. If we can suction out that debris in their nose, they can then breathe again. And they can eat again. And it’s sort of dramatic, how much of this helps.

So, what we have set up this year is a suction clinic. It’s one room, down the hallway from the ER. It’s a place where the respiratory therapist will suction out the kid’s nose and make sure that they’re otherwise (not severely ill).

They use a suction device on the wall that plugs in. It’s got a little more horsepower, shall we say (than a suction bulb sold over the counter). There’s a little sort of flexible straw that gets inserted deep into the nasopharynx, and we pull out goo. Then, we send people home with a device that they can use at home, which is one step above bulb suctioning but not quite as invasive as what we’re doing.

In the first three weeks of this clinic, we’ve had probably somewhere in the neighborhood of about 100 visits. And of those 100 visits, 10 of those kids were seen by the respiratory therapist and the respiratory therapist said, “You are sicker than you were last time, and I’m gonna walk you over to the ER, and we’re gonna get you checked.”

Of those 10 kids who have been taken to the ER directly from the suction clinic, five of them have been admitted to the hospital.

If you step back and you think about it, a year ago, all 100 of those kids would have been ER patients. This year, only 10 of them were. So, in essence, we’ve saved 90 ER visits – at a time when the ERs are, in essence, overrun.

And it’s worked so well after three weeks, that we are now opening additional suction clinics in Magic Valley – that opened on Monday. We’re opening up (suction clinics in) Nampa and Meridian and Fruitland in the next few days. And I think we’re going to also do Elmore next week.

Sun: Whose idea was that?

Bramwell: Well, it’s been done elsewhere. To be completely honest with you, this happened to my own grandson about three years ago. And my daughter called me and said, “My son has RSV, and they’re sending me to a section clinic.” And I said, “Well, what is that? I don’t even know what that means.”

She explained to me what her pediatrician had told her, which was, in essence, that they opened this up as a way to keep people out of the ER and out of the hospital.

In my grandson’s case, it worked unbelievably well. He never went back to his pediatrician’s office. They went to the suction clinic two or three times a day for a couple of days, and then once a day for a couple of days, and that was it. It was fantastic. And the crazy thing was how well it worked, and that no one had thought of this before.

So we, in essence, copied a program that was elsewhere. We designed it in our own way here locally, but we were in fact inspired by literature that had been published about this, as well as an anecdote from my own grandson.

Sun: Why do you think we’re dealing with this triple-demic in children right now?

Bramwell: A normal respiratory season goes either December through April, or January through April, every year. It’s very predictable. These illnesses come, we expect these illnesses to come. And they behave somewhat predictably – not because that’s when the virus chooses, but because that’s when people are around each other and not being careful … when it’s cold and people are inside.

We had 18 months without a single case of RSV in our hospital. Eighteen months. So we came out of COVID, and people threw their masks in the trash or lit them on fire or whatever they chose to do, and everybody who hadn’t gotten RSV got it. So, we had a bit of a prolonged season that whole summer and fall of last year.

This year, I think we’re just getting back more towards the normal of January-through-April. It just so happens that, this year, it’s November through wherever we land.

I think it’ll get back into a normal cadence. That’s just my thought, is that we’re getting back more towards the normal predictable seasonal stuff.

The kids who have the toughest go with this are the kids who get it for the first time – and they are commonly kids who are 8 months old and younger. By and large, those are the kids who need to be admitted to the hospital. And those are the kids who haven’t seen RSV (until now) because many of them weren’t born last season.

Sun: Are you starting to see hospitalizations from influenza in children?

Bramwell: Yes, we are starting to see them. I think I admitted somebody on Sunday who had influenza. I am seeing probably 10 times the amount of RSV compared to influenza so far.

Sun: Do you expect that to change?

Bramwell: I don’t know. I don’t know. Influenza is certainly on the rise regionally. And the statewide data suggests that influenza is probably going to take over the No. 1 spot as RSV starts to fade. So, I would expect that we would admit more kids with influenza, but oftentimes kids don’t get as ill from influenza as adults do. You know, it’s usually the extremes of age that have the trouble.

Sun: What can Idaho’s adults do to protect health care capacity for children?

Bramwell: Get vaccinated for (COVID-19, influenza and other viruses) that have vaccines. When you’re sick, stay home as much as you can. If you’re sick and you need to go out, wear a mask. Try to limit the spread of these viruses. The ERs and the hospitals are suffering right now. It takes an inordinate amount of time to see all the people that are coming, and we need the public to try and help us take care of them.