Late in the afternoon of July 15, leaders at St. Charles Health System took the unprecedented step of declaring “crisis standards of care” at all four of their locations — the first health system in Oregon to do so during the COVID-19 pandemic, according to the Oregon Health Authority.
“Effective 5 p.m. today, July 15, 2022, St. Charles Health System is operating under crises [sic] standards of care,” Chief Operating Officer Iman Simmons wrote in an internal email OPB obtained through a public record request.
The decision came in the wake of a severe staffing shortage that has left St. Charles and other hospitals across the state struggling to handle their many patients. It also happened just two hours after a temporary state rule on crisis standards had expired. The rule had required hospitals to announce crisis standards publicly and to notify state officials.
But leaders at St. Charles never announced their decision to the public. Emails obtained in a public records request show state officials weren’t fully notified until four days later.
Crisis standards are meant to be implemented when emergency situations, such as natural disasters, overwhelm a hospital’s ability to treat patients with the highest standard of care. According to the American Association of Medical Colleges, the goal of crisis standards is to “gracefully degrade services to the minimum degree needed to meet the demands.”
Hospitals in other states declared crisis standards as COVID-19 patients flooded intensive care units and stretched resources to their absolute limits, albeit rarely.
St. Charles officials told OPB and state regulators that they have never, during the current crisis, rationed care or turned away critically-ill patients. Health system officials also said they have not canceled elective surgeries, a typical — and costly — step many have used to manage patient flow and staff shortages during the pandemic.
Less clear, from interviews and records, is whether the hospital’s staffing crisis is impacting patient care in other ways.
Records show that St. Charles officials, who have struggled for months to fill critical nursing and nurse assistant shifts, attempted to use a crisis standard declaration for a different reason: To deviate from their hospital’s nurse staffing plan.
“We felt that we needed to pull the cord and let people know that we’re in a state of exhaustion,” said Chief Nursing Executive Joan Ching.
The crisis standards declaration didn’t last long. St. Charles leaders reversed course six days later after Oregon Health Authority officials informed them the hospital didn’t meet the requirements for such a declaration and that they could be violating state law.
Oregon Nurses Association spokesperson Scott Palmer called St. Charles’ communications with the state “inept and chaotic,” and said future decisions on changes to standards of care need to be made public.
“To discover that… the management at St. Charles was unaware of the specifics of Oregon law about when a hospital can, and cannot, move to crisis standards of care is deeply concerning,” Palmer wrote in an email Tuesday.
A system in trouble
Public records provided by the Oregon Health Authority show that Simmons, the system’s head of operations, initially declared an internal emergency in an email that went out shortly after 7 p.m. on Friday, July 15.
This included all four St. Charles campuses: Bend, Madras, Redmond and Prineville.
The move came as the health system was juggling multiple crises. St. Charles has lost $40 million on their operations so far this year, a spokesperson said, which resulted in laying off more than 100 employees in May and two executives last week. The system was critically short staffed, not due to any particular surge in COVID-19 patient admissions, but due to the stress that’s built over two years as the health system has run at or near 100 percent capacity.
Roughly 20% of registered nurse positions across the St. Charles system are vacant. And federal emergency funds that have paid for temporary workers to fill those vacancies during the pandemic have run out, leaving St. Charles to foot the bill for expensive travel nurses.
Ching, the head of nursing at St. Charles, said at the core of the crisis is an acute shortage of certified nursing assistants. Though some special training is required to do the work, nursing assistants are low-paid workers who perform time-consuming patient care — turning patients to prevent bedsores, taking vital signs and helping people use the bathroom — so nurses can focus on medical needs.
With nursing assistants in critically short supply, nurses have been forced to take on more of the work of direct patient care, leaving them overwhelmed and unable to take meal breaks during their 12-hours shifts, Ching said.
“It does allow nurses and not just nurses, the clinicians, to be able to feel all right about prioritizing what tasks are really necessarily central for that patient’s care, versus what we can postpone,” she said.
She did not provide specific examples of what care is being postponed.
The email records OPB has reviewed do not include any discussion of what prompted the health system’s chief operating officer to declare the hospitals had entered a crisis. They also don’t include any description of how staffing levels or patient care would be different. And exactly why the decision came on July 15, the day the public notification rule lapsed, is also unclear.
Nobody in the St. Charles system made an announcement to the public.
The Oregon Health Authority was also left in the dark for three days. The first written communication they received from St. Charles was on July 18 and referenced only an “internal emergency.” That email came from a mid-level compliance manager. It also included a request: that the state postpone any scheduled inspections of St. Charles.
“Due to this emergency we would like to request that any pending surveys be postponed until we are able to stabilize our staffing situation,” wrote Samantha Coleman, quality accreditation and licensing specialist for St. Charles.
At 6 p.m. on July 19, OHA received a more formal notification that St. Charles had implemented crisis standards four days prior, but with no details as to why. Regulators for the state replied immediately, asking for more information.
“It would be helpful if you could let us know more about which units are impacted and how operations have changed in those units,” wrote Anna Davis, an attorney and health facility survey manager for OHA.
Davis also wrote that hospital leaders should notify the public that they had entered crisis standards of care. She acknowledged that the health authority’s temporary rule had expired, but said the agency still expected St. Charles to comply with requirements to post information on their website and in the hospital that they were making triage decisions.
“OHA believes it is extremely important for you to let the public know that you are implementing crisis standards of care,” Davis wrote.
Davis asked St. Charles Accreditation Manager Ginger Walcutt to let her know that same night if they had complied.
“To clarify, St. Charles is not rationing care but rather operating outside of approved nurse staffing plans,” Walcutt responded.
The next day, she emailed Davis saying the health system did plan to publicly post information about the triage system the hospital was using. Walcutt then asked state regulators to clarify if the hospital was still bound by state rules requiring it to notify the public when crisis standards are implemented, given that the state’s interim rule had expired on July 15. (Ching later said it was a “coincidence” that the decision to declare crisis standards coincided with the rule expiring.)
Davis wrote that the hospital system’s staffing shortages, while challenging, did not give it legal grounds to suspend their nurse staffing plans.
Furthermore, because St. Charles leaders said they were not rationing patient care, Davis disputed their claim that it had actually implemented crisis standards of care. Davis warned that if St. Charles suspended its nurse staffing plans absent a state or federal emergency declaration, it could lead to sanctions, including fines for each of the four hospitals involved.
At the same time, Davis directed Walcutt to another option for lowering the staffing standards at St Charles’ four hospitals. The state’s nurse staffing rules allow hospitals to relax their standards if they can get an internal nurse staffing committee to sign off on the changes.
The nurse staffing committee at St. Charles Bend, the flagship hospital, met Wednesday to discuss their crisis staffing plan, emails show.
Staffing has been an issue in hospitals across Oregon. State Epidemiologist Dean Sidelinger told reporters last week that many hospitals are not able to use all of their beds because of trouble recruiting and retaining staff. And he highlighted Central Oregon, and St. Charles Health System, as being particularly hard hit by the problem.
Ching said St. Charles is attempting to manage an incredibly difficult situation and that the public should not be afraid to go to the hospital if needed.
“I’d like the public to really care for themselves and do as much prevention as possible,” Ching said. “That would be really helpful.”