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Transportation a major factor in rural counties’ COVID-19 response

According to the most recent predictive model, Idaho’s bottleneck in handling its surge of COVID-19 cases will not be overall hospital capacity. It will be the ability to transport critically-ill patients from small rural hospitals to intensive care units and acute care facilities with ventilators at the state’s urban medical centers.

Public health scientists estimate that Idaho will reach its peak of COVID-19 deaths around April 13 and peak use of its resources on April 14, according to updated results from a statistical model released on April 5 by the Institute for Health Metrics and Evaluation at the University of Washington. Peak usage of hospital beds is estimated at 151, ICU berths at 31 and ventilators at 26.

The good news is that Idaho is not predicted to exceed the health facility capacity at that time. The numbers of acute care beds and ICU berths in the state varies on which source is consulted. The most conservative count of resources is from IHWE, with 1,917 acute care beds and 151 adult ICU beds.

Other bed capacity figures from the Idaho Department of Health and Welfare, the American Hospital Directory, and the Kaiser Family Foundation are all higher, though none of the sources agree due to differences in how hospital beds are counted.

The bad news is that most of Idaho’s ICUs and ventilators are concentrated in its six most populated counties: Ada, Bannock, Bonneville, Canyon, Kootenai and Twin Falls. Out of Idaho’s 44 counties, 25 have small rural hospitals with just 25 beds or fewer. One quarter of all counties have no hospital at all and 32 counties have no ICU of any size. Rural counties also have lower populations, higher median ages and fewer medical professionals to serve them: 21 counties have fewer than 10 practicing physicians, and three have none at all, according to a 2016 IHWE study.

What will happen if and when these small, rural critical access hospitals need to send their critically-ill COVID-19 patients to a larger hospital or an ICU up to three hours away? Blaine County’s experience may be an example for what other rural counties may face in the next few weeks.

The impact on medical services in Blaine County has been hard, as reported in news media from Blaine County’s own Mountain Express to the venerable Washington Post. In the latter half of March, four of the seven emergency room doctors at St. Luke’s Wood River were quarantined after catching COVID-19 along with 10% of Ketchum’s first responders. By the fourth week of March, when the local hospital could no longer accommodate the volume of COVID-19 patients, many were sent to medical facilities outside of the county.

As a result, local ambulance services were pushed to their limits in Blaine. To handle the emergency, the county and the hardest-hit fire and rescue organizations created a shared incident management structure for their pooled response. The Cities of Sun Valley and Hailey currently respond to normal fire and rescue calls while Ketchum and the Wood River Fire and Rescue handle the transportation of COVID-19 patients.

Each round trip to transport a patient out of the county takes several hours. This is followed by lengthy disinfection after each trip for each ambulance used.

Both Ketchum and Wood River needed to recruit volunteers to sustain the effort and have trained them in just one day to drive and disinfect ambulances in protective gear. Ketchum borrowed an ambulance from a private company in Ada County to keep up with the demand for transporting patients to St. Luke’s Magic Valley Medical Center in Twin Falls. Blaine County Commissioners passed an emergency allocation of funds on March 27 to pay for the additional ambulance expenses incurred from responding to the COVID-19 crisis.

“Our area has been hit harder than most, but the real story is how people here have responded to this emergency,” Wood River Fire and Rescue Chief Ron Bateman told the Mountain Express. “This is something I am proud to be a part of. Our firefighters and EMTs have been courageous in handling this situation. People should feel encouraged by the quality of care people are working to give right now.”

Blaine may be rural in character with a small hospital, but it is affluent and populated in comparison with more than half of Idaho’s other rural counties.

Next door to Blaine is Butte County. Compared to Blaine, Butte has one-tenth the population. The Lost River Medical Center in Arco serves all 2,300 residents of the county plus the additional 800 residents of the valley of the Big Lost River in the southern half of Custer County. The hospital has 14 beds and no ICU. Not all 14 beds are available for acute care. As a rural hospital in an area with no nursing homes, some of Lost River’s beds are “swing beds,” occupied by long-term patients who require skilled nursing services.

According to IDHW, Butte and the southern half of Custer County are served by just two ambulance units. Though Lost Rivers has tested patients for COVID-19, there are currently no confirmed cases in its service area as of the second week in April. If Lost Rivers did experience a surge of COVID-19 cases, just transporting two patients to ICUs elsewhere on the same day would strip the region of all ground-based ambulance service.

“Let’s hope it doesn’t come to that,” Lost Rivers CEO Brad Huerta told the Idaho Business Review. “Right now, we have half our staff, little resources and no money … We don’t have a lot of money coming in because of the stay-home orders. With COVID-19, we can’t risk doing elective surgeries right now, so our surgery center is closed and our clinic has only half of its usual traffic for this time of year.”

If community spread did occur in a place like Arco and its environs, the area’s two volunteer ambulance rigs would be inadequate to cover both rescue calls and COVID-19 transport without back-up. Unlike Blaine County next door, Butte and Custer counties lack the resort communities of Sun Valley and Ketchum to plump up their tax revenues, so the county governments and volunteer ambulance organizations would be hard-pressed to pay for additional ambulance support.

The combined lack of ICUs and emergency medical ground transport in rural areas presents a challenge when multiplied by the number of Idaho’s rural counties. If rural counties confronted a surge of COVID-19 patients beyond the capacity of local hospitals, the critical need is transportation. The state has enough beds and ICUs if the IHWE study is accurate; however, the rural ambulance districts might not have enough ambulance rigs to move patients to waiting acute care and ICU beds in Idaho’s urban communities.

The data released on April 5 was the second update of the IHWE study results. IHWE has been updating its results once a week as more COVID-19 data becomes available to refine its statistical model.

The initial version of the IHWE model was issued on March 25. It originally predicted that Idaho’s peak would be a week and a half later, on April 26 when Idaho’s COVID-19 patients would occupy 1,206 of the state’s hospital beds, 181 ICU beds, and 98 ventilators. It is not yet known if or when the IHWE model will be updated next.

County Physician and Hospital Capacity in Idaho
County Population Practicing physicians per 100,000 Total hospital beds ICU and other “special care” beds
Ada 446052 288 966 215
Canyon 212230 90 193 53
Kootenai 153605 215 364 69
Bonneville 112397 199 420 61
Bannock 85065 189 205 36
Twin Falls 83666 218 224 48
Bingham 45551 111 33 5
Bonner 42711 184 25 0
Nez Perce 40155 253 145 9
Latah 39239 131 25 3
Madison 38705 134 69 18
Jefferson 27969 22 0 0
Elmore 26433 113 25 0
Cassia 23615 129 25 6
Jerome 23431 53 25 0
Payette 23041 103 0 0
Blaine 21994 285 25 2
Minidoka 20615 45 25 0
Gem 17052 93 16 0
Idaho 16337 67 41 0
Gooding 15169 47 18 0
Franklin 13279 39 20 0
Fremont 12965 16 0 0
Shoshone 12526 64 25 0
Boundary 11549 75 20 0
Owyhee 11455 9 0 0
Teton 11080 131 13 0
Valley 10401 211 25 0
Washington 10025 130 25 0
Benewah 9086 138 19 0
Clearwater 8640 177 23 0
Lemhi 7798 119 18 0
Power 7713 14 10 0
Boise 7163 22 0 0
Caribou 6918 44 25 0
Bear Lake 5962 105 21 0
Lincoln 5321 19 0 0
Oneida 4326 24 11 0
Custer 4141 0 0 0
Adams 4019 27 0 0
Lewis 3845 49 0 0
Butte 2602 113 14 0
Clark 1077 0 0 0
Camas 886 0 0 0
Data sources: IHWE, IDHW, American Hosp. Directory, U.S. Census


About Catie Clark