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SHEILA GIFFEN, MD
Executive Medical Director, Saint Alphonsus Health Alliance, Trinity Health

Illustration by Nicole Xu

While much attention has been focused on the physical and emotional strain of providing care during the COVID pandemic, there's been less discussion of the extraordinarily rapid rate of change it has brought. As administrators and clinicians constantly assess how to best care for patients, a closer look at what one health system experienced in Idaho reveals why an evolving response to care has been so vital during the past two years.

First, a look back: On March 13, 2020, Idaho officially announced its first confirmed case of the coronavirus.¹ Only 13 days later, it disclosed the state's first three deaths from COVID-19.² In those early days, some hoped perhaps the state would be unique and be spared from the contagion's reach. Maybe with appropriate measures in place, social distancing and the ruggedness of Idaho and its people, residents could ride out the wave of the pandemic with little effect on their lives. Some citizens even thought that COVID-19 was a myth, constructed by some person or group with an agenda. Unlike this segment, Idaho health care workers faced the approaching pandemic with a sense of rising anticipation and dread, having watched the global effects to date and surmising what was to come.

When the virus was first identified in Idaho, there were 1,666 known total cases in the United States and only 41 deaths.³ As of March 2, 2022, 429,476 cases have been confirmed in Idaho along with 4,772 deaths, and the numbers keep climbing.⁴ COVID-19 is here to stay. Yet, some Idahoans still reject the fact that the virus is real, that CDC recommendations are scientifically based and that social behaviors have a profound effect on the number of people being infected and dying from the disease. Health care in Idaho has been and continues to be directly impacted by this culture.

A STATE DIVIDED
Pre-pandemic, an assumption existed that people with common medical conditions could be fairly certain that standard care and treatment courses would be readily accessible. COVID-19 obliterated that assumption from the first day it infiltrated our nation. It replaced certainty with uncertainty for both patients and providers and shed light on health inequity and the need for health care to shift quickly. In essence, each of these 429,476 (and climbing) infected people experienced changing health care access and delivery, inconsistent understanding of a highly contagious and deadly disease, testing challenges and scarcity or strain on community resources.

Many of these issues mirrored those confronted worldwide. In the United States, differences emerged with communities responding variably on accepting — and following — CDC guidelines and receiving COVID-19 vaccinations. Health care administrators, public health officials and state leaders continually worked to balance decision-making around CDC guidance, economic factors, health care infrastructure, COVID rates, community needs and political and cultural factors.

The first significant statewide action occurred 12 days after identifying the first case of coronavirus in Idaho. On March 25, 2020, the Director of the Idaho Department of Health and Welfare, Dave Jeppesen, issued an order for all Idaho residents to self-isolate. Only essential businesses would remain open, and all nonessential gatherings of any size were prohibited. Those experiencing homelessness were urged to seek consistent shelter. All business and governmental agencies were to "cease nonessential operations at physical locations in the state of Idaho."⁵ Streets throughout the state's large cities became quiet, people isolated and school doors closed. Teachers struggled to educate remotely with little preparation. Toiletry and food supplies flew off grocery shelves, and stores were left barren of essentials.

Even at that time, one did not have to look far to see disbelief. Although consumers were rushing to the store and hoarding basic supplies out of fear of mass casualties and limited resources, gatherings still occurred, and people ventured out. Rules of social engagement were created that did not always follow CDC guidelines. "Bubbles" of socialization were created as if a virus would know not to cross those boundaries. The logic was difficult to follow.

ASSEMBLING TEAMS TO LEAD THE RESPONSE
While the public and businesses adjusted to new statewide mandates, the large health care systems in Idaho quickly organized. Saint Alphonsus Health System stood up its Incident Command structures, modeled after the military, in January of 2020 in preparation for day one of the approaching pandemic. After the state's first confirmed COVID case, meetings switched to virtual, and internal "town halls" were created to increase transparency amongst Saint Alphonsus Health System colleagues in Idaho and Oregon regarding higher-level decisions and pandemic updates.

Hospital and state leaders assembled a statewide network to coordinate care for community members. Saint Alphonsus Health System President and CEO Odette Bolano and Chief Clinical Officer Dr. Steven Nemerson, assuming the role of Incident Command chief, led the health system's involvement. Daily statewide Medical Operations Coordination Cell discussions helped to drive real-time decision-making regarding testing, inpatient bed availability, critical health care operations and later vaccine distributions. Leaders of Saint Alphonsus from all levels of Incident Command integrated into and led efforts on the Idaho coronavirus task force, Gov. Brad Little's Vaccine Advisory Committee, Department of Health and Welfare rapid response team calls, Long-Term Care Strike Team, behavioral health work groups, in addition to collaborative efforts regarding regional CEO and other supplementary communications. Decisions were determined around the most up-to-date information consistent with CDC guidelines.

CHANGES AT SITES OF CARE
While Saint Alphonsus Health System led statewide operational efforts, the health system's medical group and clinically integrated network collaborated to coordinate patient care throughout the system. Saint Alphonsus Medical Group expeditiously deployed three sites — in Boise, Nampa and Baker City, Oregon — the first week of the pandemic to allow for drive-through testing and evaluation by urgent care providers. These sites were implemented in tandem with a non-urgent RN triage hotline led by Mike Amo, clinical team director of the Clinically Integrated Network, to triage and guide community members to one of the three testing sites. All patients with any cough, fever, nasal congestion, shortness of breath, sore throat or loss of taste and smell were directed to one of the testing sites for assessment. "Sick" and "well" were now divided, with "sick" no longer seen at primary care clinics to avoid spread of the contagion. The very ill were sent immediately to the nearest emergency department. Those who were not critical were referred to their primary care providers for a telehealth appointment or advised an at-home course of treatment. For some patients, this course of action was adequate; however, for others, this new delivery of care was the beginning of a disconnect from traditional primary care, furthering COVID's impact on disease advancement.

Idahoans responded, wanting to know about their COVID status whether asymptomatic or symptomatic, low-risk or high-risk, with the RN hotline receiving eight calls on the first day and 497 calls by the first week. By the end of the first month, 3,875 non-urgent calls had been received and, if callers met the requirements for testing, they were then assessed at one of the drive-through sites. Other health systems and large provider groups responded similarly to the health care demand, either routing patients separately within a clinic site or to tents set up to accommodate long lines, sometimes in bitterly cold or blazingly hot weather conditions. Despite the discomfort, health care workers were not deterred, and spurred on through their dedication to care for those who were sick or uncertain.

As testing supplies were limited in early 2020, health systems, including Saint Alphonsus, instituted testing criteria following CDC guidelines due to expected high demand.Tests were like gold — counted, tracked and approved for utilization. Early on, only those who were symptomatic and high-risk could be tested. Initially tests were not processed in-house but instead through outside labs, so the wait times for results varied significantly. For this reason, patients in quarantine who did qualify for testing at one of the drive-through sites often called the hotline for lab results until processes were streamlined and turnaround times improved. Fortunately, hospitals and lab systems refined processes and supply acquisition for quicker results, so only a few ended their quarantine prior to receiving test results during that time.

A SHIFT IN DELIVERY OF HEALTH CARE
During Idaho's stay-home order, patient volumes dropped significantly, with many deferring their annual physicals and care for chronic conditions. Well-child checks decreased precipitously as well, with most parents avoiding the offices altogether and opting to defer immunizations and other preventive screenings.

However, as COVID cases increased nationally, payers one by one announced changes in their plans to allow for patient evaluations by telehealth to encourage continued care for their members. In addition, Gov. Little's issuance of Executive Order No. 2020-13 in June 2020 to suspend particular telehealth practice rules allowed for the use of Zoom, FaceTime and other applications for providers, making it easier to offer telehealth services.⁶ The Saint Alphonsus Medical Group added telehealth visits and outreach phone calls to assist vulnerable patients who were at significant risk but had concerns about coming in for their primary care appointments. Patients with social care needs were connected to the Community Resource Hub for food, housing, transportation assistance and community resources. The Family Medicine Residency of Idaho worked tirelessly with those who were homeless, screening and treating those not requiring hospitalization who were sheltered in missions or local hotels. The emergency departments sent patients home on pulse oximetry to monitor their oxygen saturation, with nurse outreach involved for close follow-up.

RISING PUBLIC TENSIONS
The shift in care delivery was stressful to all but successful in limiting the spread of COVID in early 2020. The governor's stay-home order and media coverage of COVID heavily influenced the actions of Idahoans. Health care leaders became central to messaging for the public about the coronavirus. Images of people in cars at drive-through testing sites or intubated in ICUs were regularly televised. COVID numbers were tracked daily on the morning news. As COVID unearthed health care disparities, communication efforts aimed to identify community member needs and to better share information about health access and services. The St. Alphonsus marketing and communication team was central to Incident Command strategy and operations.

Despite these efforts, sectors of the public were not swayed. Some patients and visitors to health care settings, even those with dying loved ones, refused to wear masks and follow safety measures at hospitals. Door screeners were harassed, threatened and sometimes even physically attacked while keeping hospital patients and care team members safe. In 2020, the turnover rate for door screeners was incredibly high due to this abuse, creating a need to limit entry sites into many health care settings to maintain adequate staffing, among other reasons. These community members, who often refused to acknowledge that the coronavirus was real, were frustrated by the limitations that the pandemic placed on their freedoms as individuals. With restricted visitation, loss of loved ones, loss of the status quo and much more, emotions ran high, clouding perspective on taking steps for the common good.

In response to declining COVID cases, Gov. Little reopened Idaho via a four-staged approach starting on May 1, 2020, via his Idaho Rebounds Plan.⁷ With all businesses open, the state saw the second surge of coronavirus, peaking around July 19.⁸ A similar surge occurred later in the year after Thanksgiving with Idaho close to crisis standards of care. Fortunately, the hospital systems were prepared, having planned nine months earlier the expansion of hospital beds and spaces to care for the anticipated sick. With the fourth surge at its peak that December, the Pfizer vaccine reached Idaho, and frontline Idaho health care workers received the first doses the week of December 15, 2020.⁹ Hope was in sight for exhausted providers and colleagues, who watched patients die from the virus. Meanwhile, community members continued to respond in a variety of ways to the pandemic.

Unfortunately, after the initial uptick in vaccinations, the Idaho vaccination rate remained relatively unchanged, setting the stage for the state's worst surge since the beginning of the pandemic.¹⁰ By May 2021, the vaccination rate still remained fairly unaltered and masking became less and less prominent, as noted by Gov. Little's statement in his address that month regarding Executive Order No. 2021-08, "We could talk 'til we're blue in the face about masks and whether they work — whether mask mandates work — but I think the people of Idaho are tired of hearing about it. With the roll out of the COVID-19 vaccine and steady declines in case counts and hospitalizations, masks are, thankfully, becoming a thing of the past."¹¹

One hundred and twelve days after Gov. Little's address, crisis standards of care were activated in Idaho as the Delta variant swept through the state. Idaho hospital beds were full, and all but emergency and urgent surgeries and procedures were stopped, including nonemergency cancer surgeries, heart catheterizations, biopsies and much more. Ninety percent of those hospitalized were unvaccinated. Health care providers knew the choice not to get vaccinated led to unnecessary hospitalizations and even death. Provider resiliency cracked with physicians speaking out about the emotional trauma of seeing their patients die unneccessarily.¹²

FORGING ON
Despite this trauma, Idaho health care workers continued to live up to the Hippocratic Oath. Saint Alphonsus providers and colleagues held on to the organization's core values, including honoring its commitment to those who are poor, maintaining reverence for all regardless of beliefs around COVID vaccinations and managing resources responsibly. Shifting providers from their primary practices, the system created the first COVID-19 clinic in Idaho to treat high-risk patients with the virus and long-haul symptoms. Care providers reached out to community members at risk for severe COVID complications through education, connection to community resources and access to vaccinations, once available in 2021. Additionally, more space in Saint Alphonsus facilities was created to avoid turning away patients needing urgent inpatient care. A safe remote monitoring program for COVID patients was even developed to open more hospital beds for critical patients. And the work continues.

With Idaho having one of the lowest vaccination rates in the country, the presence of COVID-19 will continue to demand increased vigilance and health care ingenuity as the virus mutates, presenting new challenges and care opportunities. Just like the communities they serve, health care workers stand strong and fierce together. They are ready.

SHEILA GIFFEN practices Family Medicine for Saint Alphonsus Health System and is executive medical director, Saint Alphonsus Health Alliance, in Boise, Idaho.

NOTES

1. "Governor Little Issues Statement Following First Confirmed Case of Coronavirus in Idaho," Office of the Governor, March 13, 2020, https://gov.idaho.gov/
   pressrelease/governor-little-issues-statement-following-first-confirmed-case-of-coronavirus-in-idaho/.
2. Niki Forbing-Orr, "Idaho Reports 3 Deaths Related to COVID-19," Idaho Department of Health & Welfare, March 26, 2020, https://healthandwelfare.idaho.gov/news/idaho-reports-3-deaths-related-covid-19.
3. Joe Sutton, "At Least 1,666 Coronavirus Cases and 41 Deaths Confirmed in US," CNN, March 13, 2020, https://edition.cnn.com/world/live-news/coronavirus-outbreak-03-13-20-intl-hnk/h_77fa590398cb13df77c6cea892954db0.
4. "Vaccine Data at a Glance," Idaho.gov, https://coronavirus.idaho.gov/.
5. 5. "Statewide Stay Home Order–Novel Coronavirus (COVID-19)," Idaho.gov, March 25, 2020, https://coronavirus.idaho.gov/wp-content/uploads/2020/06/statewide-stay-home-order_032520.pdf.
6. "Gov. Little Cuts More Red Tape, Preserves Recent Healthcare Advances Moving Forward," Office of the Governor, June 22, 2020, https://gov.idaho.gov/pressrelease/gov-little-cuts-more-red-tape-preserves-recent-healthcare-advances-moving-forward/.
7. "State of Idaho: Idaho Department of Health and Welfare Stay Healthy Order," Idaho.gov, May 1, 2020, https://coronavirus.idaho.gov/wp-content/uploads/2020/06/stay-healthy-order-stage1.pdf.
8. "Tracking Coronavirus in Idaho: Latest Map and Case Count," The New York Times, February 1, 2022, https://www.nytimes.com/interactive/2021/us/idaho-covid-cases.html.
9. Samantha Wright and Frankie Barnhill, "As Idaho Prepares to Ration Care, Health Care Workers Receive First Doses of Vaccine," Boise State Public Radio, December 16, 2020, https://www.boisestatepublicradio.org/show/idaho-matters/2020-12-16/as-idaho-prepares-to-ration-care-health-care-workers-receive-first-doses-of-vaccine.
10. "Idaho Coronavirus Vaccination Progress," USAFacts, January 30, 2022, https://usafacts.org/visualizations/covid-vaccine-tracker-states/state/idaho.
11. 11. "Gov. Little Defends Local Control, Denounces Lt. Governor's Irresponsible Abuse of Power," Office of the Governor, May 28, 2021, https://gov.idaho.gov/pressrelease/gov-little-defends-local-control-denounces-lt-governors-irresponsible-abuse-of-power/.
12. Hayat Norimine, "Saint Al's Doctor: ‘The Respect Is Leaving, the Trust Is Going'," Idaho Statesman, September 17, 2021, https://www.idahostatesman.com/latest-news/article254308768.html.