In the days leading up to Thanksgiving, trouble was brewing in Salt Lake County. The county’s seven-day average of new Covid-19 cases had roughly doubled over the past month, to more than 1,200 per day. Nearly one in four Covid tests performed in the county in November had turned up positive. Local hospitals were already pushed to their limits, and the state government was openly discussing the potential need to ration care. Now, holiday gatherings appear poised to make a bad situation even worse.
By the day before Thanksgiving, intensive care unit beds at Utah’s referral hospitals—those that treat the more severe Covid cases—were nearly full. Many nurses in Salt Lake-area ICUs were caring for double or triple their typical patient load, and health care workers said that the rationing of care—the necessity to make difficult decisions moment to moment about which patients would receive their attention—was already happening unofficially as they were torn between far too many critically ill patients.
Some health care workers were reaching the breaking point as they tried to help dying patients part from loved ones over FaceTime, says Tracey Nixon, chief nursing officer at Salt Lake City-based University of Utah Health. “These are people who fundamentally went into health care to make a difference,” she says. “This doesn’t feel like making a difference. It’s sticking fingers in a dam, and you know it’s not working very well.”
The crisis in Salt Lake is a sharp reversal for a county that just a few months ago seemed to be a standout in pandemic management. Salt Lake County, home to roughly one-third of Utah’s 3.2 million residents, early in the pandemic created quarantine and isolation facilities that helped minimize infections among its most vulnerable residents and implemented a mask mandate in June that quickly turned back a rising summer tide of Covid cases, even as cases elsewhere in the state continued to climb.
That wasn’t enough, local officials and public health experts say, in part because Salt Lake stood largely alone in the fight. Many surrounding counties didn’t require residents to wear masks, and Utah Gov. Gary Herbert didn’t implement a statewide mask mandate until November. To kick off Thanksgiving week, the state relaxed some social distancing restrictions, even as Salt Lake doctors begged the public to stay home for Thanksgiving. Although Utah Thanksgiving road trips dropped about 14% this year compared with 2019, according to travel research firm Arrivalist’s analysis of GPS signals for trips of at least 50 miles, that was the smallest drop of any state in the continental U.S.
The contrasting messages from Salt Lake County and the state of Utah are a microcosm of what’s going on across the country, public health experts say. Nearly all states remain under Covid-related emergency orders that give state and local governments broad pandemic-fighting authority including social-distancing measures, business closures, and other restrictions. But “just because governments at the local or state level have a variety of response mechanisms doesn’t mean they’re using them simultaneously or consistently,” says James Hodge, law professor at Arizona State University and director of the Network for Public Health Law’s western region. “What we’re seeing across the country is widely divergent perspectives on what we’re prepared to do.”
The Covid patients flooding Utah hospitals also underscore the virus’s potential to devastate even communities with the best natural defenses. Utah is the youngest—and one of the healthiest—states in the country. Just 30% of Utah’s residents 18 and older are considered at higher risk of serious illness if infected with Covid—the lowest level in the nation, according to the Kaiser Family Foundation.
Individual behavior—mask-wearing and social distancing—is critical in determining Covid’s trajectory in any city or state, epidemiologists say. Yet mandates alone won’t make the difference. “The messaging is as important as the mandate,” says Michael Levy, associate professor of epidemiology at the University of Pennsylvania’s Perelman School of Medicine.
For Salt Lake County, sending that message was always going to be a challenge. Up until mid-August, counties in Utah had to get the state’s permission before implementing mask mandates, with the governor’s office saying that local health departments should bring their data and analysis to the Utah Department of Health to support their requests. Salt Lake made its case in late June, noting that the county’s hospitalizations had jumped 40% in less than a month. With the state’s approval, the mask mandate took effect a few days later.
The effect was clear and convincing, local officials say. Within two weeks, cases in Salt Lake County began to decline, while cases elsewhere in the state continued to climb. Hospitalizations and deaths also dropped, says David Schuld, a Salt Lake County policy advisor for Covid response.
Armed with this evidence, Salt Lake officials pushed Gov. Herbert and the state health department for a statewide mask mandate. Gary Edwards, executive director of the Salt Lake County Health Department, says the response from the state health department was “mostly supportive, but as an entity in the governor’s cabinet, they obviously had to follow [the governor’s] direction.” Although Gov. Herbert regularly reminded residents to wear masks, he resisted any statewide regulation. “The governor preferred to use a local-first approach in extending mask requirements in Utah,” says Gov. Herbert spokeswoman Brooke Scheffler.
Salt Lake County Mayor Jenny Wilson made a direct appeal to the governor for a statewide mask mandate to curb new infections. “Salt Lake County has exhausted most tools that will make a meaningful difference,” she wrote in a Sept. 21 letter to the governor. “Despite our best efforts in Salt Lake County, cases from outside of the County will flow to our medical system and likely create a strain that the system cannot handle,” she wrote.
Rather than requiring masks statewide, Utah’s governor in October announced a new system to categorize counties as high-, moderate- or low-transmission areas based on case rates, positivity rates and ICU utilization, with masks required in high-transmission areas. The previous system, which placed areas in color-coded risk categories with corresponding restrictions, lacked clear metrics and confused residents, local officials say. For example, when Salt Lake County was upgraded from orange to yellow in May, “people let their guard down” and cases rose, Edwards says.
In early November, as the strain on hospitals grew, Gov. Herbert took the action Salt Lake officials had sought for months, implementing a statewide mask mandate as well as a two-week restriction on social gatherings among members of separate households. By that time, Salt Lake County was seeing a seven-day average of more than 1,000 daily new infections, roughly double the level a month earlier. Utah’s referral hospital ICUs reached 85% utilization—the point where they’re functionally full, due to staffing constraints.
That is when Utah’s biggest advantage in fighting Covid, its relatively young and healthy population, had a harmful side effect: The state has only 15.4 hospital beds per 10,000 residents, the second-lowest in the country, according to the Kaiser Family Foundation. Some states with less healthy populations, such as West Virginia and Alabama, have more than double that number of beds per capita.
With referral hospitals’ ICUs effectively full, “the biggest concern bar none is the ability of the rural hospitals to transfer patients,” says Greg Rosenvall, rural hospital improvement director at the Utah Hospital Association. Many rural hospitals, he says, don’t have the ICUs, personnel and equipment to handle high-acuity cases. The major urban hospitals added ICU beds, and in November, the hospital association set up a transfer command center to monitor ICU capacity and divert patients from overwhelmed hospitals to other health systems.
Adding beds or transferring patients, however, doesn’t create more ICU nurses—an asset that is in critically short supply, Salt Lake health care workers say. The Mountain America Expo Center, a convention center in Salt Lake County, is ready to be transformed into a makeshift hospital on three days’ notice—but “staffing is a significant issue with standing up this facility,” says Tom Hudachko, spokesman for the Utah Department of Health. “We will rely, partly, on volunteers from the state’s medical reserve corps.”
At University of Utah Health, all ICU nurses are working at least one extra shift every two weeks, says Nixon, its chief nursing officer. But that measure only staffs about half of the 23 additional Covid ICU beds that the hospital added to its normal count of more than 100. That means nurses may also have to care for three ICU patients at a time rather than one or two, or team up with a non-ICU nurse to care for four or five patients at once, Nixon says. “These are incredibly stressful shifts with incredibly sick patients,” she says. Nurses “can’t continue to operate like that indefinitely.”
Salt Lake-area doctors and nurses say they have had to make uncomfortable compromises. Doctors and trainees from other specialties, like gastroenterology and neurology, for example, are being pulled into the ICU, says Dr. Sean Callahan, a University of Utah pulmonologist and critical care doctor. ICU nurses working in teams may have to focus on their sickest patients, he says, leaving a non-ICU nurse to look after other patients. “This is really stretching, and the margins of error get a lot worse,” he says.
By the Friday before Thanksgiving, Utah’s referral hospital ICUs hit 96% utilization. That day, Dr. Jared Johnstun, an ICU medical director in Salt Lake City, told his team that he would be available to help 24/7. Doctors in his ICU were seeing more than 20 patients on some days, he said, whereas a comfortable patient load would be closer to 12. “We’re being stretched thinner,” he said. If the ratios continue to rise, he says, “mortality will start to go up.”
Even as hospitals were overwhelmed, the state lifted its restriction on gatherings among households at the start of Thanksgiving week and changed an earlier 10-person limit on social gatherings in high-transmission counties to a recommendation. “We think it’s a bit of a stretch” to tell people what they can do within their own homes, Gov. Herbert said at a Nov. 23 briefing, while also warning Utahns of the dangers of gathering with people outside their households. “We’re asking people to voluntarily comply with good protocol.”
Once again, Salt Lake County officials felt the state was falling out of step. “I think it’s too soon,” County Mayor Wilson said in an interview with Barron’s the day after the governor’s briefing. “We needed additional discipline.”
On the day before Thanksgiving, health care workers from Salt Lake’s Intermountain Healthcare held a press conference asking the public to avoid dangerous holiday gatherings. Get-togethers could “further drive hospitalizations to a point that we cannot tolerate,” Dr. Edward Stenehjem, infectious disease physician at Intermountain Healthcare, said at the briefing. The consequences of ignoring social distancing precautions will be “absolutely dire,” he said. “We plead with you to please stay within your families and stay within your homes.”
That day, Michelle Marshall had a day off to recover from her 12-hour shifts as an ICU nurse in a Salt Lake area hospital. The day before, she had spent an hour preparing a single patient for proning, or turning on the stomach to improve breathing, a procedure that is complex for patients attached to lifesaving equipment and can require five or six staff members working together—all while wearing a powered air-purifying respirator and other cumbersome gear. “It’s heavy, and my back and feet are suffering,” she said. But her biggest frustration, she says, is that people aren’t doing all they can to slow the virus by wearing masks, social distancing, and washing hands. “People just want us to fix what they’re not willing to fix themselves,” she says. “I’m just getting bitter about it. I don’t know what it’s going to take” to change behavior.
By Dec. 1, five days after Thanksgiving, Utah reported just over 4,000 new Covid cases, its third-highest daily total of the pandemic. The number of Covid patients hospitalized in the state crossed 600 for the first time a few days later, on Dec. 4, and on Dec. 5, Utah referral hospitals’ ICU beds were 96% full.
Write to Eleanor Laise at [email protected]