BOISE — In another ominous sign about the spread of the delta variant, Idaho public health leaders on Thursday expanded health care rationing statewide and individual hospital systems in Alaska and Montana have enacted similar crisis standards amid a spike in the number of unvaccinated COVID-19 patients requiring hospitalization.

The decisions marked an escalation of the pandemic in several Western states struggling to convince skeptical people to get vaccinated.

The Idaho Department of Health and Welfare made the announcement after St. Luke’s Health System, Idaho’s largest hospital network, asked state health leaders to allow “crisis standards of care” because the increase in COVID-19 patients has exhausted the state’s medical resources.

Idaho is one of the least vaccinated U.S. states, with only about 40% of its residents fully vaccinated against COVID-19.

Crisis care standards mean that scarce resources such as ICU beds will be allotted to the patients most likely to survive. Other patients will be treated with less effective methods or, in dire cases, given pain relief and other palliative care.

A hospital in Helena, Montana, was also forced to implement crisis standards of care amid a surge in COVID-19 patients. Critical care resources are at maximum capacity at St. Peter’s Health, officials said Thursday.

And earlier this week Providence Alaska Medical Center, Alaska’s largest hospital, also started prioritizing resources.

Thursday’s move in Idaho came a week after state officials started allowing health care rationing at hospitals in northern parts of the state.

“The situation is dire — we don’t have enough resources to adequately treat the patients in our hospitals, whether you are there for COVID-19 or a heart attack or because of a car accident,” Idaho Department of Welfare Director Dave Jeppesen said in statement.

He urged people to get vaccinated and wear masks indoors and in crowded outdoor settings.

“Our hospitals and health care systems need our help,” Jeppesen said.

In Idaho’s St. Luke’s Health System, patients are being ventilated by hand — with a nurse or doctor squeezing a bag — for up to hours at a time while hospital officials work to find a bed with a mechanical ventilator, said chief medical officer Dr. Jim Souza.

Others are being treated with high-flow oxygen in rooms without monitoring systems, which means a doctor or nurse might not hear an alarm if the patient has a medical emergency, he said. Some patients are being treated for sepsis — a life-threatening infection — in emergency department waiting rooms.

The normal standards of care act as a net that allows physicians to “carry out the high wire acts that we do every day, like open heart surgery and bone marrow transplants and neuro-interventional stroke care,” Souza said. “The net is gone, and people will fall from the high wire.”

One in every 201 Idaho residents tested positive for COVID-19 over the past week, according to a tally by Johns Hopkins University. The mostly rural state ranks 12th in the U.S. for newly confirmed cases per capita.