Hawaii’s hospitals are in crisis as the state heads into the Labor Day weekend amid a statewide surge in COVID-19 cases.

Intensive care units are overflowing, health care officials are setting up field hospitals and the state is still grappling with a potential shortage of oxygen, which is needed to treat severe cases of COVID-19, as well as patients suffering from conditions such as emphysema and lung cancer.

Currently, the only thing that has staved off a worst-case scenario, in which health care officials have to start rationing care to those most likely to survive, is 438 medical relief workers, including nurses and respiratory therapists, provided by the Federal Emergency Management Agency, according to a blunt assessment that Hilton Raethel, president and CEO of the Healthcare Association of Hawaii, provided Friday to the Senate Special Committee on COVID-19. HAH is the major trade group for hospitals and long-term care facilities.

Another 200 FEMA medical workers are expected to begin working in Hawaii on Monday.

Some hospitals already have set up tents to help triage patients, and another field hospital is being set up at The Queen’s Medical Center-West Oahu, said Raethel. The facilities can be converted to provide low-level, inpatient care, but that too requires staffing, which Raethel said remained “an acute limiting factor.”

He said the most serious breaking point right now is the lack of ICU beds. The state’s adult ICU capacity is already outstripped, with 224 ICU patients for 223 beds. About 100 of those patients have COVID-19.

“We are getting close to not being able to provide ICU care for all patients needing it, which means that some patients will not be able to get the optimal level of care to maintain health and potentially life,” he said.

Hospitals that have exceeded their ICU capacity include Hilo Medical Center, Adventist Health Castle, The Queen’s Medical Center on Punchbowl Street, Wahiawa General Hospital, Pali Momi Medical Center, Straub Medical Center and Kuakini Medical Center.

The state’s oxygen shortage, which wasn’t identified until a week ago, also remains unresolved. While last week Raethel didn’t want to disclose projections on when the state’s demand would outstrip supply, he told senators Friday that AirGas, which runs the state’s largest liquid oxygen plant, notified FEMA on Aug. 27 that Hawaii could run short as soon as Monday. Since then federal, state and hospital officials have been scrambling to find a remedy.

Two ISO containers with medical oxygen are now expected to reach Honolulu by Sunday, and another two ISO containers are scheduled for arrive by Wednesday, the Hawaii Emergency Management Agency said late Friday. The empty containers will be flown back to the mainland for refilling before being shipped back to Hawaii, cutting down on the turnaround time, which by sea is 21 to 30 days.

The state is still searching for more ISO containers, however, hampered by a global shortage brought on by the pandemic. Raethel estimated that two to four ISO containers will need to be brought into the state every week to handle demand.

Both AirGas and the state’s other liquid oxygen plant, Matheson Tri-Gas, are already operating at full capacity and have switched to producing only medical oxygen.

Meanwhile, hospitals have been working to conserve oxygen use, including canceling nonemergency procedures that involve oxygen. Raethel said that’s helped push off the immediate crisis for a couple of weeks.

The state also reached a record high on Friday of 446 patients hospitalized with COVID-19. Models anticipate that the number of hospitalized COVID-19 patients will keep rising through September and potentially surpass 500 patients by Sept. 13.

Lt. Gov. Josh Green has warned in recent days that if the state approaches 500 patients hospitalized with COVID-19, then he would recommend potential shutdowns as the state could have to start rationing care.

Amid the health care crisis, Gov. David Ige has been reluctant to implement shutdowns. While there was talk of a potential three-day shutdown over Labor Day weekend, Ige said Friday that the toll on businesses and the economy would be too high.

Health Director Dr. Libby Char indicated during the Senate briefing that she had pushed for greater restrictions, though didn’t delve into specifics other than to stress that indoor places such as churches where lots of people are congregating and singing would be high-risk. “We would advocate against that,” she said.

While Ige restricted indoor gatherings to 10 people in early August, his emergency order exempted places of worship.

Char said health officials are also working to set up more testing sites and expand the availability of monoclonal antibody treatment, an early-treatment option for COVID-19 that can be provided by shots. The state hopes to staff six new sites throughout the state that can provide the treatment, which ramps up a person’s immune system to help fight the virus.

The majority of residents hospitalized with COVID-19 continue to be unvaccinated, including 85% of patients as of Friday, prompting health officials once again to plead with people to get vaccinated against COVID-19.

Even though unvaccinated residents are taxing the state’s health care resources and jeopardizing care for people suffering from other ailments, such as heart attacks, strokes and cancer, Raethel said a patient’s vaccination status would not determine their level of care.

“We do not take into account ignorance, stupidity, misunderstandings. We treat drunk drivers, we treat people who do stupid things,” he said.

He said that if the hospitals do have to implement “crisis standards of care,” a matrix for rationing care, vaccine status would not be a factor. “We treat everyone the same way,” he said.