Frontline Caregivers Work Through Fear and Anxiety to Respond to COVID-19 Outbreak
While New York City and Washington state are among the hardest hit by the COVID-19 outbreak so far, providers across the country are racing to expand capacity and stretch their supplies of personal protective equipment (PPE) and life-saving ventilators.
• In New York state, cases of COVID-19 surged past 80,000 by early April. Under orders from the governor, hospitals in New York City are scrambling to ramp up capacity.
• Hospitals all over the country are putting surge plans in place and intensifying infection control practices to minimize exposures.
• Healthcare workers struggle with continuing shortages of PPE and airborne isolation rooms where patients with suspected COVID-19 can be stationed away safely from other patients and staff.
Frontline caregivers feel the brunt of COVID-19 as cases continue to mount and epidemiologists forecast that the worst is to yet to come.
Hospitals in New York state are particularly under siege. By early April, cases there surged past 80,000, including close to 2,000 patients who died from the illness. Public officials there continue to warn they are running desperately short of supplies, especially masks, gloves, N95 respirators, and ventilators.
Meanwhile, New York Gov. Andrew Cuomo has ordered hospitals in New York City to ramp up capacity. Further, the word has gone out to recently retired healthcare workers to help with the crisis, and thousands have reportedly signed up for duty.
Activities in Washington state, which identified the first case of COVID-19 in the United States in late January, are much the same, although the case counts are considerably lower. By early April, roughly 5,000 cases had been identified and 250 patients had died. The state is adding new hospital capacity, and it has dramatically increased its testing capabilities, processing roughly 16,000 specimens a day.
While New York and Washington are among the hardest hit states thus far, hospitals across the country are scrambling to respond to cases in their own communities, and there is no denying that frontline providers are at risk. Dozens of clinicians have been sickened by the virus, including one emergency physician who died from the illness in Washington state.
“We are clearly unprepared, and we don’t even need to talk about a pandemic,” observed Ali Khan, MD, MPH, dean of the College of Public Health at the University of Nebraska Medical Center. Khan spoke to reporters as part of an expert panel assembled to discuss the COVID-19 crisis on March 12.
“We know that we see ED and hospital diversions because we can’t handle a really bad flu year in the U.S. ... so our main focus is on helping healthcare prepare for a potential flood of patients,” added Khan, former director of the Office of Public Health Preparedness and Response at the Centers for Disease Control and Prevention (CDC).
Khan noted hospital and ED leaders in every region are looking at two potential scenarios. “How do [we] take care of patients coming in the door, [and] make sure we do it safely [while] not infecting our healthcare workers [or] other patients in our hospitals,” he asked. “Also, how do we make sure that in addition to one or two [patients] coming in — if dozens of patients are coming in — how do we take care of them?”
As far as solutions are concerned, Khan noted some EDs have started screening people outside the ED so they can quickly triage patients to where they need to go — and to places where they are less likely to infect other people. Furthermore, drive-through testing facilities are popping up all over the country so people can be screened and tested for the virus without potentially exposing other people in the healthcare setting.
“These are the conversations going on across America to get ready for a potential flood of patients coming in,” Khan observed.
“All the emerging evidence is that this is a dangerous virus,” observed Scott Gottlieb, MD, former commissioner of the Food and Drug Administration (FDA) who has been following the outbreak closely. He spoke about COVID-19 preparedness during a web-based question-and-answer session sponsored by WIRB-Copernicus Group (WCG) and Accumen on March 13. “It is maybe a once-in-a-generation pathogen that straddles that terrifying area between being contagious enough that it can spread pretty efficiently, but still virulent enough that it can cause a lot of death and disease.”
Recommendations from the CDC have been constantly in flux as investigators continue to learn more about the virus, and as circumstances on the ground evolve, particularly with respect to evidence of community transmission, explained Amber Vasquez, MD, MPH, an epidemic intelligence service officer and a member of the COVID-19 response infection prevention and control team at the CDC. Vasquez briefed providers on how to optimally protect themselves from the virus as part of a clinician outreach call conducted in early March.
One of her key messages was to lean in on established infection control techniques that facilities should be practicing already to prevent the spread of any respiratory or viral illness. “If a patient has signs or symptoms consistent with an undiagnosed viral illness, he should be immediately placed in standard contact and droplet precautions with the use of eye protection, and [the patient] should remain in place while the etiology is unknown,” she said. “As we have been supporting healthcare facilities over the course of this response ... one of the biggest challenges we have faced is that healthcare providers have been exposed to cases at higher risk levels when these precautions were not put into place.”
Of course, it is tough to adhere to such standards when frontline providers lack access to the appropriate personal protective equipment (PPE). Health systems report there have been significant supply chain challenges in obtaining such equipment. “The N95 respirators were running in short supply almost immediately around the country in January, long before there was any clinical need, and still we haven’t quite figured out how that happened,” explained Paul Biddinger, MD, chief of the division of emergency preparedness and director of the Center for Disaster Medicine at Massachusetts General Hospital (MGH). “Manufacturers and distributors are trying to do a good job of allocating to hospitals and not letting anyone buy up the market, as happened in 2009 with the H1N1 [epidemic], but they are still running in short supply.”
Biddinger, who also spoke during WCG/Accumen session on March 13, added that healthcare systems are dealing with shortages of every type of PPE, including gowns, gloves, and eye protection. “There is a lot of healthcare worker fear just like there is a lot of public anxiety. There is, frankly, a lot of fatigue,” he explained. “Even in my own hospital and healthcare system, we have had our incident command system activated since late January.”
Biddinger and his colleagues have been putting in 15- to 16-hour days on a continuing basis. “Everybody is really flat out [tired], and that obviously takes a toll at every single level, including our frontline staff,” he acknowledged.
Compounding the problem for EDs is the fact many departments are crowded already, a reality that only makes infection control more difficult. “As soon as the crowding worsens, then the opportunity for disease transmission increases,” Biddinger said. He noted that ready access to the right PPE is critical for frontline emergency staff.
Finding spaces to isolate patients under suspicion for COVID-19 also is becoming difficult for EDs. Such spaces are particularly important for patients undergoing aerosolizing procedures. For example, patients who are intubated, receiving nebulizers, or undergoing suctioning procedures should be in negative pressure rooms, and they are in incredibly short supply, Biddinger noted.
“Any ED in any hospital is trying to provide rapid turnover to meet the demand of patients who are coming in, and that is starting to be a challenge for some hospitals,” he said.
In recognition of the shortages of both PPE and isolation rooms, the CDC has updated its interim guidance regarding infection prevention and control with respect to patients with suspected or confirmed COVID 19. The agency notes that when N95 respirators are unavailable, facemasks are an acceptable alternative. Further, the CDC states that available N95 respirators should be prioritized for procedures likely to generate respiratory aerosols. Also, the guidance states that patients with suspected COVID-19 can be placed in a single-patient room with the door closed. Airborne infection isolation rooms should be prioritized for patients who are undergoing aerosol-generating procedures.
The CDC also is offering healthcare systems guidance on how to optimize their supply of N95 respirators and other types of PPE, including gowns, masks, and eye protection.
Until the shortages of PPE ease, the American College of Emergency Physicians indicates ED and EMS personnel should consider wearing the same face mask or surgical mask for their entire shifts unless the masks become soiled and require replacement.
As the outbreak has unfolded, the CDC has revised its guidance regarding healthcare workers who have experienced low-risk exposure to COVID-19. “We have removed a requirement for healthcare facilities to actively verify the absence of fever or respiratory symptoms when those healthcare providers report to work,” Vasquez reported. “Healthcare providers can continue to take this cautious approach to risk assessment monitoring and work restriction. However, with community transmission of COVID-19 in the U.S. being reported in multiple areas, contact tracing and risk assessment of all potentially exposed healthcare personnel has become impractical for healthcare facilities.”
Vasquez noted research has shown that all healthcare personnel are at some risk of exposure to the virus, whether that takes place in the community or the workplace.
“Devoting resources to contact tracing and retrospective risk assessment could divert resources from other important [infection control] activities. We are recommending that facilities shift their emphasis to more routine practices,” she said. “These include asking all healthcare personnel to self-report recognized exposures, regularly monitor themselves for fever and symptoms of respiratory infection, and to not report to work when ill.”
Furthermore, facilities should develop plans for how they will screen for symptoms and evaluate healthcare workers who are ill. These plans could include directing healthcare workers to verify an absence of fever and symptoms before these employees report to work each day, Vasquez advised.
To minimize the risk of transmission in the healthcare setting, hospitals and EDs also may need to consider additional steps such as placing physical barriers (e.g., glass or plastic) at reception areas, placing curtains between patients, and checking to make sure ventilation systems are moving air appropriately in a clean-to-contaminated flow direction, explained Capt. Lisa Delaney, MS, CIH, (USPHS), the associate director for emergency preparedness and response at the National Institute for Occupational Safety and Health and a member of the COVID-19 Response Worker Health and Safety Team at the CDC. She also spoke during the outreach call to clinicians.
“Considerations can also include limiting the number of patients going to the hospital or outpatient setting, excluding all healthcare personnel not directly involved with patient care, excluding visitors to patients with known or suspected COVID-19, and implementing source controls,” she advised, referring to key supplies such as masks and N95 respirators.
“Implementing contingency capacity actions may change daily practices but not have significant impact on the care delivered to patients or the safety of healthcare personnel,” Delaney continued. “These actions include decreasing the length of hospital stay for medically stable patients and using N95 respirators after the manufacturer-designated shelf life.”
Delaney also advised healthcare personnel to consider wearing the same N95 respirator without taking it off between encounters. “Crisis capacity strategies, which are not commensurate with current U.S. standards of care, can be considered when N95 supplies are running low,” Delaney said.
This may include prioritizing the use of N95 respirators by healthcare workers with the highest potential risk of exposure, such as those present during aerosol-generating procedures involving symptomatic patients.
The need to preserve PPE is forcing some academic health systems to alter or curb their practices regarding clinical research. “We cannot use a single piece of PPE that could be otherwise used to protect a healthcare worker and a patient in the course of clinical care,” Biddinger offered. “We have made massive changes to how we are using students to how many people enter a room for a clinical encounter.”
At the same time, Biddinger noted the health system has to balance such curbs with the obvious need to acquire knowledge related to the outbreak.
“We don’t want to just put the entire scientific enterprise on hold for a year and stop the advancement of medical knowledge. We are having some very hard discussions about how to continue selected research studies and when we need to stop other research studies,” he said. “It is that balance of safety, resource utilization, and [weighing] the importance of [each] project.”
Providers across the country are racing to expand capacity and stretch their supplies of personal protective equipment and life-saving ventilators.
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