Healthcare Workers Weather Respiratory Onslaught
‘We just keep trying to push back the tide with a broom’
By Gary Evans, Medical Writer
In a seemingly interminable viral winter, healthcare workers are facing a rare convergence of a pandemic virus and unusually high levels of seasonal flu and respiratory syncytial virus (RSV). Some are tired and sick; others sick of being tired.
“I’ve heard more people say that they are burned out or just ‘tired’ than I have any point in my career,” says Ryan Stanton, MD, FACEP, a member of Central Emergency Physicians in Lexington, KY. “It’s almost like every single shift is a marathon, but then you come back and do it again the next day. Now we’re also seeing increasing pressures from outside the emergency department with insurance, denials, down codes, ongoing irrelevant metrics, and other outside strains that make it even more difficult.”
As EDs stretch capacity to the limits to treat respiratory patients, others with various conditions and critical needs are backed up, says Torree McGowan, MD, an emergency physician at St. Charles Redmond (OR) Hospital.
“I’ve stopped counting how many patients per shift I’m diagnosing with a respiratory virus,” she says. “This has created a tremendous strain on the system because all of the regular illnesses like heart attacks and appendicitis are still happening. One of my last shifts, I walked into our 11-bed ER to find seven patients awaiting an inpatient bed. Several had been waiting 30-plus hours. One gentleman had a broken hip and had been waiting for surgery for two days.”
Research supports the consensus that boarding patients for more than four hours in the ED significantly increases the patient’s risk of complications, prolonged hospital stay, and death.
“The patients keep coming in during these times of holding as well, so I had over a dozen patients in the waiting room,” McGowan says. “I’ve had to ask a less sick patient to get out of a bed and go sit in a chair so I can use the bed. We are doing medicine in hallways, waiting rooms, and cars.”
Sick But Present
In such conditions, presenteeism may be an issue as sick emergency staff and other healthcare workers believe they must come to work to help their colleagues.
“We are really lucky in my group, because we have a physician on call just to cover when people are sick,” McGowan notes. “I’ve worked in places in the past that didn’t have a backup call system, and I’ve worked sick and miserable. It’s not right for caregivers to do, but sometimes it’s necessary. I can’t remember the last time that our nursing staff was full strength because of sick calls and staffing shortages.”
Staff shortages exacerbate the problem of managing patient surges, but at least the prolonged home isolation used in the early days of COVID-19 is not in effect, Stanton notes. Then, there are those who have simply left medicine.
“We have lost so many colleagues who have chosen to leave medicine over the past few years that our teams feel really fractured,” McGowan says. “Those of us who remain are trying to hold it together with fewer resources and [fewer] people with more patients. We also have medication shortages. We are out of some antivirals, our town is out of acetaminophen and ibuprofen at all the pharmacies, and we just ran out of a common antibiotic.”
It is hardly a revelation that the U.S. healthcare system was not ready for a pandemic, but the lack of preparedness may have fallen hardest on EDs.
“Our hospitals always run on a razor-thin margin to maximize profits,” McGowan notes. “COVID completely laid bare all of the problems with how we provide and pay for healthcare, and it has crippled systems. The ‘pop-off’ valve for hospitals is always the ER. We can’t turn people away. In a healthy medical system with good access to care and adequate inpatient capacity, ERs run smoothly. Any shock to the system shows up in overwhelmed ERs, and we just keep trying to push back the tide with a broom.”
Peaks Detected, Storm Continues
The ED tests those with respiratory symptoms for influenza and COVID-19 since antivirals are available.
“Our triage protocols test for these in the waiting room to try to improve throughput, since the tests take 60-90 minutes,” McGowan explains. “We are using a lot less Tamiflu because there is a shortage in our area, so we are reserving it for the highest-risk patients. We currently have plenty of Paxlovid for COVID, but our COVID numbers have been comparatively less. I’m probably seeing one to two COVIDs per shift, compared with 15-20 influenzas.”
There are signs the flu and RSV have peaked, but the level of circulating virus is off the charts. As of Dec. 30, 2022, the CDC estimated there have been at least 20 million illnesses, 210,000 hospitalizations, and 13,000 deaths from flu. There have been 61 pediatric flu deaths reported so far this season.1 The CDC estimates 80% of pediatric deaths in any given season are among the unvaccinated.
The challenge is vaccinating people. There was a sense of urgency at a recent CDC press conference. In addition to pandemic “booster fatigue,” there is less uptake of vaccines in general, said CDC Director Rochelle Walensky, MD.
“We have seen under-vaccination in many diseases — not just in influenza and COVID 19, but also a drop in pediatric vaccinations as a whole,” Walensky noted.
Around 47 million people have received the new COVID-19 bivalent booster with an omicron variant component, but that is only 15% of the population older than age 5 years.2
As of Dec. 30, 2022, the daily average for COVID-19 hospitalizations was 42,324, a 4% increase from the previous two weeks. However, overall cases were down by 5%, and the daily mortality average of 457 people was up 11% from the previous two weeks.3
Most of the COVID-19 deaths are in the elderly. There is an 11th-hour push to vaccinate people in high-risk groups with the bivalent boosters that include omicron subvariant components (BA.4, BA.5).
“Early surveillance shows that people who received their updated COVID-19 vaccine this year were nearly 15 times less likely to die from COVID-19 compared to people who are not vaccinated,” Walensky said.
Evidence indicating the bivalent COVID-19 booster is efficacious is accumulating. Healthcare workers who receive it will add a new layer of protective immunity.
In a recent CDC study, adults older than age 18 years who received a bivalent booster were 57% less likely to seek care at an ED or urgent care clinic compared to those who were unvaccinated. The study was conducted from Sept. 8, 2022, through Nov. 30, 2022, during a period of omicron subvariant BA.5 or BQ.1.1 predominance.4
In another recent study, 798 patients older than age 65 years received one dose of a bivalent booster in addition to at least two doses of the original monovalent vaccines. “Those who received the bivalent vaccine were 84% less likely to be hospitalized for COVID-19 than those who were unvaccinated, and 73% less likely to be hospitalized than those who received two or more doses of the monovalent vaccine,” the CDC reported.5
While some healthcare facilities are requiring the shots, they technically are not mandated under the CMS rule for COVID-19 vaccinations. CMS defines “fully vaccinated” for healthcare staff as those who are at least two weeks out from their primary vaccination series for COVID-19. This means staff who have received a single-dose vaccine, or all required doses of a multidose vaccine for COVID-19 are CMS-compliant two weeks later. No boosters are required.
Still, the CDC strongly recommends the bivalent booster, leading to something of a balancing act between the two agencies regarding healthcare immunization.
“If you’ve received only your primary COVID vaccine series, you are considered fully vaccinated, but you are not considered fully protected,” Walensky said. “To be best protected against severe disease this winter, you should get an updated vaccine as soon as you can.”
In the face of a mutating virus, many healthcare workers need no convincing to take the vaccine. McGowan received the booster as soon as it became available. “The COVID patients I cared for early in the delta and omicron surges who died were the ones who were unvaccinated,” she says. “Now, I’m seeing more patients who haven’t gotten their boosters who are getting sick enough to be hospitalized. I see firsthand how vaccination is really preventing severe disease. The first week it was available, I went in for my bivalent booster. My whole family’s been vaccinated and boosted, and we will continue to do so because it works.”
There is no vaccine for RSV, which almost overwhelmed pediatric hospitals when it emerged with a vengeance in November 2022.
“RSV activity remains elevated but is beginning to decrease in all regions,” the CDC recently reported. “[However] ED visits remain at or above the level of a typical winter RSV peak. As typically seen throughout the year, children ages 4 years and younger, especially those aged < 6 months, have the highest RSV-associated hospitalization rates currently. Compared to previous years, there are also more RSV-associated ED visits and hospitalizations among older children.”6
The Biden administration has promised federal assistance to state governors after several pediatric associations petitioned for the declaration of a public health emergency in a Nov. 26, 2022, letter. The pediatric groups emphasized “unprecedented levels of RSV happening with growing flu rates, ongoing high numbers of children in mental health crisis, and serious workforce shortages are combining to stretch pediatric care capacity at the hospital and community level to the breaking point.”7
Adding considerable fuel to the fire, two pediatricians recently authored a scathing editorial stating pediatrics has been largely abandoned, although the field came to the aid of adult facilities when COVID-19 first hit in 2020. Generally, children were unaffected then, and the pandemic derailed the seasonal outbreaks that traditionally hit pediatrics: influenza and RSV.
“Health systems were lulled into maintaining reduced workforces and bed capacity modeled on pediatric volumes during the prior year,” the authors wrote.8 “[Now], an overwhelming burden of viral respiratory diseases is taxing pediatric providers and adding considerable stress to families with infants and young children.”
CMS Lenient on Vaccine, But Use PPE
In a recent revision of its guidance, CMS took a more lenient stance, saying good faith efforts and plans would be considered in hospitals with suboptimal vaccination rates of staff for COVID-19.
“Regardless of a facility’s compliance with the staff vaccination requirements, surveyors should closely investigate infection prevention and control practices to ensure proper practices are in use, such as proper use of personal protective equipment, transmission precautions, which reflect current standards of practice, and/or other relevant infection prevention and control practices that are designed to minimize transmission of COVID-19,” CMS stated.9
Stanton says staff at his ED wear surgical masks and don N95 respirators for potentially infectious procedures. “One of the keys also is our compliance with COVID and flu vaccinations,” he says. “The flu vaccine is a good match to the dominant strain so far, and we are seeing very few cases among the staff.”
McGowan errs on the side of maximum protection, using an N95 “for every patient interaction, regardless of why they are there.”
“We currently have a fair supply of these masks, and I am trying very hard not to bring illness home,” McGowan says. “I also still have my P100 respirator from earlier in COVID that is reusable. I will switch to that if mask supply becomes a problem.”
From an infection control perspective, the three viruses call for similar patient isolation measures, but there are a few key differences, says Patricia Jackson, RN, BSN, CIC, FAPIC, infection control director at White Rock Medical Center in Dallas.
“We treat COVID with enhanced precautions, wearing an N95 [respirator] and eye protection,” Jackson says. “Flu isolation calls for droplet precautions where [healthcare workers] wear a surgical mask. COVID is probably in some category between droplet and airborne.”
Because she has spent most of her career in pediatric hospitals, Jackson knows isolation precautions for RSV patients typically are a combination of droplet and contact, with healthcare personnel using surgical masks, gowns, and gloves.
Healthcare settings also should emphasize respiratory hygiene measures, such as covering coughs to prevent spread among patients in waiting areas.
- Centers for Disease Control and Prevention. Weekly U.S. influenza surveillance report. Updated Dec. 30, 2022.
- Centers for Disease Control and Prevention. COVID data tracker. Updated Jan. 4, 2023.
- The New York Times. Coronavirus tracker. Updated Jan. 5, 2023.
- Tenforde MW, Weber ZA, Natarajan K, et al. Early estimates of bivalent mRNA vaccine effectiveness in preventing COVID-19-associated emergency department or urgent care encounters and hospitalizations among immunocompetent adults — VISION Network, nine states, September-November 2022. MMWR Morb Mortal Wkly Rep 2022;71: 1616-1624.
- Surie D, DeCuir J, Zhu Y, et al. Early estimates of bivalent mRNA vaccine effectiveness in preventing COVID-19-associated hospitalization among immunocompetent adults aged ≥65 years — IVY Network, 18 States, September 8-November 30, 2022. MMWR Morb Mortal Wkly Rep 2022;71:1625-1630.
- Centers for Disease Control and Prevention. Flu, RSV, COVID-19 and other respiratory threats this fall and winter. Nov. 19, 2022.
- American Academy of Pediatrics. Pediatric health care organizations call for national response on RSV and flu surge. Nov. 15, 2022.
- Permar S, Vinci RJ. Pediatricians and parents on the brink: This is their March 2020. Stat. Dec. 6, 2022.
- Centers for Medicare & Medicaid Services. Revised guidance for staff vaccination requirements. Oct. 26, 2022.
In a seemingly interminable viral winter, healthcare workers are facing a rare convergence of a pandemic virus and unusually high levels of seasonal flu and respiratory syncytial virus. Some are tired and sick; others sick of being tired. As EDs stretch capacity to the limits to treat respiratory patients, others with various conditions and critical needs are backed up.
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