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6 months in: What will the new normal look like for hospitals?
https://www.healthcaredive.com/news/6-months-in-new-normal-hospitals-covid/581524/
Experts say a sustained state of emergency is likely until there is a cure or vaccine for COVID-19.
The first U.S. hospital to knowingly treat a COVID-19 patient was Providence Regional Medical Center in Everett, Washington, on Jan. 20. Since then, every aspect of healthcare has been upended, and it’s becoming increasingly clear all parts of society will have to adapt to a new baseline for the foreseeable future.
For hospitals and doctors’ offices, that means building on a major shift to telemedicine, new workflows to allow for more infection control and revamping the supply chain for pharmaceuticals, personal protective equipment and other supplies. That’s on top of ongoing challenges of burned out workers and staff shortages further exacerbated by the pandemic.
Looking out even further, the industry will have to figure out how to treat potential chronic conditions in COVID-19 survivors and, until an effective vaccine is developed, how to manage new outbreaks of the disease.
Experts say U.S. hospitals are generally in a much better position for dealing with COVID-19 now than they were in March, and providers are learning more every week about the best treatments and care practices.
A June survey of healthcare executives conducted by consultancy firm Advis found that 65% of respondents said the industry is prepared for a fall or winter surge, about the inverse of what an earlier survey with that question showed.
“We’ve evolved. We’re in a much better state now than we were in the beginning of the pandemic,” Michael Calderwood, associate chief quality officer at Dartmouth-Hitchcock Medical Center, told Healthcare Dive. “There’s been a lot of learning.”
But the number of positively identified cases has now topped 4 million, and little political will exists to reinstitute widespread shutdowns even in areas where surges have filled ICUs to capacity. No treatment or vaccine for the disease exists or appears imminent. Testing and contract tracing efforts are too few and remain scattered and uncoordinated.
Whether there is a clear nationwide second wave or smaller surges in various parts of the country at different times, hospitals will need to remain in an effective state of emergency that requires constant vigilance until there is a cure or vaccine.
“Until we’re armed with that, we’re always going to have to be working like this. I don’t see any other way,” Diane Alonso, director of Intermountain Healthcare’s abdominal transplant program, told Healthcare Dive.
The fall will bring additional challenges. Flu season usually begins to ramp up in October, and if the strains in wide circulation this year are severe, that will further stress the health system. While some schools have announced they will be virtual-only for the rest of 2020, others are committed to in-person classes. That could mean increased community spread, especially in college towns. Colder weather that forces people indoors — where the novel coronavirus is far more likely to spread — will also be a complicating factor.
So far, hospitals have been reluctant to once again halt elective procedures, though some have had to, arguing that the care is still necessary and can be done safely when the proper protections are in place. But that doesn’t mean volume will rebound to pre-pandemic levels.
“While we think demand will come back, we’ve seen some flattening on demand in certain aspects that may be the new indicator of the new norm in terms of how people seek care,” Dion Sheidy, a partner and healthcare advisory leader at advisory firm KPMG, told Healthcare Dive.
Accelerating trends to provide care outside hospitals
When the number of COVID-19 cases first surged in the U.S. and stay-at-home orders were implemented nationwide, telehealth became a necessary way for urgent care to continue.
Virtual visits skyrocketed in March and April as CMS and private payers relaxed regulations and expanded coverage. Some of that will be rolled back, but much may persist as patients and providers grow more used to using telehealth and platforms become smoother.
Virtual care can’t replace in-person care, of course, and some patients and doctors will prefer face-to-face visits. The middle- to long-term result is likely to be that telehealth thrives for some specialties like psychiatry, but drops substantially from the highest levels during shutdowns throughout the country.
Other care settings outside of the hospital may see upticks as well, including at-home and retail-based primary and urgent care.
Renee Dua, the CMO of home healthcare and telemedicine startup Heal, said the company has seen virtual visits increase eight fold since the pandemic began in the U.S. and a 33% increase in home visits as people seek to continue care while reducing their risk of exposure to the coronavirus.
“The idea that you do not use an office building to get care — that’s why we started Heal — we bet on the fact that the best doctors come to you,” Dua told Healthcare Dive.
And care does need to continue, particularly vital services like vaccinations and pediatric checkups.
“You cannot ignore preventive screenings and primary care because you can get sick with cancer or with infectious diseases that are treatable and preventable,” Dua said.
Movements toward non-traditional settings existed before anyone had heard of COVID-19, but the realities of the pandemic have shifted resources and spurred investment that will have lasting effects, Ross Nelson, healthcare strategy leader at KPMG, told Healthcare Dive.
“What we’re going to see is there going to be an acceleration of the underlying trends toward home and away from the hospital,” he said.
Some of this was already underway. Multiple large health systems have established programs to provide hospital-level care at home and major employers have inked contracts to have primary care delivered to employees at on-site clinics.
PPE, staff shortages lingering
A key problem for hospitals in the first COVID-19 hotspots, such as Washington state and New York City, was a lack of necessary personal protective equipment, including N95 masks, gowns, face shields and gloves.
Also running low were supplies like ventilators and some drugs necessary for putting people on those machines.
While advances have certainly been made, the country did not have enough time to build up those supply stores before new surges in the South and West. The result has been renewed worries that not enough PPE is available to keep healthcare workers safe.
Chaun Powell, group vice president of strategic supplier engagement at group purchasing organization Premier, said “conservation practices continue to be the key to this” as COVID-19 surges roll through the country. The longer those dire situations continue, the more stress is put on the supply chain before it has a chance to recover.
Premier’s most recent hospital survey found that more than half of respondents said N95s were heavily backordered. Almost half reported the same for isolation gowns and shoe covers.
Calderwood said there has been improvement, however. “We have a much longer days-on-hand PPE supply at this point and the other thing is, we’ve begun to manufacture some of our own PPE,” he said. “That’s something a number of hospitals have done in working with local companies.”
But the ability to manufacture new PPE in the U.S. also depends on the availability of raw materials, which are limited. That means significant advancements in domestic production are likely several months away, Powell said.
Health systems have stepped up the ability to coordinate and attempt to get equipment where it’s needed most, especially for big-ticket items like ventilators. Providers are more hesitant, however, to let go of PPE without the virus being better contained.
The backstop supposed to help hospitals during a crisis is the national stockpile, which the federal government is attempting to resupply. It doesn’t appear to be enough, though, at least not yet, Calderwood said.
“One thing that concerns me is we did have a national stockpile of PPE, and I get the sense that we’ve kind of burned through that supply,” he said. “And now we’re relying on private industry to meet the need.”
Another problem hospitals face as the pandemic drags on is maintaining adequate staffing levels. Doctors, nurses and other front-line employees are in incredibly stressful work environments. The great potential for burnout will exacerbate existing shortages, just as medical schools are still trying to figure out how to continue with training and education.
“Those areas are concerning to our hospitals because our hospitals depend on a whole myriad of medical staff,” Advis CEO Lyndean Brick said. “Whether it’s physicians, nurses, technicians, housekeepers — that whole staff complement is what’s at the core of healthcare. You can have all the technology in the world but if you don’t have somebody to run it that whole system falls apart.”
On top of that is the increase in labor strife as working conditions have deteriorated in some cases. Nurses have reported fearing for their safety among PPE shortages and alleged lapses in protocol. Brick said she expects strike threats and other actions to continue.
Changing workflows
When COVID-19 cases started ramping up for the first time in the U.S., hospitals throughout the country, acting on CMS advice, shut down elective procedures to prepare their facilities for a potential influx of critical patients with the disease. In some areas, hospitals did have to activate surge plans at that time. Others have done so more recently as the result of increases in the South and West.
But few have resorted to once again halting electives. Brick told Healthcare Dive she doesn’t expect that to change, mostly because hospitals have by and large figured out how to properly continue that care.
She trusts any that can’t do so safely, won’t try.
“For the majority of our providers, except in the occasional state where they’re having a real problem right now, I think that we’re going to see elective surgeries still continue,” Brick said. “Because most of our hospitals have capacity right now. They’re able to do this successfully and securely, and it’s really detrimental to patients to not get the care that they need.”
Hospitals rely on elective procedures to drive their revenue, an added motivation to find ways to keep them running even when COVID-19 is detected at greater levels in the community.
Intermountain, based in Salt Lake City, recently performed its 100th organ transplant of the year, ahead of last year’s pace despite the disruption of the COVID-19 crisis.
Alonso, the program director for abdominal transplants, said that while transplants are considered essential services, staff did pause some procedures when electives were halted and have re-evaluated workflow to be as safe as possible to patients, who are at higher risk after surgery because they are immunocompromised.
The hospital developed a triage system to help evaluate what services are necessary based on what level of COVID-19 spread is present in the community and how many beds and staffers are available to treat them.
The system’s main hospital has certain floors and employees designated for COVID-19 treatment. Staff have been reallocated for certain needs like testing and there are plans available if doctors and surgeons need to be deployed to the ICU.
As many outpatient visits as possible are being changed to virtual, but in the building, patients are screened for symptoms and required to wear masks and follow distancing protocols.
At the transplant center, doctors were at one point divided into teams in case someone got sick and coworkers had to self-isolate.
“We went through a dry run where, at the beginning, we shut down incredibly hard to see how we could do it operationally,” Alonso said. Intermountain hasn’t had to do that again, but is ready if such measures become necessary, she said.
Brick and others said that despite the genuinely frightening circumstance brought by the pandemic, hospitals’ responses have been admirable and providers have been quick to adapt. Slow or nonexistent leadership at the federal level, especially in sourcing and obtaining PPE, has been the bigger roadblock.
“Across the board, the whole healthcare industry has responded beautifully to this,” Brick said. “Where our country has fallen down is we don’t have a master plan to deal with this. Our federal leadership is reactionary, and we are not coordinating a master plan to deal with this in the long term. That’s where my concerns are at. My concerns are not at our local hospitals. They have their acts together.”
Houston, Miami, other cities face mounting health care worker shortages as infections climb
While many hospitals have devised ways to stretch material resources — converting surgery wards into specialized covid units and recycling masks and gowns — it is far more difficult to stretch the human workers needed to make the system function.
“At the end of the day, the capacity for critical care is a balance between the space, staff and stuff. And if you have a bottleneck in one, you can’t take additional patients,” said Mahshid Abir, a senior physician policy researcher at the RAND Corporation and director of the Acute Care Research Unit (ACRU) at the University of Michigan. “You have to have all three … You can’t have a ventilator, but not a respiratory therapist.”
“What this is going to do is it’s going to cost lives, not just for covid patients, but for everyone else in the hospital,” she warned.
The increasingly fraught situation reflects packed hospitals across large swaths of the country: More than 8,800 covid patients are hospitalized in Texas; Florida has more than 9,400; and at least 13 other states also have thousands of hospitalizations, according to data compiled by The Washington Post.
Facilities in several states, including Texas, South Carolina and Indiana, have in recent weeks reported shortages of such workers, according to federal planning documents viewed by The Post, pitting states and hospitals against one another to recruit staff.
On Thursday, Louisiana Gov. John Bel Edwards (D) said he asked the federal government to send in 700 health-care workers to assist besieged hospitals.
“Even if for some strange reason … you don’t care about covid-19, you should care about that hospital capacity when you have an automobile accident or when you have your heart attack or your stroke, or your mother or grandmother has that stroke,” Edwards said at a news conference.
In Florida, 39 hospitals have requested help from the state for respiratory therapists, nurses and nursing assistants. In South Carolina, the National Guard is sending 40 medical professionals to five hospitals in response to rising cases.
Many medical facilities anticipate their staffing problems will deteriorate, according to the planning documents: Texas is hardest hit, with South Carolina close behind. Needs range from pharmacists to physicians.
Hot spots stretch across the country, from Miami and Atlanta to Southern California and the Rio Grande Valley, and the demands for help are as diffuse as the suffering.
“What we have right now are essentially three New Yorks with these three major states,” White House coronavirus task force coordinator Deborah Birx said Friday during an appearance on NBC’s “Today” show.
But today’s diffuse transmission requires innovative thinking and a different response from months ago in New York, say experts. While some doctors have been able to share expertise online and nurses have teamed up to relieve pressures, the overall strains are growing.
“We missed the boat,” said Serena Bumpus, a leader of multiple Texas nursing organizations and regional director of nursing for the Austin Round Rock Region of Baylor Scott and White Health.
Bumpus blames a lack of coordination at national and state officials. “It feels like this free-for-all,” she said, “and each organization is just kind of left up to their own devices to try to figure this out.”
In a disaster, a hospital or local health system typically brings in help from neighboring communities. But that standard emergency protocol, which comes into play following a hurricane or tornado, “is predicated on the notion that you’ll have a concentrated area of impact,” said Christopher Nelson, a senior political scientist at the RAND Corporation and a professor at the Pardee RAND Graduate School.
That is how Texas has functioned in the past, said Jennifer Banda, vice president of advocacy and public policy at the Texas Hospital Association, recalling the influx of temporary help after Hurricane Harvey deluged Houston three years ago.
It is how the response took shape early in the outbreak, when health-care workers headed to hard-hit New York.
But the sustained and far-flung nature of the pandemic has made that approach unworkable. “The challenge right now,” Banda said, “is we are taxing the system all across the country.”
Theresa Q. Tran, an emergency medicine physician and assistant professor of emergency medicine at Houston’s Baylor College of Medicine, began to feel the crunch in June. Only a few weeks before, she had texted a friend to say how disheartening it was to see crowds of people reveling outdoors without masks on Memorial Day weekend.
Her fears were borne out when she found herself making call after call after call from her ER, unable to admit a critically ill patient because her hospital had run out of ICU space, but unable to find a hospital able to take them.
Under normal circumstances, the transfer of such patients — “where you’re afraid to look away, or to blink, because they may just crash on you,” as Tran describes them — happens quickly to ensure the close monitoring the ICU affords.
Those critical patients begin to stall in the ER, stretching the abilities of the nurses and doctors attending to them. “A lot of people, they come in, and they need attention immediately,” Tran said, noting that emergency physicians are constantly racing against time. “Time is brain, or time is heart.”
By mid-July, an influx of “surge” staff brought relief, Tran said. But that was short-lived as the crisis jumped from one locality to the next, with the emergency procedures to bring in more staff never quite keeping up with the rising infections.
An ER physician in the Rio Grande Valley said all three of the major trauma hospitals in the area have long since run out of the ability to absorb new ICU patients.
“We’ve been full for weeks,” said the physician, who spoke on the condition of anonymity because he feared retaliation for speaking out about the conditions.
“The truth is, the majority of our work now in the emergency department is ICU work,” he said. “Some of our patients down here, we’re now holding them for days.” And each one of those critically ill patients needs a nurse to stay with them.
When ICU space has opened up — maybe two, three, four beds — it never feels like relief, he said, because in the time it takes to move those patients out, 20 new ones arrive.
Even with help his hospital has received — masks and gowns were procured, and the staff more than doubled in the past few weeks with relief nurses and other health-care workers from outside — it still is not enough.
The local nurses are exhausted. Some quit. Even the relief nurses who helped out in New York in the spring seem horrified by the scale of the disaster in South Texas, he said.
“If no one comes and helps us out and gives us the ammo we need to fight this thing, we are not going to win,” the doctor said.
One of the root causes of the problem in the United States is that emergency departments and ICUs are often operating at or near capacity, Abir and Nelson said, putting them dangerously close to shortages before a crisis even hits.
Texas, along with 32 other states, has joined a licensure compact, allowing nurses to practice across state borders, but it is becoming increasingly difficult to recruit from other parts of the country.
Texas medical facilities can apply to the Department of State Health Services for staffers to fill a critical shortage, typically for a two-week period. But two weeks, which would allow time to respond to most disasters, hardly registers in a pandemic, so facilities have to ask for extensions or make new applications.
South Carolina last week issued an order that allows nursing graduates who have not yet completed their licensing exams to begin working under supervision. Prisma Health, the state’s biggest hospital system, said this week that the number of patients admitted to its hospitals has more than tripled in the past three weeks and is approaching 300 new patients a day.
“As the capacity increases, so does the need for additional staff,” Scott Sasser, the incident commander for Prisma Health’s covid-19 response said in a statement. Prisma has so far shifted nurses from one area to another, brought back furloughed nurses, hired more physicians and brought in temporary nurse hires, among other measures, Sasser said.
Bumpus has fielded calls from nurses all over the country — some as far afield as the United Kingdom — wanting to know how they can help. But Bumpus says she does not have an easy answer.
“I’ve had to kind of just do my own digging and use my connections,” she said. At first, she said, interested nurses were asked to register through the Texas Disaster Volunteer Registry; but then the system never seemed to be put to use.
Later she learned — “by happenstance … literally by social media” — that the state had contracted with private agencies to find nurses. So now she directs callers to those agencies.
Even rural parts of Texas that were spared initially are being ravaged by the virus, according to John Henderson, CEO of the Texas Organization of Rural and Community Hospitals.
“Unless things start getting better in short order, we don’t have enough staff,” he acknowledged. As for filling critical staffing gaps by moving people around, “even the state admits that they can’t continue to do that,” Henderson said.
The situation has become so dire in some rural parts of the state that Judge Eloy Vera implored people to stay home on the Starr County Facebook page, warning, “Unfortunately, Starr County Memorial Hospital has limited resources and our doctors are going to have to decide who receives treatment, and who is sent home to die.”
Steven Gularte, CEO of Chambers Health in Anahuac, Tex., 45 miles from Houston, said he had to bring in 10 nurses to help staff his 14-bed hospital after Houston facilities started appealing for help to care for patients who no longer needed intensive care but were not ready to go home.
“Normally, we are referring to them,” Gularte said. “Now, they are referring to us.”
Donald M. Yealy, chair of emergency medicine at the University of Pittsburgh Medical Center, said rather than sending staff to other states, his hospital has helped others virtually, particularly to support pulmonary and intensive care physicians.
“Covid has been catalytic in how we think about health care,” Yealy said, providing lessons that will outlast the pandemic.
But telehealth can do little to relieve the fatigue and fear that goes with front-line work in a prolonged pandemic. Donning and doffing masks, gowns and gloves is time consuming. Nurses worry about taking the virus home to their families.
“It is high energy work with a constant grind that is hard on people,” said Michael Sweat, director of the Center for Global Health at the Medical University of South Carolina.
Coronavirus has turned the regular staffing challenge at Harris Health in Houston into a daily life-or-death juggle for Pamela Russell, associate administrator of nursing operations, who helps provide supplemental workers for the system’s two public hospitals and 46 outpatient clinics.
Now, 162 staff members — including more than 50 nurses — are quarantined, either because they tested positive or are awaiting results. Many others need flexible schedules to accommodate child care, she said. Some cannot work in coronavirus units because of their own medical conditions. A few contract nurses left abruptly after learning their units would soon be taking covid-positive patients.
Russell has turned to the state and the international nonprofit Project Hope for resources, even as she acts as a morale booster, encouraging restaurants to send meals and supporting the hospital CEO in his cheerleading rounds.
“It’s hard to say how long we can do this. I just don’t know” said Russell, who praised the commitment of the nurses. “Like I said, it’s a calling. But I don’t see it being sustainable.”
Hackensack Meridian Health, Maimonides Medical Center pilot sensor-embedded clothes to remotely monitor COVID-19 patients
Hackensack (N.J.) Meridian Health and New York City-based Maimonides Medical Center are partnering with remote monitoring platform Nanowear to pilot cloth-based wearable tech that monitors coronavirus patients.
Nanowear’s undergarment wearable comprises nanosensors, which detect physiological and biomarker changes that indicate when a patient’s condition is worsening and the hospitals need to further intervene. When a patient wears the garment, physicians can remotely capture and assess vitals including real-time ECH, systolic and diastolic blood pressure, temperature trends, respiration and lung volume.
The garment can collect 120 million data points per patient per day across cardiac, pulmonary and circulatory biomarker data, which is then transmitted to clinical staff.
“Nanowear’s SimpleSENSE is giving us an exponential amount of relevant data metrics about the heart and lungs from an all-in-one product that should ultimately enable us to triage lower risk patients and stratify high risk patients,” said Sameer Jamal, MD, principal investigator of the collaboration and cardiologist at Hackensack Meridian Health, according to the July 22 news release.
4 ETHICAL DILEMMAS FOR HEALTHCARE ORGANIZATIONS DURING THE COVID-19 PANDEMIC
There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.
KEY TAKEAWAYS
Rationing of care for novel coronavirus patients has been reported in China and Italy.
Medical utility based on scientific patient profiles should guide decisions to ration critical care resources such as ventilators, medical ethicist James Tabery says.
In a pandemic, public health considerations should drive decisions on prioritizing who is tested for disease, he says.
The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.
In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.
The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. “Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn’t enough of these resources than what we anticipate needing,” says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.
He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.
1. TREATMENT
In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. “The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can.”
The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.
“But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility,” Tabery says.
Medical utility is based on scientific assessments, he says. “You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient’s condition quickly.”
Rationing of critical care resources would be jarring for U.S. clinical staff.
Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.
However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.
“When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn’t look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck,” he says.
2. TESTING
There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.
While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.
“The primary purpose of the test is pure public health epidemiology. It’s about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn’t so much about who is at greatest risk. It’s about who is more likely to interact with lots of people, or who is more likely to have interacted with more people.”
A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.
“For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street.”
3. HEALTHCARE WORKERS
The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. “On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don’t want to get sick, which can incline them not to work,” he says.
“The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work,” he says.
However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. “If hospitals don’t have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem.”
4. VACCINE
When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.
“When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups,” he says.
Doctors Fear Bringing Coronavirus Home: ‘I Am Sort of a Pariah in My Family’
One doctor dreamed he was surrounded by coughing patients. “Most physicians have never seen this level of angst and anxiety in their careers,” a veteran emergency room doctor said.
SEATTLE — After her shifts in the emergency room, one doctor in Utah strips naked on her porch and runs straight to a shower, trying not to contaminate her home. In Oregon, an emergency physician talks of how he was recently bent over a drunk teenager, stapling a head wound, when he realized with a sudden chill that the patient had a fever and a cough. A doctor in Washington State woke up one night not long ago with nightmares of being surrounded by coughing patients.
“Most physicians have never seen this level of angst and anxiety in their careers,” said Dr. Stephen Anderson, a 35-year veteran of emergency rooms in a suburb south of Seattle. “I am sort of a pariah in my family. I am dipping myself into the swamp every day.”
As the coronavirus expands around the country, doctors and nurses working in emergency rooms are suddenly wary of everyone walking in the door with a cough, forced to make quick, harrowing decisions to help save not only their patients’ lives, but their own.
The stress only grew on Sunday, when the American College of Emergency Physicians revealed that two emergency medicine doctors, in New Jersey and Washington State, were hospitalized in critical condition as a result of the coronavirus. Though the virus is spreading in the community and there was no way of ascertaining whether they were exposed at work or somewhere else, the two cases prompted urgent new questions among doctors about how many precautions are enough.
“Now that we see front-line providers that are on ventilators, it is really driving it home,” Dr. Anderson said.
Doctors, nurses and other staff members in a variety of hospital departments face new uncertainty. In intensive care units, for example, health care providers must have extended exposure to people who have contracted the virus. But they know in advance of the risk they face.
In emergency departments, the danger comes from the unknown.
Patients arrive with symptoms but no diagnosis, and staff members must sometimes tend to urgent needs, such as gaping wounds, before they have time to screen a patient for Covid-19, the disease caused by the virus. At times, the protocols they must follow are changing every few hours.
“Many of us have trained for disasters, like Ebola and hurricanes,” said Dr. Adam Brown, the president of emergency medicine for Envision Healthcare, the largest provider of contract physicians to emergency rooms. “This is different because of the scale and scope of the disease.”
Add to that the shortage of protective gear and delays in testing, and health care workers fear they are flying blind.
Though the numbers are still low, Envision, which employs 11,000 emergency clinicians across the United States, has five times as many doctors under quarantine as it did a week ago, Dr. Brown said.
Several providers spoke on the condition of anonymity because their employers have told them not to talk to the news media.
The personal strain is cascading as the virus reaches new parts of the country. “Everybody feels the stress, but everybody is pulling together,” said Dr. K. Kay Moody, an emergency room doctor in Olympia, Wash., who runs a Facebook group with 22,000 emergency physicians. “That is what is keeping us OK.”
A few doctors said they were talking about bunking up in Airbnbs to create “dirty doc” living quarters to avoid endangering their children when they go home. Some are showing their partners where to find their passwords and insurance, should they end up in intensive care. Dr. Moody said she knew of at least one doctor whose former spouse was threatening to take their children away if the doctor went to work.
Many emergency physicians work as contractors, not hospital staff, so they will not necessarily be paid if they are quarantined. “As it stands, that is one of the most anxiety-provoking things,” Dr. Moody said, “on top of fear for your life.”
Nurses face similar challenges, though with less pay and support. An emergency nurse in Milwaukee said she bought her own goggles after hearing that protective gear was running low. A nurse at a rural hospital near Lake Tahoe in California said that the hospital was providing physicians with shower facilities as well as clean scrubs to wear, but that nurses had to wash their work clothes at home. She said that the physicians she worked with lobbied the hospital to provide clean scrubs for the nurses, but that the hospital concluded it would cost too much.
One doctor, who spoke on condition that the identity of the veterans hospital where she worked was not revealed, said the protocols have not kept up with the changing reality on the ground. When determining if a patient should get a separate room, she said, the emergency department still asks patients if they have been to high-risk countries, like China and Italy, even though community transmission of the virus has been well established.
Doctors have begun building plans for how they will ration supplies when there are more patients than their hospitals can handle. Emergency room doctors have experience sitting families down to advise discontinuing care because it would be futile. But in the United States, they are not used to making such calls based on resources alone.
Some said they were looking to Italy, where doctors on the front line have sometimes had to ration care in favor of younger patients, or those without other complicating conditions, who are more likely to benefit from it.
“If we get it all at once, we don’t have the resources, we don’t have the ventilators,” said Dr. William Jaquis, chair of the American College of Emergency Physicians.
Last week, Italian media reported that Bergamo, a city northeast of Milan, saw roughly 50 doctors test positive for the virus. In the region of Puglia in the south, local media reported that 76 employees had been quarantined after being exposed to patients who contracted Covid-19.
After the coronavirus broke out at a nursing facility near Seattle, Dr. Anderson sat with the leaders of his hospital, MultiCare Auburn Medical Center, to talk about how urgently they should prepare. Their hospital is ringed by nursing homes and other care facilities, and he rattled off those most at risk for fatal cases of the virus: males over 60, and those with cardiac and pulmonary problems. “I literally stopped what I was saying and realized that that was me,” he said.
He said his hospital was down to a two-day supply of surgical masks — he wears one per shift. “Those are supposed to be disposable,” he said. Now he must carefully remove and clean the mask each time he takes it off and on. “That may sound just like a nuisance, but when you’re potentially touching something that has the virus that could kill you on it, and you’re doing it 25 times a shift, it’s kind of nerve-racking,” he said.
His wife has moved to their mountain cabin, and they have given up on their retirement cruise in Europe. “I haven’t slept for longer than three hours in the past two weeks,” he said.
In the early hours of Monday morning, he could not sleep. More than 200 emails had come into his inbox since he went to bed, including news that three other health care providers had been admitted to a hospital overnight, he said.
But he plans to be at his next shift nonetheless.
“I have been doing this for 35 years,” he said, “and I’m not going to stop now.”
HENRY KOTULA 