Although health workers constitute about 3% of the population in most countries, they comprise 14% of COVID-19 cases reported to the World Health Organization (WHO), and in some countries account for up to 35% of COVID cases. WHO Director-General Tedros Adhanom Ghebreyesus noted this in a September 17 statement and added, “The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives.” As “one of the keys to keeping patients safe is keeping health workers safe,” on Thursday the Director-General issued a 5-point charter on healthcare worker safety in conjunction with Patient Safety Day.
The 5-point WHO charter urges its partner countries to:
1. Develop and implement national programs for the occupational health and safety of health workers
WHO recommends that education and training programs for health workers at all levels include health and safety skills in personal and patient safety and that healthcare licensing and accreditation standards incorporate requirements for staff and patient safety. Member countries should also review and upgrade national regulations and laws for occupational health and safety to ensure that all staff members have regulatory protection of their health and safety at work.
2. Protect health workers from violence in the workplace
Promote a culture of zero tolerance to violence against health workers. Labor laws, policies, and regulations need to be strengthened, and all healthcare workers should have access to ombudspersons and helplines to enable free and confidential reporting and support for any health worker facing violence.
3. Improve the mental health and psychological well-being of healthcare workers
Healthcare facilities must establish and maintain safe staffing levels, and ensure fair duration of deployments, working hours, and rest breaks. Mental and social support services, including advice on work-life balance, risk assessment, and mitigation should be readily available to all staff.
4. Protect healthcare staff from physical and biological hazards
Health care systems must implement patient safety, infection prevention and control, and occupational safety standards in all health care facilities. Facilities need to ensure availability of personal protective equipment (PPE), adequate quantity, appropriate fit, and acceptable quality. All facilities should maintain an adequate, locally held, buffer stock of PPE and provide workers with adequate training on appropriate use and safety precautions. Further, at-risk healthcare staff should receive vaccinations against all vaccine-preventable infections, and in the context of emergency response, be given priority access to newly licensed and available vaccines.
5. Connect the dots between policies on patient safety and healthcare worker safety
Institutions should integrate staff safety and patient safety incident reporting and learning systems, and define the linkages between occupational health and safety, patient safety, quality improvement, and infection prevention and control programs.
Regarding the latter point, the charter states that “No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe.”
For more details on the charter see the WHO announcement, “Keep Health Workers Safe to Keep Patients Safe.”
Before COVID-19 hit New York City, Mount Sinai Morningside Hospital had a flexible, 24-hour visitor policy for patients in the intensive care unit (ICU).
People would visit their loved ones at any hour of the day, coming and going as they pleased. Doctors and nurses said the constant support of family members was beneficial to these gravely ill patients.
Now, per New York State Department of Health guidelines that apply to all areas of the hospital, visitors are limited to one 4-hour session per day, and only one person is allowed at the bedside at a time. At Morningside, that has to be done between the hours of 10 a.m. and 6 p.m. so visitors can undergo temperature and symptom checks before being permitted on the floors.
Morningside ICU physicians and nurses told MedPage Today those visitation policies are too restrictive, especially as staff have become more adept at managing COVID-19 transmission risk.
“It’s particularly challenging for this community because these families have a lot of restrictions,” said Mirna Mohanraj, MD, an ICU physician at Morningside (formerly St. Luke’s Hospital), which predominantly serves minority patients from Harlem and the Bronx. “Not everyone has a flexible job they can leave for 4 hours. They don’t have the financial resources to hire childcare.”
In an emailed statement, the New York State Department of Health said that hospitals “can authorize visits longer than four hours depending on a patient’s status and condition” and noted that labor & delivery patients, pediatric patients, and those with intellectual or developmental disabilities can have a support person at all times.
“This policy remains in place to safeguard and maintain the health and wellbeing of patients, staff and visitors while the need to contain the spread of COVID-19 continues,” the statement read.
The new visitation rules are a vast improvement from the disease peak, when visitors were barred from hospitals altogether and patients died alone. But while the policy may be sufficient for patients elsewhere in the hospital, it poses particular challenges for the ICU, Mohanraj said.
“The ICU is such a dynamic place, things change frequently and unexpectedly,” she said. “It’s traumatic for a family member not to be present when things are changing rapidly.”
Morningside ICU charge nurse Jessica Montanaro, MSN, RN, said while the visitation rules “make sense on regular floors, you have more grave situations [in the ICU]. You’re dealing with death and difficult decisions. In truly grave situations, people need more support. It should be a different situation for the ICU.”
Mohanraj said the literature “shows that having family at the bedside can be beneficial to patients” in the ICU, which is why many ICUs have adopted flexible visitor policies in recent years.
“Family members can provide emotional and psychological support,” she said. “Often, they’re the ones re-orienting patients, moving their legs, alerting the nurses to issues like pain control or a bedpan.”
“They’re also the constant reminder of the full lives that patients had before they got to the ICU,” she added. “And it helps the family develop trust in us as their healthcare team.”
Hospital administrators have allowed exceptions on a case-by-case basis, as called for by the state guidelines. But that means more time spent trying to cut through red tape, and the possibility of request denials.
Eric Gottesman, MD, medical director of the ICU at North Shore University Hospital in Manhasset, New York, which was also hit hard during the COVID-19 peak, said administrators there typically make exceptions to the visitor rule for end-of-life discussions.
“We follow the guidelines but if there’s an emergent issue, we do stray a little,” Gottesman told MedPage Today. “We try to bend, not break.”
Gottesman was similarly accustomed to a liberal visitation policy before COVID-19 hit. The new policy “puts more pressure on us by having to tell patients about the limitations,” he said. “Also, if we’re on rounds and no family member is present to take in the info, we have to come back and do it over.”
So what changes would ICU doctors and nurses like to see?
Family members should be able to stay for longer than 4 hours, Mohanraj said, especially if that person is the patient’s only visitor. That visitor should also be allowed to return to the bedside after they’ve left (right now, once a visitor leaves a hospital floor, they’re not allowed to return).
Finally, Mohanraj said nighttime visits would be especially helpful because ICU patients who experience delirium typically get worse at night, so the additional family support might alleviate related issues.
Safety is the first priority, she said, and thus far preventing transmission among visitors “has been perfectly manageable,” especially as very few patients with COVID-19 remain in the hospital, she said.
ICU providers in New York hospitals say the trauma of seeing families separated during the peak of the crisis has stuck with them, and makes their current push to have family members around more urgent.
In the beginning of the crisis, visitors weren’t allowed unless a patient was imminently dying — but that’s not always easy to call, Montanaro said.
“We had difficult cases where we would allow one family member to come up and stand in the patient’s doorway, say their goodbyes, and then the patient didn’t pass,” Montanaro said.
As policies eased over time, and patients could have two visitors, she recalled a case of a dying mother with three family members who wanted to say goodbye — her husband and two sons.
“That family had to choose which son would say goodbye to their mother,” she said. “So many things about that experience will haunt us for the rest of our lives.”
In March, when New York City staggered under the weight of the COVID-19 outbreak, the images of refrigerator trucks, overwhelmed hospitals, and outdoor triage centers set Amy Kinder’s caregiving instincts afire. On April 5, 2020, the ER nurse left her home in Kokomo, Indiana and joined the thousands of dedicated nurses who came to work on the city’s frontlines. During her 21 days at Coney Island Hospital in Brooklyn, Kinder formed a tight bond with eight colleagues. Now, the nine nurses have described their experience in a new book, COVID-19 Frontliners.
“I remember my first night in the emergency department I was stopped abruptly in my tracks as I was racing down the hallway. My eyes caught movement in one of my rooms. I stopped to ensure what I was seeing. I had a patient actively dying and the patient next to her reached through the rails of the cot and held her hand trying to comfort her. I felt anguish for these patients. They did not know each other, but they were all alone. They had no one but the stranger beside them.” –Amy Kinder, COVID-19 Frontliners
In an interview with the Kokomo Perspective, Kinder said, “We felt like it was important to get the truth out there because you see on the news so many conflicting stories of what’s really happening or what was going on. So we just felt like it was important to get our frontline experience out there so other people really could see and understand what it really was like—because when I was out in New York, [it seemed] like the news sugarcoated what was really going on.”
As they attempted to communicate with non-English speaking patients, Kinder and the other nurses tried to find their footing amid scenes of chaos: “There were patients everywhere, double and triple stacked in rooms, lining the hallways, right up to the nurses’ station.” She added, “I could not believe what I was seeing. How could this be possible? Where did all of these patients come from? I thought to myself, ‘Damn, this is way worse than what I saw on the news.’”
In addition to dealing with the overcrowding and insufficient PPE supplies, Kinder and her colleagues struggled with a shocking volume of mortalities that sometimes included co-workers: “During the hardest time, we learned how to cope in ways we never had before. Not only were we seeing death in our patients but within our own healthcare family. We lost an agency nurse one night at shift change. She was found down in the bathroom. My heart still hurts for this individual’s family.”
When Kinder returned to Kokomo, she found that the experience had left marks on her psyche. Back on duty at the Ascension St. Vincent ER, “Alarms go off, and I flash back to the horror in NYC. I begin to hyperventilate worrying that we are running out of oxygen again or that a patient is in crisis. I have to talk myself down and remind myself of where I am and that I’m no longer in NYC.”
Her 21 days in New York also left Kinder with a sobering awareness of the realities of COVID. “I knew that it was a big deal, but at the same time I wasn’t really sure how big of a deal it was. There’s so much unknown about this dang virus, so I even was on the fence. But then I come home and people are mouthing, and until you’ve been out there and lived it, it hurts to hear people talk like that…”
For more details on Kinder’s experience, see the story in the Kokomo Perspective.
Getting to know the critically ill patients they’re taking care of is hard enough for ICU doctors under normal circumstances. But it’s even worse during COVID-19.
Not only are there no visiting family members to give you information, “but the patients are all similar in terms of their medical issues, they’re all on a breathing machine, and many are lying on their bellies,” explained Brian Garibaldi, MD, associate professor of medicine and anesthesiology at Johns Hopkins Medicine and director of the isolation unit at Johns Hopkins Hospital in Baltimore, in a phone interview. “You might go for days without examining the front side of their body, so we’re not seeing their face. That makes establishing connections with patients a little more difficult.”
An Idea From the Chaplain
One day Garibaldi was talking to Elizabeth Tracey, a chaplain at the hospital who also is director of audio production at Johns Hopkins Medicine — someone very familiar with audio recordings. She had an idea: how about if she interviewed patients’ family members and made a recording of what they say? “I could edit it down to a few things families really want their doctors to know about their loved one,” she said. Garibaldi was immediately on board.
In a separate interview, Tracey — who also edits and appears on MedPage Today‘s TTHealthWatch podcast, said she had heard from a chaplain colleague who told her that a physician had said after an extubation of a terminal COVID-19 patient that “I realized I didn’t know anything about this person; I didn’t know if he had children, if he was married. I didn’t know anything.” So why not give the physicians and the rest of the healthcare team personal details — “Do they have a dog? Do they like to play poker? It’s all the things that make them human,” said Tracey.
Tracey said Garibaldi emphasized one thing: “The only way this is going to work is if it’s in the voice of the family member.” So Tracey began calling family members and saying, “Hey, I’m part of the team helping take care of your loved one … Under normal circumstances you’d be here in the ICU telling us your loved one’s story. The team would like to know your loved one better as a person; would you like to spend 15 to 20 minutes talking about them?”
So far, only one person has turned her down since Tracey began doing this in April, and that was because they didn’t like the sound of their recorded voice, Tracey said.
After getting the family member’s permission, she records the phone call and edits the comments down to 2 or 3 minutes; she estimated that she has completed 30 to 40 recordings so far. Currently, the recording is distributed to the medical staff by an administrator at the hospital, although she hopes to eventually get it added as a link in the patient’s electronic health record.
A Message to the Healthcare Team
Tracey also added a second component: the opportunity for the family member to send a recorded message directly to the patient. “I said, ‘if you were talking to your family member, what would you say? Talk to them directly.'”
“They say these things that are just unbelievable,” said Tracey. One mother recorded a message for her adult daughter, whose autistic child the mother was the custodian of. “She says, ‘I want you to know that everything is forgiven,'” said Tracey. “How can you have a more powerful example of love?” Those conversations also are edited down to 2 minutes and played for the patient.
The recordings for the medical staff are very helpful, said Garibaldi. “Just learning the simple things — What would they prefer to be called by if I met them in the grocery story? What hobbies do they like? What favorite music can we program on an iPad to keep them awake and stimulated during the day? Also, learning things like what that person has accomplished in their personal and professional life; it really puts things in perspective, to put their current illness in the context of where they’ve been, where they are, and where they might want to be going.”
Dale Needham, MD, professor of pulmonary and critical care medicine at Johns Hopkins, agreed. He noted that although the medical staff speaks with patients’ family members every day, “those conversations have to be efficient and focused, whereas Elizabeth has the luxury of spending more time, and distilling it into an audio file that we can listen to and understand and easily share.”
For example, Needham said, “we found out that one patient previously had worked at a Smithsonian museum, and we found out that one of our patients likes to tango. And we found out that one of our patients that we wouldn’t have expected — was a DJ” on the weekend, while he had a white-collar job at a law firm during the week.
“This can help us understand who the patient is, and as the sedation is lightened, it helps us interact with them in a more humanized way.” It’s also mutually beneficial because the families are aware that the staff knows a little about their loved one, he added.
“What a Gift She Gave Us”
Barbara Johnson, whose late sister was a COVID-19 patient at the hospital, agreed. “I thought it was an incredible opportunity, given that none of us could see my sister,” said Johnson, of Silver Spring, Maryland, who did a recording for her sister and one for the medical staff. (You can listen to the recordings in the player above; her recording for her sister Beverly is first, followed by the one for the healthcare team at 3:25.)
When she spoke with Tracey for the recording, Johnson said she was thinking about her sister, “What would I have said if I got to talk to her” the day she was intubated? “What a gift Elizabeth gave us.”
Regarding the recording for the medical staff, “I think that when you take away the family from a hospital room, it might be hard for doctors and nurses to relate to the individuals, and the fact that they wanted to was really quite powerful for me,” Johnson said. “I really wanted them to know what made her happy, and if she was there talking to them, what would she have told them? … I also wanted them to know — in case she woke up — that she was the kind of patient that would tell them what they wanted to hear. If she was not feeling well and wanted them to feel good about their job, she would say, ‘I’m doing great.’ So I wanted them to know, just read between the lines.”
Tracey has recruited several dozen additional volunteers — including chaplains and medical residents — to make the phone calls and edit the recordings. She also has expanded the service — which she calls “This Is My Story,” or TIMS — to include other patients in the hospital, since they also aren’t getting visitors during the pandemic. She said she hoped that other hospitals would adopt the practice.
Within the hospital, “there’s definitely a lot of enthusiasm from the medical units and also an enthusiastic response from pediatrics,” she said. “What parent wouldn’t want to record ‘Green Eggs and Ham’ for their kid?”
More than a dozen registered nurses at Blake Medical Center in Bradenton, Florida, protested outside the hospital Friday, the third such protest since the pandemic began, saying hospital owner HCA Healthcare won’t give them N95 masks unless they are working with known COVID-19 patients, and doesn’t tell them when their patients later test positive.
As case counts in Manatee County climb, many patients have been admitted to the 383-bed hospital for other reasons, but later turn out to have COVID-19, said Candice Cordero, a telemetry nurse who works with stroke and cardiac patients in a step-down unit.
“We’re seeing more random patients test positive, and some have symptoms, but some don’t, or some are admitted for one thing, and start having (COVID) symptoms a few days later,” she told MedPage Today.
“We’re having a problem with the hospital being transparent with their numbers, and letting staff know when they’ve been exposed.”
The hour-long protest was called by members of the Blake Medical Center’s bargaining unit of the National Nurses Organizing Committee-Florida, an affiliate of National Nurses United. NNOC said in a news release that it has filed complaints about unsafe conditions at the hospital with the Occupational Safety and Health Administration. The statement said that at least four RNs at Blake have tested positive since late May.
The union further alleged that Blake Medical Center management requires RNs who have been exposed to COVID to continue working until they have COVID symptoms, does not test all patients prior to a procedure or operation, fails to provide PPE replacements for broken masks, and threatens RNs with discipline for raising safety concerns.
Officials for Blake Medical Center eleased this statement in response to the protest:
“In the midst of a global shortage of personal protective equipment (PPE), Blake Medical Center has been doing everything in our power to protect our caregivers and patient care teams throughout the pandemic and equip them to provide safe, effective care to our patients by following or exceeding Centers for Disease Control and Prevention (CDC) protocols.
“We have provided appropriate PPE, including a universal masking policy requiring all caregivers in all areas to wear masks, including N95s, in line with CDC guidance. While we currently have adequate supplies of PPE, we continue to provide safeguards that are consistent with CDC guidelines and help ensure the protection of our colleagues, not only today, but into the future as the pandemic evolves. The NNU fails to recognize the reality all hospitals nationwide are facing, that this pandemic has strained the worldwide supply of PPE, including masks, face shields, and gowns.”
Cordero said that recently one patient “was not properly screened in the ER who should have been on a COVID unit. That potentially exposed several nurses and the other patient in that room.”
When she complained to human resources officials, she said, she “was reprimanded verbally for speaking up and was told that if I did it again, I would receive discipline.”
The hospital should be testing all of its frontline workers regularly, she said. “We’re much more at risk of being exposed while at work than many other jobs out there. We really should be screened better than we are.”
Kim Brooks, who works in an ICU step-down unit for trauma and cardiac patients, assumes all of her patients are infected with COVID-19 and because of that, she said, she has bought her own N95 masks since the hospital won’t buy them for her.
“We know some of the nurses who are on non-COVID units are getting exposed to positive patients and now [some] are getting sick because they didn’t have N95 masks,” she told MedPage Today.
At the very least, the hospital should inform frontline workers when patients ultimately test positive on our floor, “so we can take precautions with our family,” Brooks said.
“Once we find out someone is positive, we do move them to a COVID unit. But sometimes there’s been a situation where that patient has been rooming with a COVID patient, and that patient is sometimes left on our unit to see if they turn out to be positive.”
By Cheryl Clark, MedPage Today
Hundreds of registered nurses marched outside the 478-bed Riverside Community Hospital in California for eight hours Monday during the fourth day of a 10-day strike. They accuse their administrators of ordering staff reductions that have resulted in dangerously high nurse-to-patient ratios that put themselves and their patients at risk.
The nurses say they’re sometimes forced to work their 12-hour shifts without taking a break to eat, get a drink of water, or even use the bathroom.
It’s all the more troubling as COVID-19 case counts and deaths recently spiked in that Southern California county, they said.
“You have to sneak the break in, or you get to the end of the day and it dawns on you that you’re dehydrated and you haven’t been to the bathroom all day,” said Erik Andrews, RN, a rapid response team member at the hospital and vice president of the 1,200-member bargaining unit of Service Employees International Union (SEIU) Local 121RN. He said he’s held on for 10 hours without a bathroom break while wearing an airtight respiratory mask, feeling uncomfortable and dehydrated, yet without a backup if he steps away.
“Each nurse is entitled to three paid 15-minute breaks and a half an hour off the clock every day,” Andrews said. “If I could find a single member who got all those breaks every day, I would keel over from shock because it doesn’t happen. And now it’s expected and accepted; we’re just taking it … when it doesn’t need to be this way.”
“You can’t get away without a safe break,” said Monique Hernandez, RN, a Riverside Community Hospital telemetry nurse and a member of the mediation team for SEIU. “That means someone who says I’m going to watch your patients while you go and put your feet up, take your mask off, go eat something, clock out. You can’t do that legally if there’s no one that can watch for you, because if something happens, that’s on your license.”
Wearing purple shirts, several hundred strikers carried signs around the hospital block for the last four days starting at 7 a.m. Some of the signs said, “Imagine wearing N95 for 12 hours with no breaks,” “Caution, unsafe staffing ahead,” and “You call us heroes yet treat us like zeroes.”
Riverside Community Hospital: “Misguided Tactic“
In a statement, Riverside Community Hospital officials called the nurses’ job action “a misguided tactic” that “create(s) conflict and spreads misinformation” and has “everything to do with contract negotiations.” The statement said that Riverside Community has “not laid off or furloughed a single caregiver due to COVID-19 and has spent $160 million to pay workers, some of whom are receiving 70% of their pay even when there has been no work.”
But labor officials insisted their strike has nothing to do with money and nothing to do with their current contract, which doesn’t expire until September. They are not in negotiations now.
From the labor union’s view, the problem is that when Gov. Gavin Newsom (D) ordered the state to shelter in place in mid-March, and routine hospital operations like elective surgeries came to a halt, Riverside Community Hospital’s administrators took traveler nurses, per-diem and part-time personnel off the schedule and limited hours for other workers. Union representatives estimated that they are between 200 and 400 people below where they need to be.
Hospital officials failed to realize that even though the census has been low, the workload and burden of methodically taking extra precautions — for example cleaning reusable PPE equipment in short supply — turn what were once quick, routine tasks into more complicated, step-by-step procedures, Andrews said.
“When you’re dealing with a disease that presumably is aerosolized, and very contagious, you need people to slow down and think carefully,” he said. But there is no staff available to serve as a spotter, “for when you’re donning and doffing your protective equipment.” Also, COVID-19 patients are not always housed in separate parts of the hospital, complicating safety considerations further, and nursing staff don’t always know a patient’s status.
Nurses as Housekeeping Staff
Kerry Cavazos, RN, the labor union’s chapter president and a labor and delivery unit nurse, said Riverside’s owners, the Hospital Corporation of America, told many members of the housekeeping staff, who are represented by a different labor union, not to come to work. That meant the nurses have to do housekeeping work.
Women about to give birth are brought into rooms that are still dirty from the last delivery, she said. “There was no housekeeper to clean it and there is still blood on the floor, so we have to clean it up. The woman needs to get in the bed because she’s having a baby.”
She and her fellow nurses are told to strip the beds, wipe the poles and the IV, and stock the rooms. “Those were never nurses’ tasks. And it’s not beyond us to do that but we have other things (to take care of patients) that we need to do,” Cavazos said.
Cavazos echoed the concerns expressed by Andrews. “I honestly do not believe this is safe for any patient for a nurse to not have any nutrition or any fluids for 12 hours. But we do it because that’s who we are,” she said.
California’s Staffing Ratio Rules
The issue of hospital nurse staffing is an important one in California, which two decades ago passed the nation’s first set of maximum patient-to-nurse staffing ratios in acute care hospitals. For example, one med-surge unit nurse should take care of no more than five patients at a time. In a telemetry unit, the nurse-to-patient ratio can be no more than one to four.
But according to Hernandez, there has been no financial penalty against the hospital for violating the ratio unless there was documentable harm to a patient that the staffing lapse could be blamed as the direct cause. A new law took effect early this year, imposing fines of $15,000 to $30,000 on hospitals that failed to uphold ratios. Labor officials said that while that is a welcome fix, state health officials have not yet begun to enforce it due to the pandemic.
The history of the issue at Riverside Community Hospital regarding staffing ratios goes back several years, as the SEIU unit tried to get administrators to take the staffing issue more seriously. The bargaining unit got a contract amendment last year that required the hospital to pay a nurse a “monetary penalty” if he or she had been required to absorb more patients than the ratio allowed, regardless of whether the ratio lapse caused harm.
“Everyone was happy and they kept their part,” Hernandez said, until a few months ago when that monetary penalty agreement expired and, sometime in late May, hospital officials declined to renew it. Days after that, which was the weekend of June 13 and 14, Hernandez said, at least one unit at the hospital failed to meet the ratio, “and it’s happened repeatedly” since the agreement ended.
by Cheryl Clark, Contributing Writer, MedPage Today