The American Nurses Association (ANA), representing the interests of the nation’s 4.3 million registered nurses, supports the actions included in President Joe Biden’s multi-pronged COVID-19 Action Plan, “Path out of the Pandemic” released last Thursday, in particular the new requirements and incentives to increase the vaccination rate and protect those who have been vaccinated.
“Nurses working in all roles and care settings are exhausted and frustrated about the impact of the 4th wave of COVID-19 with the burden of new cases, increased hospitalizations and many deaths that could have been prevented by a greater acceptance of vaccines,” said ANA President Ernest Grant, PhD, RN, FAAN. “ANA supports the Biden Administration plan to use every lever to increase the number of people vaccinated as the only way to get out of this crisis.”
In July, ANA called upon all health care workers to be vaccinated. This next step the Administration is taking, encouraging employers to mandate COVID-19 vaccinations, aligns with our longstanding position on immunizations, which emphasizes that effective protection of the public health mandates that all individuals receive immunizations against vaccine-preventable diseases. ANA fully supports the President’s efforts.
Last week, ANA urged the U.S. Department of Health and Human Services (HHS) to declare the current and unsustainable nurse staffing shortage facing our country a national crisis. An increasing body of evidence shows appropriate nurse staffing contributes to improved patient outcomes. ANA continues to call for the Administration to acknowledge and take concrete action to address the current crisis-level nurse staffing shortage that puts nurses’ ability to care for patients in jeopardy. The pandemic has exacerbated underlying, chronic nursing workforce challenges that have persisted for decades. Our nation must have a robust nursing workforce at peak health and wellness to meet the needs of our nation today and in the future. Stressful work environments that often require nurses to care for too many patients coupled with mandatory overtime have contributed to burnout among many nurses even before the pandemic.
“ANA applauds the Biden Administration for using its full authority to increase our nation’s COVID-19 vaccination rate and put the pandemic behind us,” said Dr. Grant. “In addition, we look forward to working with them to address the underlying systemic problems of nurse staffing shortages that with the pandemic have created a national crisis for the nation’s nursing workforce.”
We have all seen the alarming headlines: Coronavirus cases are surging in 40 states, with new cases and hospitalization rates climbing at an alarming rate. Health officials have warned that the U.S. must act quickly to halt the spread – or we risk losing control over the pandemic.
I’ve researched the history of the 1918 pandemic extensively. At that time, with no effective vaccine or drug therapies, communities across the country instituted a host of public health measures to slow the spread of a deadly influenza epidemic: They closed schools and businesses, banned public gatherings and isolated and quarantined those who were infected. Many communities recommended or required that citizens wear face masks in public – and this, not the onerous lockdowns, drew the most ire.
In mid-October of 1918, amidst a raging epidemic in the Northeast and rapidly growing outbreaks nationwide, the United States Public Health Service circulated leaflets recommending that all citizens wear a mask. The Red Cross took out newspaper ads encouraging their use and offered instructions on how to construct masks at home using gauze and cotton string. Some state health departments launched their own initiatives, most notably California, Utah, and Washington.
Nurses assembling masks during the 1918 Spanish Flu pandemic. (source: Wikicommons)
Nationwide, posters presented mask-wearing as a civic duty – social responsibility had been embedded into the social fabric by a massive wartime federal propaganda campaign launched in early 1917 when the U.S. entered the Great War. San Francisco Mayor James Rolph announced that “conscience, patriotism, and self-protection demand immediate and rigid compliance” with mask-wearing. In nearby Oakland, Mayor John Davie stated that “it is sensible and patriotic, no matter what our personal beliefs may be, to safeguard our fellow citizens by joining in this practice” of wearing a mask.
Health officials understood that radically changing public behavior was a difficult undertaking, especially since many found masks uncomfortable to wear. Appeals to patriotism could go only so far. As one Sacramento official noted, people “must be forced to do the things that are for their best interests.” The Red Cross bluntly stated that “the man or woman or child who will not wear a mask now is a dangerous slacker.” Numerous communities, particularly across the West, imposed mandatory ordinances. Some sentenced scofflaws to short jail terms, and fines ranged from US$5 to $200.
Passing these ordinances was frequently a contentious affair. For example, it took several attempts for Sacramento’s health officer to convince city officials to enact the order. In Los Angeles, it was scuttled. A draft resolution in Portland, Oregon led to heated city council debate, with one official declaring the measure “autocratic and unconstitutional,” adding that “under no circumstances will I be muzzled like a hydrophobic dog.” It was voted down.
Utah’s board of health considered issuing a mandatory statewide mask order but decided against it, arguing that citizens would take false security in the effectiveness of masks and relax their vigilance. As the epidemic resurged, Oakland tabled its debate over a second mask order after the mayor angrily recounted his arrest in Sacramento for not wearing a mask. A prominent physician in attendance commented that “if a cave man should appear…he would think the masked citizens all lunatics.”
In places where mask orders were successfully implemented, noncompliance and outright defiance quickly became a problem. Many businesses, unwilling to turn away shoppers, wouldn’t bar unmasked customers from their stores. Workers complained that masks were too uncomfortable to wear all day. One Denver salesperson refused because she said her “nose went to sleep” every time she put one on. Another said she believed that “an authority higher than the Denver Department of Health was looking after her well-being.” As one local newspaper put it, the order to wear masks “was almost totally ignored by the people; in fact, the order was cause of mirth.” The rule was amended to apply only to streetcar conductors – who then threatened to strike. A walkout was averted when the city watered down the order yet again. Denver endured the remainder of the epidemic without any measures protecting public health.
In Seattle, streetcar conductors refused to turn away unmasked passengers. Noncompliance was so widespread in Oakland that officials deputized 300 War Service civilian volunteers to secure the names and addresses of violators so they could be charged. When a mask order went into effect in Sacramento, the police chief instructed officers to “Go out on the streets, and whenever you see a man without a mask, bring him in or send for the wagon.” Within 20 minutes, police stations were flooded with offenders. In San Francisco, there were so many arrests that the police chief warned city officials he was running out of jail cells. Judges and officers were forced to work late nights and weekends to clear the backlog of cases.
Many who were caught without masks thought they might get away with running an errand or commuting to work without being nabbed. In San Francisco, however, initial noncompliance turned to large-scale defiance when the city enacted a second mask ordinance in January 1919 as the epidemic spiked anew. Many decried what they viewed as an unconstitutional infringement of their civil liberties. On January 25, 1919, approximately 2,000 members of the “Anti-Mask League” packed the city’s old Dreamland Rink for a rally denouncing the mask ordinance and proposing ways to defeat it. Attendees included several prominent physicians and a member of the San Francisco Board of Supervisors.
It is difficult to ascertain the effectiveness of the masks used in 1918. Today, we have a growing body of evidence that well-constructed cloth face coverings are an effective tool in slowing the spread of COVID-19. It remains to be seen, however, whether Americans will maintain the widespread use of face masks as our current pandemic continues to unfold. Deeply entrenched ideals of individual freedom, the lack of cohesive messaging and leadership on mask wearing, and pervasive misinformation have proven to be major hindrances thus far, precisely when the crisis demands consensus and widespread compliance. This was certainly the case in many communities during the fall of 1918. That pandemic ultimately killed about 675,000 people in the U.S. Hopefully, history is not in the process of repeating itself today.
This article was updated to correct the location of sheriffs mentioned.
“Micro-clusters” of Covid cases are now the focus in New York City’s battle against the pandemic. After a devastating spring in which COVID-19 took over 20,000 lives across its five boroughs, city public health officials and legislators have taken the fight against the virus to the streets. The health department now monitors micro-clusters as they pop up in city neighborhoods. As zip code areas are too imprecise in a metropolis of nearly 8.4 million people, officials track micro-clusters block by block and shut down hotspots to choke off the virus before it has a chance to set the city on fire again. Using a “focus zone” system, the city enforces aggressive lock-down restrictions on gatherings and businesses in hotspot red zones, and when a red zone is densely populated, more moderate restrictions are imposed in adjacent orange or yellow “buffer zone” areas to isolate the hotspots and prevent the virus from spreading to nearby neighborhoods.
Governor Cuomo’s micro-cluster tracking strategy allows for flexible, rapid responses to sudden outbreaks. As Thomas Tsai, a health policy expert at Harvard’s T.H. Chan School of Public Health, explained to Stat News: “Social distancing policy is not an on/off switch — this is a dial that needs to be calibrated to the temperature.” In the same article, Ana Bento, a disease ecologist at Indiana University elaborated, “The idea is to… from what we know, create more efficient and evidence-based types of lockdowns. In different cities and in different states, these lockdowns may look very different from each other.”
In a city of nearly 8.4 million people—fertile ground for any epidemic—wresting control away from the virus entails a mammoth, intensive, and a constantly vigilant Test & Trace Corps comprised of doctors, public health professionals and community advocates. New York City currently has over 200 free COVID testing centers at hospitals, health centers, and pop-up locations located across all five boroughs. The state testing program has achieved considerable penetration, administering over 700 daily tests per every 100,000 residents. During August and September, 45-50,000 residents were tested every day, and since cases started to surge in late October, as many as 58,000 people have been tested in a single day (NYC testing figures).
NYC Mayor Bill DeBlasio explains the city’s Track and Trace system.
Positive cases and micro-clusters are monitored and aided by a team of over 4,000 contact tracers. Every day, the Test and Trace Corps sends about 500 COVID-positive New Yorkers a “Take Care” package with PPE and other equipment for a 10-14 day quarantine: a medical-grade mask, sanitizing wipes, hand sanitizer, thermometer, two at-home testing kits for contacts, and a pulse oximeter to monitor their oxygen levels. If they are unable to isolate themselves at home, those testing positive are provided with temporary quarters in a local hotel. At present, the Corps has a 98% compliance rate (i.e., in 98 out of every 100 positive cases the patients are complying with quarantine guidelines and staying indoors alone).
How has the city been faring in its block-by-block micro-cluster battle? With April’s images of refrigerated morgue trucks still fresh in their minds, many New York residents continue to accept the restrictions of social distancing, but exceptions are inevitable in a city containing a multitude of diverse neighborhoods and cultures. Like their counterparts all over the US, NYC officials are contending with “COVID Fatigue,” complacency, and expressions of heated resentment by residents and businesses in locked down neighborhoods. Overall, the zone-based lockdown program seems to be working, but the system may be sorely tested by the current surge and the approach of winter. “We’re all heartened at the fact that this is working,” Jackie Bray, deputy executive director of NYC Test & Trace Corps, told the Washington Post, but “We’re clear-eyed [about] how hard this is going to be to sustain through the fall and the winter.”
But is the system working? New York City cases more than doubled between November 2 and November 22. Governor Cuomo and Mayor de Blasio once again closed public schools on November 18, indoor dining is no longer permitted in the city (many argued that dining inside restaurants should have ceased earlier), and an emergency hospital has been reopened on Staten Island to reduce the pressure on other area hospitals.
Nurses who value evidence-based practice know that wearing a mask can help save lives—but it can be a trial to get the message across and overcome the reluctance of patients, family, and friends. Of course, patient education is often an uphill battle, but what nurse can resist the pull of that phrase “help save lives?” Amid the flurry of confusion and anxiety-fueled misinformation, nurses enjoy a public trust that allows them a unique opportunity to fulfill their role as patient educators. Here are some basic considerations and information sources to help you become a leader in the mask-wearing crusade.
I Wear an N95 Mask for Most of My 12-Hour Shift, and YOU’RE Complaining About Discomfort?
Nurses have been donning gloves and surgical masks for 100 years now. Present-day 3-ply surgical masks are lightweight and ergonomic, and prior to the pandemic, you probably did not spend much time thinking about them. When an epidemic strikes, though, out come the N-95s (albeit in insufficient numbers)! And frankly, if an N95 is part of your daily gear—if you are coping with the extra effort of inhaling through those layers, bruising from the tight fit, or worrying that weeks of use has turned your “disposable” burden into a biohazard—well, it can be pretty hard to listen to someone gripe about wearing a surgical or cloth mask. After all, wearing shoes can be downright painful, but most people do not decide to throw away their footwear and take up a barefoot lifestyle.
It might help to keep in mind that for a non-clinician, having to wear a face cover—and live in a community where most people are masked—is not just inconvenient and uncomfortable; it is a shocking, alienating experience. Refusing to wear a mask is irrational, but that irrationality is fueled by fear and is often kindled by resentment. The challenge is to soothe that primitive, shock-induced fear and instill a healthier sort of fear: “what you should be afraid of is catching the virus and/or infecting your family: here’s something you can do to protect them and yourself.”
You Know the Evidence that Wearing a Mask Saves Lives: Share It!
Just as AIDS taught us that wearing condoms can save lives, covid-19 is teaching us to wear masks to protect ourselves and our communities during a respiratory-based viral pandemic. Numerous studies have linked the use of face masks with lower rates of infection, including a new one from the CDC indicating that mask mandated and social distancing curbed the summer Arizona outbreak by 75%. We have also seen that even where there is extensive and regular testing, communities that frown on face masks are extremely vulnerable to COVID. In July, both the ANA and the AANP issued statements urging the public to heed the evidence and wear masks. Citing a June 27 Lancet article, AANP president Sophia L. Thomas said, “Research shows that wearing a mask results in a 65%-85% reduction in the wearer’s risk of contracting infections. Let us pledge to do our part to protect each other.” Some good sources to share include:
You can stay up to date on new evidence by creating a Google Alert or searching for “face masks study” and clicking “tools” and selecting “past month.” This short blog post from the AACN offers some valuable tips for evaluating sources: https://www.aacn.org/blog/going-viral-covid-19-and-the-internet.
Raise Awareness of the Masking Dos and Don’ts
A mask is useless if it is not worn and handled properly. People adjust their masks with exposed hands, let their masks hanging off their chins, neglect to wash cloth masks daily, and wear disposable masks the way many nurses wear N95s: for weeks on end, but without the sterilization steps you take with clinical PPE. Make sure people know the basic “do this; don’t do that” points of mask-wearing. The National Foundation for Infectious Diseases says:
Do—wear masks in public and around people outside your households
Do—wash cloth masks daily
Do—make sure your mask fits snugly from nose to chin (and keep it there)
Don’t—remove a mask in public if other people are within six feet
Don’t—use a scarf, bandana, or gaiter, or wear a mask with gaps or valves that let air in or out
Don’t—use a mask that is soiled, damaged, or torn
For those who prefer audiovisual information sources, you can share the link to this excellent two-minute video by St Louis University infectious disease expert Timothy Wiemken (URL: https://cdn.field59.com/STLTODAY/38b9541d3110d1ea70e72ef8168c56270361d1d0_fl9-1080p.mp4). One of his key messages is “if you’re wearing a mask, the first thing you want to do is wash your hands.” He also offers advice on donning a mask, handling, and cleaning.
Tis the Season to… Wear a Mask
Now that we are on the cusp of peak coronavirus season—and with Covid infections spiking around the country and the world—it’s time to remind people to be mindful and educate the misinformed. The onset of Fall/Winter weather is already thinning the ranks of patrons at the ad hoc sidewalk cafes that added a European flavor to so many US cities this past summer. Most al fresco activities are slacking off as the air chills, and as we spend more time indoors we ease the path of those infamous “crowned” viral particles. As a recent Stat article on Covid-19 and cold weather notes, “Studies show significantly more infections happen and spread when the relative humidity falls from between 40% and 60% — a range typical in warmer weather — to 20%. That research draws from past outbreaks of flu and MERS, which is caused by another coronavirus.”
An October MIT Technology Review article remarked that as yet, the virus has no established weather-based patterns: “the infection… peaked in some US cities, such as Boston, when temperatures were in the 40s and in others, such as Houston, when they were in the 90s,” but “epidemiological research from MIT, Harvard, Virginia Tech, and the University of Connecticut suggests the coronavirus likewise is more infectious in low relative humidity—anything below 40% will help the virus thrive. That’s bad news for most of the US, where relative humidity routinely drops as low as 15% on the coldest days, compared with typical indoor relative humidity of 50% to 70% in the summer.” As cases during the latest surge mount, we need to spread the word that by wearing a mask—and wearing it properly—is an essential component of a happy 2020 holiday season.
Nursing care coordinators today are asked to do much more with less in managing the health of high-risk and chronically ill patient populations. The COVID-19 pandemic adds another layer of complexity to this already difficult job.
Nurse care coordinators have always been responsible for managing large caseloads of chronically ill patients. The goal is always to help them improve health. So, what has changed since the COVID-19 pandemic began?
During this time of pandemic and resulting economic constraints, nurse care coordinators can expect to be called upon to manage larger, more complex caseloads with fewer resources.
The value that nurse care coordinators deliver now is measured by much more than reduced cost of care, patient satisfaction, and better outcomes related to chronic disease management, although those measurements are significant.
Today, value is also measured by how quickly the nurse care coordinator assesses the chronically ill for additional or changing socio-economic issues and community health care inequity due to the COVID-19 pandemic. Value also is measured by the expediency with which action is taken to facilitate resolution for a larger and more complex case load.
Crucial interventions
The impact of COVID-19 on communities served by nurse care coordinators becomes even more critical where chronic disease and health care inequity exists and social determinants of health (SDOH) are not favorable.
Due to reductions or closures, some patients sheltering in place are becoming disconnected from community agencies and services that once served them. Others are experiencing a new life event – such as the loss of work, income and health insurance.
Nurse care coordinators have their fingertips on the pulse of available community resources and can quickly make those often life-saving connections.
Web-based care coordination technology tools are available that help health care organizations coordinate care for high-risk patients across the care continuum and support electronic collaborative communication between the nurse care coordinator and the patient’s primary provider at the point of care, regardless of the electronic health record used (EHR) or location.
These tools can enable organizations to move to value-based care, manage total population health, ensure appropriateness of care across all care settings, and achieve high-quality outcomes.
When managing high-risk and chronically ill patient populations, it is imperative now to quickly reach out to those patients and screen them for actual COVID-19 exposure, potential risk of exposure, and educational needs related to COVID-19 risk, to ensure that time-critical management occurs.
How to guide high-risk patients
Effective screening requires evidence-based assessments that lead to the development of actionable evidence-based care coordination care plans. These care plans can help address the additional health, SDOH, financial and educational needs of high-risk patients.
There are a range of important questions to ask that can be linked to workflows that uncover SDOH challenges for patients. These questions are important for guiding high-risk patients in a manner that helps prevent and manage exposure to COVID-19.
Some of those questions are:
Are you experiencing a decrease of income to cover current expenses?
Have you experienced a job loss?
Are you currently sheltering in place?
Do you have a safe place to shelter?
Do you have access to food and meals?
What support systems do you have?
Do you have medications readily available for the month?
Do you need any additional medication resources?
The response to each of these questions may require the nurse care coordinator to complete one or more actionable care plan interventions to resolve an identified problem. This may require collaboration with a patient’s primary provider, health plan, health system, community agency, support system and extended care team.
Standardizing the care coordination process leads to better outcomes. Consistently engaging and linking patients to high-quality community resources, health care providers, services, and care team members can also reduce the cost of care, reduce health care inequity, and improve patient satisfaction.
That’s a great value to the patient, community, and health care organization.
