Hospital Staffing Disruption COVID-19

It is inevitable that as COVID-19 spreads in the community, hospitals and other healthcare providers will experience staffing disruption. Our doctors, nurses, aides, technicians, and other medical staff are on the frontlines, providing direct patient care to those with suspected COVID-19 and to other patients who still need medical treatment during this time.

The CDC has issued recommended work restrictions and monitoring for healthcare personnel (HCP) exposure to COVID-19 patients. As of March 13, 2020, the CDC recommends that hospitals exclude HCP with medium- and high-risk exposures from work for 14 days from the latest exposure and report the exposure to the local public health authority for active monitoring. However, the CDC has recognized the significance of clinical judgment, and coordination with local public health officials, with respect to staffing decisions.

There are three exposure categories based on an HCP’s contact with a COVID-19 patient: (1) high-risk; (2) medium-risk; and (3) low-risk. The category varies, depending on whether the COVID-19 patient was wearing a mask, whether the HCP was wearing appropriate PPE, and the length of exposure.

a.) Continuity of Patient Care

As the outbreak continues, hospitals should work with their local public health authority to establish a realistic, reasonable policy for protecting patients and HCP while ensuring continuity of care. The CDC notes that hospitals may need to allow asymptomatic HCP with exposure to a COVID-19 patient to continue working when staffing options are exhausted, and provides some guidance:

• The HCP should report temperature and absence of symptoms prior to each shift.
• The HCP should wear a facemask while at work for 14 days after the exposure, if there is a sufficient supply of facemasks.
• If the HCP develops symptoms of COVID-19, even mild symptoms, they must stop performing patient care services, notify their supervisor, and leave.

Ultimately, hospitals must use their clinical judgment in conjunction with the CDC’s guidelines to assign risk levels, which are one factor to consider in determining whether an employee should return to work. This is a fluid process and the one-time assignment of a risk level does not permanently determine whether the HCP will continue to work. Re-exposures are likely and staffing needs vary by shift, so whether a certain staff member should return to work must be reevaluated each shift.

Hospitals should consider several factors when evaluating whether the HCP in question should return to work: hospital need, time since last exposure, type of patients treated, and the nature of contact with COVID-19 patient. These factors will evolve as we learn more about the virus and which factors are most significant will also depend on the healthcare setting.

b.) Precautions to Protect HCP

To protect HCP and ensure sufficient available staff to treat patients, hospitals should also consider taking precautions prior to even encountering a COVID-19 case. For example, hospitals should considering providing patients with masks who present to the ED with signs and symptoms of respiratory illness. If the patient is wearing a mask, then the risk category will be lower for HCP encountering the patient, even without all of the recommended PPE. Hospitals may also consider requiring its HCP to wear eye protection in addition to masks when encountering patients with symptoms of respiratory illness, even if eye protection is not ordinarily required.

c.) Identifying HCP Most At-Risk

In preparing for a disruption in staffing due to COVID-19, hospitals should consider the HCP most likely to encounter risky exposure because of their job duties and make arrangements to supplement those positions. The CDC elevates the risk category for extensive body contact with a patient, like rolling the patient. Patient care technicians are routinely in close contact with patients for prolonged periods as they assist patients with personal hygiene and grooming, and take vital signs. Likewise, radiology technicians performing portable x-rays will necessarily come into prolonged, close contact with the patient while positioning for x-ray. The CDC also elevates the risk category if the HCP performed or was merely present for a procedure likely to create more respiratory secretions, like sputum induction or nebulizer therapy. Respiratory therapists are likely to encounter higher risk exposure.

With this knowledge, hospitals should reach out to staffing agencies or find other avenues to supplement their ancillary staff. Further, ancillary staff generally are not confined to one part of the hospital and perform services across all types of patients. Hospitals will have to use their clinical judgment to determine in conjunction with their local public health authority how to balance the protection of patients and HCP while ensuring that services are provided to patients in need.