By Marzieh Eghtesadi, MD

Over the Easter long weekend in April 2020, I offered my support as a physician to help  long term care (LTC) facilities, previously unknown to my practice, facing high mortality from Covid-19. Amongst risk factors previously reported about cross contamination, movement of health care personnel across various facilities was also prevalent in the  LTC setting.⁽¹⁾ However, I had the opportunity to witness other critical contributing factors that likely set up these facilities for poor outbreak control. These included mistrust towards institutional authority by healthcare workers who felt inadequately protected, as well as worker exhaustion from overtime, specifically for nursing staff.

Considering that, in many places globally, health authorities are gradually reopening public establishments and the possibility of a second wave of infection, the risk factors described in this paper may help improve healthcare management and patient outcome in  LTC facilities.

Like many countries facing the pandemic, Canadian health care facilities have not been spared from shortages in personal protective equipment (PPE). This has resulted in more stringent institutional guidelines for their use, for instance in procedures involving high risk of aerosol generation. There have even been situations where  health authorities have  prohibited the use of PPE, for example N95 masks, the reasoning being that viral exposure is likely minimal in LTC facilities. However, despite recommendations from public health experts, I realized  many frontline workers in LTC facilities did not share the view their risk of exposure to Covid-19 was negligible. This caused frustrations within staff when N95 masks became scarce and their use prohibited. For these workers, their unshakeable conviction lives were in danger could in part be explained by the large number of casualties they witnessed. Although patient deaths witnessed in LTC facilities were deemed as collateral damage of  Covid-19, it was evident the high death tolls had caused psychological distress in these frontline workers. Even though significant mortality was expected in the elderly infected in LTC facilities, this was extremely difficult for healthcare workers to witness. I believe institutional authorities  failed to see an expected complication of Covid-19 did not translate into an expected subjective reaction by healthcare providers; in fact, it is possible for workers in LTC facilities these deaths were a traumatic event, with risk of long-term psychological sequelae. In that manner, despite the urgency for health authorities to instate efficient ways of allocating PPE, which included prohibiting their use in select settings, I believe more efforts could have been made to communicate the rationale behind certain decisions. For instance, a platform for healthcare workers to voice their concerns could be instated, instead of using means of unidirectional communication with authoritarian instructions. This would imply that local institutional authorities commit time and resources to engage in dialogue and reassure their healthcare providers that they are not simply pawns to be deployed, without adequate protection, and that their lives matter.⁽²⁾ Amongst the concerns brought to my attention, some felt a sense of injustice, fearing PPE was diverted to protect “more valuable” workers, for example in highly specialized tertiary care centers. Therefore, simply instructing them to not wear N95 masks had generated more fear than reassurance. Open dialogue can improve communication about  aerosol generating procedures, distinguishing, for example, the lower risk with conventional oxygen therapy from the higher risk of high flow, humidified, heated oxygen. Institutional authorities must show appreciation for the clinical judgement of their staff, reassuring them that even scarce PPE would be made available for high risk situations, including  LTC facilities. This can lead to improved healthcare provider compliance with guidelines, therefore discouraging inappropriate behaviors like personal stockpiling, which likely contributed even more to PPE shortage.

Another setback I observed was nursing staff working overtime. Effective use of PPE requires great vigilance and frequent shift rotation to avoid cross contamination. Previous studies have shown increased patient mortality and care tasks left undone with higher patient-to-nurse ratios and overtime shifts over 12 hours.^{(3, 4)} For healthcare workers exhausted from supplementary hours, the burden of repetitively donning and doffing PPE can lead to mistakes in rigorous protocol conformity. Moreover, there was team instability, given many workers were quarantined or in self-isolation, which led to repatriation of retired and possibly less experienced staff on infected units. Lack of stability of familiar staff can lead to cross contamination, as in previous health outbreaks with inexperienced staff, particularly during doffing of PPE.^{(5, 6)}

When considering my own hesitations upon entering these Covid-19 LTC facilities with poor control of pandemic outbreak for the first time, I realize that fear should not guide our response to help. On the contrary, for those of us whose clinical activities have been significantly reduced to redirect essential services to Covid-19, we should, even if minimal, offer coverage in these LTC facilities, to alleviate workload and allow local teams recuperate. I encourage us all to find comfort, strength and resilience amongst each other, realizing that this pandemic is a new challenge for everyone.

Adding to staff exhaustion, much stress and distraction was caused to nursing staff answering phone calls by distressed family members of isolated patients. It was not unusual for nurses to take time to cry in hiding during their breaks. They cared directly for patients, but were required to also handle these difficult calls, often threatening lawsuits and complaints, making it difficult to provide conscientious patient care and stay  focused on PPE protocol. While awaiting national guidance about compassionate care for the families of isolated patients, I encourage management to designate an experienced staff member to answer these calls, on every Covid-19 unit, as soon as there is restriction for visitors.⁽⁷⁾ This would unburden nurses from the emotionally exhausting task of communicating with distressed and mourning family members.

Finally, in regards to disease cross contamination by non-medical staff, I realized maintaining correct protocol precautions required improved training of housekeeping staff. Indeed, due to concerns of  Covid-19 infection, sanitation staff initially believed, for example, that garbage and PPE disposal bins should be placed far away and outside patient rooms. Given PPE doffing should be done inside infected patient rooms, this could lead to healthcare workers cross-contaminating sterile areas on their way to  remotely placed disposal units.

There may have been several reasons why housekeeping personnel were not following proper protocol, including that they were not included in certain hospital communications or poor understanding of constantly evolving pandemic guidelines. In relation to the latter, there has been an overwhelming quantity of communications sent out by various public health authorities, requiring all healthcare staff  dedicate significant time to stay up to date with contingency guidelines. It would be unreasonable to expect staff who are less fortunate (compared to physicians for example) to invest so much extra time unpaid, outside of working hours and away from their families, if they feel financially undervalued.

In conclusion, the global Covid-19 pandemic has tasked public health authorities with the heavy responsibility of protecting individual rights, while ensuring collective safety and guiding allocation of scarce resources and material. This should not translate into abrupt policy implementation, especially within LTC facilities hardest hit by patient deaths and where staff are vulnerable to suffer psychological distress. Public health and institutional management authorities should maintain open communication with all frontline healthcare workers, including those in LTC facilities, who bring a unique perspective in facing the pandemic. Healthcare staff must also take part in decision-making, especially when urgent measures are implemented,  to alleviate fear and improve compliance. Finally, the value of every individual from the healthcare workforce must be recognized; this requires  health institutions to ensure, both towards medical and non-medical staff,  that conditions are safe, humane and financially-compensated.

References

1. McMichael TM, Currie DW, Clark S, Pogosjans S, Kay M, Schwartz NG, et al. Epidemiology of Covid-19 in a Long-Term Care Facility in King County, Washington. The New England journal of medicine. 2020.
2. The L. COVID-19: protecting health-care workers. Lancet. 2020;395(10228):922.
3. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Jama. 2002;288(16):1987-93.
4. Griffiths P, Dall’Ora C, Simon M, Ball J, Lindqvist R, Rafferty AM, et al. Nurses’ shift length and overtime working in 12 European countries: the association with perceived quality of care and patient safety. Medical care. 2014;52(11):975-81.
5. Tomas ME, Kundrapu S, Thota P, Sunkesula VC, Cadnum JL, Mana TS, et al. Contamination of Health Care Personnel During Removal of Personal Protective Equipment. JAMA internal medicine. 2015;175(12):1904-10.
6. Lim SM, Cha WC, Chae MK, Jo IJ. Contamination during doffing of personal protective equipment by healthcare providers. Clinical and experimental emergency medicine. 2015;2(3):162-7.
7. Wakam GK, Montgomery JR, Biesterveld BE, Brown CS. Not Dying Alone — Modern Compassionate Care in the Covid-19 Pandemic. New England Journal of Medicine. 2020.

Author contact details:

Marzieh Eghtesadi, MD, Associate professor at Centre Hospitalier de l’Université de Montréal, Canada
marzieh.eghtesadi@mail.mcgill.ca