Health care providers testing and caring for patients with COVID-19 symptoms are on the front lines of the pandemic, potentially putting their own lives at risk while trying to get a grasp on the growing crisis. Across the nation, their mission to provide patients with reliable care is becoming an increasingly difficult one as hospitals and clinics confront a limited supply of tests and protective gear, and scramble to preserve their most important resource — trained professionals — by keeping their staffs healthy.
In response to the growing strain brought on by the pandemic, providers are coming up with new workarounds when the normal protocols, like seeing patients in person, have become fraught with risk. Meanwhile, how health care institutions approach potential cases of COVID-19 is entirely dependent on what resources they have at their disposal — a dilemma that may spur innovation, born of tough choices.
“Unfortunately, what supplies we have really dictates our clinical decision-making, which is not how you ever want things to be, right? You want to have sound clinical decision-making and then have the supplies to meet that decision-making,” said Shoshana Aleinikoff, medical director of HealthPoint Midway in Washington state. “But we’re operating in this reverse system where the decisions we’re making about who to test are really directly dependent on whether or not we have the right equipment to do the testing.”
That kind of clinical decision-making is particularly dire in places like New York City, currently the deadliest virus hot spot in the United States, where local guidelines recommend prioritizing testing for hospitalized patients given the “critical shortage” of collection swabs and other supplies needed to transport tests.
On the other side of the country, at Aleinikoff’s community health center located just outside of Seattle — the metro area where the first case of COVID-19 in the U.S. was confirmed in late January — clinicians adapted by conducting telehealth appointments over the phone to advise their patients, some of whom are instructed to come in for testing.
Initially, given their limited number of tests, her staff focused their efforts on those with serious respiratory symptoms or who fell into high-risk categories due to their age or other underlying health conditions. The testing process, Aleinikoff said, is the same as conducting routine blood work.
“The only difference between the normal labs [and the ones] that we’re doing is that we’re wearing full protective gear,” Aleinikoff said. “And we’re actually doing these tests in a tent outside in our parking lot just to take extra precautions for our staff’s safety and trying to reduce any possible spread in our clinic.”
When potentially infected patients arrive, staff members greet them at the door and ask most patients to wait in their cars to be tested inside tents that have been set up in the parking lot. A small number of patients who need to be seen by a physician are brought into a specific waiting room that’s isolated from other patients who aren’t presenting respiratory symptoms.
By mid-March, Aleinikoff and her staff had “very limited test supplies” with “no signs” that they’d get more anytime soon. But just a few days later, the network that includes her clinic received hundreds more tests from the federal government. Now, HealthPoint Midway has been testing around five to 10 patients per day, a rate that she believes her staff will be able to maintain — if not ramp up — in the coming days. For now, they will also be able to test more people who are presenting symptoms, not just those who are very ill or who fall into a high-risk category.
In downtown Seattle, health care providers at the University of Washington Medical Center have taken a very different approach to COVID-19 testing. Researchers there have developed their own test for the virus so that they could get quicker results. When tests were solely available through the Centers for Disease Control and Prevention, patients waited three to five days to get a diagnosis.
Using its own tests allows the center to check “a much larger portion” of the people coming in and get results back within 10 to 12 hours. Other tests, when available, can take several days to render results.
“We’ve gone from essentially testing only people who were the sickest patients or somebody who had no contact or travel to China,” Seth Cohen, a physician at the UW Medical Center, said. “Now, we’re essentially testing most people who are coming in with respiratory symptoms.”
That’s important given the wide range of severity for COVID-19 cases. Testing anyone with symptoms, from those with mild potential cases that resemble a common cold, to those who have been hospitalized, allows for better data collection and understanding of how this virus can manifest in different people. In South Korea, their widespread testing is believed to have stemmed the spread, and contributed to relatively low death rates from COVID-19 in that country.
Cohen and his team share the concern that health care workers could be “disproportionately affected” by COVID-19, and that the virus has the potential to “spread rapidly through a hospital” between health care workers and clinics. Testing in an exam room is also a time-intensive process, given the need to disinfect surfaces in between patients. Their solution: A drive-thru clinic set up in the hospital’s parking garage — an ideal location given its good ventilation and shelter from the elements — to test any staff or students associated with the University of Washington medical system in hopes of keeping everyone safe.
“If they test negative, we can get them back to work so that we don’t have as many issues with staffing shortages,” Cohen said. “But if they test positive, we want to make sure that they are away from the hospital and home so that they are not spreading it to their colleagues or to our patients.”
The University of Washington health system has tested over 2,000 staff members, about 4 percent of whom have tested positive for COVID-19. In mid-March, a separate drive-thru testing site was opened to serve patients who already have “established medical care” in that system, as opposed to members of the general public. Cohen said that so far, between 7 to 10 percent of that population has tested positive for the virus.
Cohen said that his biggest concern as the crisis goes on is making sure his medical system has enough doctors and nurses to care for patients and enough hospital beds for everyone who needs them, including those who don’t have COVID-19. He and his staff are thinking now about “potentially creative solutions” in case there is a surge in the number of patients in need of care for severe cases of the virus.
In a hopeful sign, last week marked the first time there was a decline in patients that were hospitalized for COVID-19 symptoms in Washington state since February, when community spread was first reported in the state.
Two states away, registered nurse Jamille Cabacungan is treating patients at the University of California – San Francisco Medical Center. She said her experience so far has been “anxiety inducing,” particularly because she and her fellow nurses were not told in advance when their first COVID-19 patient arrived to receive care in early February.
“These patients came to our unit and we had no training [and] no awareness at all before coming to shift. I know the nurses’ union [and the] California Nurses Association alerted the university to, kind of, give us a heads up,” Cabacungan said. “This was a good five days before the patients came, and there was no communication from UC.”
Although her employer has since provided staff with more training to care for COVID-19 patients, Cabacungan still doesn’t feel that those measures are sufficient. All hospital staff have been trained in how to utilize personal protective equipment like N-95 face masks, face shields and goggles, but she believes that, given the heightened anxiety of a new pandemic, additional “hands on training” and clearer communication from the university would have helped nurses feel safer and more prepared.
Cabacungan is also concerned about the CDC’s decision to relax guidelines for health care professionals who are responding to this crisis. She said that she and her colleagues have to “fight” to access personal protective equipment, and that they’ve begun reusing face shields and masks.
They have also created a voluntary list that allows nurses to select “yes” or “no” when it comes to being assigned to patients who do, or do not, have COVID-19, taking into consideration factors like whether those nurses have elderly parents or young children at home, or are pregnant. They’re taking it upon themselves, she said, to make sure nurses are safe and that appropriate assignments are being made in their unit.
Back in the Seattle area, as the pandemic continues to grow in the U.S., Aleinikoff and her colleagues are now determining how they’ll continue to meet the needs of their community — including those who have medical needs separate from COVID-19 — while potentially facing a smaller staff due to public health measures put in place to reduce spread.
So far, though, none of the staff members at any of the clinics in her network have tested positive for the virus. Staff are also now screened before they come into work each day by a greeter who checks their temperature and asks if they are experiencing any symptoms associated with COVID-19. They then receive a sticker on their badge verifying that they’ve been screened that day.
HealthPoint Midway is now conducting most visits over the phone, and the small number of patients who do need to come into the clinic are separated from those who are presenting respiratory symptoms.
“The large majority of our patients are having virtual visits,” Aleinikoff said. “[We are] really trying to limit the number of both staff and patients who come into our building on any given day.”
Suzanne Laurel is the medical director at HealthPoint Auburn, another clinic in Aleinikoff’s south Seattle network. Her staff has turned the vacant second floor in her building into what they’re calling their “respiratory clinic,” allowing them to separate potential COVID-19 patients from those who are seeking medical care for other reasons.
Laurel said she and her staff are conserving their personal equipment possible in anticipation of a likely shortage down the road. They are reusing masks when possible and disinfecting gloves and goggles rather than using disposable ones. They have also ordered launderable white coats for providers to wear, given the shortage of protective gowns.
Thinking about the next few weeks or months can be “overwhelming,” Laurel said. But every day, she and her staff meet for daily briefings to discuss the latest updates on COVID-19 and regularly go over reminders of best practices for using personal protective equipment, washing hands thoroughly and other important measures to reduce their chances of infection.
“I have utter confidence that the health care workers that I work with are here for the long haul and ready to take care of whoever comes in, no matter their ability to pay for a test, regardless of their illness status. It’s what we’ve always done here in community health centers and [what] we’ll continue to do,” Laurel said. “I just hope that we will get the resources we need to be able to do it safely for our staff.”