Nurse Believes Big Island Hospital’s Policies Could Spread COVID-19March 25, 2020, 6:47 PM HST (Updated March 25, 2020, 6:47 PM)
A 20-year veteran of Hilo Medical Center is concerned that a lack of personal protective equipment, coupled with what she described as unsound hospital policy, could turn a facility on the frontlines of the COVID-19 pandemic in Hawai‘i into an epicenter for its spread.
Diana Machado first started working at HMC in 1999. She is currently employed as a registered nurse in the surgical pediatric department, which she said has been designated the “COVID-19 patient holding ground” since the hospital began preparing system-wide for an outbreak of the virus on the Big Island.
But the hospital’s preparations, both logistically and as they regard physical resources, aren’t doing enough to protect HMC personnel or its patients from the disease, Machado contended.
“Hospital staff, from what I’m seeing, are the ones who are going to be spreading (COVID-19) once it becomes a real issue,” Machado said. “The fear is we are going to become carriers into our own families.”
HMC protocol in the past has been one surgical mask per patient visit, after which that mask was discarded. Now, healthcare workers are using the same mask for an entire shift and often for several days at a time.
After the news that COVID-19 cases were confirmed in Hawai‘i, hospital administration confiscated every mask off of every floor, holding them under “lock and key,” Machado said.
To procure fresh personal protective equipment (PPE), nurses must make a request of the nurse manager on the floor, who then calls the nurse supervisor, who then must approve the request and travel to the floor with a new mask.
“Due to a worldwide shortage of PPE and massive disruptions in the supply chain, and in order to preserve our current supply, we have had to secure our PPE supplies and carefully distribute them as needed,” Hilo Medical Center said in a statement to Big Island Now on Wednesday.
“At this moment in time, we have enough PPE to care for our patients,” the hospital continued. “What we cannot be sure of is the future supply, so that is why we are starting conservation measures now.”
Treatment of potential COVID-19 patients at HMC began with the following PPE available to all personnel in all interactions: gowns, gloves, N95 masks and eye protection. The same level of PPE is still being used for aerosol-generating procedures such as intubation and respiratory treatments.
Personnel is now being advised, however, to use a regular mask instead of an N95, eye protection and gloves for routine care.
“We started off with a much higher level of PPE than what is currently being used,” HMC said. “We now know that the main way the illness is spread is by respiratory droplets and relatively close contact of 3-6 feet.”
Machado contended the hospital’s definitions of risk and spread have changed based on the level of PPE it can provide, resulting in “watered-down” safety criteria that have robbed more and more personnel their access to PPE.
“We were told this is an airborne virus,” she said. “Now it’s a droplet virus that requires less protective mask cover.”
According to current HMC policy, masks are only swapped out if they are visibly soiled or soaked with an employee’s “sweat, saliva or whatever else,” Machado said.
“Following current CDC guidelines for PPE conservation, everyone is instructed to wear the mask until it is no longer protective,” the hospital said. “No longer protective would include, but is not limited to: Excessively moist, soiled, contaminated or has lost its integrity.”
As for how long frontline responders wear used equipment on average, HMC said durations vary.
“There is not a specific time period a mask is used for. How long a mask lasts will vary by use,” the statement said. “Current practice is not ideal, but due to the shortage of PPE and the real risk of running out, we have been put in this position to reuse PPE.”
The extra danger at which this places hospital personnel and the patients they treat remains unknown, HMC said.
“The risk cannot be quantified,” HMC wrote. “There are no studies on prolonged use of PPE.”
The hospital added that mitigating measures such as frequent hand washing, not touching the mask itself and storing used masks in plastic bags have been implemented to manage the potentially increased risk of infection.
Machado said PPE access has gotten scarce enough that hospital personnel have been advised to make their own masks at home or solicit private donations.
She added that healthcare workers are not provided masks unless they’re headed toward direct interaction with a potentially infected patient. HMC said that statement is not entirely accurate.
“Employees are issued a mask if their patient assignment includes a case which would require a mask,” the hospital’s statement said. “There are … conditions other than COVID-19 where mask use is indicated.
“Those with no immediate contact with patients are not at risk.”
So far, the hospital has been right. The policy hasn’t yet proved a health risk, as no HMC employees have tested positive for COVID-19 as of Wednesday, March 25.
However, the hospital has not confirmed any cases of the virus in its patients through on-site testing. This could mean COVID-19 has not yet presented inside HMC facilities, and the hospital’s policies have yet to face their toughest tests.
Currently, masks that are used during the treatment of potentially infected patients are also being re-used, as long as they are stored in the room where they were first used.
“Just having to re-use those masks poses a lot of risk right there,” Machado said.
Machado believes because of this practice and others, that it’s only a matter of time before what she says are inadequate policies come back to hurt HMC employees and patients in meaningful ways.
“So far, we’ve had patients testing negative,” Machado said, “but it takes up to four or five days to know the results of a test. We are basically exposing ourselves to those patients with very little protection.”
That exposure, she continued, is putting other patients and the families of HMC nurses and doctors at considerable risk.
If and when healthcare workers at HMC contract COVID-19, Machado believes the virus will spread through the ranks like wildfire.
“It is inevitable that workers will get sick, it’s just a matter of time,” she said. “We’re very ill-equipped. We have this lockdown, this social distancing in public, but that changes the instant we step into the hospital. We’re gathering together at nurse stations. We’re not protecting patients against what we might be carrying.”
Beyond patient health, Machado said she’s concerned about the families of healthcare workers. Public school facilities in Hawai‘i are shut down until at least April 30. The cost of childcare outpaces many people in the state, including a significant percentage of healthcare personnel.
As a result, children are at home during the day. During working hours, many of her colleagues’ children are staying with their grandparents, Machado said.
Thus, keiki are exposing the elderly — the most vulnerable age demographic to COVID-19 — through prolonged intimate contact.
“The time is coming when we’ll have an influx of patients all positive for COVID-19, all exposed,” Machado said. “We’ll be trying to quarantine a nurse at home when she has young kids. That won’t work, but no one (at the hospital) is exempt from caring for (potentially infected) people.”
Machado went on to say that hospital administration has been slow to respond to common sense suggestions from its staff about other measures to keep healthcare personnel and their communities safe.
“They’re ignoring frontline workers,” who have asked for new scrubs upon arrival for shifts, a place to shower before they return home and lodging options for those willing to quarantine themselves from their families for the duration of the outbreak, Machado said.
“We are working on processes for all the things mentioned here,” HMC responded. “Hospital scrubs laundered (on-site). Showers for employees. A place for employees to stay if they do not wish to go home.”
The hospital has also begun posting staff at the front door who screen patients and employees for signs of COVID-19.
“We would not turn someone away because we thought they had COVID-19 and needed medical attention,” HMC explained. “That being said, not all people sick with the illness would require hospitalization. Most do not. Employee screening is part of our process.”
Sentinels ask those entering the building if they’re congested, have a cough or have a fever. If any of those symptoms present in employees, they’re supposed to be sent home, Machado said.
“One day, I was congested and had intermittent coughing,” she continued. “I was handed a mask and told to go to work.”
Testing and worker’s compensation
Finally, Machado said the hospital is not providing COVID-19 testing for its workers — a contention with which HMC also took exception.
“Testing is based on criteria. Testing asymptomatic individuals has little to no value,” the hospital said. “We would test anyone who is at risk of having the illness, including employees.”
Machado disputed that claim, saying she was sick enough to warrant a test from Kaiser-Permanente after the hospital refused to provide her with one based on its definition of a lack of criteria. Her results came back negative for the virus.
Worker’s compensation claims for missed work, due either to a positive COVID-19 test or quarantine time while waiting for results, are examined case-by-case, HMC said.
It would have to be proven that an employee contracted the virus during the normal course of professional duty for a worker’s compensation claim to payout.
“If an employee contracts COVID-19 on the job, the expectation is that our staff will go home to recover until (they are) well enough to return to work,” the hospital wrote. “Employees can file for worker’s compensation and a case will be opened to review and determine if the worker contracted COVID-19 on the job.”
When asked if the administration felt hospital policies were inadequate to protect employees, patients and surrounding communities, HMC said, “This situation is unprecedented. We are doing our absolute very best with the resources currently available to plan for this.”
“We would never purposely jeopardize the health of our employees, our patients (or) the public,” the hospital continued. “This is an extreme situation, which has caused us to look at healthcare delivery in a very different way. … Everything we are doing has been thought out to the best of our abilities using all the best information and resources currently available.”
Machado disagreed, adding she was disillusioned by the fact that she’s reached out to the office of Hawai‘i County Mayor Harry Kim, the state Department of Health, her own nurse’s union and HMC’s Human Resources Department and found no urgency within any of the four agencies as related to her claims and concerns.
“We’re acting like we’re doing something,” Machado said, “but were’ ill-equipped and doing things without having any common sense behind them.”
Hilo Medical Center is accepting donations of PPE at its Human Resources Office, which is located below the hospital on the corner of Waianuenue Avenue and Rainbow Drive.