Last week, nurses and staff at Providence Sacred Heart and Holy Family hospitals shared their concerns for their own safety and that of their patients, as the hospital system worked to restrict the use of personal protective equipment that's in short supply globally.
Though their concerns were grim, none of the nurses from Spokane's Providence hospitals who spoke with the Inlander were willing to share their names publicly, for fear of losing their jobs. In other systems, including one in Bellingham, Washington, health care workers who've expressed concerns with the way their employers are handling COVID-19 have been fired.
All the nurses who spoke with the Inlander shared that under conservation efforts, Providence has put its N95 high-filtration masks under "lock and key," only to be used during the highest-risk respiratory treatments. Significantly more effective than surgical masks, the N95 masks have been shown to effectively filter the novel coronavirus.
Workers are being asked to use those N95 masks multiple times with the same high-risk patients (those with respiratory symptoms, for example), with normal surgical masks being worn during other times of the day, and staffers are being asked to use the same mask all day if possible.
Significantly, nurses were not allowed to bring their own masks if they had them at home, or use homemade face masks being donated by the community.
That last part has since changed.
After we first reported this news on Inlander.com last Thursday, March 26, Providence sent out a news release on Monday to announce it would allow nurses to bring in their own masks if they have them, or use cloth masks when dealing with patients who don't require "isolation protocols."
For those isolated patients, including those with COVID-19 symptoms, the policy remains the same, and nurses need to receive an N95 mask and other equipment from a centralized location at their hospital, according to Providence.
"We need to reiterate that the conservation measures we've taken are due to the global shortage of personal protective equipment (PPE)," Providence's news release states. "Providence has followed federal health care authority guidelines to keep our caregivers safe while at the same time, looking ahead to ensure we have enough supplies to handle a potential patient surge."
Still, the concern remains for nurses who worry that both symptomatic and asymptomatic patients may expose them to the virus in their daily work, and the workers may then spread that to their patients and families.
"Even with all the equipment on, we still don't feel it's adequate," one nurse says. "Guidance says the N95 is what you should wear. To have my organization say, 'No, the surgical mask is fine,' we're very doubtful we're being protected."
CONFUSING POLICY
Leading up to this week, the mask policy was changed several times, the nurses report, with unclear reasoning.
For example, when some industrial N95 masks were donated to Holy Family last week, they were handed out to patients with respiratory symptoms while they sat in a common area in the ER waiting room. Nurses weren't allowed to use them.
"The facility is not letting us use them because we have not been trained or fit-tested for them," one nurse said. "It's disconcerting that people are trying to get us supplies and we're not able to use them."
Providence spokeswoman Jennifer Semenza confirms the system is conserving masks and PPE and notes that it is also following guidance for protection issued by the Food and Drug Administration and the Centers for Disease Control and Prevention. However, she writes that the N95s were not held back due to fit-testing issues.
"Fit tests for N95 masks are continuous," Semenza writes. "The issue was not about fit testing, it was about using our PPE supply in appropriate care situations."
Nurses also report that while symptomatic patients wait to be seen, there is no physical separation between them and others waiting in the ER other than social distance, as one seating area has been designated for respiratory symptoms.
From there, if a patient is seen for severe respiratory symptoms and needs to be intubated or have a nebulizer treatment, nurses are allowed to get an N95 mask from a supervisor. But then they're asked to wear that mask up to a handful of times with that same patient, nurses say. Normal protocol would call for throwing away the mask after each visit to the room.
Re-using both surgical and N95 masks and not having enough access to the higher filtration N95 masks has many nurses worried they could contract COVID-19.
Moreover, even though Providence says it is reducing the use of masks to prepare for a surge in patients, the action is creating a fear among nurses that if masks are already in short supply, the region may not be able to handle a potential surge of patients.
"Not knowing what it is going to look like is almost worse than being in the middle of it, I imagine," one nurse says. "It's the worst kind of anxiety because it never leaves you."
CONSERVATION STRATEGY
If treating a patient suspected of having COVID-19, nurses are asked to wear gowns, gloves, eye protection and face shields or surgical masks, unless they're doing a "high-risk" procedure like intubating a patient or using a nebulizer, when droplets are most likely to become airborne, one nurse explains. If doing that higher risk procedure, an N95 mask would be worn.
"Some materials and equipment such as masks, gowns and gloves are in short supply," Semenza, the Providence spokeswoman, tells the Inlander by email. "This is a worldwide issue, not just a local one."
Washington agencies are coordinating efforts to collect more personal protective equipment via purchases through manufacturers, donations and requests to the Strategic National Stockpile. As of a March 26 press call, the state had that week obtained and started distributing 500 ventilators, 1,200 gowns, 500,000 N95 masks and 130,000 surgical masks.
Other items on the way included an order for 2.4 million N95 masks and 13,000 thermometers, and it was anticipated that there'd be another order for 2.2 million N95 masks, 300 ventilators and 2,500 disposable stethoscopes, said Linda Kent, with the Department of Enterprise Services, on the call.
Spokane County now has a collaborative drive-thru test site set up at the Spokane County Fair and Expo Center where people with symptoms can be tested. The hope is for the site to help minimize the use of protective equipment at local hospitals and reduce the risk of patients going there and spreading the virus. (Because of inclement weather, officials were considering other temporary locations for testing.)
But if someone appears at an ER for testing, the ER may not, by law, send them away to get that testing done elsewhere, Semenza says.
"We have an obligation to treat them in that location," she writes.
People who have a fever and a dry cough and/or difficulty breathing may now self-refer to the fairgrounds test site to get evaluated and see if they should be swabbed, without needing a doctor's referral. They're still asked to also meet another high-risk criteria, including age, underlying health condition, or being a health care worker.
While Providence hospitals await shipments from manufacturers and potentially the Strategic National Stockpile, some surgical masks are also being collected and sent to Medline Industries for reprocessing and reuse, Semenza writes.
"They can reprocess about half of what is collected," Semenza writes. "After proper decontamination protocols are followed, the products are as safe and functional as brand new ones."
And now, with the change in policy, the hospital system may start accepting donations that started rolling into a centralized location last week.
In response to an outpouring of community support, including crafters who've taken it upon themselves to start sewing face masks, Spokane's Emergency Coordination Center has opened a donation site. The centralized donation site at the Spokane County Fair and Expo Center, 404 N. Havana St., will be open daily from 9 am to 3 pm, to accept donations of personal protective equipment. It will accept new, unopened personal protective equipment including masks, gloves, eye protection, gowns, hand sanitizer, paper towels, toilet paper and household disinfectants.
MultiCare also has designated volunteers working on making masks to supplement their supply.
"In an effort to conserve our current protective personal equipment (PPE) we are creating our own masks to supplement our purchased masks," says George Hampton, regional marketing director for MultiCare Health System, in a release.
Spokane Fire Chief Brian Schaeffer said donations of protective equipment should be processed through the centralized donation site to ensure proper decontamination and dissemination. ♦
Staff writer Josh Kelety contributed to this report.
