COVID-19 nurse speaks out about immense challenges faced by health care workers in a Mississauga hospital

 

When the novel coronavirus began spreading like wildfire throughout the world, few knew how to best address the deadly and highly contagious virus that has now claimed the lives of over 300,000 people worldwide. 

Now, two months into strict (but easing) lockdown measures in Ontario, some of the nurses on the front lines of the crisis are frustrated and fear that hospitals have not been listening to them—or doing their absolute best to protect them. 

"Every step of the way, we've had to fight," says Jane*, a nurse in Trillium Health Partners—Credit Valley Hospital's 1A COVID unit who asked not to be named. 

Jane says she and other nurses have had multiple run-ins with hospital management over the course of the ongoing pandemic and alleges that nurses have had to fight for adequate personal protective equipment (PPE) while dealing with challenging patient loads. 

She also said the newness of the novel coronavirus—and the substantial unknowns—should prompt hospitals to be more protective of staff and to take more precautions to prevent transmission, especially to potentially vulnerable patients. Instead, she alleges that "corners have been cut" when it comes to patient care and PPE.  

Over the course of the crisis, Jane says she has expressed concerns over the regular redeployment of COVID unit nurses to other departments, a practice Trillium Health Partners (THP) says is in line with provincial guidelines. 

"The hospital wasn’t implementing the safety measure of keeping health care workers COVID-specific because they are confident that their infection prevention and control practices (IPAC) are rigorous," she says. 

In her opinion, however, they're not rigorous enough to justify sending COVID nurses and health care workers to treat and care for patients in other units.

"But in my opinion their IPAC measures are dismal, and now 1A COVID is on outbreak," Jane says. 

According to THP's website, nine health care workers on the 1A COVID-19 unit tested positive for COVID-19 between April 18, 2020, and May 6, 2020. On its site, THP says the staff cases were acquired from a number of sources, including the hospital and the community. As a result, an outbreak was declared in consultation with Peel Public Health.

The outbreak has since been declared over. 

Jane says it took an outbreak to force the hospital to examine its redeployment policies. 

"Only now that we are on outbreak did the hospital decide to keep health care workers who were potentially exposed during the outbreak period on 1A for now. We ought to have COVID-specific staff at all times, preferably voluntary and with a financial incentive," she says. 

In an email to insauga.com, Trillium Health Partners said that redeployments are the norm because precautions are taken to prevent virus transmission.

"Aligned with the provincial government’s guidance, health care workers are permitted to work on different units, including designated COVID-19 units. A COVID-19 unit has rigorous infection prevention and control practices in place and because of this, staff are able to safely move to other areas of the hospital without putting others at risk," the health organization says. 

"Across the hospital, we are practicing safety precautions like appropriate use of PPE, regular and enhanced cleaning, physical distancing and proper hand hygiene. We have also ensured our staff and professional staff have received the required training related to COVID-19 to keep them, patients and the community safe." 

Jane also alleges that hospital policies led to another outbreak—which was declared on March 30, 2020—on the 1D rehab unit. According to a memo obtained by insauga.com, a total of 14 people (seven patients and seven staff members) tested positive for COVID-19. While that outbreak has since been declared over, Jane alleges the outbreak occurred because a COVID-positive patient was transferred to a ward room on 1D—something that she believes should not have happened in the first place. 

Jane isn’t the only nurse concerned about reportedly inadequate hospital procedures. According to a document outlining nurses’ concerns that was given to insauga.com, nurses have asked for extended cuff gloves, more rigorous filling of the hand sanitizer pumps outside of patients’ rooms, and better cleaning of the COVID unit.

The document also posited that having two patients in a room is unsafe, especially if a nurse has both patients and must stay in the room for more than 30 minutes at a time.

“Another safety concern is a breach in droplet/contact precautions in these rooms. We have to doff gowns too closely to patients in beds close to the door,” the document reads.

“We doff the gown less than one metre away from a patient and they cough. Two nurses who have cohort patients can't also doff at the same time, so the other nurse has to wait for the first person to doff properly first.”

Another major concern that Jane says has gone unaddressed is the redeployment of nurses to patients they are not experienced in caring for. At the start of the crisis, the 1A COVID unit was a surgery unit, and nurses trained in caring for surgical patients were tasked with caring for those suffering from the novel coronavirus.

"They redeployed the surgical team that I was on to COVID and instead of restaffing the unit with medicine nurses, they used us. Our surgical patients were taken care of by nurses who didn't get adequate training," she says. 

Jane alleges a patient suffered a pulmonary embolism due to inadequate care provided by a nurse who did not have the experience to care for him. 

THP says that while the hospital has moved nurses to other units, it would not require a nurse to do work he or she is not capable of doing.  

"There are several highly qualified staff, including surgical nurses who have been redeployed to work in other areas and units and been given additional training around COVID-19. The safety of staff and patients is a priority for THP and we would not require a nurse to work outside of their scope of practice,” THP says.  

Jane argues that the scope of practice is a separate matter from the scope of expertise or experience. 

"This nurse was working within their scope of practice, but was inadequately trained for the surgical population and this resulted in a very, very negative outcome for this patient. He went in for surgery and an overnight stay, but due to this unsafe arrangement by the hospital, he had a massive pulmonary embolism and heart attack and was in the hospital for a month," she says. 

Jane also alleges that surgical nurses like herself are being ordered to care for medicine, renal and psych patients on 1A, something that's beyond the scope of their expertise. 

"We should be redeploying nurses from these areas to go with these patients," she says. 

Another issue that Jane says came up frequently was difficulty accessing all requested PPE, including N95 masks. She also says nurses were told that scrub caps are not necessary.

THP says there is currently enough equipment to go around.  

"We currently have adequate supply of PPE for all health care workers and remain focused on practicing good stewardship of these resources. We have also increased education on how to appropriately use PPE and have specialized coaches available seven days a week to support and educate our health care workers on proper PPE," THP says.

"Scrub caps are not PPE as they are not impermeable, although staff may choose to wear them. All staff are required to use appropriate PPE in certain care areas such as a mask, face shield, gown and gloves. In addition, all staff have been advised to perform a point of care risk assessment before entering a patient room to determine the procedures that will be required and to ensure they are using the appropriate PPE."

Jane says that while scrub caps might not be considered essential PPE, they help health care workers feel safe.

"My hair is not made of bleach. A load of virus could land on my hair, and then as I’m donning and doffing the mask and face shield my hair could touch my face. The scrub cap keeps my hair in place, and I’ll wash the cap with my scrubs," she says, adding that most nurses are ignoring hospital policy and wearing scrub caps they brought from home.

Jane also says that masks are still an issue. 

"We are using flimsy level 2 masks, one every four hours, when we are spending long amounts of time standing very close to patients, washing them, feeding them, hoisting them up in and out of bed, changing bandages," she says. 

"Patients are coughing in our face, or their phlegm is evaporating on their linens. There's no word yet on how these were tested for extended use with COVID areas. 'Good stewardship' of physical resources should not take priority of good stewardship of human resources. They seem to forget we are people, and that we are not expendable."

Jane says nurses do have an adequate supply of face shields, and that she's seen a huge improvement in that type of equipment. 

"Face shields we have enough of, so a big thank you to 3D printing companies who churned them out. We got bags of streaky shields with old wipes and paper towels in them before, so I’m glad they’re now cleaner and sometimes come individually wrapped."

Ultimately, Jane argues that battles over what is and isn't necessary PPE made her feel unsafe.

"My nurse friends in other hospitals feel safe where they're working. I don't feel safe. We're doing what we can to protect ourselves and that goes above and beyond what they're telling us to do. We wear N95 even though they say we don't need to. We wear scrub caps, even though they say we don't need to. Most of us are women, so we're making our own scrub caps."

Jane says that nurses have only been able to access N95 masks because the Registered Nurses' Association of Ontario (RNAO) advocated for nurses to decide whether or not an N95 is needed during a point of care risk assessment. 

"That's not the hospital, that's the RNAO backing us," she says, adding that rigorous protective measures are needed at a time when experts are still trying to figure out if airborne transmission is possible.  

Jane says another stressor over the course of the crisis has been the patient load. With one COVID nurse assigned to up to four patients, she says the risk of error is higher when nurses need to move quickly between patients. The document regarding nurses’ concerns also outlined issues with patient load, adding that many COVID patients need more attention because they’re confused or at high risk of falling. 

“The majority of the COVID unit population is confused/falls risk patients, patients who need total care, patients who are quickly desaturating or pre-ICU patients, which makes it impossible to balance your entire patient load especially if you have patients who are in different hallways,” the document reads.

“Most COVID positive patients we admit now are total care with multiple comorbidities coming from nursing homes.”

Jane says the nurse to patient ratio is inherently problematic. 

"Four to one is the pre-pandemic ratio. It’s crazy to expect safe IPAC practices and an acceptable level of care when ratios are four to one on a COVID unit, especially as we get the already-very-unwell patients from units on outbreak," she says. 

"It's a safety issue. You're not getting adequate care. Your grandma could die alone because the nurse is with another patient who is screaming in pain out of anxiety. It's a disaster."

THP says the hospital tries to maintain a three-to-one ratio whenever possible. 

"Patient to staff ratios are continuously assessed and adjusted based on patient volumes, patients’ health circumstances as well as staff availability. For COVID-19 units, the staffing ratio whenever possible has been three-to-one and no more than four to one." 

Jane says that concerns about the patient load were taken into account, but that some mitigating measures came with their own challenges. 

"They hired externs, which helps with the workload. The problem is they’re often young and inexperienced, so you’re relying on a smaller group of trained nurses to handle a bigger patient workload, and we know patients with COVID can deteriorate very quickly. Also, I don’t think they plan to have externs on night shifts," she says. 

Dr. Lorne Small, Medical Director, Infection Prevention and Control at Trillium Health Partners, acknowledges that it's been difficult for front line health care workers and that the hospital has had to respond in real-time to the evolving crisis. 

“The safety of patients, the community and everyone working at the hospital is our top priority at all times. Over the last several months we have taken a number of steps to prepare and respond to COVID-19 including adding more critical care beds, increasing testing capacity and creating special units designated exclusively to COVID-19 patients and providing specialized training to staff," Small says. 

"These are standard infection control practices that limit the spread of infection. The COVID-19 situation is very dynamic and our practices evolve as the situation changes. Recognizing that this can be a highly stressful time for staff, especially those working on COVID-19 units, we have implemented a number of supports and regularly meet with staff to address any concerns and make improvements.”

Small says the hospital is grateful for the work staff has done throughout the pandemic. 

"In these unprecedented times we are incredibly grateful for everyone working in the hospital who continue to show immense courage in the face of this pandemic and have been working tirelessly around the clock to provide safe, exceptional patient care." 

While all hospitals have certainly had to deal with a steep learning curve, Jane says the ultimate takeaway is that COVID is still very new, and should, therefore, compel hospitals to go above and beyond to protect the people who work closely with ill and vulnerable patients. 

"We are not 100 per cent sure that airborne transmission doesn’t happen especially since nurses have prolonged contact in close quarters with confirmed cases. We should be not be gambling with the basest of protection."

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