Who Needs to be Tested for Coronavirus?
At the start of a 24-hour shift Thursday, Jeremy Nelson, a physician assistant, looked out onto an empty emergency room floor at the critical access hospital in Independence.
In recent days, his patients have been directed to area clinics or telemedicine services to help make room for the anticipated wave of patients diagnosed with COVID-19, the respiratory disease caused by the novel coronavirus.
“It’s a calm before the storm,” said Nelson, 40, who works at the facility and at two other eastern Iowa hospitals.
While Nelson said he feels prepared so far to respond to the virus, others aren’t feeling so sure.
Iowa health care workers and the organizations that advocate for them shared concerns with the Des Moines Register about long hours and a lack of personal protective equipment and other protective measures. Some warned the issues could exacerbate Iowa’s existing shortage of health care providers.
The state ranks 42nd in the nation for the number of physicians per 100,000 people — a number that includes emergency room doctors — according to a January 2020 report from the University of Iowa Carver College of Medicine.
Frontline workers concerned
Now, as the health care system is expected to become inundated with new virus-infected patients, Iowa’s frontline workers are already reporting concerns.
Workers in some instances have reused disposable masks and gowns between patients, have lacked masks for employees screening patients for COVID-19 symptoms, and, in keeping with an Iowa Department of Public Health directive, have been asked to keep working if they are exposed to the virus as long as they aren’t showing symptoms.
Those concerns were echoed by frontline staff from several health care systems in Register interviews and outlined in a complaint filed Tuesday with the Occupational Safety and Health Administration against the VA Central Iowa Health Care System, which includes a Des Moines hospital and several clinics in other cities.
“You wouldn’t send a firefighter into a fire without equipment … and that’s what they’re doing to us,” said a health care worker at the VA Central Health Care System, who spoke to the Register on the condition of anonymity out of fear of employer retribution. That worker did not file the OSHA complaint.
“I signed up to take care of people,” the VA worker said. “But I also expect my employer to be providing me the proper equipment.”
Jerry Self, Jr., a spokesman for the VA Central Health Care System, denied the allegations made in the OSHA complaint. Self said the facilities are following federal safety guidelines.
“The facility is not reusing disposal gowns or masks,” Self said in a statement. “The facility is using washable gowns, and washing them after every use. Each gown has 75 washes, which is being tracked. This is in line with CDC guidance.”
A veteran tested positive for COVID-19 on Wednesday, but “the risk of transmission to other patients and staff remains low” because the patient is being kept in respiratory isolation, Self said.
As of Friday, Iowa has reported that 235 people had tested positive for the highly contagious virus in the state. Three Iowans have died.
While the state works to get more personal protective equipment, known as PPE, from a national stockpile, officials are also looking for ways to relieve Iowa’s existing frontline workers. Since the virus was first detected in Iowa on March 8, health care workers have been increasingly working longer hours, a problem intensified by coworkers who are absent either because they are quarantined or have no one to care for children who might normally be in school or child care but for coronavirus measures.
“The pain-in-the-pinch that we were feeling beforehand, is coming into where our providers are having to work longer hours,” said Kady Reese, a spokeswoman for the Iowa Medical Society. “It’s (felt) really across the board. It’s physicians. It’s our nurses, our direct care workers.”
On Sunday, Gov. Kim Reynolds relaxed restrictions on licensing requirements “to remove barriers” for frontline workers who want to “step up and serve in medical professions” during the coronavirus crisis.
“We are in unprecedented times right now and we’re going to continue to be flexible, adjust and figure out a way we can meet the needs of Iowans,” Reynolds said at a news conference Tuesday. “ … We’ve made some changes to allow retired health care professionals to come back online, for students to come into the fold.
“So, I mean, every day we’re looking at different solutions that we can provide Iowans to make sure that we have the services available to them.”
Reynolds also called for churches, schools and community centers to open temporary day cares for children of frontline workers in industries including health care, emergency services, food production and supply and manufacturing.
Before pandemic: Too few workers. Now: Workforce even more at risk
Experts warn, however, that the health care system will be even more overwhelmed — and the workforce even more restrained — if doctors, nurses and other frontline workers aren’t given the proper tools to keep themselves safe while they treat their patients.
Nationwide, health care workers face a shortage of proper protective equipment, including respirator masks, gloves and gowns, that, if not addressed, will continue putting them at risk for contracting the coronavirus, ultimately taking them out of the workforce while they recover to prevent further spread of the disease, or worse, dying.
“Those on the frontlines are at greater risk of contracting and spreading the virus, particularly if they don’t have proper (personal protective equipment),” said Di Findley, executive director of Iowa CareGivers.
Iowa CareGivers represents the more than 40,000 direct care workers in Iowa who provide services such as bathing, dressing and feeding patients in hospitals, nursing homes, assisted living or group homes.
“This will compound what was already a dire situation,” Findley said.
Since at least 2015, the Iowa Legislature has allocated about $3.3 million annually to encourage Iowans to study and practice medicine in the state.
The governor’s Future Ready Iowa initiative also aims to steer Iowa’s students to skilled jobs in high demand. The job in the highest demand? Registered nurses, according to the initiative’s job posting site, iowaworks.gov.
In a study released in January, the University of Iowa Carver College of Medicine found Iowa is short 361 physicians across eight different specialties.
Additionally, there are an estimated 8,015 job vacancies in health care and social assistance, according to a 2019 workforce needs assessment by Iowa Workforce Development.
Those shortages, while a concern now, could get worse as Iowa’s population increases — and ages.
The U.S. Census Bureau has estimated that by 2030, 22.5% of Iowans will be 65 years or older, a nearly 15% increase from 2000. Iowa’s general population is expected to increase by 4.9% — 155,514 people — by 2030.
“If current trends continue, Iowa’s shortage of primary and non-primary care physician workforce will worsen over the next decade,” the University of Iowa Carver College of Medicine report warns.
Health care professionals open doors to usher in helping hands
A lack of workers coupled with an aging population may make coping with the coronavirus even more difficult, if, as expected, Iowa’s infection numbers increase.
Reynolds’ public health emergency proclamation in mid-March allows Iowa’s licensing boards to grant emergency licenses to health care practitioners whose licenses have expired and to students who have not completed their required clinical, practical or internship experience.
The directive also waives background checks.
The emergency licenses last only through the governor’s emergency declaration, which expires April 16, and through any extensions she may order.
Each licensing board is tasked with creating their own requirements.
On Wednesday, the Iowa Board of Respiratory Care and Polysomnography said emergency licenses would be granted to recent graduates who have not completed their licensing exams and students with a letter of recommendation from their program administration verifying they can perform entry-level work.
“It would fall upon both the practitioner and the emergency licensee holder to not practice beyond their education and training, and the facility to monitor them to help keep them from getting in over their head,” said Tony Alden, board executive.
Respiratory therapists, in particular, are needed for treating patients stricken with COVID-19 as the disease causes trouble breathing and, in the more serious cases, may require a ventilator. Alden said the board does not know how many people would qualify under its new order.
On Thursday, the Iowa Board of Physician Assistants voted to give emergency licenses to recent graduates who have not yet taken their exams and to license holders from out of state. Both are already available to the board when issuing temporary licenses.
Meanwhile, others are being reallocated to take on new jobs during the crisis.
Findley said some of her direct care workers who work in personal homes or in nursing homes have been asked to fill hospital and clinic shifts to lighten the load.
Employees who normally work at a wellness center at Primary Health Care have been tasked with manning a drive-thru testing site on Des Moines’ south side, said Deb Kazmerzak, executive director of The Iowa Chronic Care Consortium.
And in-home respiratory therapists are being pulled from their patients’ homes to help staff the hospitals, a member of the Iowa Board of Respiratory Care and Polysomnography reported.
A personal protective equipment shortage leads to tension
Iowa is facing a shortage of personal protective equipment that would give frontline workers the necessary protections to keep them safe and working through the crisis.
On Thursday, Reynolds signed an executive order halting all nonessential and elective surgeries as a way to preserve personal protective equipment.
The state’s Homeland Security director, Joyce Flinn, said at a news conference Wednesday they’re communicating with hospitals and clinics across the state about needs, ordering from the national stockpile and working with businesses to make resources. The state has ordered hundreds of gowns, gloves, swabs and test kits, as well as ventilators, she said.
State officials have not publicly provided specific data on how much personal protective equipment has been ordered or where it’s being delivered.
The Iowa National Guard has delivered 140 pallets of personal protective equipment to 55 counties since distribution began Tuesday, according to a news release.
It did not specify where those deliveries were being made, but a Homeland Security situation report obtained by the Register said there’s “a focus on ‘hot spot’ locations where patient care facilities have identified a less than seven-day supply of PPE.”
The shortage, along with loosened Centers for Disease Control and Prevention guidelines on proper equipment, have created a “tension” between adequate protection and adequate supply, according to a health care worker at the University of Iowa Hospitals and Clinics.
“We want to be safe, but we don’t want to run out,” said the employee, who spoke on the condition of anonymity. The hospital has instructed its staff to reuse certain masks as part of its efforts to preserve equipment.
That lack of equipment has left hospitals without 432 additional workers that could be helping during the crisis. Third- and fourth-year students at Des Moines University medical school have been pulled from their hospital rotations by the university due to lack of personal protective equipment, said Steve Halm, dean of the College of Osteopathic Medicine.
“I won’t put our students in that position without proper PPE,” he said. “So that’s an important step, beyond what I have control of, that has to happen to create a good backup for our current physician workforce.”
The students are doing online learning for the foreseeable future; Halm said the school is prepared to teach online for the next two to three months. He’s been reassured by the Commission on Osteopathic College Accreditation that his students can still graduate with the proper requirements to enter the workforce July 1.
“We are very sensitive to the workforce challenges, and one of my goals is to maintain our education process so that in two or three years when our current students are ready to go into the workforce, there’s not a gap,” Halm said.
Iowa’s lack of protective equipment has also prompted congressional attention.
In a March 19 letter to federal health officials, U.S. Rep. Abby Finkenauer, a Democrat, said she’s heard some supplies already sent from the National Strategic Stockpile were expired, dating from the H1N1 outbreak in 2009.
“With shortages of personal protective equipment now top concern for our local health systems, we worry that much more may be needed to improve the capacity of our local health care infrastructure in Iowa,” she wrote. ” … With documented cases of community spread of COVID-19, our health systems must be prepared to provide services to as many Iowans as possible and a lack of basic medical supplies puts patients — and providers — at risk.”
The shortages in workforce and supplies have led to collaboration. Area hospitals in Des Moines have partnered to share information and resources.
“Looking at the immediacy of the response, we also have the foundation for a network to really leverage the experience, through COVID-19, to kind of strengthen those opportunities that we have to say, ‘This is what we have to do to address this,'” Reese said.
Nelson, the physician assistant in Independence, said for now he’s spending his days getting ready for an influx of patients. While he’s grateful that his health care system has made preparations, he’s now anxiously waiting for what may come in the next few weeks — including whether there will be enough supplies.
“We know that there’s going to be a surge,” he said.
Barbara Rodriguez covers health care and politics for the Register. She can be reached by email at [email protected] or by phone at 515-284-8011. Follow her on Twitter @bcrodriguez.
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