Dealing with Staffing Challenges During a Pandemic

With COVID-19 infecting hundreds of thousands of healthcare workers, requiring them to stay home for extended periods of time, the pandemic has wreaked havoc on the way medical practices and hospitals operate.

According to the CDC, more than 218,000 healthcare workers had tested positive for COVID-19 by mid-November. And last month, as the Midwest exploded with new cases, 900 staff members at the Mayo Clinic were infected in a two-week period alone.

“This has been and remains a challenge from an operational as well as a financial perspective,” said Myles L. Pensak, MD, chair of otolaryngology at the University of Cincinnati College of Medicine in Ohio and the Triological Society’s executive vice president. “The more we’re down in staff, the more we must cut back patient encounters. It’s an issue across the healthcare delivery food chain that negatively impacts everyone.”

Whether healthcare workers are infected on the front lines, in the grocery store, or by letting their guard down during leisure time due to pandemic fatigue, spiking cases are currently a big problem. And, just like in the general public, healthcare workers hold varying beliefs about safety protocols.

“Some healthcare workers follow the recommendations to the letter, and others do not,” said Anand K. Devaiah, MD, associate professor of otolaryngology, neurosurgery, and ophthalmology at the Boston University School of Medicine and Boston Medical Center. “There are healthcare professionals who are vocal on social media and other platforms advocating positions contrary to public health recommendations. This has been going on for months and adds to the public distress and discord. The recommendations are important for everyone to follow, realizing that as we learn they can change, and they’re there for a reason.”

First Surge Lessons

Last March and April, the otolaryngology department at NYU Langone Health in New York City saw the highest volume of sick staff members during the pandemic, according to J. Thomas Roland Jr., MD, Mendik Foundation chair in the department of otolaryngology–head and neck surgery and co-director of the NYU Cochlear Implant Center at NYU Langone Health. “Many of the infections could be attributed to social interactions and groups of physicians in close contact in touchdown computer spaces, before the mask wearing requirements were in place,” he said.

The departmental peak at NYU occurred prior to implementing basic safety protocols such as universal mask wearing and frequent hand sanitizing, as well as otolaryngology-specific safety measures, including specific protocols for scoping and examination. Other protocols put in place included HEPA filters in the office to purify the air every five to 10 minutes and filters placed on suction devices.

“Once we had protocols in place, very few staff members became sick as a result of a work exposure,” Dr. Roland said, “including staff working on the front lines treating acutely ill admitted patients known to be infected with SARS-CoV-2.” Despite absences, NYU was fortunate to have adequate staffing across departments; when additional staffing was needed to maintain care, employees were flexible to help cover across the institution.

The more we’re down in staff, the more we must cut back patient encounters. It’s an issue across the healthcare delivery food chain that negatively impacts everyone. —Myles L. Pensak, MD

“This is true from reception staff through attending physicians,” said NYU family nurse practitioner Brittany Millman Glickberg, who works with Dr. Roland. “During the peak of the pandemic, our residents, PAs and NPs, and many attending physicians altered their roles in the hospital to help treat acute COVID-19 patients in whatever capacity was deemed necessary and also within the ENT scope of practice.”

Some hospitals and practices were very fortunate in avoiding COVID-19 infections among their staff. “We’ve been really lucky in our department,” said J. Pieter Noordzij, MD, vice chair of clinical affairs, department of otolaryngology, Boston University School of Medicine. “As far as I know, we’ve only had a few staff members who’ve contracted COVID-19, with no significant cluster outbreaks in our department.” Dr. Noordzij added that not only have his department and hospital taken precautions very seriously, but so have both the city of Boston and the state of Massachusetts, with a governor who’s been vocal about the benefits of wearing a mask and social distancing.

While staff in other areas of Boston University School of Medicine and Boston Medical Center came down with COVID-19, some of whom worked in the OR, Dr. Devaiah said staffing wasn’t a problem because this coincided with the mandate to slow clinical operations and move away from elective visits in person to reduce exposure risk and hospital burden. And when they realized they were going to have to furlough some staff during the shutdown, departments asked for volunteers.

“There were a certain number of staff who were scared to come to work and wanted to furlough, and who had enough sick leave built up that they could furlough without financial repercussions,” said Dr. Noordzij. “The staff who wanted to work weren’t forced onto furlough. As far as I know, everyone got what they wanted, which worked out nicely.”

There are public health experts at BU that we’ve relied on to make projections and they’ve been quite accurate. We hope they’ll be accurate again. —J. Pieter Noordzij, MD

Once things started to ramp up in late May and June, Boston University School of Medicine and Boston Medical Center began bringing staff back from furlough, though some were nervous about returning. The department let them know how seriously they took staff safety, with measures to make the clinic space safer, including fewer patients in the waiting room and limits on the number of people in the break room at one time. “Everybody got the picture that it was safe to come to our clinic and work there,” said Dr. Noordizj.

Fall Surge

In the Midwest in the fall and winter, where cases were spiking, hospitals were filling up and taxing ICUs. “Our ambulatory practice has, just as in the springtime, decreased office visits and increased telehealth visits,” said Dr. Pensak. “Transitional units are being brought online, and we’ve begun to limit elective surgeries requiring postsurgical hospitalization.” While staffing hasn’t been an issue so far at the University of Cincinnati College of Medicine, they are relying on an increasingly limited pool of nursing travelers, according to Dr. Pensak.

There are big differences between the spring and winter surges, however. “The things we learned during the first wave will definitely help us in these next waves, but we have to be nimble and understand there’s a set of circumstances for winter that are different from the first time around, some of which will impact us positively and some of which will impact us negatively,” said Dr. Devaiah.

Occupation Type Of Healthcare Personnel (HCP) With COVID-19 — Six Jurisdictions,* FEB. 12–July 16, 2020

Characteristic (no. with available information)	No. (%)
Healthcare support worker**	1,895 (32.1)
Nurse***	1,742 (29.5)
Administrative staff member	581 (9.8)
Environmental services worker	330 (5.6)
Physician	190 (3.2)
Medical technician	135 (2.3)
Behavioral health worker	128 (2.2)
First responder	113 (1.9)
Dietary services worker	113 (1.9)
Dental worker	98 (1.7)
Laboratorian	68 (1.2)
Occupational, physical, or speech therapist	65 (1.1)
Pharmacy worker	62 (1.1)
Respiratory therapist	44 (0.7)
Phlebotomist	25 (0.4)
Physician assistant	13 (0.2)
Other	311 (5.3)

*Alaska, Kansas, Michigan, Minnesota, North Carolina, and Utah.
**Includes nursing assistant (1,444), medical assistant (123), and other care provider or aide (328)
***Specialty not specified.
Source: CDC. “Update: Characteristics of Health Care Personnel with COVID-19 — United States, February 12–July 16, 2020,” Sept. 25, 2020.

The positives include a better understanding of infection risk and control and greater access to PPE, both of which help both the general population and healthcare workers to avoid infection. Other pluses are the medications, procedures, and protocols that have been found to mitigate the effects of COVID-19 should patients need to be hospitalized.

The negatives boil down to pandemic fatigue: People have grown weary of wearing masks and social distancing nine months into the pandemic. “We should be understanding of the fact that dealing with COVID-19 is difficult, but we should also be vigilant about not taking shortcuts or dropping our guard,” said Dr. Devaiah.

In the Operating Room

Staff absences can particularly hurt in the OR. Dr. Pensak said the OR staff at his hospital are extremely taxed and the hospital has had to cut back on paid time off. “Indeed, staff availability will be the rate limiter for both the amount and quality of care provided,” he said.

At NYU, all elective surgeries resumed in May, with precautions to keep staff and patients safe. According to Dr. Roland, all staff in the OR are cross trained on many different kinds of cases to maintain good coverage should staff be out sick. NYU has also trained internal staff to fill potentially necessary roles should New York City have a second drastic COVID-19 wave.

Circulating nurses, surgical techs, and other team members who work in the OR will often be assigned to specific services, to cultivate a sufficient number of people with a high expertise level. —Anand K. Devaiah, MD

“An example of this includes proactively training medical-surgical nurses in peritoneal dialysis, a form of dialysis not previously widely used at NYU, as a means of conserving hemodialysis machinery and staffing,” said Millman Glickberg. “Our staffing and facilities remain limber to approach any future COVID-19 challenges.”

Boston Medical Center does a significant amount of cross training of scrub techs and circulators in the OR. “That way we have flexibility and have less concern if one of the people who normally scrubs for cranial base is out, for example,” Dr. Devaiah said. However, like many other institutions, his department has been moving toward a more high-performance OR team model, where a very select group performs certain procedures to improve efficiency in the operating room.

“Circulating nurses, surgical techs, and other team members who work in the OR will often be assigned to specific services, and even specific procedures within specific services, to cultivate a sufficient number of people with a high expertise level,” said Dr. Devaiah. “This allows them to be more effective, efficient, and comfortable in the room, but means having a smaller number of people who would scrub for or circulate these cases. That can be a problem if enough people are out or cross-covering for others.”

This problem can be magnified during a pandemic in which there are staff shortages, as it puts stress on those filling in to cover cases they aren’t used to covering. While Dr. Devaiah said NYU hasn’t had to cancel surgeries due to staffing as far as he’s aware, it did require patience when working with those who didn’t circulate or scrub with their team regularly. “Thankfully, they would come in ready to learn. We would spend additional time making sure they knew what the instruments were so they became comfortable working on a case that they might not otherwise do,” he said.

Looking to the Future

Despite hazard pay for clinicians working overtime, adherence to unionized contract guidelines for nurses, and ramped up psychological services for healthcare workers at their workplaces, employee and faculty wellness during a pandemic can still be a major challenge. While office staff may not be asked to put in extra time, they might be multitasking and pushed to their limits. And the sheer volume of very sick patients can inevitably be overwhelming to those caring for them day after day.

“Sadly,” Dr. Pensak said, “there’s no easy answer, and all our leadership is encouraged to heighten their listening skills to anticipate and recognize when staff or colleagues are getting burned out.” (See “Wellness Rx: Embracing Optimism” on page 18 to learn more about the value of maintaining optimism during the pandemic.)

As the pandemic continues, as of this writing, Boston University School of Medicine physicians anticipate another surge but think it will be only half as bad as the first in terms of patients needing ICU beds. While the total number of cases in their state may look worse than before, Dr. Noordzij said those contracting the virus now are younger and tend to do better, with fewer requiring hospitalization and those who do less likely to end up in the ICU. “There are public health experts at BU that we’ve relied on to make these projections, and they’ve been quite accurate,” he said. “We hope they’ll be accurate again.”

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Renée Bacher is a freelance medical writer based in Louisiana.