Lessons for Supporting the COVID-19 Healthcare Workforce
Prior disasters can teach us how to best support them today.
Posted Apr 30, 2020
Healthcare workers have suddenly become soldiers on the pandemic frontline under tremendous hardships. They are repeatedly exposed to the virus and worry about lack of protective equipment and lack of ventilators [Ramney et al, 2020]. They sleep in their cars or in separate rooms at home to distance themselves from their own family [Babinger and Chen, 2020]. Some health care workers have been evicted from their apartments [Dwyer, 2020]. Others have been fired by their hospitals for protesting the lack of protective equipment [Carville et al, 2020]. They face incredibly difficult ethical dilemmas regarding who should be ventilated and who should not [Rosenbaum, 2020].
Although we never before encountered a pandemic on the scale of COVID-19, prior disasters also posed incredible challenges to healthcare workers, from which we can learn.
Ebola. Time Magazine awarded the 2014 Person of the Year to the Ebola caregivers, a nod to the courage and sacrifice of thousands of healthcare workers. In Sierra Leone, the healthcare worker fatality rate of 71% was more than twice the country’s overall Ebola fatality rate [Linshi, 2020]. Health care workers watched their colleagues become Ebola victims themselves, which diminished their morale and willingness to work and resulted in staff shortages. Some hospitals in Liberia were shut down due to loss of healthcare workers. Many health care workers were accused by their own communities of being “Ebola carriers” and faced isolation from mistrustful neighbors [Hayden, 2019].
Intensive training sessions on properly assembling gear, disposing equipment, and disinfecting measures greatly improved Ebola patient outcomes [Jones-Konneh et al, 2014]. Public education with support and influence from local community leaders helped somewhat to mitigate fears regarding Ebola transmission [Krenn, 2019].
SARS. When SARS hit Toronto hospitals in 2003, health care workers identified poor organizational responses in their own institutions as the biggest problem [Moore et al, 2005]. They cited a lack of consistent safety instructions alongside frequently changing directives. They did not believe the workplace placed sufficient importance on safety measures for staff.
Health care workers wanted to help others but did not see themselves as heroes or martyrs [Hsin and Macer, 2005]. Many health care workers risked losing their jobs by refusing to join hospital SARS teams in order to protect their families [Sibbald, 2003]. The health care workers fighting SARS in Taiwan had high rates of burnout and post-traumatic stress, even months after the outbreak, with up to 75% of health care workers suffering psychological morbidities [Chong et al, 2004].
At the height of the SARS crisis in Singapore, hospitals brought in occupational health professionals to manage institutional protocols and address health care workers’ concerns [Koh et al, 2005]. These professionals monitored hygiene practices, evaluated modifications to ventilator usage, and surveyed staff on symptoms and mental health status. Facilities such as changing rooms, showers, and places for rest were also implemented to better support health care workers.
Hurricane Katrina. The health care workers stranded in New Orleans hospitals in the days following Hurricane Katrina in 2005 had to evacuate critically ill patients to safer ground without protocols, external support, or transport resources [Gray and Hebert, 2007]. Floodwater knocked out electricity, backed up sewage systems, and cut communication lines. There was little food or fresh water. Temperatures reached over 100 degrees.
Health care workers improvised to evacuate, transporting the most critically ill through hospitals without functioning elevators to reach rooftop parking areas and await helicopter rescue [Sullivan, 2005]. Medical staff and volunteers ventilated critically ill patients by hand after electricity shut down. Physicians also encountered extremely difficult ethical dilemmas when forced to choose who to save based on resources available. Years later, health care workers reported substantial rates of post-traumatic stress disorder for which few received mental health care [Battles 2007].
Indian Ocean Tsunami. When 100-feet tall walls of water crashed down on shoreline communities in Indonesia, Thailand, and Sri Lanka in 2004, those hospitals left standing were seriously damaged, with substantial loss of health personnel. In Banda Aceh, Indonesia, 75% of health care workers died or were displaced [Centers for Disease Control, 2005].
At the Takuapa Hospital in Thailand, health care workers and surgical services were quickly overwhelmed [Wattanawaitunechai et al, 2005]. Only nine physicians were initially available to manage hundreds of cases in the first week. Health care workers from neighboring hospitals arrived to address staff shortages, and patients with more serious conditions were stabilized then evacuated to neighboring hospitals with more resources.
Lessons Learned. These four disasters illustrate several top priorities for supporting the healthcare work force:
Supply protective equipment to protect against viral transmission. Health care workers cannot be expected to work without adequate protective equipment and training that includes fit-testing. In addition, they need to be screened and tested for possible infection. Present day shortages of equipment and testing need to be remedied.
Establish and follow emergency protocols. Hospitals need protocols to guide health care workers in all anticipated aspects of the emergency response, including setting up isolation units and/or makeshift hospitals, transporting non-infected patients to other sites.
Guide ethical decision making. Hospitals need to provide guidance for health care workers facing life and death decisions in the face of limited medical resources. They should establish ethics teams to support ethical decision making and consultation services on palliative care for the dying [Hamblin, 2020].
Provide temporary housing and isolation resources. Health care workers working in a pandemic should be provided options for temporary housing, including parking and meals. They also need help with isolation resources in hospitals, such as showers and changing rooms.
Recruit other health care workers to maintain services for non-COVID patients. Even during a disaster, other illnesses will continue to require attention. Health care organizations should recruit other health care workers, newly graduated medical students, or volunteers, to meet other essential health needs.
Support and treat emotional consequences. Health care workers need help to cope with the high risks for traumatization and burnout. They should be provided with psychosocial and mental health support through online resources, psychological first aid, employee assistance, and screening and referral to mental health services.
COVID-19 is an unprecedented challenge for health care workers, but we can learn much from prior disasters about how to support them. Because every disaster is also a new opportunity to learn, we should also be working towards innovative ways to provide support to those on the front line.
This article was co-authored with Vivian Jin, medical student, University of Illinois at Chicago, College of Medicine.
Ranney ML, Griffeth V, Jha AK. Critical supply shortages — The need for ventilators and personal protective equipment during the Covid-19 pandemic. New England Journal of Medicine. 2020 Mar 25. doi: 10.1056/NEJMp2006141.
Bebinger M, Chen A. Bringing home Something Deadly: How Health Workers are Isolating From Their Families. WBUR. 2020 Apr 3 [Cited 2020 Apr 11]. Available from: https://www.wbur.org/commonhealth/2020/04/03/bringing-home-something-deadly-how-health-workers-are-isolating-from-their-families
Dwyer J. The Doctor Came to Save Lives. The Co-op Board Told Him to Get Lost. The New York Times. 2020 Apr 3 [Cited 2020 Apr 11]. Available from: https://www.nytimes.com/2020/04/03/nyregion/co-op-board-coronavirus-nyc.html?fbclid=IwAR3OBhLrziSAEV02zeWr5UE8W4C61w6NgGP33QMb3Q2NWQz0biIS7lXcUys
Carville O, Court E, Brown KV. Hospitals Tell Doctors They’ll Be Fired If They Speak Out About Lack of Gear. Bloomberg. 2020 Mar 31 [Cited 2020 Apr 11]. Available from: https://www.bloomberg.com/news/articles/2020-03-31/hospitals-tell-doctors-they-ll-be-fired-if-they-talk-to-press
Rosenbaum L. Facing Covid-19 in Italy - Ethics, logistics, and therapeutics on the epidemic’s front line. New England Journal of Medicine. 2020 Mar 18. doi: 10.1056/NEJMp2005492
Linshi J. Ebola healthcare workers are dying faster than their patients. Time Magazine. 2014 Oct 3 [Cited 2020 Apr 11]. Available from: https://time.com/3453429/ebola-healthcare-workers-fatality-rate/
Hayden S. How misinformation is making it almost impossible to contain the Ebola outbreak in DRC. Time Magazine. 2019 Jun 20 [Cited 2020 Apr 11] https://time.com/5609718/rumors-spread-ebola-drc/
Jones-Konneh TEC, Murakami A, Sasaki H, Egawa S. Intensive education of health care workers improves the outcome of Ebola virus disease: lessons learned from the 2014 outbreak in Sierra Leone. Tohoku J Exp Med. 2017; 243(2): 101-105.
Krenn S. Lack of Understanding, Mistrust Allows Ebola to Spread in DRC. Johns Hopkins Center for Communication Programs. 2019 Apr 24 [Cited 2020 Apr 11]. Available from: https://ccp.jhu.edu/2019/04/24/trust-mistrust-ebola-spread-drc/
Moore DM, Gilbert M, Saunders S, Bryce E, Yassi A. Occupational health and infection control practices related to severe acute respiratory syndrome: health care worker perceptions. Workplace Health & Safety Journal. 2005; 53(6): 257-266.
Hsin DH, Macer DRJ. Heroes of SARS: professional roles and ethics of health care workers. Journal of Infection. 2005; 49: 210-215.
Sibbald B. Right to refuse work becomes another SARS issue. Canadian Medical Association Journal. 2003: 169(2): 141-141a.
Chong MY, Wang WC, Hsieh WC, Lee CY, Chiu NM, Yeh WC, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. The British Journal of Psychiatry. 2004; 185(2): 127-133.
Koh D, Lim M, Ong C, Chia S. Occupational health response to SARS. Emerging Infectious Diseases. 2005; 11(1): 167-168. doi:10.3201/eid1101.040637.
Gray BH, Hebert K. Hospitals in Hurricane Katrina: challenges facing custodial institutions in a disaster. J Health Care Poor Underserved. 2007; 18(2); 283-98.
Sullivan L. How New Orleans’ Evacuation Plan Fell Apart. NPR. 2005 Sep 23 [Cited 2020 Apr 11]. Available from: https://www.npr.org/templates/story/story.php?storyId=4860776
Battles ED. An exploration of post-traumatic stress disorder in emergency nurses following Hurricane Katrina. J Emerg Nurs. 2007; 33(4): 314-318.
Centers for Disease Control. Assessment of Health-Related Needs After Tsunami and Earthquake --- Three Districts, Aceh Province, Indonesia, July--August 2005. Morbidity and Mortality Weekly Report. 2006; 55(04): 93-97.
Wattanawaitunechai C, Peacock SJ, Jitpratoom P. Tsunami in Thailand - disaster management in a district hospital. New England Journal of Medicine. 2005; 352: 962-964.
Hamblin J. An Ethicist on How to Make Impossible Decisions. The Atlantic. 2020 Apr 1 [Cited 2020 Apr 11]. Available from: https://www.theatlantic.com/health/archive/2020/04/social-distance-ration-doctors-care/609229/