The Centers for Disease Control and Prevention recently put out new COVID-19 guidance aiming to mitigate staffing shortages, but the recommendations could harm patients and healthcare staff, nurses and doctors claim.
CDC recommends that healthcare workers who are asymptomatic or experiencing mild COVID-19 symptoms and aren't feverish return to work at short-staffed hospitals after five days of isolation, even if they haven't had a negative test. Healthcare providers—many of which are operating near or at capacity—are left to weigh the consequences of exposing workers and patients to the virus and not having enough staff to care for every patient.
"Nurses are walking away from the bedside," said Kathleen Murphy, president of the Massachusetts Nursing Association and an intensive care nurse at Brigham and Women's Hospital in Boston. "They can't go through this again because of these ethical dilemmas. We're all wrestling with the decreased quarantine time guidance by the CDC because we don't want to put our patients or colleagues at risk."
Few hospitals are at "crisis" capacity as defined by the CDC, which as a last resort puts no restrictions on COVID-positive workers. But that could change soon, observers warn.
"In the coming weeks, we could get there," said Margo Wolf O'Donnell, a partner at Benesch, Friedlander, Coplan & Aronoff who focuses on labor and employment. "The five day return to work period may be creating angst, but I think it is needed to keep society going for the next few weeks."
Only about 265, or 9%, of Illinois' 3,000 intensive care beds were available as of Wednesday, according to the Illinois Department of Public Health. Nearly 2 in 5 ICU beds were occupied by a COVID-19 patient. Around 17% of all of the state's hospital beds were available, IDPH data show. Many hospitals, in Illinois and other states, are pausing non-urgent procedures again.
About 60% of Brigham's beds are occupied by unvaccinated COVID-19 patients and the hospital is running around full capacity, Murphy said. The hospital has had to close some beds due to staffing shortages and about a quarter of the Brigham's night-shift nurses have been calling out sick, she said.
Workers often have to take paid time off or sick leave when they quarantine, which could contribute to turnover.
"It's not just nurses, it's respiratory therapists and physicians too," Murphy said. "We plain old don't have enough staff."
The CDC shortened recommended isolation periods from 10 days to five based on data that show that COVID-19 is most contagious a day or two prior to the onset of symptoms and two to three days after. While many healthcare experts believe isolation doesn't need to last longer than five days, most recommend negative tests before returning to work.
"Since the CDC issued these new guidelines, there has been controversy and confusion within healthcare organizations," said Craig Laser, a clinical associate professor at Arizona State University. "Hospital staffing is in crisis mode most days right now so the guidelines don't really address how to apply them in these times."
The CDC's guidelines are risky, the American Medical Association said.
"Potentially hundreds of thousands of people—could return to work and school infectious if they follow the CDC's new guidance on ending isolation after five days without a negative test," AMA president Dr. Gerald Harmon said in a statement, noting that an estimated 31% of people remain infectious five days after a positive COVID-19 test. "Physicians are concerned that these recommendations put our patients at risk and could further overwhelm our healthcare system."
Health systems are taking different approaches as to when COVID-positive employees should return to work. Disclosure policies regarding infection risks also vary.
A Colorado-based health system is not requiring their employees to get a COVID-19 test when they have symptoms, an internal memo shows. "Staff and providers with symptoms of a runny nose, sore throat, body aches and/or loss of taste or smell may continue reporting to work unless symptoms worsen," it reads.
Sioux Falls, South Dakota-based Sanford Health said that any employee exhibiting symptoms should not work.
"First and foremost, we are not asking any of our employees to come to work if they feel ill. We want to make sure they have the opportunity to stay home and heal and return to work when they feel well enough," said Dr. Jeremy Cauwels, chief physician at Sanford.
The Cleveland Clinic adopted the CDC's new recommendations. It is asking workers who have been vaccinated or who have had COVID-19 in the past six months to return to work after five days if they are asymptomatic or have mild symptoms and no fever. Workers do not need negative tests to return to work, the clinic said in a statement.
Healthcare workers who are COVID-19 positive are required to wear surgical masks or N95s and may have their assignments changed to protect immunocompromised patients, Cleveland Clinic said.
The changes only apply to locations in need, a spokesperson for the clinic said. The Cleveland area has seen COVID-19 cases spike, leading major local systems to postpone non-urgent procedures.
Providence, which operates hospitals in five western states, said it follows CDC and local health department return-to-work requirements for staff exposures, asymptomatic and symptomatic COVID-19 cases.
"In emergency situations only, CDC guidelines and some local health department requirements do allow hospitals to staff COVID units with COVID-positive caregivers," a Providence spokesperson said. "While we are facing staffing shortages, fortunately Providence has not resorted to this staffing model."
Neither Providence nor the Cleveland Clinic said whether patients would be notified if a COVID-19 positive worker was treating them. Healthcare facilities should inform patients and personnel when the facility is operating under crisis standards, outline operational changes and describe infection prevention measures, according to the CDC.
Many systems, as suggested by the CDC guidelines, are considering which areas of the hospital should be off limits to staff testing positive and what mitigation strategies will be required, such as constant masking with an N95 or equivalent respirator, said Nancy Foster, vice president of quality and patient safety policy for the American Hospital Association.
"This announcement from the CDC will allow healthcare workers to safely return to caring for patients sooner, which will help to alleviate the severe workforce shortage crisis facing hospitals across the country," the association said in a statement.
The CDC guidance largely insulates hospitals and other healthcare organizations from lawsuits, attorneys said.
"When they are making decisions in a crisis, that makes it difficult for a lawsuit to succeed as long as they are being prudent as possible under the circumstances," said Colin Luke, a partner at Waller Lansden Dortch & Davis. "Hospitals want to err on the side of workplace safety, and are doing whatever they can to protect the workforce and still deal with the needs of patients."
Most hospitals are asking workers to return after a five-day isolation period even if they don't have a negative test, industry observers said.
"Healthcare organizations are taking the gamble that if they don't know the status of staff and staff are not reporting being ill, that they are healthy and can work. What's ethical and what is permissible are two different things," Arizona State University's Laser said. "Given the nature of this entire pandemic, disclosure of illness status and vaccination status remains a difficult situation."
It is "absurd" that the CDC would tell clinicians who are positive for a highly infectious respiratory pathogen that is airborne that they should go back to work, said Matthew Cortland, a lawyer in Massachusetts.
"That's not normal," he said.
It's unclear how protected healthcare workers would be from malpractice lawsuits because those regulations vary from state to state, Cortland said.
"As a matter of bioethics, I think it is clear that patients have the right to know whether any of the healthcare workers taking care of them are positive for SARS-CoV-2," he said.