Nurses at Alta Bates Summit medical center were on edge as early as March when patients who had tested positive for Covid-19 began to show up in areas of the hospital that were not set aside to care for them.
The Centers for Disease Control and Prevention had advised hospitals to isolate Covid-19 patients to limit staff exposure and help conserve high-level personal protective equipment that’s been in short supply.
Yet Covid patients continued to be scattered through the Oakland hospital, according to complaints to California’s division of occupational safety and health (Cal/Osha). Areas of concern included the sixth-floor medical unit where veteran nurse Janine Paiste-Ponder worked.
Covid patients on that floor were not staying in their rooms, either because they were confused or uninterested in the rules, according to Mike Hill, a nurse in the hospital intensive care unit. Hill, who is also the hospital’s chief representative for the California Nurses Association, said that staff was not provided highly protective N95 respirators.
“It was just a matter of time before one of the nurses died on one of these floors,” Hill said.
Two nurses fell ill, including Paiste-Ponder, 59, who died of complications from the virus on 17 July.
The California Nurses Association has filed complaints to Cal/Osha, the state’s workplace safety regulator. Similar concerns have swept across the US, according to interviews, a review of government workplace safety complaints and health facility inspection reports.
Covid patients have been mixed in with others for a variety of reasons. Limited testing has meant some patients carrying the virus were identified only after they had already exposed others. In other cases, they had false-negative test results or their facility was dismissive of federal guidelines, which carry no force of law.
As recently as July, a National Nurses United survey of more than 21,000 nurses found that 32% work in facilities that do not have dedicated Covid units. At that time, the coronavirus had reached all but 17 US counties, data collected by Johns Hopkins University shows.
Federal work-safety officials have closed at least 30 complaints about patient mixing in hospitals nationwide without issuing a citation. They include a claim that a Michigan hospital kept patients who tested negative for the virus in the Covid unit in May. An upstate New York hospital also kept Covid patients in the same unit as those with no infection, according to a closed complaint to the federal Occupational Safety and Health Administration.
Federal health and human services officials have called on hospitals to notify them each day whether a patient who came in without Covid-19 but developed an apparent or confirmed case of Covid-19 within 14 days. Hospitals filed 48,000 reports from 21 June through 28 August, though the number reflects some double or additional counting of individual patients.
At Alta Bates in Oakland, hospital staff made it clear in official complaints to Cal/Osha that they wanted administrators to follow the state’s unique law on aerosol-transmitted diseases.
The regulations call for patients with viruses like Covid-19 to be moved to specialized units – or to a specialized facility – within five hours of identification.
Initially, in March, the hospital outfitted a 40-bed Covid unit, according to Hill. But when a surge of patients failed to materialize, that unit was pared to 12 beds.
Since then, a steady stream of virus patients have been admitted, he said, many testing positive only days later – and after they had been in regular rooms in the facility.
From 10 March through 30 July, Hill’s union and others filed eight complaints to Cal/Osha, including allegations that the hospital failed to follow isolation rules for Covid patients, with some being placed on the cancer floor.
State officials responded to complaints by reaching out by mail and phone to “ensure the proper virus prevention measures are in place”, and two investigations are ongoing, according to Frank Polizzi, a spokesman for Cal/Osha.
A third investigation related to transport workers without N95 respirators moving confirmed or possible coronavirus patients at a Sutter Health facility near the hospital resulted in a $6,750 fine, Cal/Osha records show.
The string of complaints also say the hospital did not give staff members who cared for virus patients the personal protective equipment (PPE) required by state law – an N95 respirator or something more protective.
Instead, Hill said, staff on floors with Covid patients were provided lower-quality surgical masks, a concern reflected in complaints filed with Cal/Osha.
A Sutter Health spokesperson said the hospital took allegations, including Cal/Osha complaints, seriously and its highest priority was keeping patients and staff safe.
The statement also said that “cohorting”, or the practice of grouping virus patients together is a tool that “must be considered in a greater context, including patient acuity, hospital census and other environmental factors”.
CDC guidelines are not strict on the topic of keeping Covid patients sectioned off, noting that “facilities could consider designating entire units within the facility, with dedicated [staff]” to care for infected patients.
That approach succeeded at the University of Nebraska medical center in Omaha. A recent study reported “extensive” viral contamination around patients with Covid-19 there, but noted that with “standard” infection-control techniques in place, staff who cared for infected patients did not get the virus.
The hospital set up an isolation unit with air pumped away from the halls, restricted access to the unit and trained staff to use well-developed protocols and N95 respirators – at a minimum.
What worked in Nebraska, though, is far from standard elsewhere.
In southern California, leaders of the National Union of Healthcare Workers filed an official complaint with state hospital inspectors about the risks posed by intermingled Covid patients at Fountain Valley regional hospital, which is part of for-profit Tenet Health. There, the complaint said, patients were not routinely tested for Covid-19 upon admission.
One nursing assistant spent two successive 12-hour shifts caring for a patient on a general medical floor who required monitoring. At the conclusion of the second shift, she was told the patient had tested positive for Covid.
The worker had worn only a surgical mask – not an N95 respirator or any form of eye protection, according to the complaint to the California department of public health. The nursing assistant was not offered a Covid test or quarantined before her next two shifts, the complaint said.
The public health department said it could not comment on a pending inspection.
Barbara Lewis, southern California hospital division director with the union, said Covid patients were kept on the same floor as cancer patients and post-surgical patients who were walking the halls to speed their recovery.
A hospital spokeswoman, Jessica Chen, said the hospital “quickly implemented” changes directed by state health authorities and does place some Covid patients on the same nursing unit as non-Covid patients during surges. She said they were placed in single rooms with closed doors. Covid tests were given by physician order, she added, and employees could access them at other places in the community.
That contrasted, Lewis said, to high-profile examples of the precautions that might be taken.
“Now we’re seeing what’s happening with baseball and basketball – they’re tested every day and treated with a high level of caution,” Lewis said. “Yet we have thousands and thousands of healthcare workers going to work in a very scary environment.”