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APRIL 15, 2020 -- The world has been reeling under the spread of the new coronavirus. Much has been said about protecting health care workers, but almost nothing has been said about surge staffing for when patient loads double and triple in most hospitals.
Even before the pandemic, every region in the world already suffered from a shortage of physicians, nurses, and other healthcare workers to care for their regular load of patients. COVID-19 pushing droves of people into hospitals compounds this existing predicament, putting inordinate pressure on healthcare workers. This pressure and the high patient-to–healthcare worker ratios lower the quality of care given and increase the risk of loss of healthcare workers to COVID-19, exhaustion, stress, and burnout.
It's now time for countries and systems to focus on surge staffing and tap into hitherto unused reserves of healthcare workers to bolster the healthcare workforce and meet the exponential increase in demand for their services in hospitals and health systems worldwide.
Health systems need to do what in the field of medicine is called "task shifting," and decide what type of tasks will be done by existing healthcare workers and what less complex but equally vital tasks will be done by newly onboarded healthcare workers, many of whom may not have worked at the hospital level for years. The design of new surge teams needs to be decided.
How to Do Task-Shifting
For example, one ICU attending may lead a team of five community doctors for the medical management of a large ICU. A senior ER nurse could lead a team of five community nurses to screen or care for patients in the ER. Emergency contracts must be created to bring these new workers onboard. Licensing and medical malpractice issues must be arranged with regulators, insurers, and governments.
The federal government has already taken a large step in allowing US licensed physicians to work across state borders, and states are waiving restrictions on other healthcare workers. Many governments will waive COVID-19 malpractice lawsuits during this crisis, but this needs to be documented. We must develop short, competency-based trainings and job aids to get surge staff up to speed on the management of COVID-19 patients.
Most important, every facility needs to create a list of healthcare workers who have agreed to work in the hospital during the COVID-19 surge. Local hospital associations can help as well to ensure that healthcare workers who are available to work are distributed to local hospitals according to need.
There's a large pool of healthcare workers currently doing clinical work in nonhospital settings that could be shifted to hospital care. This includes primary care workers, surgery center workers, and outpatient specialty care workers. We also need to quickly re-onboard healthcare workers in nonclinical jobs such as education, management, public health, and sales. They can be shifted to provide care in hospitals and assigned tasks on the basis of their educational qualifications, experience, and competencies.
Healthcare workers currently not in the job market could be quickly brought on board—assuming that they wish to be. Almost every country has tens of thousands of qualified healthcare workers who are not currently practicing for a number of reasons, such as sabbaticals, breaks for family care, or lack of employment opportunities. Although this is one of the best short- and long-term measures to bolster the healthcare workforce, this approach may require refresher courses depending on the extent of the break in service.
Protecting Our Healthcare Workers
While it's essential to tap into multiple staffing sources such as these, safety and security are paramount. All healthcare workers must have access to appropriate personal protective equipment (PPE). Because there is community spread of the novel coronavirus in most communities, the mandate for PPE applies to all healthcare workers no matter what patient group they are caring for. If hospitals understandably cannot furnish PPE, they should allow healthcare workers to wear their own PPE. In fact, the Joint Commission has issued a statement that healthcare workers should be allowed to wear their own PPE.
Morale among American healthcare workers is very low, and many state that they feel that they have been betrayed by their hospital administrators. Already there have been several walkouts by nurses and auxiliary healthcare workers, and there are already rumors circulating in the medical community that some of the above categories of healthcare workers will be drafted and forced to work in unsafe conditions with little or no pay.
However, none of them should be forced to work just because they are capable of doing so. Such support should be completely voluntary and include incentives such as appropriate compensation and forgiveness of health education debt.
If these reserves of healthcare workers choose not to be in contact with suspected or confirmed COVID-19 cases, they can choose to focus on the considerable number of non-COVID-19 patients who still need essential medical care. These include pregnant women and those in labor; newborns; patients with strokes, trauma, and other medical emergencies; patients with chronic conditions like diabetes and hypertension; or those with recurrent needs such as dialysis and blood transfusions.
Healthcare workers who have recently retired and are in good health may be brought back to the workforce. As they are qualified and experienced, they would need less additional training and onboarding and can hit the ground running. One important consideration, though, is that due to their age, it would be a priority that these healthcare workers be assigned to non-COVID-19 care or if they provide COVID-19 care, they must be prioritized for PPE and for emerging treatments.
Another potential pool of surge healthcare workers is medical and nursing students. They can be quickly trained for specific tasks or roles and are most suitable for need-based deployment in hospitals linked to their schools, with which they are already familiar.
They can assist physicians, work as scribes documenting the medical record, or perform a variety of other jobs in the hospital and health system. For example, medical students at the University of Minnesota have organized childcare services for the children of healthcare workers.
The United States has thousands of people who graduated from US-accredited medical schools but did not match to a residency. There is precedent for enlisting these "graduate physicians" in clinical care, and several states have a history of licensing them to practice as "associate physicians."
The United States also has tens of thousands of healthcare workers who trained and practiced abroad but are not licensed in this country. These workers can do nonclinical work in hospitals; state governments can waive licensing requirements or provide workers with short-term licensing so that they are allowed to practice in the United States. There is precedent for this, as California has allowed a limited number of Mexico-licensed physicians to practice in California.
In especially hard-hit areas, it would be wise to bring on non–healthcare workers to meet highly specific needs within the health system. Short term, competency-based skill training could be used to train non–healthcare workers for specific tasks within the health system. Depending on their educational and work background, these non–healthcare workers could be taught a range of skills, such as assisting with patient transport, logistics, stocking of medical supplies, cleaning, ensuring that healthcare workers have food and a clean place to sleep, security, and management of crowds and patient flows in hospitals. This leaves qualified healthcare workers with more time to devote to patient care–related activities.
In our conversations with other physicians, we've learned that most hospitals were not doing this level of concrete planning. Now is the time to plan for surge staffing to ensure that hospitals are not overwhelmed and that every patient receives the best care possible.
Kate Tulenko, MD, MPH, MPhil, is the chief executive officer for Corvus Health in Alexandria, Virginia, and an adjunct associate professor in the Division of Health Systems at Johns Hopkins School of Public Health.
Natasha D'Lima, MHM, is a health workforce specialist with Corvus Health.
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