PROVIDENCE — For two years, nursing homes and long-term congregate health facilities in Rhode Island have battled to keep COVID-19 out.
In recent days, two of them let the virus in: A nursing home and the state-run long-term hospital used asymptomatic but COVID-positive workers. They said they had no other choice.
It was an extraordinary step, one that is permitted under federal guidelines but one that, experts say, should only be used as a last resort. The state’s Eleanor Slater Hospital and the privately owned Respiratory and Rehabilitation Center of Rhode Island in Coventry have become the first in the state to do it.
As COVID cases soar in Rhode Island, and with the health case system already critically understaffed, they might not be the last.
“As a former defense secretary said, you don’t get to go to war with what you want, you go to war with what you have,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “And we’re at war with this virus.”
Osterholm said the U.S. is facing a “viral blizzard” right now. Hospitals, nursing homes and other health care facilities will face difficult choices, he said: Do you have someone who’s infected with COVID-19 but wearing a N95 mask at a patient’s bedside, or do you have no one at all? Even non-health care facility settings will face these choices: What happens to the medical supply manufacturers if they have an outbreak?
“This is a sad situation we’re in, but thank God there are health care workers that are willing to do that, with the idea that the greater good is to try to save these patients’ lives and at the same time try to minimize any risk,” Osterholm said. “Over the next 10 days, a lot of places will be making that same choice Rhode Island is making. This is not a matter of if, this is a matter of when and how many.”
The facilities in Rhode Island taking this step are, at the very least, a regional outlier.
Massachusetts’ guidelines don’t even account for these crisis levels of care, and no hospitals there are resorting to them, according to the commonwealth’s Department of Public Health and the Massachusetts Health and Hospital Association. Maine has adopted guidance that would allow health care facilities to use these crisis standards, but none are, the state’s Center for Disease Control and Prevention said. Health officials in Vermont, Connecticut and New Hampshire did not respond to questions about it.
The experts interviewed for this story said earlier this week they weren’t familiar with anywhere else where this was taking place right now. But it’s difficult to gauge the policies across all 50 states, and a news story said that an Akron-based hospital chain had also taken that step. Rhode Island’s two biggest hospital chains — Lifespan Corp. and Care New England — aren’t there yet, but they aren’t forcefully ruling it out either.
That means it’s rare, but not unprecedented, in the U.S., whose Centers for Disease Control and Prevention recommends using it as the last resort. Those recommendations, which were updated in late December, outline what to do if a health care worker gets sick.
There are three levels. Under conventional situations, the worker should stay out for 10 days, or seven days if they test negative. Under contingency situations, health care workers should stay out for five days, return to work if they don’t have symptoms or if their symptoms are improving. In crisis situations, there are no restrictions on COVID-positive workers, though employers should prioritize asymptomatic or mildly symptomatic workers.
Rhode Island last week adopted much of that guidance, with the “crisis” standards verbatim. But it didn’t adopt the CDC’s “conventional” guidance for 10 days of isolation. Instead it said that in any situation, even conventional ones, workers could come back after five days if their symptoms had resolved or were resolving. Nobody would argue that what hospitals are facing in Rhode Island now is conventional, with emergency doctors describing the system as “collapsing.”
Eleanor Slater Hospital and the Respiratory and Rehabilitation Center of Rhode Island went into crisis mode soon thereafter. (Eleanor Slater is licensed as a long-term acute care hospital. It is not where a patient would go in the immediate aftermath of a car crash, but the place a patient might go if a car crash left them permanently disabled. Many of its patients stay there for years, some decades. It also has psychiatric facilities.)
Eleanor Slater Hospital said it used two asymptomatic COVID-positive staff members on Saturday and three on Monday. One family member of a patient told the Globe she wasn’t notified about it, and the hospital only later posted about it on its website. Eleanor Slater was the last health care facility in the state to stop using unvaccinated workers, and one of the first to start using COVID-positive workers.
Eleanor Slater Hospital declined to say Wednesday how many patients are infected with COVID there now.
The Respiratory and Rehabilitation Center of Rhode Island said it had one asymptomatic, COVID-positive employee working only in the COVID-positive unit.
According to a notice that went out Dec. 29 and obtained by The Boston Globe, the facility notified families that it was entering “crisis” levels of staffing, but the notification did not explicitly say that it meant a COVID-positive worker would be there.
The downsides to this approach are profound, experts say.
“There are certainly situations where COVID-positive staff are better than no staff (particularly if they’re asymptomatic, vaccinated, and caring for COVID-positive patients),” Dr. Megan Ranney, associate dean at the Brown University School of Public Health and a Rhode Island emergency doctor, said in an email. “But this crisis standard could be misused in many ways — and could hurt both workers, and patients.”
Going into this crisis mode will be up to the hospitals and nursing homes, but they have to report it to the state and post information about it. Many hospitals in the state were already in contingency mode, and were looking at crisis mode, state Department of Health official Dr. James McDonald told health care providers on a Dec. 29 call.
“We’re trying to minimize this as much as possible,” McDonald said. “Obviously we prefer people who are COVID-positive not to be working. As you can see, we’re in a very difficult time in our state right now.”
McDonald said hospitals should try to have COVID-positive workers only caring for COVID-positive patients. Right now, the entire health care infrastructure, the entire workforce, is threatened by the fast-spreading Omicron variant.
In addition to potentially spreading the virus, though, using COVID-positive workers could actually exacerbate staffing problems, because healthy workers might resist working alongside colleagues who are infected.
“I think the idea of using people who are COVID-positive, even masked and vaccinated, in this setting, particularly with a variant as infectious as Omicron, is hard to justify,” Dr. Chris Beyrer, epidemiologist at the Johns Hopkins Bloomberg School of Public Health, said in an interview. He added later: “It’s also true that we all have an expectation that if we show up in an emergency room, we’re going to be cared for. And the idea that that wouldn’t be the case is really tough.”
Maryland, Beyrer noted, had taken a number of steps to address its own staffing crisis, including calling in the National Guard and waiving interstate licensing requirements. One thing that the health care system in the U.S. needs to think about adopting is “task shifting,” which is how AIDS care is delivered in parts of Africa. Task shifting is when people with a lower level of training take higher-level tasks. Nurses, not doctors, deliver much of the HIV and AIDS care in parts of Africa. They do it effectively.
“We’re not accustomed to thinking and operating this way,” Beyrer said, “but we haven’t had this kind of a threat and a challenge to our health care system in 100 years.”