Rationing PPE Means Checking on COVID Patients Less Often. This Can Be Deadly.

Every morning, between 7 and 8, at Long Island Jewish Medical Center in Queens, several coronavirus patients are pronounced dead.

It’s not that more people die at the beginning of the day, according to two medical providers at the hospital. But as a new shift arrives, doctors and nurses find patients who have died in the hours before and went undetected by a thin overnight staff.

Health care workers at several New York hospitals say they aren’t entering patient rooms as often as usual. They say they are worried for their safety and are trying to conserve scarce personal protective equipment. And they say there are simply too many critically ill patients to provide the sort of continuous monitoring that should be standard.

“People haven’t been seen in several hours overnight,” a medical provider at Long Island Jewish said. “And when the morning team comes on, the person is sicker, or dead.”

Across the city in Brooklyn, a similar ritual plays out each morning at Maimonides Medical Center, according to two doctors at the hospital. As the day shift begins, so does the blare of alarms: a patient’s heart has stopped and they need to be resuscitated. “We hear the overhead speakers say, ‘Code 3, Tower 7, Patient Room 732, Bed 1.’ Then there will be another one. And another one,” a doctor at Maimonides said.

“Normally there are so many steps we would take to keep a close eye on them,” the doctor said. “But we’re so swamped with patients coming in that we can’t keep up.”

In New York City, the epicenter of the virus, the surge in COVID-19 patients has overwhelmed many hospitals, forcing some health care workers to rethink and at times forgo certain essential safeguards.

In interviews, doctors and nurses at nine hospitals told ProPublica that to ensure they have enough PPE, like sterile gowns and masks, and to keep themselves from contracting the virus, hospital staff are not consistently providing the level of attention needed, and that lapses in care are imperiling COVID-19 patients, whose health can deteriorate very quickly.

The hospitals themselves insisted this wasn’t so, saying their staff members have enough PPE and asserting that efforts to conserve equipment and protect staff weren’t affecting patient care.

The pressures that front-line staff are reporting reveal what appears to be a disconnect between official policy and the decisions being made each day in beleaguered hospital wards. From hospital to hospital, the concerns raised and accounts provided were remarkably similar.

Some of the hospital workers interviewed by ProPublica said that in scaling back the level of care, they have missed important changes in patients’ conditions they would ordinarily catch. One Brooklyn nurse said she and her colleagues have accidentally let patients’ medicine bags run empty. And at another hospital in Brooklyn, a doctor said that last weekend, a 46-year-old patient took off his oxygen mask to go to the bathroom. No one noticed. They later found the man dead on the bathroom floor.

At many hospitals, when a patient “codes” — meaning their hearts or breathing have stopped — the response has slowed, too. In normal times, a team would rush into the room, scrambling to assess the patient and perform CPR. Now just a couple people go in, and often only after they stop to put on protective gear.

Hospital staff said they’ve had to adapt standards and come up with stopgaps. A doctor in Manhattan said he has taken to instructing patients, from outside their rooms, on how to change their own oxygen settings: The doctor stands outside the glass window, calls the patients over the phone, tells them how to turn on the oximeter, hook it up to their finger, read the knob on the machine, dial down the rate of oxygen and turn the monitor to face the window. “But you’re talking to someone who is sick and who doesn’t know how these machines work,” the doctor said.

In New York City, more than 21,000 people have been hospitalized with COVID-19. Staff are stretched thin caring for so many critically ill patients, and some nurses are being asked to monitor up to 16 people at a time. The strain is exacerbated by a shortage of PPE.

Without sufficient equipment to feel safe, staff say they need to limit their exposure to the virus. They also want to limit how many supplies they go through. On Sunday, the president of SUNY Downstate Medical Center announced that the hospital was running out of gowns and would turn to garbage bags and rain ponchos.

One nurse at a Manhattan hospital said nurses are using N95 masks for up to 11 days, and getting a new one is always a struggle. In typical times, they wouldn’t even go from one patient’s room to another without changing masks. Now, they’re scolded if they ask for more before their current mask is visibly dirty. Some of their colleagues have started deliberately ripping the mask’s cord so their bosses have to give them a new one.

This week, a nurse employed by Maimonides started a GoFundMe campaign to raise money to buy her colleagues PPE. “We are in dire need of constant PPE to help us do our job safely & diligently,” she wrote. (After she was contacted by ProPublica for comment, she took down the fundraiser. Last weekend, a nurse in Newark was suspended after using GoFundMe to buy PPE.)

A spokeswoman for Maimonides said the availability of PPE should not be a factor in patient care there. “We have had sufficient inventory of PPE to protect our staff and patients from the beginning of the pandemic. This is evident by our decision to mask our staff in our emergency room in the very early stages of the pandemic, followed by masking our entire hospital workforce soon thereafter. We did institute preservation-of-PPE guidelines for staff to reduce waste.”

In response to the idea that patients code especially often during morning shift change, she said, “It is our experience that codes take place around the clock and are not clustered around any specific time.”

A spokesperson for Northwell Health, the health care network overseeing Long Island Jewish, told ProPublica: “The claim that there has been a surge of deaths between 7 and 8 a.m. as a result of staffing shortages is blatantly false and disputed by our critical care specialists who have been on the front lines of this pandemic. …The e-ICU staff remotely monitor patients’ vital signs and alert on-site staff to any changes in patients’ conditions. … About 80% of COVID-positive patients within LIJ are not in intensive care but their pulse oximeters (the device that monitors oxygen saturation of a patient’s blood) are checked regularly throughout the day and night.”

“I strongly disagree with the assessment that we are lacking PPE,” the spokesperson also said.

Hospital staff describe being put in an excruciating position. They are risking their lives and working tirelessly for their patients, and they’ve told reporters they’re pained by not being able to give the quality of care they’re used to. But they’ve seen their colleagues get sick and they don’t want to bring the virus home to their families. And they know that if they fall ill, they wouldn’t be able to care for patients at all. “Everyone has seen some otherwise healthy, young person die,” said the provider at Long Island Jewish. “And they don’t want that to be them.”

Dr. Leigh Vinocur, spokesperson for the American College of Emergency Physicians, told ProPublica that coupled with PPE shortages, the highly contagious virus can force hospitals into a difficult calculus. “Of course, we want to do what’s best for the patient, and in this situation we have to cut corners that we wouldn’t usually,” she said. “But the alternatives are losing half your workforce. Using all your resources on one patient, doing everything, everything, using all your PPE.”

A Vital Loss of Precision

Critical care demands vigilance and precision. “It is the most meticulous part of medicine,” Vinocur said. “You’re managing every little vital sign. … You’re literally managing the physiology of the patient.”

For the sickest coronavirus patients, hospital staff control everything from the patient’s breathing to their kidney function. In normal times, providers say, patients this sick would have continuous, one-on-one monitoring, so that every change is noticed and acted upon. But now, providers say that sort of attention is impossible.

In a standard ICU, patient monitors are hooked up to a central system, so it’s easy to track everyone’s vital signs from afar. But in hospitals overwhelmed by COVID-19 patients, non-ICU floors have been converted into intensive care units, and they don’t always have enough continuous oxygen monitors to check patient levels remotely. Instead, staff members check levels the old-school way. “Someone walks around the floor with an oxygen monitor, checks your oxygen in that moment in time and then walks away,” the Long Island Jewish provider said. “And then no one checks it until the next person comes by — which is usually every four to six hours.”

In order to contain infection, many hospitals keep the doors to patients’ rooms closed, and doctors at Maimonides said that for some rooms, it’s impossible to see inside. “And that’s so scary,” a second doctor at the hospital said, “because you’ll walk in and a patient will be half on the bed and half on the floor.”

A man with COVID-19 was recently admitted to a third hospital in Brooklyn and asked a doctor how long it was before he could leave. Before her shift ended, the doctor told him that he required oxygen, and he’d need a few days to recover. When she returned to work the next morning, she learned that the patient had taken a turn for the worse. He was on a high-concentration oxygen mask, at 15 liters per minute, the last step before intubation for COVID-19 patients.

Before the virus, doctors would check on patients on such a high oxygen setting every hour. But no doctor had evaluated this patient overnight and nurses had only checked his vital signs every four hours, the resident said.

That morning, the doctor found that he was taking 37 breaths per minute, a dangerously rapid rate. He was drowsy and sweating and gasping. “His breathing was going to stop at any moment,” she said. The resident raced to the ICU to arrange an intubation. “I didn’t want him to code and have a brain injury,” she said. The patient needed a ventilator, but it would be another four hours before one became available.

Even in units where it’s easy to check patients’ vitals without entering their room, infrequent contact can mean other important changes fall through the cracks. For patients on ventilators, nurses must manage several crucial medications, and without frequent contact, it can take too long to realize that an IV bag needs to be replaced. The IV pumps have alarms to alert staff when the bags are running low, but since patients’ doors are closed, nurses can’t always hear them.

“That’s happened to me, where it’s like, ‘Oh my fentanyl’s out.’ And I didn’t notice,” a nurse at Brooklyn Hospital Center said. “We’re seeing that quite a bit. … No one’s letting their IV bags go completely dry for an extended period, I don’t think. But you’ll look at the monitors and say, ‘Dude, do you see that your patient’s blood pressure is super low?’”

Brooklyn Hospital Center did not respond to requests for comment.

“Patient Care Is Suffering”

Many of the medical staff interviewed said routine standards of care have also been neglected as hospitals switch into crisis mode. “If someone has a leaking stool bag, are you going to go in and change it every hour?” the Manhattan nurse asked. “No. You’re not going to expose yourself.”

It’s unclear how, exactly, hospitals’ legal obligations to patients have changed during this crisis. On March 23, New York Gov. Andrew Cuomo issued an executive order, as part of broader disaster emergency efforts, that temporarily limits liability for health care workers. The order modifies existing law to provide that many medical professionals are immune from civil liability for injury or death as a direct result from their actions or omissions, unless gross negligence can be proved. The wording, though, is vague. Inside the hospital, there’s still uncertainty about the changes, according to a clinical administrative staff member at a hospital in Queens. And though some legal experts believe the order applies to hospitals, they are not explicitly written into the order. “There’s still a lot up in the air, regulatory-wise,” the clinical administrator said.

Front-line heath care workers have been sending incident notes to the clinical administrator, who has flagged fatal cases in the state’s online tracking system, though there has been little time for follow-up.

Several doctors said that efforts to conserve PPE can affect a patient’s care most when they are rapidly deteriorating. The Manhattan doctor explained that before COVID-19, if someone called a rapid response — meaning that a patient was at risk of losing a pulse within minutes — “all of us would rush into the room and there would be multiple moving parts to maximize the care and assess the situation quickly.” Now, the policy is that the first person to get into the room makes the assessment. No one else from the medical team can enter, only a COVID-19 hospitalist and intensivist, when they arrive.

Recently, the doctor said, he was summoned for a rapid response for one of his patients, and when he got to the room, he found that a nurse was already inside. He had to stand outside and talk to her through the window: “Does this patient have a pulse?” he asked. The nurse said no. Before the coronavirus, the team likely would have started CPR. Instead, the doctor waited in the hall for the COVID-19 intensivist and hospitalist. They came within two minutes and decided to forgo CPR, as the patient, who was on dialysis, had a bad prognosis and CPR increases everyone’s exposure. Still, if a doctor had been the first in the room, the doctor might have decided to start compressions immediately. “A nurse is not going to make that decision on their own.”

As they do their best to take care of their patients, doctors and nurses feel that their hands are tied. “We’re trying really hard to do our jobs and help people, but it’s a really fine line. We’re not being protected. We don’t have the right equipment. Nurses are getting sick,” the Brooklyn Hospital Center nurse said. “What do you expect? Patient care is suffering.”