An Update from Washington State Regarding Caring for Perinatal Patients with COVID-19
Saturday, April 4, 2020
By Lauren Hamilton
Across the country, maternal healthcare workers are attempting to stay informed as hospitals rapidly change their protocols to match the ever-escalating threat of COVID-19. In a time when so much is still unknown about the virus and its effect on pregnant people and their babies, PQI has partnered with Michele Kulhanek, MSN, RNC-OB, C-EFM, Director of Safety and Quality, Maternal Infant Health at Washington State Hospital Association, to provide frequent updates from Washington State that offer guidance and resources to all maternity care providers navigating this crisis.
Michele, in a matter of days, New York hospitals went from instituting a controversial ban on partners and birth support from the labor and delivery room to overturning that policy when the NY State Health Department intervened. Can you give us your thoughts on changes to labor support policies across the country?
“It is a horrible place to be – trying to protect our hospital staff and do the right thing for every patient every time. We know the evidence for continuous labor support – Shorter duration of labor and birth, fewer medical interventions during labor and birth, including instrumental vaginal births, increased spontaneous vaginal birth, and more positive feelings about the birthing experience. With the known benefits of support during labor and delivery, WSHA recommends obstetric patients may have one partner and one birth support person accompany them. We do realize that there are other considerations for hospitals and they are making the best decisions based on the current information and the supplies at hand. I think the variation we see between our hospital’s visitation policies are based on community spread, supplies available, and the data we have about this virus. All of these factors change day-to-day, with each new patient, each situation, each new case we hear about. Does the hospital have enough supply to give to partners and birthing support people their own Personal Protective Equipment (PPE)? How do we keep doing what is proven to be best and what women deserve and keep everyone safe; these are extraordinary circumstances we are caring for people in. Hospital staff are leaving their families to show up and care for patients and they need to be protected. If we don’t find ways to keep our staff safe, we are in bigger trouble than we are right now.
If limiting visitors to your units, especially for COVID-19 positive or PUI, how can we help people feel supported, connected, and less afraid? We may need to get creative and offer iPads, video conference platforms, or other forms of communication to support birthing people through these unprecedented times. Is this as comforting or effective as having support in-person? Most likely not, but as hospitals are making individual considerations for who and how many can be present during labor and delivery, we must try everything we can to continue to provide evidence-based, respectful, and equitable patient-centered care.
One of the things I hear from doulas in Washington is that their clients are very understanding. They just want to know the policy ahead of time. It is crucial that hospitals communicate temporary restrictions on visitors and/or support persons to pregnant people and their support networks early and often -finding more than one outlet to share updates so people can prepare as much as possible. Communication should be culturally specific to the people served and available in other languages. People are afraid that they will be going through birth alone; it is important for nurses and providers to remember that they are coming to us feeling this way. We must find every opportunity for transparency and clarity in our decisions.”
How are hospitals in Washington dealing with the uncertainty around asymptomatic patients who seem healthy but are still able to infect others?
“With news of COVID positive asymptomatic cases, it is likely staff and patients are coming to work or the hospital and unknowingly exposing others. We are now seeing some hospitals go to universal masking to care for all patients. Some are asking patients to don surgical masks. Again, this may greatly depend on their supply and it is unfortunate that not all hospitals have that as an option. Also, wearing masks may not be tolerable for patients at all times, especially during the second stage of labor, but may help prevent further spread of the virus. Some hospitals are starting to assign staff a stash of masks and eyewear for all patients and this will surely impact supplies but could be considered to keep staff healthy and at work. The main worry is keeping staff safe and from exposing one another. I am watching closely for stronger evidence and guidance on this practice.
Most hospitals are screening visitors at hospital points of entry and every 12 hours. We are counting on people coming into the hospitals to disclose if they have symptoms or have been in contact with others who are sick. This is imperative in minimizing the spread within the hospital. Staff are also being screened. Leaders at one Washington hospital said they send home, on average, 5 staff per shift. Staff may not realize they have a temperature, or they are coming to work out of obligation to their colleagues.
One hospital system in Washington is providing rapid testing to all patients admitted to labor and delivery, as well as testing patients scheduled for cesarean section or medical induction of labor in advance. This helps determine exactly where to place these patients and what equipment is needed. This isn’t available state-wide, but it is exactly what we need.”
Speaking of masks and testing...what are your thoughts about the dwindling supply of both?
“The national shortage of PPE is infuriating. Not having enough PPE to protect staff is one of the reasons hospitals are restricting partners and birth support persons. Fortunately, our state government and communities are working hard to increase production – from the Department of Corrections making gowns to a local furniture manufacturing company making thousands of masks daily (organizations can learn more about connecting factories with health care services here). There is a lot of variation in what is available depending on resources on hand at each facility-each hospital is optimizing its supply of PPE during the shortage. That may mean extending use beyond manufacturers guidelines. Some hospitals are sterilizing N95 masks in-house for reuse, provided they are not soiled with makeup or other debris.
We are also finding that many staff are confused about when to wear what. Per guidance from the Centers for Disease Control and Prevention (CDC), surgical facemasks can be used when N95, Powered Air Purifier Respirators (PAPR/CAPR) are not available. The CDC has a checklist of strategies for optimizing the current supply of N95 respirators during the response to COVID-19. It can be found here. Multiple professional organizations, including the Society for Maternal Fetal Medicine, American College of Obstetricians and Gynecologists, the Association of Women’s Health, Obstetric and Neonatal Nurses, and the American College of Nurse Midwives have submitted an open letter to the CDC outlining their concern that the CDC’s statement on PPE needs to be revised because it is being interpreted to mean that clinicians caring for women in labor do not need to wear PPE.
The CDC’s advice can be unsettling; we are seeing more and more health care workers fearful and anxious about the current situation. The reality is that in facing PPE shortages, we do the best we can with what we have--no one likes this reality. Some staff are bringing homemade masks to wear over their surgical masks. Recommendations from the CDC, Departments of Health, etc. vary on this practice. My hope would be that if staff are wearing home masks that there is a communicated process about how to store, transport, and launder these masks. Once the normal supply chain is restored, the CDC says to resume the use of appropriate PPE for all PUI and COVID 19 positive patients. Everyone agrees that clinicians need to continue to use N-95 or Powered Air Purifier Respirators (PAPR) for all aerosol-generating procedures. The challenge is what to do if there are not enough PPE supplies.
At a minimum, all patients having a vaginal birth who are persons under investigation (PUI) or COVID-19 positive should include appropriate PPE of a surgical mask, eye or face shield, gown, and gloves. Many OB providers and staff are using N-95 masks or Powered Air Purifier Respirators (PARR) for other occasions, from rounding on patients to the second stage labor (pushing), not only of PUI or COVID 19 positive patients but negative patients as well. Again, we need to ensure we are optimizing supplies. While birthing has not consistently been defined as an aerosolizing procedure, it is a time of prolonged contact with a patient and the possibility of producing droplets during deep exhalation and pushing. The American Journal of Obstetrics and Gynecology published labor and delivery guidelines authored by Dr. Boelig, et al. These authors state that since “second stage of labor is likely high risk for aerosolization and N-95 mask should be used.”
As we learn more about how the virus can (or may) be transmitted, it is important to consider enteric contact precautions with potential for fecal exposure, as well as asymptomatic spread. In addition, there are other questions being raised, such as, whether administering oxygen via facemask or via nasal cannula increases the amount of aerosolization of the virus and whether the use of nitrous oxide increases the risk of aerosolizing the virus. There is much that is still unknown at this time.”
When are you testing perinatal patients and staff?
“The lack of testing also continues to be problematic. Even for hospitals that have enough tests, the turn-a-round time for results can be up to 8 days. Using in-state laboratories can decrease the time to wait for results, as well as rapid testing options. I spoke to one nurse colleague who told me they had more than a dozen nurses out as PUI. These kinds of situations can be devastating-another example of why we need point of care rapid testing.
Appropriate PPE and rapid testing availability are two things we all need right now - these two things would allow hospitals to loosen birthing support person restrictions, lessen the time of separation from baby, and get PUI staff back to work sooner.”
Have you seen any creative staffing models emerge as a way to help healthcare providers fill whatever gaps may be left by PUI staff?
“There have been some suggestions recently about creating alternating health care workers and OB clinical teams (one or two weeks on, then off for one or two weeks) in order to help limit exposure and keep hospitals staffed appropriately. I am a bit skeptical of this working--first of all, there were staffing shortages prior to the pandemic but also I think about our rural and critical access hospitals whose labor, delivery, postpartum and nursery nurses who usually wear several other hats – maybe they are a L&D nurse, but they also float to the emergency department or are a part of another specialized team within the hospital. There isn’t a one size fits all answer to this, but I think there are things hospitals can do to help keep staff healthy and on the frontlines:
- If your unit has 8-hour shifts, move to 12-hour shifts if possible
- Consider training OR/PACU and short-stay nurses since elective surgeries are canceled
- Start an “on-call” group to assist in covering when other staff need to leave
- Use everyone to their highest-level scope of practice to decrease the burden on doctors and nurses – have nurse practitioners or certified nurse-midwives help with triaging or postpartum discharges
- Have staff practice social distancing in the break room and at the nurses’ stations
- Consider universal masking for staff for all patients, all shift
- Begin call-in huddles, if you haven’t done so already, to limit the number of people in gathering in one area together
- Ensure only essential personnel respond to emergencies, attend deliveries, and limit the trips in and out of PUI and COVID positive patients’ rooms by clustering care
- Are there low-risk patients who could have intermittent auscultation of fetal heart rate instead of continuous fetal monitoring? This may free up a nurse to do other tasks instead of watching a fetal heart monitoring screen, as well as equipment if the unit were to experience a surge in patients.
- Are there alternate locations for giving birth – for low-risk patients?”
Michele Kulhanek's Additional Recommendations:
1. Considerations Regarding Separation of Mothers and Babies
- There is insufficient data and conflicting recommendations on whether to routinely separate mom from baby.
- The CDC guidelines do not categorically recommend separation - the language reads “consider” temporary separation.
- This conflicts with the World Health Organization’s recommendation to keep the dyad together, including skin to skin, kangaroo care, and supports breastfeeding. The WHO recommends these activities to be done along with proper infection prevention, such as wearing a mask and completing proper hand hygiene.
- It is essential that providers are engaging patients in conversations about the risks of separation and the benefits of separation so pregnant and birthing people have what they need to make an informed decision.
- The decision should be made with the mother, not to the mother.
- Separation should depend on the following
- Clinical condition of the mother or newborn (ICU/NICU admission)
- Mother’s choice/preference based on evidence and risks/benefits
- Unit limitation or configuration
- If the dyad is separated and the mother intends to breastfeed, support pumping to help establish a milk supply. Offer lactation consultation.”
2. Work to Eliminate Inequities
- This pandemic will have huge implications on our most vulnerable communities. People who have less access to resources and who may be more likely to feel uncomfortable expressing their wishes or concerns. We cannot forget why we brought in doulas into hospitals in the first place – because they have improved outcomes for low income and communities of color. Historically, we have not done a good job listening to women, especially women of color. We need to give people the opportunity to be heard.
- We need to track data by race/ethnicity.
3. Keep Up-to-Date
- The CDC and professional organizations are posting regular updates. It is important to frequently review the recommendations from the CDC and from the professional organizations.