SHIFTING HSE GUIDANCE to staff for how to cope with Covid-19 suggests that growing pressures have forced some isolated healthcare workers to return to work early and pregnant staff to remain on the frontline – contrary to the official advice at the beginning of the crisis.
By tracking several versions of official HSE guidance to staff, TheJournal.ie has found that advice drafted in January has been significantly tweaked, updated and in some cases largely repudiated by the current advice as of 3 April.
The changes come as the challenge facing hospitals grows as the number of coronavirus cases in Ireland increases daily, adding to the already heavy demand on ICUs.
At the end of January, the advice to staff stated: “Close contacts of a confirmed case will be unable to remain at work and should be advised to limit their movements and interactions with others.”
That advice has not changed, but it now comes with a significant proviso. The same guidance document, dated 12 March, states:
Close contacts of a confirmed case may not remain at work and should undergo active follow-up. An exception may be made for HCWs [healthcare workers] who may be required to return to work based on essential service needs.
The document states that ‘essential’ staff “may be allowed to return to work with twice daily monitoring, during their 14 day monitoring period”.
By 3 April, this area was considerably expanded upon. Now labelled a “derogation”, the definition of ‘essential’ had been expanded.
If, despite redeployment efforts/recruitment, an area cannot be staffed safely or a critical skill set to provide critical/essential services is unavailable, then derogation from management may be given to HCWs from the identified critical services to return to the workplace under appropriate monitoring.
And while there are protocols in place – HSE guidance details the level of monitoring a healthcare worker should receive if they return to work early – the change is a major shift from guidance issued only weeks before, indicating how rapidly regulations are changing for staff in the fight against Covid-19.
In some cases, staff say that even this guidance isn’t being followed.
One nurse, who is isolating after testing positive for Covid-19, told TheJournal.ie that despite being a close contact of several patients confirmed as coronavirus cases, she was not told to go home.
Other nurses on her ward also met the definition of close contacts. “We didn’t have enough staff to send all of us home once we became a close contact,” she said.
In response to this, a spokesperson for the HSE said that it “cannot comment on individual circumstances but where required an essential healthcare worker may receive a derogation to stay at work under active monitoring”.
Changing guidance
As the coronavirus crisis unfolded inside Irish hospitals, one thing quickly became clear – some kind of balance would need to be sought between risk to staff and keeping hospitals functioning.
And as the weeks unfolded, the availability of PPE also became a key factor in decision-making.
All the way back at the start of March, it was reported that 100 staff were self-isolating in Cork University Hospital after a patient was confirmed to have Covid-19.
Some patient appointments were reduced and rescheduled as part of infection control measures as the HSE responded to one of the earliest cases of the virus in Ireland.
Quickly, however, it became apparent that such an approach was unsustainable and staff soon returned to work if they hadn’t developed symptoms.
Since then, guidance has been updated several times as the HSE responds to the spread of coronavirus in the population.
During this crisis, occupational health staff in hospitals play a key role in managing the safety of healthcare workers.
The latest advice, dated 3 April and titled “Healthcare Worker Management By Occupational Health” is the 11th version of this guidance to be issued since 31 January.
TheJournal.ie has tracked changes to the guidance for healthcare workers from 31 January until 3 April, as the HSE adapted to the growing coronavirus outbreak.
Some of the changes are considerable. The document circulated in January stated that pregnant healthcare workers should not be rostered to work with Covid-19 patients.
By 12 March, the advice was updated to state that healthcare workers “who are pregnant or immunocompromised secondary to illness or treatment, and who have indicated that they would like to be redeployed” should not be rostered to work with confirmed cases.
By 3 April, the advice stated that pregnant healthcare workers or those with other pre-existing diseases, “who adhere to recommended Infection Prevention and Control precautions are unlikely to be at greater risk of acquiring COVID-19″.
The guidance states that they “do not need to be excluded from providing care to such patients”.
“Where possible and consistent with expressed preference of the healthcare worker it is pragmatic to allocate these healthcare workers to the care of other patients if feasible, based on staffing availability,” it continues.
It’s a situation that has triggered concerns. On 27 March, the INMO sent a letter to the HSE’s National Director of HR, Anne Marie Hoey – the union said that it is “increasingly concerned at the behaviour of managers, towards pregnant staff who have indicated a wish to be redeployed away from the front line”.
Pregnant staff, especially in the third trimester, can be particularly vulnerable to some respiratory infections – while women who become unwell in the later stages of pregnancy are generally more vulnerable.
The INMO called for greater clarity on HSE advice for pregnant staff, adding that the “clear message must be that pregnant women of any gestation will be protected if working during the Covid-19 pandemic”.
Current advice, dated 30 March, from the Royal College of Obstetricians and Gynaecologists in the UK states that “pregnant women of any gestation should be offered the choice of whether to work in direct patient-facing roles during the Covid-19 pandemic”.
After 28 weeks, the advice states that women “should be recommended to stay at home”.
The HSE has not taken this position. In a document published on 30 March, the HSE states that the UK Royal College of Obstetricians and Gynaecologist recommendations are not “evidence-based”.
Referencing guidance from the Irish Institute of Obstetricians and Gynaecologists, the HSE states that pregnant staff who follow infection control precautions “do not need to be excluded from providing care to such patients”.
There is currently very little evidence of pregnant women or newborns suffering more from Covid-19 than the rest of the population and there is no data to suggest that contracting Covid-19 could cause an increased risk of miscarriage.
Responding to a question from TheJournal.ie on Friday at the Department of Health briefing, the HSE’s Chief Clinical Officer, Dr Colm Henry, said that generally “there are a number of variations between us and other countries in terms of advice given”.
“If there is a change in the recommendations of the UK, that’s something the expert advisory group, which meets regularly a number of times a week, will be considering. Our advice is never static,” he said.
Derogation
The “derogation of ‘essential’” healthcare workers is a major change in the guidance to staff.
Pre-empted in the guidance issued on 12 March, by 3 April the derogation had expanded to set out the protocols for monitoring staff who return to work – breaking the approaches down into active and passive monitoring.
“If, despite redeployment efforts/recruitment, an area cannot be staffed safely or a critical skill set to provide critical/essential services is unavailable, then derogation from management may be given to HCWs [healthcare workers] from the identified critical services to return from the workplace under appropriate monitoring,” the guidance document of 3 April states.
“Where the HCW is a close contact”, it continues, managers should consult with Occupational Health to see if the risk is low enough for this person to return to work.
This derogation had not appeared in any of the previous guideline documents seen by TheJournal.ie.
Put simply, it significantly alters the HSE approach to healthcare staff who are seen as close contacts. To be a close contact, a healthcare worker must have had a “cumulative, unprotected exposure during one work shift”.
This means having face-to-face contact with a confirmed case while not wearing gloves, a gown or any kind of PPE equipment for over 15 minutes.
More specifically, a close contact is someone who has had unprotected exposure to bodily fluids from a confirmed case.
The advice might sound familiar – it’s the same kind of advice that would apply to members of the public. And the next step is the same too.
The advice for any close contact is to not remain at work. At home, they must restrict their movements and monitor themselves for symptoms for 14 days. But, unlike a member of the public, the chances of being a close contact are significantly higher for healthcare staff.
The derogation means that more staff – if they’re asymptomatic – could return to work early.
Close contact
The definition of close contact also shifted between January and March. At the beginning, household contacts for staff were treated as being close contacts.
A few weeks later in March, it had been removed from the definition.
By 3 April, healthcare workers who had a “household contact who is symptomatic and self-isolating, awaiting testing/results” could be considered for a derogation to return to work.
A household contact was no longer mentioned as a close contact.
Testing
With healthcare workers making up a significant proportion of all cases, guidance has also been expanded on when staff can get tested.
In March, the guidance had stated that “if the HCW reports a fever, respiratory symptoms or other symptoms consistent with Covid-19 infection within the first 14 days following the last contact, they must contact Occupational Health”.
As of 3 April, symptomatic healthcare staff will only be tested if they have:
Responding to questions about how the guidance had changed, a spokesperson for the HSE said that it “continues to operate in the evolving situation presented by the global pandemic Covid-19″.
“The approach which has been taken to date in Ireland is in line with guidance from the WHO and ECDC. We continue to monitor developments internationally and, under the guidance of the WHO, ECDC and NPHET, to provide evidence-based updated and revised advice in response,” the spokesperson said.
“In this evolving situation critical services cannot be delivered without the derogation of essential health care workers who are required to keep critical services running.”
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