'All it would take is one person': COVID-19 protective gear zones raise concerns for nurses, doctor, union

A new stoplight-coded method to determine which personal protective equipment is available to different health-care workers is raising concerns about safety among those professionals.

The guidelines colour-code health-care settings as red, orange or green zones, with personal protective equipment — masks, gowns and associated gear — appropriate to each zone, Manitoba health officials said Tuesday.

"This is what nurses have anxiety about," said Darlene Jackson, president of the Manitoba Nurses Union.

"It doesn't matter where I talk to a nurse, whether it's rural and northern, whether it's in acute care [or] long-term care, they are all continuing to raise concerns about their ability to access PPE."

The new guidelines issued by Shared Health Manitoba say medical gear is being reserved for those doing the "highest risk" work to provide the most "critical services" during the COVID-19 pandemic.

The novel coronavirus that causes COVID-19 has changed the way hospitals operate and caused worldwide shortages of protective gear, as countries try to keep their health-care workers safe while treating patients. COVID-19 is related to the deaths of six people in Manitoba, where 257 cases have been identified as of Wednesday, and non-essential services have been shut down by emergency health orders designed to encourage isolation.

A total of 25 health-care workers have been infected with COVID-19 during the pandemic, Shared Health Chief Nursing Officer Lanette Siragusa said Wednesday, accounting for roughly 10 per cent of the province's total cases.

That includes four cases of the illness identified among health-care workers over the past week, out of 11 new cases in the province over that period.

At least two of the new cases involved people who contracted the illness on the job while wearing protection, Siragusa said during Wednesday's daily COVID-19 briefing.

"It sounded like they were all using PPE," she said, meaning that any potential spread of the illness by the workers was "probably was very minimal."

Contact tracing is ongoing to determine how the other two workers diagnosed this week contracted COVID-19, Siragusa said.

"But at this point we need to make sure that those who are in the high-risk settings, in high-risk situations … have the PPE available to them, and also make sure that it's reasonable and appropriate for all staff," she said.

Shared Health is continuing to meet with unions to work through the new recommendations, she said, which are evolving based on "what is the evidence telling us and [looking] at other jurisdictions in terms of what they have moved to in this phase of the pandemic."

With overall low numbers of new cases and as active cases continue to decrease over time, she said Shared Health is trying to find a balance to ensure workplace health and safety.

Who gets what kind of equipment is determined by the new risk zones announced on Tuesday.

Red zones are settings and situations involving care or service for individuals with confirmed cases of coronavirus; orange zones involve individuals who meet the criteria for COVID-19 testing, have been tested and whose results are pending; and green zones are considered areas that are "non-suspects" for COVID-19, Siragusa said Tuesday.

"Supply levels and demand continues to be a challenge, and changes day by day depending on the area of need and the timing of deliveries."

Provincial public health and infection prevention and control staff have identified supplies that must be on hand, Siragusa said.

There have been challenges getting orders of personal protective equipment, known by the shorthand PPE, into the province and shipped in the proper volumes, she said.

"We have been really looking at every two weeks, can we get the supplies out to the regions, to the staff? Can we look at a more centralized approach to it? Because we are very fearful that there's theft and potentially hoarding that we've heard of," Siragusa said Tuesday.

"We are taking every possible step to ensure appropriate protection remains available to staff in high-risk situations and settings for the duration of this pandemic, no matter how long it's going to last, and the appropriate use now will conserve supplies that we will need later."

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Jackson is concerned the change will limit or exclude many nurses.

"If this is because of a shortage of PPE, that is absolutely frustrating and maddening," she said.

"Shared Health has finally admitted that they're not guaranteeing access for more than two weeks at a time," she said, "so when I hear the announcement today that we're now going to zones, that's very worrying, because if it is based on a lack of PPE or supply issue with PPE, then it is not based on safety for nurses and patients, and that's very concerning."

Jackson wants all front-line workers in the health-care system to have the choice of a basic surgical mask, an N95 respirator, or a full-face respirator with fresh filters, depending on the situation.

Part of nurses' daily duties involve regularly assessing the risk involved in patient care and making plans to safely respond, she said.

It takes away a nurse's discretion to decide what types of protection are needed, for example, while using swabs to test for COVID-19, she said.

"That is very disheartening."

Those working in red zones are "absolutely needing to be fitted with the highest possible standards" of gear, but even in a green zone, it should be available if the risk is there, she said.

The zone system won't necessarily work everywhere, she said, particularly in rural facilities with massive combined units involving pediatric, palliative, surgical and medical clients.

"It's very difficult to say, 'This unit is a green zone,' when you have a mixed bag like that," she said. 

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Jackson is demanding more transparency about supply levels for front-line workers.

She understands stock is not infinite given the worldwide shortage, but restricting access to physical barriers puts more people at increased risk, she said.

"That's the most important thing. If our health-care workers are not safe, they possibly could be getting the virus and then that puts our patients at risk."

Dr. Danielle Paradis, a Prairie Mountain Health Region physician who splits her time between a private clinic and the Ste. Rose General Hospital, echoed Jackson's concerns.

Paradis is worried the new zones create arbitrary boundaries that often do not exist in rural health-care facilities that use makeshift areas for COVID-19 patients, where often it takes longer for gear to trickle down and travel is more prevalent.

"I still believe that having universal PPE would be in the best interest of any community," she said.

"I can see what they're trying to do with the zones, but all it would take is one person."

Risk isn't confined to zones, union says

The Manitoba Association of Health Care Professionals agrees that more protection for everyone would be best, and says one of their members is proof of that.

Nearly three weeks ago one of their health workers tested positive for COVID-19. They contracted it while on the job union president Bob Moroz said, and they were not wearing PPE at the time because the protocols were not in place to do so.

"The PPE protocols were at best vague, and at worst non-existent," said Moroz.

"It was not a standard procedure [at the time] for people to wear PPE. Members were asking at the time if they could," said Moroz.

Moroz said instead health-care workers were following the guidance of supervisors and managers to tell them when they should be wearing protective gear.

"And literally that's what happened in a case like this, they were told that this person had been cleared, screened, etc,  they're fine," he said.

 "It turns out that wasn't the case."

Moroz said the worker was someone who moves throughout a health-care facility and would be in contact with multiple people in various areas.

He questions how even with colour-coded zones, a worker can trust there isn't risk.

"We simply don't know what we're walking into," he said.

"Manitobans and people in general are expected to behave as if we're all positive," he said.

"The same has to be true in reverse when we're talking about health-care workers, we have to assume that every interaction we have has that positive potential."

Moroz said workers that enter these high risk zones are at greater risk, and should have the appropriate PPE,  but that risk may not disappear once they leave it.

"They're also at risk for bringing that exposure to areas that may be deemed a 'green zone' if we can use that sort of terminology," he said.

"Is there PPE for an orange zone person or red zone person to change to go into a green zone? We're still waiting on details," he said.

The new zone system is just another layer of confusion for health-care workers as they try to navigate changing protocols while their own safety is in the balance, Moroz said.

"At one point they were given no protective equipment, then they had at least some protective equipment, now you're going to find the situation where if I now work in a 'green zone' as determined by the employer, that protective equipment that was good two weeks ago or a week ago is now being taken away again."