Labor

When COVID-19 cases swelled in New York and other northern states this spring, Erik Andrews, a rapid response nurse at Riverside Community Hospital in southern California, thought his hospital should have enough time to prepare for the worst.

Instead, he said his hospital faced staffing cuts and a lack of adequate personal protective equipment that led around 600 of its nurses to strike for 10 days starting in late June, just before negotiating a new contract with the hospital and its owner, Nashville-based HCA Healthcare.

"To feel like you were just put out there on the front lines with as minimal support necessary was incredibly disheartening," Andrews said. Two employees at RCH have died from COVID-19, according to SEIU Local 121RN, the union representing them.

A spokesperson for HCA told Healthcare Dive the "strike has very little to do with the best interest of their members and everything to do with contract negotiations."

Across the country, the pandemic is exacerbating labor tensions with nurses and other healthcare workers, leading to a string of disputes around what health systems are doing to keep front-line staff safe. The workers' main concerns are adequate staffing and PPE. Ongoing or upcoming contract negotiations could boost their leverage.

But many of the systems that employ these workers are themselves stressed in a number of ways, above all financially, after months of delayed elective procedures and depleted volumes. Many have instituted furloughs and layoffs or other workforce reduction measures.

Striking a balance between doing union action at hospitals and continuing care for patients could be an ongoing challenge, Patricia Campos-Medina, co-director of New York State AFL-CIO/Cornell Union Leadership Institute.

"The nurses association has been very active since the beginning of the crisis, demanding PPE and doing internal activities in their hospitals demanding proper procedures," Campos-Medina said. "They are front-line workers, so they have to be thoughtful in how they continue to provide care but also protect themselves and their patients."

At Prime Healthcare's Encino Hospital Medical Center, just outside Los Angeles, medical staff voted to unionize July 5, a week after the hospital laid off about half of its staff, including its entire clinical lab team, according to SEIU Local 121RN, which now represents those workers.

One of the first things the newly formed union will fight is "the unjust layoffs of their colleagues," it said in a statement.

A Prime Healthcare spokesperson told Healthcare Dive 25 positions were cut. "These Encino positions were not part of front-line care and involved departments such as HR, food services, and lab services," the system said. 

Hospital service workers elsewhere who already have bargaining rights are also bringing attention to what they deem as staffing and safety issues.

In Chicago, workers at Loretto Hospital voted to authorize a strike Thursday. Those workers include patient care technicians, emergency room technicians, mental health staff and dietary and housekeeping staff, according to SEIU Healthcare Illinois, the union that represents them. They've been bargaining with hospital management for a new contract since December and plan to go on strike July 20.

Loretto Hospital is a safety-net facility, catering primarily to "Black and Brown West Side communities plagued with disproportionate numbers of COVID illnesses and deaths in recent months," the union said.

The "Strike For Black Lives" is in response to "management's failure to bargain in good faith on critical issues impacting the safety and well-being of both workers and patients — including poverty level wages and short staffing," according to the union.

A Loretto spokesperson told Healthcare Dive the system is hopeful that continuing negotiations will bring an agreement, though it's "planning as if a strike is eminent and considering the best options to continue to provide healthcare services to our community."

Meanwhile in Joliet, Illinois, more than 700 nurses at Amita St. Joseph Medical Center went on strike July 4.

The Illinois Nurses Association which represents Amita nurses, cited ongoing concerns about staff and patient safety during the pandemic, namely adequate PPE, nurse-to-patient ratios and sick pay, they want addressed in the next contract. They are currently bargaining for a new one, and said negotiations stalled. The duration of the strike is still unclear.

However, a hospital spokesperson told Healthcare Dive, "Negotiations have been ongoing with proposals and counter proposals exchanged."

The hospital's most recent proposal "was not accepted, but negotiations will continue," the system said.

INA is also upset with Amita's recruitment of out-of-state nurses to replace striking ones during the COVID-19 pandemic.

It sent a letter to the Illinois Department of Financial and Professional Regulation, asserting the hospital used "emergency permits that are intended only for responding to the pandemic for purposes of aiding the hospital in a labor dispute."

Article top image credit: Healthcare Dive

There's no end in sight for the country as it grapples with another surge of COVID-19 cases.

That's especially true for nurses seeking the reprieve of their hospitals returning to normal operations sometime this year. Many in the South and West are now treating ICUs full of COVID-19 patients they hoped would never arrive in their states, largely spared from spring's first wave.

And like many other essential workers, those in healthcare are falling ill and dying from COVID-19. The total number of nurses stricken by the virus is still unclear, though the Centers for Disease Control and Prevention has reported 106,180 cases and 552 deaths among healthcare workers. That's almost certainly an undercount.

National Nurses United, the country's largest nurses union, told Healthcare Dive it has counted 165 nurse deaths from COVID-19 and an additional 1,060 healthcare worker deaths.

Safety concerns have ignited union activity among healthcare workers during the pandemic, and also given them an opportunity to punctuate labor issues that aren't new, like nurse-patient ratios, adequate pay and racial equality.

At the same time, the hospitals they work for are facing some of their worst years yet financially, after months of delayed elective procedures and depleted volumes that analysts predict will continue through the year. Many have instituted furloughs and layoffs or other workforce reduction measures.

Healthcare Dive had in-depth conversations with three nurses to get a clearer picture of how they're faring amid the once-in-a-century pandemic. Here's what they said.

Elizabeth Lalasz, registered nurse, John H. Stroger Hospital in Chicago

Elizabeth Lalasz has worked at John H. Stroger Hospital in Chicago for the past 10 years. Her hospital is a safety net facility, catering to those who are "Black, Latinx, the homeless, inmates," Lalasz told Healthcare Dive. "People who don't actually receive the kind of healthcare they should in this country."

Data from the CDC show racial and ethnic minority groups are at increased risk of getting COVID-19 or experiencing severe illness, regardless of age, due to long-standing systemic health and social inequities.

CDC data reveal that Black people are five times more likely to contract the virus than white people.

This spring Lalasz treated inmates from the Cook County Jail, an epicenter in the city and also the country. "That population gradually decreased, and then we just had COVID patients, many of them Latinx families," she said.

Once Chicago's curve began to flatten and the hospital could take non-COVID patients, those coming in for treatment were desperately sick. They'd been delaying care for non-COVID conditions, worried a trip to the hospital could risk infection.

A Kaiser Family Foundation poll conducted in May found that 48% of Americans said they or a family member had skipped or delayed medical care because of the pandemic. And 11% said the person's condition worsened as a result of the delayed care.

When patients do come into Lalasz's hospital, many have "chest pain, then they also have diabetes, asthma, hypertension and obesity, it just adds up," she said.

"So now we're also treating people who've been delaying care. But after the recent southern state surges, the hospital census started going down again," she said.

Amy Arlund, registered nurse, Kaiser Permanente Medical Center in Fresno, California:

Amy Arlund works the night shift at Kaiser Fresno as an ICU nurse, which she's done for the past two decades.

She's also on the hospital's infection control committee, where for years she's fought to control the spread of clostridium difficile colitis, or C. diff., in her facility. The highly infectious disease can live on surfaces outside the body for months or sometimes years.

The measures Arlund developed to control C. diff served as her litmus test, as "the top, most stringent protocols we could adhere to," when coronavirus patients arrived at her hospital, she told Healthcare Dive.

But when COVID-19 cases surged in northern states this spring, "it's like all those really strict isolation protocols that prior to COVID showing up would be disciplinable offenses were gone," Arlund said.

Widespread personal protective equipment shortages at the start of the pandemic led the CDC and the Occupational Safety and Health Administration to change their longstanding guidance on when to use N95 respirator masks, which have long been the industry standard when dealing with novel infectious diseases.

The CDC also issued guidance for N95 respirator reuse, an entirely new concept to nurses like Arlund who say those changes go against everything they learned in school.

"I think the biggest change is we always relied on science, and we have always relied heavily on infection control protocols to guide our practice," Arlund said. "Now infection control is out of control, we can no longer rely on the information and resources we always have."

The CDC says experts are still learning how the coronavirus spreads, though person-to-person transmission is most common, while the World Health Organization recently acknowledged that it wouldn't rule out airborne transmission of the virus.

In Arlund's ICU, she's taken care of dozens of COVID positive patients and patients ruled out for coronavirus, she said. After a first wave in the beginning of April, cases dropped, but are now rising again.

Other changing guidance weighing heavily on nurses is how to effectively treat coronavirus patients.

"Are we doing remdesivir this week or are we going back to the hydroxychloroquine, or giving them convalescent plasma?"Arlund said. "Next week I'm going to be giving them some kind of lavender enema, who knows."

Erik Andrews, registered nurse, Riverside Community Hospital in Riverside, California:

Erik Andrews, a rapid response nurse at Riverside Community Hospital in California, has treated coronavirus patients since the pandemic started earlier this year. He likens ventilating them to diffusing a bomb.

"These types of procedures generate a lot of aerosols, you have to do everything in perfectly stepwise fashion, otherwise you're going to endanger yourself and endanger your colleagues," Andrews, who's been at Riverside for the past 13 years, told Healthcare Dive.

He and about 600 other nurses at the hospital went on strike for 10 days this summer after a staffing agreement between the hospital and its owner, HCA Healthcare, and SEIU Local 121RN, the union representing RCH nurses, ended without a renewal.

The nurses said it would lead to too few nurses treating too many patients during a pandemic. Insufficient PPE and recycling of single-use PPE were also putting nurses and patients at risk, the union said, and another reason for the strike.

But rapidly changing guidance around PPE use and generally inconsistent information from public officials are now making the nurses at his hospital feel apathetic.

"Unfortunately I feel like in the past few weeks it's gotten to the point where you have to remind people about putting on their respirator instead of face mask, so people haven't gotten lax, but definitely kind of become desensitized compared to when we first started," Andrews said.

With two children at home, Andrews slept in a trailer in his driveway for 12 weeks when he first started treating coronavirus patients. The trailer is still there, just in case, but after testing negative twice he felt he couldn't spend any more time away from his family.

He still worries though, especially about his coworkers' families. Some coworkers he's known for over a decade, including one staff member who died from COVID-19 related complications.

"It's people you know and you know that their families worry about them every day," he said. "So to know that they've had to deal with that loss is pretty horrifying, and to know that could happen to my family too."

Article top image credit: Yujin Kim/Healthcare Dive

By: Thomas Sugarman, MD and Hartwell Lin, MD

As COVID-19 surged through New York City this spring, local hospitals increased their ICU capacity by 500%. But despite this feat, they still hit a wall.

They didn’t have enough critical care physicians to staff those beds.

The takeaway: when it comes to pandemic preparedness, your clinical staffing plan is every bit as important as your facilities plan. You not only need more beds and providers; you also need the right expertise — plus systems to support and manage it.

As emergency physicians, we learned this firsthand while providing critical care relief in New York.

In April, California Gov. Gavin Newsom’s office asked our physician group, Vituity, to provide clinical support to New York City Health and Hospitals. In addition, we were charged with helping develop policy recommendations to prepare California for future COVID-19 surges.

When we arrived at our assigned hospitals, we were moved by the resilience of the New York City providers, who had been working tirelessly for weeks. At the same time, the process of integrating relief physicians with diverse backgrounds into clinical care proved complicated – especially as knowledge of COVID-19 changed daily.

Many local physicians assigned to the COVID-19 unit had minimal experience managing ICU patients. (Imagine a psychiatrist or pediatrician who hasn’t changed a central line since medical school.) As emergency physicians, we were comfortable with critical care procedures and resuscitation but were less experienced with ongoing management. We therefore depended on local physicians for both clinical direction and practical help navigating our new hospitals.

Fortunately, the strong climate of teamwork meant no provider was left behind. In addition, we were supported by Vituity critical care partners, who were available to advise and consult with front-line volunteers.

So how can health systems plan now to staff a potential surge? Here are our recommendations.

1. Adapt Your Clinical Command Structure

Because the New York City hospitals had far too many ventilated patients for the available pulmonology/critical care physicians to manage, they implemented an effective pyramid model.

• Native intensivists and pulmonologists (1-2 per hospital) served as both clinical experts and incident commanders who coordinated needed resources with hospital administration.
• Each COVID-19 unit was managed by intensivist fellows or physicians with critical care experience. Emergency physicians sometimes filled this role when needed.
• Finally, teams of clinicians consisting of an attending, resident, and intern from various specialties managed direct patient care. Physician assistants provided additional bandwidth, sometimes replacing interns and performing many procedures.  
• Additionally, dedicated clinical teams covered night shifts, and specialist teams were available for renal, infectious disease, cardiology and related consults.   

Relief clinicians were plugged into the pyramid based on expertise. Each team included local physicians familiar with the hospital.

2. Build Your Team in Advance

While the exact composition of your clinical pyramid will be situation-dependent, it’s never too early to start identifying key leaders. Imagine your hospital sees a three-to-ten-fold increase in critical patients. What roles you can fill from within your health system? If you notice gaps, start reaching out now to potential clinical partners.

Consider how you will integrate visiting doctors, including those working outside of their specialties. It’s vitally important that your local clinical leaders connect with incoming relief physicians to ensure they understand their responsibilities and points of contact.

Also consider logistics. When possible, centralize or outsource credentialing, travel, scheduling, training, orientation and related tasks to free up bandwidth for your front-line clinicians. It’s usually easiest to work with one or two organizations that can supply the specialists you need. Some physician groups also have the infrastructure to assist with the logistics.

3. Connect Daily with the Front Line

Finally, as a healthcare leader, stay engaged with your clinical teams. While centralized support is essential, rapidly shifting knowledge of COVID-19 requires agile decision-making that is best left to front-line providers.

Perhaps the best way to harmonize executive and clinical agendas is through daily outreach. Identify pain points and help to create solutions. Giving your teams just 10 to 15 minutes of undivided attention sends a message of support and solidarity.

In Summary

Adding beds may be the easiest part of preparing for a COVID-19 surge. Don’t forget to give equal attention to clinical capacity, including onboarding, scheduling, and providing practical and moral support to your expanded teams. Ensure that leadership stays visible and keeps communication lines open. Having a well-prepared surge plan along with leadership support will go a long way toward improving patient outcomes and boosting provider morale.

Read more insights from the New York City delegation.

Thomas Sugarman, MD, helped coordinate and deployed to New York City with the Vituity delegation. He is a practicing emergency physician and assistant medical director.

Hartwell Lin, MD, led the Vituity delegation of more than 50 clinicians to New York City. He is a practicing emergency physician, regional director, and elected member of the Vituity Board of Directors.

Article top image credit: Ventdusud via Getty Images

Dive Brief:

• Service workers at Chicago’s Loretto Hospital reached a tentative agreement with management Friday on a new contract, averting a strike planned to start Monday. The agreement raises the minimum starting wage to at least $15 an hour for all hospital employees represented by SEIU Illinois.
• Those employees include patient care technicians, emergency room technicians, mental health staff and dietary and housekeeping staff, who’ve been bargaining with hospital management for a new contract since December.
• The "Strike For Black Lives" was planned in response to "management's failure to bargain in good faith on critical issues impacting the safety and well-being of both workers and patients — including poverty level wages and short staffing," the union alleged.

Dive Insight:

Loretto is a 122-bed safety net hospital in Chicago’s Far West Side, a predominantly Black and Latino area. Service workers voted to authorize a strike July 9, but instead of striking will now “celebrate their contract victory and show their solidarity for workers across the city and country calling for the resources, wages and workplace protections needed to protect Black lives on the job and in our communities,” the union said.

With the killing of George Floyd at the hands of Minneapolis Police officers nearly two months ago and the unrest that followed, the nation’s labor unions have become more closely allied with the Black Lives Matter movement.

Their collaborations culminate this Monday with the Strike for Black Lives, a nationwide one-day work stoppage by unionized workers intended to continue the push to eliminate systemic racism, organized by the Service Employees International Union.

SEIU Illinois cheered reaching an agreement with Loretto Hospital late last week after more than seven months of negotiations.

There was a lot to celebrate for the workers represented by the union, which are among the lowest-paid employees at the hospital. They received raises ranging from $1.25 to $3 per hour and all will receive premium pay on any day their departments are short-staffed. They also received promises of more stable work schedules and protections for any employees who are immigrants.

Other victories in the contract include improved staffing provisions and Fair Work Week provisions providing hospital employees greater stability with their work schedules, according to the union.

The Loretto pact highlights enhanced union activity during the COVID-19 pandemic, leading to work stoppages and unionization efforts. Even physicians and the American Medical Association have lended their support to the Black Lives Matter and labor movements.

"Loretto workers witness the impact of poverty on community health every day on the job," the union said. "Their fight for a fair contract, and their willingness to go on strike, was motivated by the desire to have the resources they need in order to provide quality care for their patients — without becoming victims of poverty and poverty-related health conditions themselves."

Article top image credit: Healthcare Dive

Dive Brief:

• Only a quarter of the 21,200 nurses recently surveyed by National Nurses United, the country's largest nurses union, think their employers are providing a safe workplace during the pandemic.
• Concerns over personal protective equipment persist, with 87% of nurses reporting they re-used at least one type of single-use PPE, such as an N95 respirator or a face shield. Though Centers for Disease Control and Prevention and Occupational Safety and Health Administration guidance now allow for such methods in certain circumstances, the union said the process is not safe, effective or scientifically proven.
• Staffing has gotten much worse recently, 27% of nurses reported. Thirty-percent said they were assigned to a clinical care area where they were expected to care for patients that require new skills or competencies and 42% of those nurses said their reassignment hindered their ability to do their job safely.

Dive Insight:

Nurses and other healthcare workers across the country staged protests and went on strike in recent months, sounding the alarm on what they deem as unsafe working conditions while fighting a highly infectious virus.

The health systems they work for, though, are also struggling, as widespread delays for non-COVID-related care continue depressing volumes and revenues. Many have instituted cost reduction measures, including furloughs or layoffs, while it remains to be seen if, and when, they'll return to pre-pandemic volumes.

The NNU survey results were gathered from more than 21,000 union and non-union nurses in all 50 states throughout this month.

Beyond inadequate PPE and staffing concerns, nurses also fear inadequate isolation of confirmed or suspected COVID-19 patients is putting other patients and staff at greater risk of infection, according to survey responses.

Ideally, patients with suspected COVID-19 cases and confirmed positives should be isolating in negative pressure rooms to avoid cross infection. But only 15% of nurses reported that COVID-19 patients were always placed in a negative pressure room, and 32% said their facility does not have a dedicated COVID-19 area or unit.

Nurses also said they've had trouble getting tested for the virus to know whether they've been exposed. Months into the pandemic, just 23% of nurses surveyed said they'd been tested for COVID-19, and only 31% said their systems screen every patient.

According to an NNU release, the union wants the Occupational Safety and Health Administration to pass an emergency temporary standard for infectious diseases that would require more protections for healthcare workers.

It's also still pushing for President Donald Trump to use the Defense Production Act to order the mass production of PPE, as it has since the start of the pandemic.

Both of those measures are featured in House Democrats', $3 trillion relief legislation, which the union supports. Senate Republicans countered it Monday with their own relief bill, which NNU Executive Director Bonnie Castillo said in a statement doesn't include those provisions or others "that would protect nurses and our patients."

Article top image credit: Getty Images

Dive Brief:

• The Pennsylvania Department of Health this week issued an order requiring hospitals to update protocols ensuring staff safety throughout the COVID-19 pandemic. New policies include universal mask wearing for everyone entering a facility and comprehensive contact tracing among workers.
• Hospital staff who have been in contact with confirmed or probable COVID-19 cases must be notified within 24 hours and provided instruction for quarantine and work exclusion. The order also requires testing for both symptomatic and asymptomatic staff after exposure upon that employee's request.
• The policies cover all hospital staff, including those in therapeutic, social, housekeeping or dietary services, as well as maintenance. Pennsylvania hospitals have until Monday to adhere to the new rules.

Dive Insight:

Healthcare workers across the country have faced an intense physical and psychological toll in caring for COVID-19 patients. Many have dealt with inadequate personal protective equipment.

To date, more than 72,000 healthcare workers nationwide have tested positive for the virus and more than 380 have died, according to the Centers for Disease Control and Prevention, which warns those estimates are certainly an undercount.

In New York, nurses sued hospitals and the state health department alleging unsafe working conditions amid the pandemic. One lawsuit was tossed out by a judge arguing the dispute should be resolved in arbitration.

More than 5,000 healthcare workers in Pennsylvania have tested positive for COVID-19, according to a statement the Pennsylvania Association of Staff Nurses and Allied Professionals sent to Healthcare Dive.

"Since March, [the union] has been fighting to hold hospitals accountable for their lack of PPE and policies that have left dedicated frontline healthcare employees and their patients vulnerable to COVID-19," the group said.

At the union's urging, Pennsylvania Gov. Tom Wolf's "administration is, through this new order, forcing hospitals to be accountable to their employees and ensure that they, and therefore their patients, are safe," the 8,500-member group said.

The new mandates in Pennsylvania focus on effective contact tracing that is labor intensive, Gerald Maloney, chief medical officer for Geisinger Health, which operates 10 hospitals in the state, told Healthcare Dive. 

"It's possible in the past three days I was around 96 people, and now somebody has to call all of them," Maloney said.

But the unique setup of hospitals, carefully accounting for the whereabouts of patients, visitors and staff, make tracking COVID-19 exposure somewhat more do-able than in other settings. Some facilities are also brimming with untapped labor after implementing furloughs or other workforce reduction measures to offset ongoing volume declines.

Geisinger has more than 30,000 employees, some of whom have now been tapped to help with contact tracing efforts following the cancellation of elective surgeries and temporary closure of some facilities.

The health system does in-house COVID-19 testing, Maloney said, rendering faster results than public health laboratories and helping staff determine who needs to self-quarantine or who may have been exposed.

Other new state guidelines further outline what constitutes adequate PPE for healthcare workers. Those assigned to provide direct patient care in COVID-19 units must be provided particulate-filtering respirators approved by the National Institute for Occupational Safety and Health.

If unavailable, respirators approved by the Food and Drug Administration, including through an Emergency Use Authorization, are permitted. If a mask becomes soiled, damaged or otherwise ineffective, it must be replaced as soon as practical.

After the onset of the COVID-19 pandemic, the CDC changed its guidance on N95 respirators and surgical mask usage for healthcare workers, allowing them to bring homemade coverings, extend their use and employ new decontamination procedures.

Some advocacy groups, such as National Nurses United, say the new PPE guidance puts nurses at risk.

During a House Committee and Oversight Reform hearing Wednesday, NNU Executive Director Bonnie Castillo said that after the decontamination process, masks are often returned deformed or with loosened straps. There is also limited scientific evidence proving the process is safe or effective, she said.

"We know that reuse will result in more infections, and more nurses and frontline workers falling ill and out of the workforce," Castillo said.

The union and other advocacy groups are still calling for the Trump administration to fully invoke the Defense Production Act in order to supply frontline workers with enough effective PPE.

Correction: A previous version of this article misstated the number of hospitals Geisinger has in Pennsylvania. The system has 10 hospitals in the state.

Article top image credit: Dollar Photo Club

Dive Brief:

• The New York State Nurses Association filed three lawsuits Monday alleging unsafe working conditions at hospitals as providers across the country struggle to obtain adequate personal protective equipment amid the novel coronavirus pandemic.
• The nurses organization sued the New York State Department of Health, Montefiore Medical Center and Westchester Medical Center, arguing nurses were not properly trained for redeployment from hospital units and not receiving PPE. They seek injunctive relief.
• Westchester Medical Center Health Network in a statement denied the allegations and called the lawsuit irresponsible and a distraction from patient care. Montefiore said union leadership was attacking colleagues "selflessly doing all they can to fight COVID-19 and save lives." A health department spokesperson said the agency couldn't comment on pending litigation but the state is taking every step necessary to ensure workers "have the support and supplies needed to address this unprecedented public health emergency."

Dive Insight:

New York has been the hardest hit state as COVID-19 shuts down much of the country and threatens to overwhelm hospitals. Finding adequate PPE for providers has been a persistent problem.

In a recent survey from group purchasing organization Premier, 75% of respondents said they had difficulty finding isolation gowns and 67% had trouble procuring N95 masks. Providers have resorted to reusing their supplies and the Centers for Disease Control and Prevention has said other material can be used during patient care as a last resort.

Some healthcare workers have taken to bringing their own PPE, but many hospital policies forbid that practice. The Joint Commission last month came down in support of the workers.

A report from the HHS Office of Inspector General earlier this month, affirmed by the American Hospital Association, found "widespread shortages of PPE put staff and patients at risk" and said hospitals noted uncertain availability of supplies and sharp price increases.

In a letter published Friday in the New England Journal of Medicine, a Massachusetts chief physician executive describes incredible efforts to eventually obtain pallets of masks for his hospital, delivered in trucks disguised as food service vehicles.

"Our supply-chain group has worked around the clock to secure gowns, gloves, face masks, goggles, face shields, and N95 respirators. These employees have adapted to a new normal, exploring every lead, no matter how unusual," wrote Andrew Artenstein of Baystate Health.

NYSNA, which represents 42,000 members, said in court filings at least six of its registered nurses have died due to COVID-19 contracted at work and 84 have been hospitalized.

The lawsuit against Westchester, a nearly 900-bed facility in the Hudson Valley region, also alleges "intimidating RNs who have spoke out publicly about deficiencies" in the hospital's response.

Bronx-based Montefiore has about 1,500 beds. NYSNA is suing on behalf of 3,000 nurses there.

While the filings mark some of the first large-scale legal actions on behalf of healthcare workers during the COVID-19 crisis, nurses and other providers have been speaking out for weeks about lack of PPE.

National Nurses United is planning a protest Tuesday in front of the White House to call attention to healthcare workers who have become infected on the job. Also Tuesday, nurses at Providence Saint John's in Santa Monica, California, will be gathering to show support for nurses the union said were suspended after requesting PPE.

Even before the COVID-19 pandemic, nurses in New York were arguing their working conditions were untenable. About a year ago, 10,000 nurses were planning a strike of three health systems, including Montefiore, and said staffing levels were inadequate.

The standoff was resolved when the hospitals agreed to wage increases and the hiring of 1,450 new nurses.

Article top image credit: Naomi Eide/Healthcare Dive

Dive Brief:

• A federal judge in New York tossed out a lawsuit Friday that was brought by the New York State Nurses Association over allegations the Montefiore Medical Center in the Bronx isn't doing enough to protect nurses from contracting COVID-19.
• The NYSNA's lawsuit and emergency injunction sought to compel the court to force Montefiore to increase the availability of PPE and other supplies. However, Judge Jesse Furman, an appointee of President Barack Obama, said the dispute should be resolved in arbitration per the terms of the collective bargaining agreement and that it wouldn't be appropriate for the court to grant the injunction pending the arbitration.
• Still, despite the loss in federal court, the nurses association said that Montefiore had agreed to a number of provisions, including providing nurses with properly fitting N95 masks daily and sick pay to nurses out with COVID-19.

Dive Insight:

In a statement to Healthcare Dive, Montefiore said the "ruling recognizes the unions' disgraceful and counterproductive behavior for what it is — a distraction from our efforts to save lives throughout the crisis." The dismissal will allow the hospital "to return our focus 100% to caring for our patients," it said.

Although the judge dismissed the nurses lawsuit, he seemed sympathetic to their plight. However, he cautioned that the arbitration process needed play out without the court's interference.

" ... the Court cannot say that the likelihood of infection (let alone death) in the absence of an injunction is so great as to render the arbitral process meaningless. That is not to say that Montefiore cannot or should not do more to protect its nurses than it is; it is merely to say that, under the parties' collective bargaining agreement, that is an issue for the arbitrator, not this Court, to decide," Furman said in his Friday order.

NYSNA said arbitration over its safety grievance will take place.

"Every safety improvement that Montefiore Medical Center has made was the result of nurses fighting for working conditions that protect the health and safety of nurses and patients," the union, which represents more than 42,000 nurses in New York, said in a statement.

Two other lawsuits the NYSNA brought against Westchester Medical Center and the New York State Department of Health are still pending in state courts, the group said.

New York has been hard hit by the novel coronavirus, bearing the brunt of outbreak in the United States with more than 316,000 confirmed cases, or 27% of the caseload in the U.S., according to Monday's figures from Johns Hopkins Coronavirus Resource Center.

Medical workers including nurses are on the front lines of the pandemic, deemed essential workers and continuing to treat those infected with the virus. The Centers for Disease Control and Prevention reported on April 14 that about 9,300 healthcare workers contracted the disease. A majority of those were female (73%) and the median age was 42. Though, the CDC cautioned this was likely an underestimation of the total cases among healthcare workers.

Article top image credit: Naomi Eide/Healthcare Dive

Dive Brief:

• An estimated 720 nurses at AMITA St. Joseph Medical Center in Joliet, Illinois, went on strike Saturday after contract negotiations stalled between the hospital and nurses union. Both sides have been negotiating a new contract since early spring and nurses are currently working under a contract that expired May 9, according to the union representing the nurses, the Illinois Nurses Association.
• Nurses at the hospital held a strike vote in May and about 90% approved, according to the union. Since negotiations began, INA has filed four unfair labor practice complaints against the hospital for alleged intimidation and coercion and for refusing to bargain in good faith.
• A St. Joseph spokesperson told Healthcare Dive the hospital is ready to continue negotiations in good faith with unionized nurses and is prepared to deliver uninterrupted care during the strike. The two sides had a meeting on June 30 and have another planned for Wednesday.

Dive Insight:

Concerns about staff and patient safety during the pandemic, namely adequate personal protective equipment, nurse-to-patient ratios and sick pay, are leading nurses around the country to strike against their employers for better conditions. Some of them have ongoing, or upcoming contract negotiations, boosting their leverage.

At AMITA St. Joseph Medical Center, unionized nurses authorized a strike just after their contract expired in early May. Months later with negotiations at a standstill, they issued a 10-day strike notice to the hospital and its owners, including St. Louis-based chain Ascension.

Negotiations have been supervised by a federal mediator. On Friday, the hospital presented the union with its final offer. A St. Joseph spokesperson told Healthcare Dive the offer "addressed many of the issues under negotiation, including retention of extended illness benefits (EIB) and wage increases for years two and three of the contract — no three-year wage freeze — as well as tuition reimbursement and anniversary paid time off."

But nurses still walked off the job Saturday, and it’s unclear how long the strike will last.

Nurses in other parts of the country are striking, too. An estimated 1,200 nurses at Riverside Community Hospital in southern California wrapped up a 10-day strike today and will start negotiations for a new contract with owner HCA Healthcare, the country’s largest for-profit hospital operator.

Both HCA and Ascension cite major financial losses due to the pandemic, though both contend they haven’t had to institute furloughs or layoffs as other health systems have done.

But the unions representing nurses and other healthcare workers are pointing to federal stimulus money some of the giant chains have received as evidence they could easily afford to comply with the unions' requests.

Ascension received more than $200 million in federal funding to offset pandemic-related losses that it doesn't have to pay back. HCA received the most out of all for-profit operators, with a $1 billion grant.

Article top image credit: UFCW Local 400

Dive Brief:

• With no plans for another meeting between unionized nurses at Riverside Community Hospital in California and Nashville-based HCA Healthcare, both sides are gearing up for a strike Friday. It's expected to last through July 6 — a day before contract negotiations between HCA and the union are set to begin.
• Citing staffing and safety concerns, the union issued a 10-day strike notice on June 15 to the country's largest for-profit hospital chain. Recent job listings from HCA show it's been looking to hire backup nurses ahead of a potential work stoppage, along with new labor relations directors in Denver and Nashville, among other locations.
• Riverside Community Hospital argued that the motivation behind the union's strike notice "has very little to do with the best interest of their members and everything to do with contract negotiations." The system said it has plans to ensure appropriate staffing and continued services for any type of event, including a strike, but did not respond to repeated requests to elaborate.

Dive Insight:

It's unusual for a labor union to strike just days before its next shot at negotiating a better contract for workers. But that's what happening at Riverside Community Hospital, where the COVID-19 pandemic is exacerbating long-simmering staffing issues.

The staffing issues at RCH predate the pandemic, though in California COVID-19 cases are surging following lifted stay-at-home orders. 

Insufficient personal protective equipment, inadequate safety measures and recycling of single-use PPE is another issue the nurses have brought attention to. A survey of the union's members found only 27% at HCA hospitals reported having access to N95 respirators in their unit, significantly lower than other hospitals surveyed.

Early last year at RCH, reportedly low staffing levels led unionized nurses to vote in favor of authorizing a strike. HCA responded by entering into a mediated settlement with those nurses, resulting in a yearlong improved staffing agreement that helped avert a work stoppage.

That agreement ended May 31, following several extensions and a refusal from HCA to continue the mediation process, a spokesperson from SEIU Local 121RN, the union representing the nurses, told Healthcare Dive.

But the union's authority to go on strike still stands. It's unclear exactly how many nurses out of RCH's nearly 1,200 plan to strike. One nurse estimated 800 and another said a majority. The vote to strike had 98% approval, the union said.

They are protesting the end of the staffing agreement and new conditions they say leave too few nurses caring for too many patients.

California's staffing law, Title 22, is the first in the country to enforce nurse-patient ratios. Unionized nurses in other states have pushed for the same mandates in recent years.

Kathy Montanino, an RCH nurse and union representative, told Healthcare Dive the hospital went without any known nurse-patient ratio infractions for the duration of the yearlong staffing agreement. Fewer than 14 days after the agreement expired, three units at RCH reported having inadequate nurse-patient ratios, Montanino said.

And this time around it doesn't look like a strike will be so easily averted. Four days after issuing the 10-day notice, the union sent HCA a final proposal to resolve the staffing issues "collaboratively, prior to resorting to regulatory, legal, and other permissible actions," according to the proposal letter. A union spokesperson said HCA responded but did not agree to honor those proposals.

Some of the terms proposed include ensuring HCA's compliance with statewide public health regulations, such as denying transfers into the hospital once staffed beds are at capacity.

The union also wants all units to be staffed with a designated charge nurse at all times, and for those nurses to not be included in nurse-patient ratios when engaged in activities other than direct patient care.

Article top image credit: Flickr user Medill DC