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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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Am I right reading this that the HSE have rewritten their own rules and guidelines when it comes to pregnant and immunocompromised staff, despite the increasing numbers of frontline staff who are becoming infected with Covid-19. They’ve basically said tough sh!t to these staff, they have the same risk as everyone else. This seems to fly in the face of their own advice to these groups outside the HSE and everyone else’s advice to them. It’s as if they ran out of PPE, increasing numbers of staff became infected, so they simply rewrote the rule book to ensure the most compromised members of their staff could be placed in harms way. That’s criminal. How many managers in the HSE have become infected?
@Arch Angel: the article is slightly misleading regarding staff with certain pre existing conditions or receiving certain medications eg immunosuppressants. Staff members reaching certain criteria are not allowed to work. But unfortunately pregnancy is not included on the list
@Kim Keoghan: you are correct there are staff where I work off due to immunnosuppressants. I am still working in community healthcare seeing clients face 2 face and hope my nursing management would consider if they need to redeploy me they wont take my underlying conditions into account however not counting my chickens. Be safe
@Laura Mulholland Weatherwax: You too !
@Arch Angel: If it suits. I have worked in the health sector for many years and see that primary staff are often asked to do overtime (24hr shifts plus); work in difficult conditions even when understaffing is an issue for long periods from days to months; and can be required to undertake 13 hr shifts without a break. Yet it will be the same staff who are blamed if a mistake is made due to tiredness, or being burnt out. During this current crisis with Covid-19, I understand how stressful it can be to work when understaffed, but surely the health of nurses, doctors, social care workers etc. should be protected by law and not just by an ever-changing reductive set of guidelines? Any thought?
@Arch Angel: how many times did you contradict yourself in your own statement and I had to stop after about 3 paragraphs.
@Gary Conroy: Are you a HSE manager Gary?
That’s no surprise! We are literally soldiers in a war here! They do not care! I’ve been in the frontline for 25yrs, I have tried management, it is so corrupt and unsafe! I could not be part of it. I have stepped down because There is an a sense of humanity! It is a business
@Gwen Murphy: sorry mistake, I’ve reposted
Please stay safe everyone
@Gwen Murphy: Well fair play to you for trying though. This is seemingly the norm these days, if you give out about let’s say our government being corrupt then you just get shutdown because other countries are worse!! How dare they ? Why do citizens except this & think ah it’s okay?
@Gwen Murphy: you’re absolutely right in saying that. Even I had to step down due to the same reasons. It’s just buisness without any empathy or sympathy to the staff.
There was a story couple weeks back in the irish times about paying hedge fund managers millions of euros and looking how irish nurses are putting their lives on the line in terrible conditions even before this outbreak in comparison. The country is now watching how the next government reacts
@Donal Kehoe: I think it’s time we started paying people based on their value and contribution to society, rather than things like speculative gambling that often endangers people’s lives. Hedge funds often gamble on healthcare, among other industries, forcing health sector and health insurance providers to cut corners to meet certain profit margins, thereby putting people’s lives in jeopardy. For too long we have held aloft, through status and wealth distribution, people who offer nothing to society. Hedge fund managers are leeches. And, like good leeches, they need to be stamped out.
@Brian Ó Dálaigh: 100% agree. Imagine if politicians were payed based on results rather than popularity. We’d very quickly have the top people in the correct positions.
@Rossa Crowe: I agree. Salary v skills/experience in Ireland is way off.
@David Corrigan: nurses get 1100 a week .
@Rossa Crowe: TDs should be paid whatever minimum wage is set at and should have to use the public healthcare and transport.
You would see workers wages and healthcare improve very quickly then.
@Lapsy Pa: which equates to about 2400 after tax per month and that’s if you’re on at least the fifth year increment and have worked a week of 12 hour nighthifts and a weekend in your monthly duty. If you work a basic month with no night duty or weekend, on the fifth increment you will earn 682.44 euros per week.
If there’s ever one good thing to come out of all this ( and god knows we need something) it just goes to show how wonderful people are & the solidarity & kindness that’s coming out from everyone & Neighbours are getting to know & talk to each other “ again” so here’s to you all & stay safe x
@Colette Kearns: that’s great but the article is about the complete lack of care for vulnerable healthcare workers. In UK government are advising pregnant women after 28 weeks and especially healthcare workers to self isolate and stay home and here they are told to go ahead to work and if they can be redeployed to look after non covid patients then do that, if not then they should look after them if staff unavailable to cover. It’s a disgrace. Pregnant women just need to look after themselves and their babies now as they are completely on their own
*Insert comment about how Ireland are dealing with the crises(plural) better than every other EU nation particularly UK to divert attention from the shambolic Government handling of equipment provision, testing, police powers and economic provision here*
@Jack Inman: you can do both. We are not doing better than every other EU nation. But, we are doing better than a lot. That doesn’t mean that the government should be immune from criticism. Indeed, there are a lot of questions that should be asked of them.
God help them all.
@Carl: Totally. Why are they still using the”if in close contact for 15 minutes” that’s been completely debunked now.
“ if there is a change in the recommendations of the U.K…”
Come again ? Why this continuous copying of the U.K. ? Has the HSE a need to follow one of the worst examples in the world with regards to the outbreak ?
The staff , patients , in fact the whole community , are recklessly being put at risk and this is part of their answer ? This is just the maddest most reckless thing I’ve read so far .
Front line staff are incredible to be fair, rarely in hospital, had to go to A&E with a kidney stone yesterday, kept in overnight, the care is and was second to none.
That’s no surprise! We are literally soldiers in a war here! They do not care! I’ve been in the frontline for 25yrs, I have tried management, it is so corrupt and unsafe! I could not be part of it. I have stepped down because There is no regard for humanity! It is a business
It’s ‘everyman for himself’. The people behind the desk giving orders don’t care about your health, they only care about their ‘numbers’. YOU are the only one who will look after your health in this pandemic. If the PPE isn’t there REFUSE to work. It’s suicidal otherwise.
@lapse pa Nurses get approximately €1100 every 2 weeks (depending on where you work, hours worked etc), which works out at €550 every week. I know this because I am a nurse.
@Aine Darcy: so i get paid more than you but you do a far more important job than me, that’s not fair. How are the HSE supposed to attract and keep staff when you can make more money with less stress elsewhere? All the doctors and nurses that have came back to help, what will happen to them when this crisis is over and the HSE go back to making cuts?
Politicians never did and never will give a hoot about the healthcare system.
This is why they shovel money into it without it being managed properly, and this is why these amounts of money will never be enough.
Even with the country being run by a few doctors, teachers and landlords.
It’s a disgrace. No protection for pregnant workers and their unborn babies.
Haven’t shifted anyone in 3 weeks
That’s no surprise! We are literally soldiers in a war here! They do not care! I’ve been in the frontline for 25yrs, I have tried management, it is so corrupt and unsafe! I could not be part of it. I have stepped down because There is an a sense of humanity! It is a business
That’s no surprise! We are literally soldiers in a war here! They do not care! I’ve been in the frontline for 25yrs, I have tried management, it is so corrupt and unsafe! I could not be part of it. I have stepped down because There is an a sense of humanity! It is a business
@Gwen Murphy: the phrase “frontline” we are fighting a war, in the trenches, how are wars one with leaders ours are hiding in offices in suits not scrubs, unfortunately keep fgff voting in we will never change.
there are obviously different pay grades depending on qualifications and experience – they are public knowledge – the good thing to come out of this crisis is that people unhappy with the health services in ireland are more clearly distinguishing between the frontline staff compared to the over bloated inefficient management and admin – the pay for office workers in managemt positions has bloaated in past 20 years but the results are not there to show the service is well run – the public support for frontline workers should not be conflated with anger of mismanagement of health sector
have your say