COVID-19 vaccine is stored at -80 degrees celsius in the pharmacy at Roseland Community Hospital on Dec. 18, 2020 in Chicago. (Photo by Scott Olson/Getty Images)
One day after the Montana Hospital Association submitted a letter to Gov. Greg Gianforte asking for his help in combating the current COVID-19 spike, health care professionals from a wide variety of fields presented a united front on Thursday in asking for Montanans to get vaccinated and wear masks as the state and country experience a surge in COVID-19 cases primarily driven by the powerfully infectious delta variant.
In the past week, the state saw 2,259 cases and 23 new deaths, and the increased spread has once again crowded hospitals across the state.
“Our message is choose to protect yourself and your loved ones by getting a vaccine now,” said Dr. Pamela Cutler, president of the Montana Medical Association. “Also important, masking is a tried and true measure that protects the wearer and protects others too. It works.”
The current rise in cases is occurring at a faster clip than a year ago, and health care professionals say they are worried about a future without proper mitigation efforts and sufficient vaccination.
Between July 1 and August 18 of 2020, the seven-day average of cases increased from 45 to 96. In that same period this year, the seven-day average increased from 49 to 380, according to COVID-19 data collected by Johns Hopkins University.
“It’s not deja vu; it’s groundhog’s day,” said Rich Rasmussen, president and chief executive officer of the Montana Hospital Association. “If we don’t take vaccinations seriously, I think we will see a constant rolling of surges for the foreseeable future … we will have to bake in regular disruption to our lives.”
With a renewed urgency due to the delta variant, medical providers said they are looking down the barrel of a flu season that could compound capacity and low hospital staffing levels. They are getting calls for hospital beds from as far away as Texas, and they said traveling nurses, filling in on shortages, are sleeping in their cars because of housing costs.
As of Thursday, nearly 1 million doses of the vaccine have been administered, and 454,117 Montanans are fully vaccinated. About 22,000 Montanans with weakened immune systems are eligible for a third COVID-19 shot, the state health department said Wednesday in a press release.
“This is great news because we know the impact COVID-19 has with high-risk groups,” DPHHS Director Adam Meier said in the release. “The updated recommendations will ensure those most vulnerable to complications from COVID-19 can get as much protection as possible.”
Starting Sept. 20, all people who have received the Moderna or Pfizer vaccine will be eligible to receive a third shot eight months after receiving the second dose. On Monday, the Department of Public Health and Human Services reported 85 percent of people hospitalized last week were not vaccinated.
Participating in the call for masking and vaccinations was the Montana Hospital Association, Montana Medical Association, Montana Chapter of the American Academy of Pediatrics, Montana Academy of Family Physicians, Montana Academy of Physician Assistants, Montana Chapter of the American College of Obstetricians and Gynecologists, Montana Nurses Association and Montana Chapter of the American College of Emergency Physicians.
Along with pushing mitigation efforts, the Montana Hospital Association sent a letter to Gov. Greg Gianforte asking for his help combating the current COVID-19 spike. They asked him to declare a state of emergency for essential workers and use federal funds received through the American Rescue Plan Act to make short- and long-term investments to combat the health care staffing shortages, among other requests.
Since taking office, Gianforte has favored personal responsibility and the vaccine as the way out of the pandemic, calling the vaccine the “light at the end of the tunnel.” On June 30, Gianforte ended the public health state of emergency, saying, “we are out of the tunnel, and we are surrounded in light.” Since then, the seven-day average death rate has increased fivefold, with just under half of the additional 83 deaths occurring in August and more than 7,000 new cases reported.
Gianforte did not respond to questions from the Daily Montanan about mask mandates or the requests from MHA. But last week told the Montana State News Bureau he would not implement a mask mandate as cases and hospitalizations increase.
“The governor has said, ‘Talk to your doctors when you’re making these decisions.’ That’s us. ‘Talk to your providers, talk to the nurses.’ You know, that’s us,” Cutler said while emphasizing the importance of vaccination and masking.
She also underscored the importance of masks in schools: “It worked for our schools last year, and it can keep our kids in school this year.”
MASKS IN SCHOOLS
With no approved vaccine for children under the age of 12 and no direction from state education authorities, Montana school districts face the challenge of implementing their own masking plans.
“As a local control state, our locally-elected school boards are entrusted with listening to parents and making decisions about student learning. Parents are the primary decision-makers for their children’s healthcare, and they must be at the center of any discussions about vaccinations and masking,” said Elsie Arntzen, the Montana superintendent of public instruction.
Arntzen has opted not to issue any statewide mask guidance or instruction ahead of the upcoming school year. The Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend masking for K-12 students. On Wednesday, President Joe Biden announced support for mask mandates in schools and said his administration would do everything it legally can to protect school boards trying to keep schools safe.
While K-12 school districts vary widely on masking, the University of Montana and Montana University came together this week to encourage students, faculty, staff and visitors to wear masks.
“I am very worried about going back to school. We are dealing with a different virus than we were dealing with during the winter. The delta variant is more transmissible, so going to school without mitigation measures is going to be a disaster,” said Dr. Lauren Wilson, vice president of the Montana Chapter of the American Academy of Pediatrics.
Wilson said as people stopped wearing masks, there was an unusual spike in cases of the respiratory syncytial virus, or RSV, which causes common cold-like symptoms. “We saw typical winter RSV level numbers this summer … We’re still seeing hospitalizations due to respiratory viruses now that we weren’t seeing last winter.”
Masking and social distancing last year meant there was virtually no flu season, which allowed hospitals more capacity, but Wilson said children returning to school unmasked could contribute to occupying the limited capacity hospitals have.
“Part of the concern is those viruses can cause hospitalizations in children, specifically children under the age of 2, and our hospitals are very full at the moment due to a number of different factors, including rising COVID hospitalizations,” Wilson said. “Anything we can do to keep people out of the hospital right now is very important.”
The pandemic has been extraordinarily difficult for health care professionals and students alike, said Heather Zaluski, psychiatrist and chief medical officer of the Shodair Children’s Hospital.
“Simply put, the COVID-19 pandemic has had devastating effects on children’s mental health,” she said, pointing to the teen suicide rate in Montana which she said was 12 percent higher in 2020 than it was in 2019.
“Learning and growing academically, spending time with peers, having routine and structure, and feeling safe in the world, all promote healthy child development,” she said. “Conversely, being isolated from peers, worrying about the state of the world, losing loved ones, and failing, academically, are all detrimental to children’s mental health … For these reasons, it is of utmost importance that we do everything we can to prevent a worsening of the COVID surge that we are currently seeing in Montana.”
STAFFING SHORTAGES AND HOSPITALIZATIONS
There were 200 active hospitalizations in Montana on Thursday. While that is less than half of the active hospitalizations at the pandemic’s peak, it is still taking a significant toll on hospitals with less patient capacity due to staffing shortages.
“The capacity is impacted by the ability to staff the beds … and right now, there is a staffing shortage,” Rasmussen said.
According to a DPHHS report released on Monday, half of Montana’s 10 Prospective Payment System hospitals reported 70 to 90 percent of staffed beds were occupied. Additionally, on Aug. 9, larger Montana hospitals reported 33 patients in intensive care units due to COVID-related illness, while a week later, that number had grown to 49, a rise of 49 percent.
During Thursday’s Zoom press conference, Dr. Greg Hansen, CEO of a critical care access hospital in Montana and chairman of the MHA board, said that the rise in hospitalizations has led to multiple complications, including holding patients in emergency rooms until beds open.
“I’ve spoken with both clinical and administrative colleagues at a number of critical access hospitals, and I’ve found stories where they are having to call and transfer patients as far as Utah in order to find open beds,” he said.
Inversely, Montana has received calls from hospitals as close as Idaho to as far as Texas looking for open beds; Rasmussen said: “Everyone is scrambling.”
Brian Whitlock, CEO of the Idaho Hospital Association, said it is facing similar issues as Montana.
“There are increasing numbers of COVID cases and decreasing numbers of staffed available hospital beds, and at any point, during the day, one of our hospitals may be trying to find a place to for a patient,” he said. “Beds are not the issue. Staffing is the issue. Not enough travel nurses, and I don’t know if we have enough money to get what we need. The prices have gone up.”
The use of travel nurses has increased along with the recent spread of the virus, said Vicky Byrd, CEO of the Montana Nurses Association.
“Nurse staffing shortages existed prior to this pandemic, but they have currently been made worse due to the COVID virus, registered nurse vacancy rates are increasing, and travel nurse usage is increasing,” she said during the press conference. But, she said, travel nurses are only a Band-Aid solution.
“With every state competing for nurses, we are robbing Peter to pay Paul,” she said.
Among the challenges that exist in recruiting nurses to Montana is the astronomical housing prices, Byrd said.
“Nurses on the ground … many of them are coming to Missoula or Bozeman to work, but they can’t afford housing, they can’t secure housing, they’re sleeping on their friend’s couch, some of them are sleeping in their car, and that’s just very real,” she said.
Also contributing to the shortage of nurses are those leaving the industry due to fatigue from the first 18 months of the pandemic.
“The past year was devastating on the nursing workforce,” she said. “Montana nurses are exhausted, but we’re very resilient.”
HOSPITAL ASSOCIATION CALLS ON GIANFORTE FOR HELP
While personal responsibility is one part of the puzzle, the MHA, which includes all of Montana’s hospitals, sent a letter to Gianforte on Wednesday with requests for the Governor they say will help curb the spread of the virus.
“Every community served by a member organization is struggling with the lack of clinical, professional, and support team members. The struggle to maintain access is at an acute level, leaving hospitals to rely on out-of-state traveling nurses,” read the letter. “The most recent surge in the coronavirus has only made recruitment efforts more difficult.”
One request is for Gianforte to declare a state of emergency for essential workers. As the entire country struggles with staffing shortages, traveling nurses are in high demand. Without a state of emergency for essential workers, which streamlines the state’s ability to license healthcare workers and boost healthcare staffing more rapidly, Montana is putting itself at a disadvantage, Rasmussen said.
MHA also asked Gianforte to declare a transportation and logistics state of emergency to help hospitals combat food, oxygen and linen shortages. This emergency declaration would allow the use of the National Guard for transportation and logistics and would temporarily waive daily hour driving restrictions on drivers. Gianforte made a similar move in his effort to fight wildfires.
In addition to the emergency declarations, the MHA asked Gianforte for short-term and long-term investments in the health care field. The association is asking Gianforte to use ARPA funds in executing a master contract for workforce needs to address immediate concerns.
“Without a master contract, hospitals have to pay for their own traveling nurses, and if you are a smaller hospital, you do not have the same purchasing power as a larger facility or the state of Montana,” Rasmussen said. He said a master contract between the state and NuWest, a traveling nurse firm, under former Gov. Steve Bullock, helped address nursing shortages during the peak months of the pandemic.
Long term, the association said in the letter it wants to see ARPA money invested in health care education. According to the letter, more than 370 nursing students were denied access to nursing programs in Montana last year because of a lack of nursing school slots.
“Montana is competing nationally for healthcare talent. It is extremely difficult to recruit to fill vacancies when all 50 states are doing the same. Unfortunately, healthcare providers oftentimes compete with each other for workforce and simply hire from each other. This process does not yield new employees,” the letter read.
COMPLICATIONS BETWEEN STATE AND FEDERAL GOVERNMENT
On Wednesday, President Joe Biden announced nursing homes will have to begin vaccinating employees next month to receive Medicaid and Medicare funding.
The new federal mandate will not conflict with a recently passed law, House Bill 702 which prohibits most employers, including hospitals, from requiring employees to get vaccinated. However, the new law carved out several provisions for school districts and nursing homes, which means Biden’s mandate should not conflict with existing state law so long as the federal government and the CDC recommend vaccination.
However, doctors offices, hospitals and other medical professionals, like dentist, are subject to the new law, which means health care officials may not be able to require all employees to vaccinate.
“This is the very issue that we mentioned during the legislature when you would have federal policy contravene state policy, and that’s where we are today,” Rasmussen said.
But the more pressing question, he said, is whether Biden will extend the mandate to hospitals: “Everyone is waiting to see whether or not this will be extended to hospitals, and again, this would be 100 percent avoidable had the legislature not chosen to put (medical facilities) in this very difficult position.”
During the legislative session, health care professionals strongly opposed HB702, saying it would harm hospital staff and patients and lead to logistical complications and the ability to recruit healthcare workers.
“What was difficult for us is that HB702 applies to all vaccines,” Cutler said. “We cannot require our staff to get any vaccine, and this is against everything we’ve ever known or believed about public health and about the value of vaccination programs.”
Generally speaking, Jean Branscum, CEO of the Montana Medical Association, said her organization supports mandating vaccines, saying it’s not only about the health of the physicians and nurses, but it’s for the patients, too.
“Physicians have the right to protect their patients,” she said. “It’s about protecting those who are immunocompromised so that when they come to a provider, they know it’s safe, but now we’re not able to provide that level of assurance.”
She said there are many scenarios — from elderly patients with underlying health conditions, people going through chemotherapy whose immune systems are compromised, and even newborn babies who can’t get vaccinated who could be put at risk under the new law.
“You want your staff to be vaccinated against childhood diseases to protect the babies,” she said.
With different rules for nursing homes, hospitals and even federal facilities, the messaging is unclear to many patients, which adds to the struggle. “It’s very confusing for patients, and I think they’re now beginning to realize what (HB702) did.”
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