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As upper management patrolled the halls at one hospital in California, telling staff they could be fired on the spot for wearing N95 masks brought from home, one nurse asked to see the policy. The administrator told her that, if she was going to wear one, she needed a note from her doctor.

"One of my biggest concerns is the nontransparent way management is addressing these issues," said the nurse, who did not want to give her name. "If we don't start treating healthcare workers as adults, providing us with honest information, adequate protection, and supplies, I am terrified that this current situation will quickly escalate, not just with viral spread, but with staffing shortages through contagion and/or the 'rats off a sinking ship' scenario."

As hospitals watch their supply of masks and other personal protective equipment (PPE) dwindle, they have severely curtailed their use. But the constraints have become so restrictive that physicians and nurses on the frontlines of the COVID-19 pandemic believe their health is being sacrificed to assuage staff and patient morale. Practitioners are reacting with fear and rage, and they are facing everything from ridicule to reprimand — or worse — for taking matters into their own hands.

Some are being told by their hospital administrators they cannot wear PPE in hallways or that they can't bring their own PPE to a facility. In some cases, practitioners are being threatened with disciplinary actions or even fired when they have continued to use gloves, masks, or other gear.

The hospitals point to a variety of reasons for their actions, from the idea that PPE needs to be conserved and used as minimally as possible to the notion that it scares patients.

Private Facebook groups, Twitter, and other social media outlets are bursting with stories from doctors, nurses, and other healthcare workers. Many are anxious and fearful. Some are losing faith in administrators who tell them that working without PPE is safe, even while providing no evidence to back up those assertions. Still others are just plain angry.

"I'm tired of hearing stories of docs and nurses getting reprimanded by the ‘suits' for wearing a freakin surg mask when they are on the unit because it ‘looks bad,'" tweeted Ali Haider, MD. "Do you know how many HCP are admitted in the US? Are you on the wards? I say F that. Protect yourselves. #COVID19."

https://twitter.com/yourheartdoc1/status/1242257020780195842

At a hospital in the Chicago area, one clinician found and wore a P100 mask to work, and said the infection control nurse told him, "You cannot wear this mask in the hallways, you're scaring people," he told Medscape Medical News. He notes that he was ridiculed by others on staff for wearing it — many of those same colleagues were working unprotected.

An emergency physician in Maryland said that his hospital had warned physicians that they could not walk around with masks or other PPE. And when an administrator saw he was wearing a surgical mask on the ward, he told the physician that he was "not setting a good example for other staff members," and that "it was important during this time to not scare patients."

"I'm angry just talking about this and almost want to disclose the hospital," he said, but added that doing so "would be certain termination for me."

He, like others contacted for this story, did not want to name their institution or themselves, for fear of retribution.

The retribution, however, has already begun. One nurse in Oklahoma was fired reportedly because he wore a surgical mask while inserting an IV line in a patient at the Oklahoma Heart Hospital. The nurse told local TV station WBRC that a supervisor told him to take it off because it was scaring patients. He took off the mask, but when he told human resources department of his concerns, he claims he was fired on the spot.

According to a memo issued a week ago by California Nurses Association and National Nurses United, nurses at Kaiser Permanente were being told they could be fired on the spot for wearing their own N95 masks.

The nurse who was told she needed a doctor's note to wear a mask was one of those affected by Kaiser's policies. But today, she was told at a staff meeting that workers could now wear masks as much as they wanted, and that they could bring their own from home. Nurses and physicians immediately started wearing masks in all patient rooms, she said. "I'm thinking the backlash finally brought about some sanity," she told Medscape Medical News.

Kaiser had not responded to a request to comment on the new policy as of press time. But spokeswoman Elizabeth Schainbaum said the earlier recommendations were "in line with CDC guidance, recommendations by the World Health Organization, and the practices of other healthcare providers around the country."

Non–Evidence-Based Policies?

Employers frequently have cited guidance issued by the Centers for Disease Control and Prevention (CDC) or state health departments, said physicians and nurses who spoke with Medscape Medical News about this issue.

But many decry the most current CDC guidance, which included a recommendation that — when facemasks were not available — healthcare providers "might use homemade masks (eg, bandana, scarf) for care of patients with COVID-19 as a last resort." And yet, the CDC also acknowledges in the same statement that those are not considered PPE, since their ability to protect healthcare providers is unknown. While many hospitals and health systems are relying on CDC's advice as a foundation, others appear to be creating ad hoc PPE policies.

In Michigan, the local arm of Ascension Health — which has 150 hospitals in 20 states — issued a policy memo March 21 that seemed to chide healthcare workers. "There are no arbitrary inequalities, and we cannot and will not disadvantage or advantage one group over another," said the memo to all staff.

It directed that PPE be limited to providers in contact with patients under investigation, confirmed COVID-19 cases, and those screening for possible respiratory infections. "All associates and clinicians in care settings outside those listed above should not be using scarce PPE resources, such as standard surgical masks, N95 masks, gowns, goggles and face shields," the memo said.

A few days later, an updated policy stated that a single surgical mask could be used for the entirety of a single day, from patient to patient, unless it was "wet, grossly contaminated or used in aerosolized procedures." Similarly, N95 masks, and gowns, can be reused "between COVID-PUI patient

Rooms" unless "soiled or contaminated," the memo stated.

"The fact that we're expected not to change masks or wear them in the first place is very concerning for most physicians," a clinician who practices in the system told Medscape Medical News.

Medscape Medical News has contacted Ascension for comment on the memos, but has not received a response.

"Social Comfort" Masks

At Phoenix, Arizona-based Banner Health — which has 28 hospitals, including three academic medical centers, in six states — workers reportedly had masks pulled off their faces, were told to reuse PPE, and reprimanded for wearing the gear, according to the Phoenix New Times.

Banner spokesperson Becky Armendariz told Medscape Medical News that it could not substantiate those allegations but said that "no team member has been suspended as a result of PPE misuse."

"We are closely monitoring our stock of equipment and supplies, which include personal protective equipment for healthcare workers to safely engage with patients," she added, and said that Banner's PPE recommendations were based on CDC and World Health Organization guidelines.

The system is also allowing its workers to wear what it's calling "social comfort masks," that is, masks brought from home. "While Banner does not endorse personal mask use as effective in preventing disease transmission, we recognize that team members may want to engage in the use of these masks for their own personal relief," Armendariz said.

One Banner physician told Medscape Medical News that she found the policy "offensive," in that it appears that it doesn't take health care practitioners' concerns seriously and that it seems to be encouraging people to use homemade masks.

"It's just so inappropriate to a physician to be given a letter to say that you can wear a fake mask if it makes you feel more comfortable," said the doctor.

Oregon: Do As You're Told

While many organizations are supporting healthcare workers objecting to being placed in harm's way, some seem to be coming out in support of employers.

The Oregon State Board of Nursing, noting that it was receiving reports of nurses refusing to accept patient assignments if facilities were following Oregon Health Authority guidance only, said that was unacceptable. "Nurses cannot refuse an assignment solely because the employer is utilizing OHA guidelines rather than WHO or CDC guidelines," said the board in a position statement.

The American Academy of Emergency Medicine released its own position statement, declaring that it would support any emergency physician who was threatened or terminated for wearing self-supplied PPE, including "assistance with filing an OSHA [Occupational Health and Safety Administration] complaint and pursuit of litigation for wrongful termination."

Meanwhile, Boston-based Partners HealthCare is doing exactly the opposite: They now require all staff to wear masks on site at all times, according to the Boston Globe. As of publication, Partners had not responded to a request to comment on how it would manage to provide enough masks to carry out the new policy.

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