To be delivered via email & public distribution

December 20, 2021

To:  The Arizona Hospital Association

Arizona health systems and healthcare facilities leadership

Governor Doug Ducey

Don Herrington, Interim Director of Arizona Department of Health Services (ADHS)

Dr. Richard Carmona, Senior Public Health Advisor to Gov. Ducey and ADHS

Members of the Arizona State Legislature

Members of the Board of Supervisors for all Arizona Counties

Arizona’s Mayors

 

Arizona’s healthcare system is in crisis. Our healthcare workforce is suffering from moral injury and burnout from the sustained onslaught that wave after wave of COVID has had on us, our families, and our communities. The COVID-19 pandemic is running unmitigated throughout the state and is straining our hospitals and affecting patient standards of care. Our current situation is unsustainable. 

We - the undersigned physicians, nurses, allied healthcare workers, Public Health professionals, and other clinical support staff from across the state of Arizona - unite together in our nonpartisan call for health system leaders and elected officials to immediately respond to the current crisis by implementing preventative measures that will dramatically reduce the spread of COVID-19 and protect our communities.

In order to rapidly reduce the spread of COVID-19 and to make every attempt possible to avoid worsening the crisis in Arizona hospitals, we implore our leaders to implement the following interventions: 

Health system leaders must immediately: 

• Adjust and enforce consistent hospital visitation policies that minimize risk of COVID transmission to family visiting the patient and subsequently to the communities they live in, via requiring proof of vaccination status (ideally, vaccine/booster requirement) and enforcement of PPE compliance policies;
• Require N95 masking for everyone working in patient care areas and KN95 masking for visitors, due to SARS-CoV-2 being an airborne respiratory virus;
• Coordinate advocacy to state, county, municipality leadership and lawmakers for implementation of an indoor mask mandate in public spaces, including K-12 schools, while Arizona’s hospitals are in contingency and/or crisis standards of care and for these indoor mask mandates to remain in place whenever inpatient or ICU staffed bed availability falls below 20%;
• Provide access to and voice public support for mandatory vaccination policies for healthcare staff, state employees, and university and community college faculty/staff/students;
• Advocate for vaccine requirements for the public when entering public establishments where masks are optional;
• Work with the state to provide vaccinations and boosters (when indicated) to patients at time of discharge from the emergency department and/or inpatient setting;
• Coordinate advocacy, resources, and strong support for maintaining isolation and quarantine guidelines as set forth by public health departments;
• Provide access to rapid response COVID-19 testing within health care facilities for health care workers;
• Enact efforts to stabilize, recruit, train, and retain the healthcare workforce to improve staffing over the medium and long-term. This should include equitable pay to current health care employees to focus on retention and hazard pay to those covering extra shifts due to healthcare worker shortages;
• Create active and transparent plans for scaling care for COVID patients via field hospitals with appropriate staffing, including frequent transparent communication with the healthcare workforce and the community.

Elected officials must immediately:  

• Mandate mask use in all indoor spaces, including all K-12 schools, while Arizona’s hospitals are in contingency and/or crisis standards of care (for any resource, including ECMO - extracorporeal membrane oxygenation), to remain in place whenever inpatient or ICU staffed bed availability falls below 20%;
• Supply free high quality masks (N95, KF94, KN95) for community members, ensure accessibility, and develop educational materials on their use;
• Urgently increase testing capacity, availability, and accessibility – to include widespread mass testing sites coupled with robust contact tracing with isolation and quarantine guidelines;
• Provide access to free rapid home COVID testing kits along with resources and guidance for isolation and quarantine requirements;
• Re-introduce widespread mass vaccination PODs administering boosters (where indicated) and vaccines for individuals 5+ years of age;
• Create a state coordinated and funded vaccination and booster campaign of assisted living facilities, nursing homes, long term care facilities, inpatient rehab centers, emergency departments, and hospitals;
• Implement vaccine requirements for entry into public establishments where masks are optional;
• Provide guidelines and funding for improved ventilation and HEPA filtration in schools, businesses, and other indoor public spaces;
• Develop public health messaging strongly encouraging masking with high quality masks, physical distancing, limiting crowd sizes, vaccination/boosters, and frequent testing.

As members of the Arizona healthcare and public health workforce, we need our healthcare employers, state, county, and municipality leadership, state legislators, and our governor to take definitive action to prevent the collapse of our state healthcare ecosystem and to avoid further social and economic damage to our state. It is well within the purview and scope of an ethical duty to patients and the community at large for healthcare facility and health system leadership to work proactively with Arizona lawmakers and policy makers to prevent more unnecessary deaths by implementing the above mitigation measures and by demanding immediate and dynamic measures from our state leadership. During each surge healthcare workers have begged for a proactive response from state and hospital leadership: in June 2020, October 2020, December 2020 - January 2021, August 2021, October 2021 and now again in December 2021. Continued inaction by our hospital leaders and lawmakers will be viewed by the healthcare community as an informed decision to ignore the health and safety of the communities you serve and an attack on those sacrificing their health and safety to care for their community.

To read additional background outlining why these actions are so imperative, inclusive of the following topics, please see the section below the area where you can sign:

• Arizona's current healthcare crisis
• The effect of Omicron on Arizona's healthcare system
• Continued threats to Arizona's healthcare staffing

If Arizona continues on its current course in the face of combined Delta + Omicron surges, we will face collapse of our healthcare system, including the need to triage hospital resources, accelerated loss of life and long-term disability in our high vulnerability state, and worsening of severe healthcare workforce shortages. To minimize these impending catastrophes, Arizona leaders must act swiftly to implement multiple measures that will slow the spread of COVID-19 and protect the health of all Arizonans.

The healthcare workers who have signed on to this letter demand that our elected officials and healthcare leaders work together to immediately implement the interventions outlined above to mitigate the impact of this crisis. Since March of 2020, we have urged individual responsibility and personal risk assessment without appropriate responsive efforts from many in the community who, due to no fault of their own, do not fully understand the crisis at hand. State-wide and hospital leadership underplaying the value of protecting your community over personal autonomy directly results in what we are seeing in our communities today. Lives will be lost unnecessarily and our healthcare system will fall deeper into crisis if you do not act now, and with urgency.

Sincerely,

The undersigned Arizona healthcare workers (physicians, nurses, allied healthcare workers, Public Health professionals, and other clinical support staff) from across the state of Arizona 

 

 

Additional background information on why the above requested actions are so urgently needed:

Arizona’s current healthcare crisis:

The impact of COVID-19 on our state has been immense. As of December 18th, Arizona has the 4th highest COVID-19 death rate in the United States (323/100,000) and, tragically, is on course to join the top three. From December 2020 – December 2021, COVID-19 was the leading cause of death in our state, ahead of cancer and heart disease. Within this last week, our state has had the fewest number of available hospital beds since the start of the pandemic, with less than 450 inpatient beds and less than 75 ICU beds statewide. This month it was announced that ECMO is not available for patients in need – we are currently in crisis standards of care for the most critically ill patients with respiratory failure. In addition to non-COVID health related emergencies, the highly contagious and deadly Delta variant has played a critical role in increasing the number of inpatient admissions. Now, the even more contagious Omicron variant is further accelerating the spread of COVID. The largest hospital system in Arizona, Banner Health, had the foresight earlier this month to appeal directly to the community at large with a public statement announcing that more than half of their 18 hospitals in the state were operating over 100% capacity, with the whole health system operating around 97%. Recent reports indicate that 32% of inpatient beds and 41% of ICU beds are in use by COVID-19 patients, which is the highest since early February 2021. These numbers are not static, but have been deteriorating due to transmission, and will likely deteriorate even more rapidly as Omicron becomes dominant. 

Notably, most hospitalized patients with COVID are unvaccinated: 

• Northwest Medical Center reported that approximately 85% of their COVID hospitalized patients are unvaccinated,
• Banner Health reported that this number was closer to 88% for those in the Intensive Care Units,
• ValleyWise reported more than 95% of hospitalized patients were unvaccinated.

Numerous health systems, such as Mayo Clinic, ValleyWise and Dignity Health, are postponing non-emergent surgeries and procedures. Patients who need a hospital bed for non-COVID related health problems are waiting days for one or being transported out of state to receive care. Furthermore, last week the Arizona Department of Health Services called upon FEMA on behalf of multiple Arizona hospitals with a request to send aid, both monetary and in the form of healthcare workers, to meet the ever increasing demands on our healthcare system due to low state COVID-19 vaccination rates, difficulty accessing vaccines and testing in a timely fashion, and inconsistent use of other proven preventative public health measures by the general public. Public health measures are essential to prevent continued increase of caseloads by achieving an R less than 1 despite high transmissibility of Omicron in both vaccinated and unvaccinated populations.

The effect of Omicron on Arizona’s healthcare system: 

With the Omicron variant circulating in our communities, we anticipate that case rates will continue to climb at a pace we have not yet encountered in previous COVID surges. Harvard University experts agree that combined Delta and Omicron surges are imminent and pose additional threat to an already overtaxed Arizona healthcare system. Based on early epidemiologic data in other countries where it is now widespread, Omicron appears to be at least twice as infectious as the Delta variant, and it poses a much greater risk of COVID reinfection and infection of vaccinated individuals. Public health experts with the World Health Organization have stated that Omicron is spreading faster than any variant to date and that vaccines alone will not protect our communities. They clearly state that additional prevention measures such as masking, physical distancing, robust ventilation, and hand hygiene need to be implemented and maintained to control transmission. They stressed that while no single measure is enough to stop the spread of Omicron, together they are enough to reduce pressure on healthcare systems around the world, especially those on the brink of collapse.  

Without immediate action and intervention, the impending Omicron surge will cause many preventable deaths, for both patients infected with COVID-19 and those seeking care for non-COVID life-threatening illnesses. Arizona is designated as a state with a “very high” vulnerability level by Covid ActNow, with 48% of the population living in a high vulnerability area. States with this designation have pre-existing economic, social, and physical conditions that make it more difficult to respond to and recover from a COVID surge. As such, Arizonans will be disproportionately impacted with higher morbidity and mortality than residents of other states by the approaching Omicron surge. It is imperative that Arizona not solely rely on calls for individual responsibility; hospital leaders and lawmakers must implement robust mitigation measures across the state for proactive community-wide protection.

Continued threats to Arizona’s healthcare staffing: 

Arizona’s current and future healthcare staffing is threatened by the continued failure of our state to universally adopt preventative public health measures, the reluctance to take action to alleviate the burden on our healthcare system, and the lack of pay equity for those working on the frontlines. Without robust community mitigation efforts, we anticipate a large percentage of current healthcare workers will fall ill with the Omicron variant despite their vaccinated status, putting additional strain on staffed hospital bed capacity and contributing to further spread of the virus. Furthermore, since the start of this pandemic the healthcare field has witnessed a tragic loss of healthcare workers from COVID-related illness and death, and with many others leaving their chosen professions due to the trauma and moral injury resulting from the massive number of witnessed (preventable) deaths. According to a recent report from the American Medical Association (AMA), one in five physicians and two in five nurses intend to leave practice in the next two years. A poll conducted earlier this year reported that an estimated 18% of healthcare workers have quit their jobs, 31% have considered leaving, and over 75% citing continued supply and staff shortages negatively affecting them and their workplace.

Not only are healthcare workers suffering from the mental health toll of this pandemic, but they are being asked to work additional shifts, cross-cover different departments that are not within their area of expertise, and are being paid inconsistently across hospital systems for their work. Many nurses are leaving to become travel nurses after learning the (more substantial) pay provided by Arizona hospitals to “travelers” for the same level of work as their employed position. We need our hospitals to value healthcare workers currently employed, and to pay them equitably for their additional labor and the taxing working conditions they are encountering. These highly skilled individuals cannot be replaced easily; it takes time and substantial cost to replace healthcare workers. The authors of the AMA study cite prior research showing that “replacing a nurse may cost up to 1.2 to 1.3 times their annual salary. Replacing physicians may cost $250,000 to more than $1 million per physician.” Arizona will continue to face serious healthcare access issues for years to come as a result of pandemic-related attrition with high replacement cost, coupled with a pre-existing healthcare worker shortage, particularly in primary care. This healthcare worker shortage, along with a high percentage of the aging population in our state, weighs heavily on our healthcare system and ensures increased demands are imminent. These demands, without proactive action today, are detrimental to the future health and wellness of our families and communities while exacerbating existing health inequities.

Inconsistent visitor policies implemented among Arizona hospitals further perpetuates the spread of this dangerous disease in our communities. The highly infectious Omicron variant circulating in our community makes this particularly worrisome. Some hospitals allow for family members to visit patients who are ill with COVID with variable PPE compliance. As healthcare workers, we understand the need for families to feel supported and to have closure when a loved one is dying. However, vaccination/booster status and PPE compliance policies should be implemented to not only help reduce the spread, but to prevent continued moral injury to healthcare workers who are watching these visitors leave the ICU to inevitably infect someone else.

 

 

Citations:

https://www.nytimes.com/interactive/2021/us/covid-cases.html, December 18, 2021

Devoid, A. COVID-19 becomes Arizona’s leading cause of death. Tucson.com. December 19, 2021. https://tucson.com/news/local/covid-19-becomes-arizonas-leading-cause-of-death/article_01c6eaa6-5c61-11ec-9929-47566ac81cb0.html

Arizona Department of Health Services COVID-19 Dashboard. https://www.azdhs.gov/covid19/data/index.php#hospital-bed-usage

Tang, T. Banner Health warns Arizona hospitals stretched to limit. AP News. December 14, 2021. https://apnews.com/article/coronavirus-pandemic-health-arizona-c1b3db28b716c388035ac1e344243717

Thomason, B. Phoenix-area hospitals pause non-emergency surgeries. AZFamily.com. December 13, 2021. https://www.azfamily.com/news/continuing_coverage/coronavirus_coverage/phoenix-area-hospitals-pause-non-emergency-surgeries/article_a678eb96-5c73-11ec-be7a-d34d395dc161.html

Phillips, M. FEMA expected to send help to Arizona hospitals. Abc15.com. December 16, 2021.

Ungar L and Johnson CK. U.S. faces double coronavirus surge as omicron variant spreads. PBS NewsHour. December 15, 2021. https://www.pbs.org/newshour/health/u-s-faces-double-coronavirus-surge-as-omicron-variant-spreads 

UK Health Security Agency. SARS-CoV-2 variants of concern and variants under investigation in England: Technical briefing 31. December 10, 2021.

Pulliam, JRC. et al. Increased of SARS-CoV-2 reinfection associated with emergence of the Omicron variant in South Africa. medRxiv 2021 (BMJ preprint). Updated December 2, 2021. https://doi.org/10.1101/2021.11.11.21266068. Accessed December 16, 2021.

Kimball, S. Omicron is spreading faster than any other Covid variant, WHO warns. CNBC.com. December 14, 2021. https://www.cnbc.com/2021/12/14/who-says-omicron-is-spreading-at-a-rate-not-seen-with-any-other-covid-variant.html

COVID ActNow Arizona statistics. https://covidactnow.org/us/arizona-az/?s=27091596. Accessed December 16, 2021.

Bateman, C. Alarm as almost 20% of South Africa’s healthcare workers contract Covid. Mail & Guardian. December 9, 2021. https://mg.co.za/coronavirus-essentials/2021-12-09-alarm-as-almost-20-of-south-africas-healthcare-workers-contract-covid/

Sinsky, CA, et al. COVID-Related Stress and Work Intentions in a Sample of US Health Care Workers. Mayo Clinic Proceedings: Innovations, Quality & Outcomes. 2021:5(6); 1165-1173. https://doi.org/10.1016/j.mayocpiqo.2021.08.007

Galvin, G. Nearly 1 in 5 Health Care Workers Have Quit Their Jobs During the Pandemic. Morning Consult. October 4, 2021. https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/