Employees at Valley Medical Center had a brush with COVID-19 even before the outbreak became publicly known in Western Washington after a man twice visited the Renton hospital in late February.

“He came into the Emergency Department, got discharged, a few days later came in very sick and was admitted” to the critical care unit, said Jamie Park, the hospital’s chief medical officer.

On Feb. 29, the day after an outbreak was confirmed in Western Washington, Valley notified staffers about the suspected case, and that night received a positive test result for the patient.

The next day, in a March 1 conference call, hospital administrators told some clinicians as many as 350 staffers could have been exposed during the man’s visits, according to two physicians who listened to the call.

Valley leaders say that number merely reflects the number of staffers who accessed the patient’s electronic records and that it was difficult to tell from records who could have had contact with him.

Park said the hospital contacted staffers who had close contact with the patient within 24 hours, identified those who had symptoms consistent with COVID-19 and got multiple staffers tested. Of 48 people with known exposure to the patient, only two tested positive for COVID-19.

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In the weeks that followed, Valley continued to test employees as the outbreak spread. By April 6, the medical center would screen 789 employees for symptoms, test 358 of those employees and find 39 positive for COVID-19, according to Liz Nolan, a Valley spokesperson. Nineteen employees have fully recovered. Valley employs nearly 4,000 people at its hospital and clinics and is part of UW Medicine.

One of those employees — an Emergency Department physician assistant — was admitted to the hospital’s Critical Care Unit (CCU) with COVID-19 and was in critical condition last week. The employee has been discharged since, Nolan said on Monday.

“It has shook all of us,” Park said.

Interviews with more than a dozen frontline Valley employees, including multiple physicians, and copies of emails and internal documents underscore the concerns of many employees who said that COVID-19’s sudden arrival left staff and administrators scrambling. Directives changed regularly and sometimes confusion reigned, fueling employees’ fears for their safety.

And since the outbreak began, a rift in understanding, amplified by stress, risk and fear, has grown between some Valley employees and management over access to personal protective equipment (PPE), testing availability and criteria and infection-control measures.

Valley is hardly an outlier among hospitals in Washington. Tales of hospital workers who lack protective equipment or who are getting sick are common, as are stories of bravery amid risk in the state’s hospitals.

Several health care workers, including physicians, said they became concerned that staffers were not only left unprotected in the face of possible exposure but that some could have been spreading COVID-19.

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“You have now created a place where you are transmitting actively the disease” one physician said in an interview.

Meantime, administrators say they’ve had to make difficult, prudent and unpopular decisions, like enforcing strict testing criteria and rationing medical supplies in advance of an expected patient surge.

“If we walk around with masks because we feel safer today, we may endanger employees a month from now,” Park said. “We’re all scared. Frontline caregivers are scared. We, as administrators, we’re human. We’re scared of making the wrong decision — making a decision where we can’t supply employees with what we need.”

“You do NOT need to wear a mask”

The employees each spoke on the condition their names not be used, fearing they would lose their jobs. Several mentioned the widely shared dismissal of an emergency room physician, Ming Lin, who publicly decried what he called a lack of protective measures at PeaceHealth St. Joseph Medical Center in Bellingham and was later fired.

Some employees’ concerns began early in the outbreak, when they were told several times in staffwide emails to avoid wearing surgical masks.

“If you have no symptoms, you do NOT need to wear a mask,” read a March 5 email.

Several workers say managers also directed them in person to forgo masks.

“They didn’t want to scare the patients,” said someone who checks patients in at a Valley Medical Center facility. “I don’t feel like they cared whether we were protected or not.”

Administrators said masks have become an emotional issue with staff as they conserve and prioritize resources.

Early in the outbreak, employees’ surgical-mask use spiked 300% and there was a “scary 24-hour period where we were down to a one-day utilization of masks,” said chief nursing officer Theresa Braungardt.

Meantime, multiple physicians at urgent or primary care facilities reported seeing high volumes of patients with COVID-19 symptoms.

“There seemed to be an imminent threat of spread and we were behind,” one physician said.

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For nearly two weeks after the outbreak was identified locally and knowing that experts suspected community transmission of the virus, Valley facilities used procedures to screen patients for evaluation that focused on their travel histories rather than merely symptoms of COVID-19, according to multiple employees and documents.

“Who cares about travel? This is a hot spot. This is irrelevant,” one physician said. (Valley leaders said their guidance hewed closely to that of the Centers for Disease Control and Prevention.)

Multiple employees told The Seattle Times several patients bypassed these screenings, only to present symptoms in exam rooms where health care workers were not prepared with as much PPE as they wanted.

Later, after patients were transferred to Valley’s Emergency Department and tested positive for COVID-19, no one in hospital management followed up with workers about their potential exposure, the employees said. These employees learned of it through co-workers or by reviewing patient charts.

After possible exposure, multiple employees said they called in to management and to Valley’s employee health program and were told to continue working.

One urgent care physician raised alarms with management and other clinicians in an email shared by a different Valley staffer with The Times.

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The physician reported seeing an older patient who was reluctant to wear a mask. After ordering a chest X-ray and finding pneumonia in both of the patient’s lungs, the doctor wrote that she grew worried for her safety.

“I was very concerned and before entering that room, wanted more protection — but I discovered we still don’t have a CAPR,” the physician wrote, referring to a Controlled Air Purifying Respirator system, which protects wearers from aerosolised and airborne droplets.

Without a CAPR, the physician continued to see the patient, writing that she had to “arm wrestle” the patient to the emergency room and the room remained in use for the rest of the day.

The patient was tested after visiting the emergency room and four days later returned a positive result, according to the email.

“No one communicated anything to me,” the physician wrote, adding that she called Valley’s employee health program and was told that without symptoms, she should not be tested and should continue working.

“So I am at work today … hoping I am not carrying this to my staff/clinic and patients,” the physician wrote. “Is anyone else other than me concerned?”

Similarly, two CCU nurses said several hospital employees struggled to get tested in early March, even after they exhibited COVID-19 symptoms and reported exposures.

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“I spiked a temperature, I had a sore throat that got worse. I do have a cough now and I was short of breath,” one nurse said. “Employee health told me that’s probably just anxiety.”

Park said Valley has been steadfast in sticking to state Department of Health guidelines for employee testing, in part to ensure reliable testing supply.

“With our criteria, we have adequate testing supplies to test patients and employees,” Park said, adding that testing was easier now as laboratories ramp up processing, but test-kit supply remained a challenge.

In an attempt to reduce exposure risk in urgent care clinics’ exam rooms, the administration in mid-March erected tents in three urgent and primary care facility parking lots so health care workers could evaluate patients with upper respiratory infection (URI) symptoms outdoors.

Multiple employees say administrative workers who do not have medical or PPE training have been tasked to verbally screen patients for triaged care.

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“If patients have certain symptoms and questions … we don’t have all the knowledge to answer the questions,” said one worker, whose usual job is to perform patient check-ins.

A medical assistant said it was hard to understand the purpose of the tents when testing for COVID-19 was not available at these sites. Patients with mild symptoms are told to go home. Patients with more severe symptoms are sent to the hospital’s drive-through testing program for further tests.

“We’re just collecting money. Let’s keep seeing these coughs and colds as long as we can,” the medical assistant said.

Valley leaders said the triaged screenings help medical providers find patients who are more sick than they appear and to test for influenza.

A group of 14 physicians, physician assistants and nurse practitioners on March 23 sent an email to Valley leadership, urging Valley to move toward telehealth or virtual visits and expressing concerns about access to PPE and training with it.

“We worry that VMC is fueling the fire of the COVID-19 pandemic by opting — at a critical time — to see patients live with URI symptoms that cannot clinically be distinguished from Covid,” the health care workers wrote, referring to upper respiratory infection symptoms.

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“Patients should be either at home, or they should be in the hospital receiving care that we cannot provide for in the urgent care,” they wrote, adding concerns about PPE protocols.

A March 25 reply from top Valley leaders, including Park, CEO Rich Roodman and Chief Medical Director Matt Mulder, acknowledged the tents were not ideal, but that virtual visits were not available for urgent care. He said the PPE provided was sufficient and offered more training for its use.

“While the CDC recommended that patients with mild symptoms stay at home if possible and we have reiterated that message, we cannot stop those with mild symptoms from arriving at our doors. There is no perfect solution,” the leaders wrote, adding that some patients need in-person visits and that tents will help reduce emergency department volumes.

The leaders asked the providers to recognize “we are not in a normal operating scenario as we prepare for an expected astronomical surge of COVID-19 patients within the next three weeks.”

The medical center system closed two urgent care clinics on Saturday. Some employees were told they could work in respiratory tents, the Emergency Department or take vacation during COVID-19’s interruption to operations.

Valley on April 1 changed its policy to allow more widespread mask use, following an inquiry from The Times and policy changes at UW Medicine. Park said better scientific understanding of how COVID-19 spreads and supply chain improvements prompted the measure.

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Surge in patients

Valley leaders began to see a surge in COVID-19 patients last week.

“Last Sunday, I think we had 10 positives and now we have 38,” Park said on Thursday, adding that space in the CCU has been expanded by 10 beds.

Nurses with critical care experience have been called away from other units, many now shuttered, to help.

“If you’re taking care of these patients, it’s not risk-free and that’s a different contract than many people were signing when they got into these jobs,” Park said. “The majority of people are getting with it.”

But where administrators see a challenge embraced, some hospital workers see prior issues — which they describe as low staffing, lack of supplies and tensions between workers and management — exacerbated now in crisis.

Health care workers store personal protective equipment in plastic bags on the wall in the Valley Medical Center critical care unit. Nurses say a shortage of personal protective equipment and the storage practices have made them concerned for their safety.(Courtesy photo)
Health care workers store personal protective equipment in plastic bags on the wall in the Valley Medical Center critical care unit. Nurses say a shortage of personal protective equipment and the storage practices have made them concerned for their safety.(Courtesy photo)

These days, the unit’s walls are lined with plastic bags marked with initials or names, according to a photo shared by a nurse. Inside each bag are face shields and N95 respirators workers have been asked to keep for their sole use — and reuse. N95 respirators are labeled as “single-use,” disposable devices, though many health care systems are extending their use.

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“Normally all of those are disposable,” a critical care nurse said. “I think the administration is out of touch with what’s happening. I think we are being asked to potentially sacrifice our lives. There’s no way not to contaminate yourself reusing equipment.”

Some people’s masks and face shields have gone missing during emergency code blues, the nurse said. “It’s so disorganized.”

Supply concerns have strained the relationship between staff and management at Valley Medical Center in Renton. A critical care nurse reported reusing an N-95 respirator for a week even after its soiling. Plastic barriers on some of Valley’s Controlled Air Purifying Respirators have been replaced with ACE bandages.  (Courtesy photo)
Supply concerns have strained the relationship between staff and management at Valley Medical Center in Renton. A critical care nurse reported reusing an N-95 respirator for a week even after its soiling. Plastic barriers on some of Valley’s Controlled Air Purifying Respirators have been replaced with ACE bandages. (Courtesy photo)

Added another nurse: “I take mine home … I don’t want to be caught without one later on.”

After seeing a colleague treated in the unit, one nurse said her “worst fear” had been realized.

“Seeing one of our own was very distressing.”

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