VAMCs Also Called on to Backstop Overwhelmed Civilian Hospitals
WASHINGTON—While most of the country was nearing the end of its second full week of lockdown due to COVID-19, VA was in the midst of two massive administrative undertakings.
The first was familiar to many businesses dealing with the pandemic: figuring out the safest, most effective way to remain operational. The second was unique to VA: Preparing to act as a backstop to civilian hospitals to deal with the surge of pandemic patients.
Because the virus has deadlier consequences for older adults, one of VA’s first moves was to adopt a “no visitor” stance at its nursing homes. VA’s 134 nursing homes serve 41,000 veterans around the country—all of whom are older and many of whom have multiple existing health conditions that make them vulnerable if they were to become infected.
The only exception to the no visitor policy is when veterans are in their last stages of life on hospice units. In those cases, visitors will be limited to that veteran’s room. The same policy was applied to VA’s 24 spinal cord injury and disorder centers.
Both nursing homes and SCIDS suspended new admissions, except in very limited cases. SCIDS would accept inpatients to address acute clinical needs but put a hold on routine matters, while nursing homes will only accept resident transfers from VA facilities once patients have been determined not to be at risk for infection or already infected.
VA also was one of the first healthcare systems to begin screening patients for COVID-19 and limiting visitors at all of its facilities—something that VA Secretary Robert Wilkie said helped limit the number of cases in VA hospitals in the early days of the pandemic.
VA saw the first veteran in its care die from COVID-19 on March 14 at the Portland, OR, VAMC. The veteran also was the first pandemic fatality in Oregon. That death helped spur VAMCs across the country to begin restricting all visitors from their facility.
Within the week, VA had begun restructuring activity within its hospitals to try and protect patients and staff from infection. The department cut the number of routine appointments by one-third and canceled elective surgeries and had begun shifting some outpatient care to telehealth.
Beginning March 23, the department suspended funeral honors and other large gatherings at its 142 national cemeteries. Veterans can still be buried at the cemeteries, with families able to be present in groups of 10 or less. VA said it planned to keep cemeteries open for visitors but urged guests to be mindful of travel recommendations and restrictions.
Though Wilkie regularly assured the public that the number of infected veterans was relatively low, VA expected it to rise swiftly. On March 16, the department requested an additional $16 billion to be added to the pandemic stimulus bill then being debated in Congress.
Part of that $16 billion is slated for use on additional bandwidth to support the department’s telehealth capabilities, which VA expected to rely on more as hospitals filled and veterans were being asked to seek care from home if possible. The department also wanted the additional bandwidth so that more of its employees could telework.
While the department was figuring out how it could continue its normal operations, it was also preparing to support civilian hospitals. The VA’s rarely-employed “fourth mission”—added by Congress in 1982 to VA’s missions of providing healthcare, benefits, and overseeing national cemeteries—is to act as the nation’s emergency backup healthcare system in the event of war, natural disaster, or pandemic.
Louisiana was the first state to officially ask for assistance. On March 19, Gov. John Bel Edwards, predicting that his state’s hospitals would quickly exceed capacity, requested permission for his state to send patients to a VA hospital in New Orleans. Over a week later, that request was still pending.
Meanwhile, on March 29, VA hospitals in Manhattan and Brooklyn began freeing as many as 50 beds for nonveteran, nonCOVID-19 patients to try and relieve the pressure on the city’s civilian hospitals. By that point, New York City had become one of the nation’s epicenters for infection.
Wilkie said in interviews that VA was prepared to deploy as many as 3,000 emergency personnel, as well as mobile medical units and pharmacies, and that VA had been training regularly for emergency response scenarios.
Perhaps VA’s largest challenge in treating the patient surge caused by the pandemic is a lack of providers. As of December 2019, VHA had about 44,000 vacant full-time posts, with medical officer and nurse shortages a common problem across all 140 VA medical centers.
On Thursday, March 19, the Office of Personnel Management gave VA permission to begin rehiring retired medical professionals to treat the flood of expected patients. OPM also granted permission for the department to waive the salary offset if the employee was receiving federal retirement annuities.
VA immediately posted notices on its social media feeds: “WE NEED YOU! Help us in the battle against the COVID-19 pandemic.” OPM’s permission is good through March 2021 and interested providers are urged to apply at vacareers.va.gov.
While VA finds ways to bolster its staff, employee unions representing VA healthcare workers called on the department to do more to protect its staff during the pandemic. In a joint statement released March 16, five unions representing 350,000 VA employees said that VA’s lack of preparation was putting front-line healthcare workers directly at risk.
“If our nurses and healthcare workers are not protected, that means our veteran patients, their families and our wider communities are not protected,” said Irma Westmoreland, RN, and vice president of National Nurses United.
The statement calls on VA to implement maximum safeguards for employees, including full-body coverings when appropriate; communicate with staff when there is a possible or confirmed COVID-19 case; and conduct a thorough investigation after a COVID-19 patient is identified to ensure that all staff and individuals exposed are identified and notified. The statement called on any worker exposed to the virus to be placed on paid precautionary leave for at least 14 days.
“We know our VHA system is superior in many respects to the private, civilian healthcare system, and we have the know-how, capacity and skills to tackle this virus,” the statement declared. “We can set an example for the country.”
Following weeks of criticism that VA was not properly prepared for the pandemic, the department made its COVID-19 Response Plan public on March 27. The plan breaks out VA’s response into phases. At the time of the plan’s release, VA was in the middle of Phase 2—Initial Response.
For Phase 2, the response plan provides best practices for the screening, intake, and treatment of patients suspected of having COVID-19. It also directs hospitals to split inpatient units in VA hospitals into two zones: one with dedicated staff and space for COVID-19 care and one for all other patient care.
Phase 3 is triggered when the hospital finds itself overwhelmed. It advises hospital to begin using whatever alternate sites of care are available, including buildings not traditionally used for healthcare and mobile field hospitals. It also recommends hospitals reduce or stop all routine care and provide continuation of care for non-infected patients at other locations or through other mean, such as telehealth.
It also asks hospital managers to consider a number of assumptions about the course of the pandemic and what challenges they soon might have to face.
Those include: the possibility that the pandemic could last up to 18 months with multiple waves of illness; that there could be critical shortages of hospital equipment, as well as morgue capacity; and that absenteeism may reach 40% due to illness, the need to care for family members and fear of infection.
Phase 4 of the response plan details strategies for how a VA facility will begin to restart normal operations following the pandemic.
VA priorities during this phase would be to reinitiate services that had been curtailed, assess the health and well-being of staff and clean and restock facilities. However, the plan notes that recovery should be coupled with preparation for a second wave of COVID-19 patients. Facilities, the plan admits, might never return to operating exactly how they did pre-pandemic and will be asked to develop “a new standard of normalcy for the provision of healthcare delivery.”