Key Points

  • Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for HCP and for safe patient care.
  • Maximizing interventions to protect HCP, patients, and visitors is critical at all times, including when considering strategies to address staffing shortages.
  • CDC’s mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency strategies followed by crisis strategies are provided to augment conventional strategies and are meant to be considered and implemented sequentially (i.e., implementing conventional strategies followed by contingency strategies followed by crisis strategies).

Introduction

This guidance is for healthcare facilities that are expecting or experiencing staffing shortages due to COVID-19.  Conventional strategies for return to the workplace for HCP with SARS-CoV-2 infection or higher-risk exposures are described in the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2

Maintaining appropriate staffing in healthcare facilities is essential to providing a safe work environment for HCP and safe patient care. If community transmission levels rise, staffing shortages could occur due to HCP illness or the need to care for family members at home. Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these shortages.  These plans and processes include communicating with HCP about actions the facility is taking to address shortages, maintaining patient and HCP safety, and providing resources to assist HCP with anxiety and stress.

CDC’s mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency, followed by crisis capacity strategies, augment conventional strategies and are meant to be considered and implemented sequentially (i.e., implementing contingency strategies before crisis strategies). For example, if, despite efforts to mitigate, HCP staffing shortages occur, healthcare systems, facilities, and the appropriate state, local, territorial, and/or tribal health authorities might determine that, in order to ensure the availability of healthcare, certain HCP with suspected or confirmed SARS-CoV-2 infection should return to work before the full conventional Return to Work Criteria have been met under the criteria set forth below.

Allowing HCP with SARS-CoV-2 infection to return to work before meeting the conventional criteria could result in healthcare-associated SARS-CoV-2 transmission. Healthcare facilities (in collaboration with risk management) should inform patients and HCP when the facility is utilizing these strategies, specify the changes in practice that should be expected, and describe the actions that will be taken to protect patients and HCP from exposure to SARS-CoV-2 if HCP with suspected or confirmed SARS-CoV-2 infection are requested to work to fulfill staffing needs.

As part of conventional strategies, it is recommended that healthcare facilities:

  • Ensure any COVID-19 vaccine requirements for HCP are followed, and where none are applicable, encourage HCP to remain up to date with all recommended COVID-19 vaccine doses.
  • Understand their normal staffing needs and the minimum number of staff needed to provide a safe work environment and safe patient care under normal circumstances.
  • Understand the local epidemiology of COVID-19-related indicators (e.g., community transmission levels).
  • Communicate with local healthcare coalitions and federal, state, and local public health partners (e.g., public health emergency preparedness and response staff) to identify additional HCP (e.g., hiring additional HCP, recruiting retired HCP, using students or volunteers), when needed.

Contingency Capacity Strategies to Mitigate Staffing Shortages

When staffing shortages are anticipated, healthcare facilities and employers, in collaboration with human resources and occupational health services, should use contingency capacity strategies to plan and prepare for mitigating this problem. These include:

Adjusting staff schedules, hiring additional HCP, and rotating HCP to positions that support patient care activities.

  • Cancel all non-essential procedures and visits. Shift HCP who work in these areas to support other patient care activities in the facility. Facilities will need to ensure these HCP have received appropriate orientation and training to work in these areas that are new to them.
  • Attempt to address social factors that might prevent HCP from reporting to work, such as need for transportation or housing that allows for physical distancing, particularly if HCP live with individuals with underlying medical conditions or older adults.
    • Consider that these social factors disproportionately affect persons from some racial and ethnic groups, who are also disproportionally affected by COVID-19 (e.g., African Americans, Hispanics and Latinos, and American Indians and Alaska Natives).
  • Identify additional HCP to work in the facility. Be aware of state-specific emergency waivers or changes to licensure requirements or renewals for select categories of HCP.
  • As appropriate, request that HCP postpone elective time off from work. However, there should be consideration for the mental health benefits of time off and that care-taking responsibilities may differ substantially among staff.

Developing regional plans to identify designated healthcare facilities or alternate care sites with adequate staffing to care for patients with SARS-CoV-2 infection.

Allowing HCP with SARS-CoV-2 infection who are well enough and willing to work to return to work as follows:

HCP with mild to moderate illness who are not moderately to severely immunocompromised:

  • At least 5 days have passed since symptoms first appeared (day 0), and
  • At least 24 hours have passed since last fever without the use of fever-reducing medications, and
  • Symptoms (e.g., cough, shortness of breath) have improved.

Healthcare facilities may choose to confirm resolution of infection with a negative nucleic acid amplification test (NAAT) or a series of 2 negative antigen tests taken 48 hours apart*.

HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised:

  • At least 5 days have passed since the date of their first positive viral test (day 0).

Healthcare facilities may choose to confirm resolution of infection with a negative NAAT (molecular) or a series of 2 negative antigen tests taken 48 hours apart*.

* Some people may be beyond the period of expected infectiousness but remain NAAT positive for an extended period.  Antigen tests typically have a more rapid turnaround time but are often less sensitive than NAAT.  Antigen testing is preferred if testing asymptomatic HCP who have recovered from SARS-CoV-2 infection in the prior 90 days.

  • Considerations for determining which HCP should be prioritized for this option include:
    • The type of HCP shortages that need to be addressed.
    • The types of symptoms they are experiencing (e.g., persistent fever, cough).
    • Their degree of interaction with patients and other HCP in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment?
    • The type of patients they care for (e.g., consider patient care only with patients known or suspected to have SARS-CoV-2 infection rather than patients who are immunocompromised).
  • If HCP are requested to return to work before meeting all conventional Return to Work Criteria, they should still adhere to the recommendations described below.
    • They should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen.
    • Until they meet the conventional return to work criteria:
    • They should wear a respirator or well-fitting facemask at all times, even when they are in non-patient care areas such as breakrooms.
    • If they must remove their respirator or well-fitting facemask, for example, in order to eat or drink, they should separate themselves from others.
  • To the extent possible, they should practice physical distancing from others.
  • Patients (if tolerated) should wear well-fitting source control while interacting with these HCP.

Crisis Capacity Strategies to Mitigate Staffing Shortages

When staffing shortages occur, healthcare facilities and employers (in collaboration with human resources and occupational health services) may need to implement crisis capacity strategies to continue to provide patient care. When there are no longer enough staff to provide safe patient care:

Implement regional plans to transfer patients with COVID-19 to designated healthcare facilities, or alternate care sites with adequate staffing.

If shortages continue despite other mitigation strategies, as a last resort consider allowing HCP to work even if they have suspected or confirmed SARS-CoV-2 infection, if they are well enough and willing to work, even if they have not met all the contingency return to work criteria described above.

  • Considerations for determining which HCP should be prioritized for this option include:
    • The type of HCP shortages that need to be addressed.
    • Where individual HCP are in the course of their illness (e.g., viral shedding is likely to be higher earlier in the course of illness).
    • The types of symptoms they are experiencing (e.g., persistent fever, cough).
    • Their degree of interaction with patients and other HCP in the facility. For example, are they working in telemedicine services, providing direct patient care, or working in a satellite unit reprocessing medical equipment?
    • The type of patients they care for (e.g., consider patient care only with patients known or suspected to have SARS-CoV-2 infection rather than patients who are immunocompromised).
  • If HCP are requested to work before meeting all criteria, they should be restricted from contact with patients who are moderately to severely immunocompromised (e.g., transplant, hematology-oncology) and facilities should consider prioritizing their duties in the following order:
    • If not already done, allow HCP with suspected or confirmed SARS-CoV-2 infection to perform job duties where they do not interact with others (e.g., patients or other HCP), such as in telemedicine services.
    • Allow HCP with confirmed SARS-CoV-2 infection to provide direct care only for patients with confirmed SARS-CoV-2 infection, preferably in a cohort setting.
    • Allow HCP with confirmed SARS-CoV-2 infection to provide direct care only for patients with suspected SARS-CoV-2 infection.
    • As a last resort, allow HCP with confirmed SARS-CoV-2 infection to provide direct care for patients without suspected or confirmed SARS-CoV-2 infection. If this is being considered, this should be used only as a bridge to longer term strategies that do not involve care of uninfected patients by potentially infectious HCP.  Strict adherence to all other recommended infection prevention and control measures (e.g., use of respirator or well-fitting facemask for source control) is essential.
  • If HCP are requested to return to work before meeting all Return to Work Criteria, they should still adhere to recommendations described below.
    • They should self-monitor for symptoms and seek re-evaluation from occupational health if symptoms recur or worsen.
    • Until they meet the conventional return to work criteria:
      • They should wear a respirator or well-fitting facemask at all times, even when they are in non-patient care areas such as breakrooms.
        • If they must remove their respirator or well-fitting facemask, for example, in order to eat or drink, they should separate themselves from others.
      • To the extent possible, they should practice physical distancing from others.
      • Patients (if tolerated) should wear well-fitting source control while interacting with these HCP.

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