Patricia Short navigates the halls and quarantine zones in the nursing home where she works, checking residents for COVID-19 symptoms, testing them when they show signs of coronavirus infection and telling their frustrated family members they still can't come inside to visit.
It's been an unrelenting nine months for Short and other long-term care facility staff and residents across Washington, with more than half of the state's coronavirus deaths linked to long-term care.
Some of her coworkers at the Yakima County nursing home have quit or retired. Short, a nurse of more than 25 years, has endured more than one outbreak.
But she's still optimistic — because the vaccine has arrived in Washington and is due soon in the state's nursing homes.
It could bring relief to workers and residents, who health officials have said will be prioritized along with health care workers at high risk. The state's goal is for all to receive the first dose of the two-dose vaccine by the end of January, said Michele Roberts, acting assistant secretary for the state Department of Health.
The Food and Drug Administration cleared Pfizer-BioNTech's vaccine for emergency use Friday, setting off a flurry of action to begin vaccinating the state's more than 170,000 residents and employees in long-term care facilities. On Monday morning, 3,900 doses of Pfizer's coronavirus vaccine arrived at UW Medical Center in Seattle, and the FDA will review a vaccine from Moderna and the National Institutes of Health this week.
Most of the state's approximately 4,000 long-term care facilities are expected to begin receiving vaccines sometime after Dec. 28 under a federal partnership with CVS and Walgreens.
"I see it as something that will help," Short said. "If enough of us get vaccinated."
Still, she had questions. How should she prepare for possible side effects? And how might her facility contend with short staffing if some of her co-workers needed time off because of a reaction to the vaccine?
"Amazing organizational feat"
As health officials rapidly prepare for a daunting logistical challenge, similar questions have surfaced from a weary workforce and from facility administrators, who also worry about how quickly the vaccines will arrive. And some experts are concerned about vaccination requirements that may slow a successful rollout.
The stakes could hardly be higher, as nursing homes and other long-term care facilities endure one of the harshest spates of outbreaks yet this year.
In all, 10,492 people who visited or work or live in nursing homes, assisted-living facilities, adult family homes and supported-living facilities have tested positive for the virus, up by more than 500 cases from the week before. More than 1,500 of them have died since the first outbreak in the U.S. began unfolding in late February at the Life Care Center of Kirkland, where more than a fourth of the 120 residents died.
More than two-thirds of the state's 208 nursing homes have at least one active coronavirus case as of Monday.
Vaccinations will come to the facilities slowly at first, until the state unleashes a trove of doses later this month. The state is recommending nursing homes come first for vaccination before other long-term care facilities.
From the state's initial shipment of 62,000 doses of the Pfizer vaccine, 1,000 will be allocated this week to long-term care facilities through Consonus Pharmacy, which contracts with senior communities nationwide. Consonus plans to vaccinate 7,000 additional people as doses arrive.
The health department expects 402,000 doses by end of year, if the Moderna vaccine is also approved. It plans to set aside enough Pfizer doses to activate the federal program on Dec. 28 with CVS and Walgreens, which will handle vaccinations for more than 2,600 of the state's long-term care facilities.
Vaccinating everyone at such facilities will be "an amazing organizational feat," said Dr. Sabine von Preyss-Friedman, president of the Washington Society for Post-Acute and Long-Term Care Medicine and a member of a state COVID-19 advisory group.
But Von Preyss-Friedman, who is also medical director at Issaquah Nursing and Rehabilitation Center, still has concerns over what she views as "barriers" throughout the federal pharmacy partnership program.
For example, rather than allowing for electronic or verbal consent, the pharmacies will require each resident to sign a written consent form for the vaccine, an especially burdensome requirement at a time when residents' families aren't able to visit. Walgreens asked facilities to have the consent form signed the day of vaccination, which adds another challenge, according to materials sent to state officials last week.
The pharmacies are also asking for photocopies of residents' insurance cards, and Von Preyss-Friedman said gathering those could be a challenge.
Walgreens and CVS are planning to visit each facility three times in a two-month period to complete vaccinations, which she said is not enough to spread out vaccinations among staff members in case some have reactions.
Long-term care facilities, meanwhile, have long contended with staffing shortages that have worsened in the pandemic. Having even a small percentage of workers out on a given day could be a problem for many.
"I don't think it's going to be chaotic," Von Preyss-Friedman said. "But I think there's potential that we will have all of these vaccines, but we won't be able to use them to the extent that would really help."
It's unclear which facilities CVS and Walgreens will visit first.
This has caused anxiety for some, including Erica Gaertner, director of McKay Healthcare & Rehab in Grant County. An outbreak ravaged her facility last month, infecting 24 out of 31 residents and the bulk of its staff, including Gaertner, who has a lingering cough.
"What I haven't heard is, where do we fall?" Gaertner said. "I'm a little facility out in the middle of nowhere."
Will workers get vaccinated?
It's also unclear how many long-term care workers will be willing to get the vaccine at first. Only 68% received influenza vaccinations in the 2018-19 flu season, compared to 95% of hospital workers, according to national data from the Centers for Disease Control and Prevention. But coronavirus has been more devastating, and state health officials caution that vaccine acceptance remains unclear.
Recent polls have found that a significant number of Americans and seniors are hesitant about the vaccine.
Among Black Americans and other people of color, polls have found higher levels of uncertainty, some of which is connected to racist medical practices, such as the Tuskegee syphilis study, and discrimination in the health care system. People of color make up a disproportionate amount of Washington state's long-term care workforce.
"We have to make sure we are getting out the information and getting it out in culturally competent ways," said Adam Glickman, secretary-treasurer for SEIU 775, which represents unionized long-term care workers in Washington. "There's a lot of history and structural racism to overcome."
Organizations like LeadingAge Washington, which represents nonprofit long-term care facilities, emphasize the need for education on the vaccine's efficacy and potential side effects, according to Deb Murphy, the organization's CEO and president.
Leah Meadows, a registered nurse at Martha & Mary Health Service in Poulsbo, presumed that hesitancy among staff in her facility — about half expressed willingness to get vaccinated in a recent survey — was a reflection of concerns in the larger community.
To address concerns, the nursing home's medical director held a question-and-answer session with staff, she said.
"I'm feeling more confident in the decision to go ahead with the vaccine," she said, "and we're hoping the rest of our staff will feel the same."
A gap in the plan
Multiple counties told The Seattle Times that adult family homes, which provide care for up to six people, largely did not sign up for the federal pharmacy program. In King County, only about a third of 1,203 homes signed up.
This may be due to challenges of the sign-up process, rather than a lack of interest, said John Ficker, executive director of the Adult Family Home Council.
Ficker acknowledges that adult family homes present a "logistical nightmare," with more than 3,300 such homes across the state. He noted that the workers often have less medical training than at other facilities and are more likely to be immigrants and people of color.
"In many ways, our providers are the ones most in need of support and help," he said.
It's not yet clear how the adult family homes will receive vaccines, although the state may partner with other pharmacies. Some will likely have to wait for the Moderna vaccine, which doesn't require temperatures as low as the Pfizer vaccine does for storage and comes in quantities of 100 doses, rather than Pfizer's 975.
Officials in King County would like to help close the gap, perhaps through a mobile vaccine unit. But they're worried about funding, especially if CARES (Coronavirus Aid, Relief, and Economic Security) Act funding isn't extended past this year, said Public Health — Seattle & King County policy director Ingrid Ulrey.
"We're at a very precarious point of having incredible funding uncertainty, at the same time not only that we're planning for the massive vaccine effort but as cases are spiking," Ulrey said. "It's such a struggle right now, really a perfect storm."
A very different problem
In one of the most rural reaches of the state, John McReynolds, the CEO of North Valley Hospital and its nursing home in Tonasket, Okanogan County, said he had to deal with another dilemma altogether.
As a small medical facility, with just 200 employees and a 42-bed nursing home, he learned from DOH that he could expect 975 doses of the vaccine. He expected the shipment could come this week, making his nursing home likely one of the first to receive the vaccine.
The shipment size is the smallest available for the Pfizer vaccine. But it's more than what McReynolds expected he would need for 200 employees and nursing home's residents, despite DOH's plan not to send facilities more than they can use.
His hospital bought an ultra-cold freezer bought several months ago amid reports that the Pfizer vaccine could win early emergency approval, but doses, which must be stored at -94 degrees Fahrenheit, would sit unused for weeks when others may need it.
His task has been to coordinate with others in the region to ensure that doesn't happen. He also hoped there won't be any other hiccups before it arrives, after a year filled with challenge. His nursing home's recent outbreak claimed 15 lives.
"It seems like everything in the pandemic has been delayed and there's been something that's happened that doesn't make it go as smooth as possible," he said.
Still, he was confident it would come.
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