Supporting the Health Care Workforce During the COVID-19 Global Epidemic | Critical Care Medicine | JAMA | JAMA Network
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March 12, 2020

Supporting the Health Care Workforce During the COVID-19 Global Epidemic

Author Affiliations
  • 1Northwestern Memorial HealthCare, Chicago, Illinois
  • 2Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
  • 3Brigham and Women’s Hospital, Boston, Massachusetts
  • 4Harvard Medical School, Boston, Massachusetts
JAMA. 2020;323(15):1439-1440. doi:10.1001/jama.2020.3972

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread internationally. Worldwide, more than 100 000 cases of coronavirus disease 2019 (COVID-19, the disease caused by SARS-CoV-2) and more than 3500 deaths have been reported. COVID-19 is thought to have higher mortality than seasonal influenza, even as wide variation is reported. While the World Health Organization (WHO) estimates global mortality at 3.4%, South Korea has noted mortality of about 0.6%.1-3

Vaccine development and research into medical treatment for COVID-19 are under way, but are many months away. Meanwhile, the pressure on the global health care workforce continues to intensify. This pressure takes 2 forms. The first is the potentially overwhelming burden of illnesses that stresses health system capacity and the second is the adverse effects on health care workers, including the risk of infection.

In China, an estimated 3000 health care workers have been infected and at least 22 have died. Transmission to family members is widely reported. Despite recognition that transmission occurs mostly via symptomatic individuals, there are reports of asymptomatic individuals who transmitted the disease to multiple family members.4 These reports underscore the need for prevention of cross-infection. Evidence related to transmissibility and mortality inform the clinical community of the importance of vigilance, preparation, active management, and protection.

Adherence to the Centers for Disease Control and Prevention’s (CDC) recommended guidelines advances safety.5 SARS-CoV-2 is spread by droplet and contact. It is not principally an airborne virus. Therefore, ensuring routine droplet barrier precautions, environmental hygiene, and overall sound infection prevention practice is indicated. To ensure minimal risk of infection when treating patients with COVID-19, the CDC recommends the use of personal protective equipment including a gown, gloves, and either an N95 respirator plus a face shield/goggles or a powered, air-purifying respirator (PAPR). However, airborne precautions are not used in daily, routine care of patients with general respiratory illness.

The widespread use of recommended barrier precautions (such as masks, gloves, gowns, and eye wear) in the care of all patients with respiratory symptoms must be of highest priority. In emergency departments, outpatient offices, homes, and other settings, there will be undiagnosed but infected patients, many with clinically mild cases or atypical presentations. There is limited availability of N95 masks, respiratory isolation rooms, and PAPR, particularly in outpatient offices, to feasibly evaluate every patient with respiratory illness and such measures are not routinely necessary.

Protection is achievable even without N95 masks or PAPR. In a study of outpatient health care personnel in diverse ambulatory practices, medical masks applied to both patient and caregiver provided effectively similar protection as N95 masks in the incidence of laboratory-confirmed influenza among caregivers who were routinely exposed to patients with respiratory viruses.6 Adherence to CDC evidence-based guidelines for masks, hand hygiene, and environmental hygiene enhances the safety for health care workers.

Many additional questions and concerns remain, especially in high-risk sites and clinical settings. One problem is in the emergency department, where crowding is identified as a major concern. Rigor in the use of recommended precautions for all patients with respiratory illness is especially important. Placing a facemask on the patient at arrival, supplying tissues, promoting cough etiquette, and providing for hand hygiene and surface decontamination are all important steps. Those patients with symptoms of suspected COVID-19 should be rapidly triaged and separated from the general population ideally in a well-ventilated space with a distance of at least 6 feet from others until they can be placed in an isolation room. Caregivers who encounter any patient with respiratory illness should wear a mask and gloves, with goggles as recommended. Even when COVID-19 is not suspected, it may be present so routine use of these precautions and increased environmental and personal hygiene is advised. Strict adherence to guidelines is of elevated importance for the protection of health care workers. A focus on worker protection through specific training and encouragement of adherence to barrier precautions and hygiene recommendations may help provide a priority focus. Telling caregivers to focus on their safety and being clear and specific about how to do so can promote calm during an epidemic.

In addition to recommended masks for patients and other barrier precautions, enhanced hand hygiene and surface decontamination are key to safety. The coronavirus is known to live on surfaces for hours or days,7 but it is also effectively killed by available disinfectants when properly used. Masks, goggles, gloves, and other barrier precautions will fail to protect caregivers who later encounter contaminated surfaces and fail to wash their hands. Health care personnel must focus on meticulous hand hygiene, avoiding contaminating workspaces. Clinical staff should clean workspaces and personal items such as stethoscopes, mobile phones, keyboards, dictation devices, landlines, nametags, and other items with hospital-provided disinfectants or alcohol-based disinfectants.5 It is sensible for environmental services workers to increase the frequency of cleaning of commonly touched surfaces such as light switches, countertops, chair arms, escalator railings, elevator buttons, doorknobs, and handles. Active decontamination is not merely a technical issue, it also is reassuring to stressed and concerned caregivers, patients, and visitors.

The consequences of delayed recognition of a patient with COVID-19 are significant. Contact tracing for exposure to a case of COVID-19 is no longer routinely recommended, so health care workers must consider themselves at elevated risk of exposure. Health care workers must self-monitor, report signs of illness, and not engage in patient care while exhibiting infectious symptoms.

Recognizing that symptoms of COVID-19 may be mild, the development of pragmatic policies for health care workers who have respiratory illness should be considered. When health care workers exhibit respiratory symptoms, they should not provide direct patient care. When testing, vaccination, and treatments become available, the health care workforce should be considered a priority for evaluation and treatment. Because workforce safety is a high priority, active training in the proper use of barrier precautions and hygiene practices is important.

Many health care workers have conditions that elevate risk for severe infection or death if they become infected with COVID-19, so organizations will need to decide whether such workers, including physicians, should be redeployed away from the highest risk sites. It is not possible to entirely eliminate risk, but prudent adjustments may be warranted. New sites may need physician and nurse expertise, including telemedicine services, patient advice lines, and augmented telephone triage systems.

Recognizing the risk of health care worker shortages, organizations are banning travel to medical meetings, canceling conferences, limiting nonessential travel, and recommending that personal travel be curtailed. The travel restrictions are not just to affected regions but to domestic and international sites to keep caregivers close and available. Avoiding travel and crowds may also decrease risk of infection.

While health care workers often accept increased risk of infection, as part of their chosen profession, they often exhibit concern about family transmission, especially involving family members who are elderly, immunocompromised, or have chronic medical conditions. While the CDC and Occupational Safety and Health Administration provide clear recommendations, it is evident that more is required to optimize safety in the current environment. Health care workers may ask whether their family members can receive priority for testing, vaccination, and treatment when the testing becomes available. Ensuring care of health care workers’ family members would enhance workforce confidence and availability, but the feasibility and advisability of family priority is yet to be determined. For front-line caregivers, the concerns about transmitting the virus to family members will need to be addressed.

Conversations with front-line caregivers may help reduce anxiety. Topics for discussion might include protective planning for the home such as separation of living spaces and bathrooms and when such separation should be implemented. Protocols for routine arrival home after duty will be a point of discussion, including the benefits of taking off shoes, removing and washing clothing, and immediately showering. These protocols are optional because evidence is unclear, but they may be sensible. Some discussion might be given to changing from personal clothing to hospital-supplied scrubs on arrival to work and changing back to personal clothes to return home. Facility experts may provide guidance about home surface decontamination, including effective products and techniques. There is a need to strike a balance, however, because these ideas might increase anxiety among overworked caregivers. Long work hours make any additional home preparations and extra home cleaning a significant challenge. On the other hand, it can be sensible and reassuring. The focus should be on supportive conversations, clear guidance when recommendations exist, attempts to minimize misinformation, and efforts to reduce anxiety.

Hospital personnel, including caregivers, support staff, administration, and preparedness teams, all will be stressed by the challenges of a prolonged response to COVID-19, and leadership must emphasize the importance of self-care as the center of the response. Transparent and thoughtful communication could contribute to trust and a sense of control. Ensuring that workers feel they get adequate rest, are able to tend to critical personal needs (such as care of an older family member), and are supported both as health care professionals and as individuals will help maintain individual and team performance over the long run. Liberating clinicians and administrative team members from other tasks and commitments allows them to focus on the immediate needs. Provision of food, rest breaks, decompression time, and adequate time off may be as important as provision of protocols and protective equipment as days turn into weeks, then months. Frequent information and feedback sessions with local managers and the broader facility community, complemented by clear, concise, and measured communication, will help teams stay focused on care and secure in their roles.

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Article Information

Corresponding Author: James G. Adams, MD, Northwestern University, 211 E Ontario St, Ste 200, Chicago, IL 60611 (jadams@nm.org).

Published Online: March 12, 2020. doi:10.1001/jama.2020.3972

Conflict of Interest Disclosures: None reported.

References
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WHO Director-General’s opening remarks at the media briefing on COVID-19: 3 March 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---3-march-2020
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Del Rio  C, Malani  PN.  COVID-19—new insights on a rapidly changing epidemic.   JAMA. Published online February 28, 2020. doi:10.1001/jama.2020.3072PubMedGoogle Scholar
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JAMA Network. Coronavirus disease 2019 (COVID-19). https://jamanetwork.com/journals/jama/pages/coronavirus-alert
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Bai  Y, Yao  L, Wei  T,  et al.  Presumed asymptomatic carrier transmission of COVID-19.   JAMA. Published online February 21, 2020. doi:10.1001/jama.2020.2565PubMedGoogle Scholar
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Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with confirmed coronavirus disease 2019 (COVID-19) or persons under investigation for COVID-19 in healthcare settings. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
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Radonovich  LJ  Jr, Simberkoff  MS, Bessesen  MT,  et al; ResPECT investigators.  N95 respirators vs medical masks for preventing influenza among health care personnel: a randomized clinical trial.   JAMA. 2019;322(9):824-833. doi:10.1001/jama.2019.11645PubMedGoogle ScholarCrossref
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    6 Comments for this article
    EXPAND ALL
    Important Practical Advice
    Shlomo Monnickendam, University of Tel Aviv | Maccabi Healthcare Services
    Thank you for this timely, much needed practical advice. You addressed the concerns I have as a (older) primary care physician, especially how to deal with patients with "simple" colds and what to do in order to protect my family.
    CONFLICT OF INTEREST: None Reported
    Importance of Viral Load in Mortality of Health Workers
    Babak Tf Tf, Assistant Professor of Medicine | Isfahan University of Medical Sciences
    Until this time in our University Hospital, specially linked for coronavirus in the center of Iran,  we fortunately have had a low mortality among medical staff & health personnel despite the experience of other hospitals in Iran. I think type of exposure to virus load is an important factor because in spite of our national self-protecting guideline and recommendations of the government there is a notable difference in health worker mortality in the north compared to southern parts. We had a surge of infections in the North part of Iran about 1 week ago, and during this week our local morbidity and mortality may rise. If so, I think the load of viral shedding is an important factor for health personnel.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Contingency planning
    Packard Day, Ph.D. |
    Using the Great Influenza pandemic of 1918-19 as a template, let me suggest that hospitals/healthcare agencies should begin immediately to plan for how they will reinforce their existing palliative care work force.

    For example, using Great Influenza as a worst case scenario, imagine an RN force that experiences attrition of 1/3 of its numbers due to general sickness, death, or overwork. Now imagine another 1/3 that fails to show up for work and is thereby lost due to personal fear, panic, selfishness, or anxiety. The remaining 1/3 of RNs are then left to care for a new patient cohort
    that has increased 50X in size from the hospital’s ordinary influx of ER traffic.

    What to do? What is the plan? Admittedly, the potential numbers are daunting, but it is far better to try to answer these questions now than it is to wait until reality demands immediate action.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Droplet Not Airborne, Still?
    Dvora Inwood, MA, BA | Arena.io, Healthcare Staffing
    Is this guidance still correct in light of the possibility that COVID-19 may be more airborne than previously thought? Is there any way the general public can support efforts that health systems are struggling with when it comes to supply chain/FDA approval? We heard about the debacle with university tests sitting unattended at FDA for approval weeks into the situation. The general public will want to mobilize and help in whatever way the acute care sector wants, we just have not had traditionally clear communication from that sector as to what is needed. Perhaps articles like this can serve that purpose as well as internal communication purposes among healthcare professionals?
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Comforting
    Sharon Argenbright, MSN RN | Group Homes
    This thoughtful piece provides me comfort. I know these precautions like the back of my hand. I've got this. Now if we could just get the equipment through the pipeline, stat, and reinforce Doctors Adams and Walls' message over and over: we can do this. Thank you for your sensitivity to what it is the front line is living through.
    CONFLICT OF INTEREST: None Reported
    Suggestion How to Further Protect Medical Personnel
    Nailya Bulatova, MD, PhD, Professor | The University of Jordan, School of Pharmacy, Department of Biopharmaceutics and Clinical Pharmacy, Amman, Jordan
    Although I am not personally involved in care of patients with COVID 19, I have watched the process of donning and then removal and disposal of personal protective equipment recommended by a number of professional bodies (e.g., NHS), which led me to the thought that one additional step may be recommended before the PPE removal. Simply having a shower with warm water mixed with liquid soap which can neutralize the virus effectively could be an easy and non-expensive measure, when resources are limited, that can protect healthwork force from being infected. Or, it could be using a chamber with a disinfectant mist as advertised by some companies from Vietnam or Turkey, for example. But it is essential to apply this before the PPE removal.
    CONFLICT OF INTEREST: None Reported
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