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Best practices emerging for protecting healthcare workers from coronavirus

Mitigation strategies will become increasingly important as healthcare organizations look to protect staff members from contracting the disease.

Jeff Lagasse, Associate Editor

The COVID-19 coronavirus continues to spread around the globe, and more than 800 cases have been detected in the U.S. alone, prompting world health officials to educate the public on virus avoidance strategies such as frequent handwashing and refraining from touching one's face.

But healthcare workers on the front lines of treating the disease are at risk of exposure due to the nature of their jobs, and there are things they, too, can be doing to protect themselves. As care teams come to terms with the nature of the coronavirus and its spread, best practices are starting to emerge.

Those strategies will become increasingly important as healthcare organizations look to protect their staff members from contracting the disease. It's a vital component in ensuring workforce shortages don't make the situation worse.

A number of studies, guidelines and best practices have been published in recent days that aim to contain the coronavirus's spread.

For example, health systems can protect healthcare workers during the outbreak when best practices for infection control are diligently applied, along with lessons learned from recent outbreaks, according to a study published in Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

THE HONG KONG APPROACH

Researchers from Queen Mary Hospital in Hong Kong reported that zero healthcare workers contracted COVID-19, and no hospital-acquired infections were identified after the first six weeks of the outbreak, even as the health system tested 1,275 suspected cases and treated 42 active confirmed cases of COVID-19. Eleven healthcare workers, out of 413 involved in treating confirmed cases, had unprotected exposure and were quarantined for 14 days. None became ill.

This, the authors said, is due to appropriate hospital infection-control measures such as vigilant hand hygiene, wearing surgical masks in the hospital, and using personal protective equipment during patient care, especially when performing procedures that generate aerosols.

The researchers also conducted an experiment taking air samples from close to the mouth of a patient with a moderate level of viral load of coronavirus. The virus was not detected in any of the tests, whether the patient was breathing normally, breathing heavily, speaking or coughing, and tests of the objects around the room detected the virus in just one location, on a window bench -- suggesting environmental transmission plays less of a role in COVID-19's spread than person-to-person transmission.

Though there were no reported deaths at the Hong Kong hospital, at least two healthcare workers died of COVID-19 in Wuhan: Dr. Li Wenliang, 34, who died on Feb. 7, after sounding the alarm about the illness; and his colleague who worked in the same department, Dr. Mei Zhongming, 57.

When the first reports of a cluster of pneumonia cases came from Wuhan, Hong Kong's 43 public hospitals stepped up infection-control measures by widening screening criteria to include factors like visits to hospitals in mainland China. When the screening process identified a patient infected with the coronavirus, the patient was immediately isolated in an airborne-infection isolation room or, in a few cases, in a ward with at least a meter of space between patients.

Enhanced infection-control measures were put in place in each hospital, including training on the use of personal protective equipment, staff forums on infection control, face-to-face education sessions, and regular hand-hygiene compliance assessments. Hospitals also increased the use of personal protective equipment for healthcare workers performing aerosol-generating procedures like endotracheal intubation or open suctioning for all patients, not just those with or at risk for COVID-19.

In China, where the deadly virus began spreading at least 10 weeks ago, the number of cases has peaked and is now on the downside of a bell curve, according to epidemiologist Dr. Bruce Aylward, Team Lead for the World Health Organization, reporting to WHO in late February after his return from China.

At the time, the number of cases in the U.S. stood at 14, not counting the repatriated Americans returned home from the Diamond Princess cruise ship and from Wuhan, China.

Cases have climbed to over 800 in the U.S. Unlike China, which isolated individuals, in the U.S. those with mild symptoms, and not requiring hospitalization, are sent home and told to self-quarantine.

INDIVIDUAL RESPONSE IMPORTANT

How individuals respond to government advice on preventing the spread of COVID-19 will be at least as, if not more important, than government action, according to a commentary from researchers at the University of Oxford and Imperial College London in the UK, and Utrecht University and the National Institute for Public Health and the Environment in the Netherlands.

Vaccine development is already underway, but it's likely to be at least a year before a vaccine can be mass-produced, even assuming all trials are successful. Social distancing is therefore the most important measure. This includes early self-isolation and quarantine, seeking remote medical advice and not attending large gatherings or going to crowded places. The virus seems to largely affect older people and those with existing medical conditions, so targeted social distancing may be most effective.

Government actions will be important, including closing workplaces, schools and institutions where COVID-19 has been identified, and making sure that good diagnostic facilities and remotely accessed advice, like telephone help lines, are widely available. Ensuring the provision of specialist healthcare is also vital. The researchers warn, though, that large-scale measures may only be of limited effect without individual responsibility. All measures, of course, will have an economic impact, and some stricter measures, such as shutting down entire cities, as seen in Wuhan, China, may be less effective in Western democracies.

The researchers highlight that wider support for health organizations and healthcare workers during an epidemic is vital in any case. During the Ebola epidemic in 2014 and 2015, the death rate from other causes like malaria and childbirth rose sharply due to overwhelmed health services. The number of deaths indirectly caused by Ebola was higher than the number of deaths from Ebola itself.

In comparison with the seasonal flu and SARS, it now seems likely that the epidemic will spread more slowly, but last longer, a situation that has economic implications. Seasonal flu is generally limited by warmer weather, but it is not known if the weather change will affect COVID-19. Researchers say it will be important to monitor its spread in the Southern Hemisphere. They will continue to collect and analyze data to monitor the spread, while ongoing clinical research into treating seriously ill patients is also necessary.

AMA PROVIDES GUIDANCE

To answer questions about possible exposure to COVID-19, the Centers for Disease Control and Prevention has updated its guidance for risk assessment. This guidance is available for health personnel with potential exposure in a healthcare setting to patients with the coronavirus. It details risk levels and what to do if exposure occurs. But the risk of transmission of SARS-CoV-2, which causes COVID-19, is still incomplete, and the precision of the current risk-assignment is limited.

The American Medical Association has provided COVID-19 resources for doctors, other health professionals and the public, and will provide continual updates.

"Think about the patient with COVID-19 and the procedure being performed," said Sara Berg, the AMAs senior news writer. "If a physician or other health professional is not wearing proper PPE (their eyes, nose, or mouth were not protected) and is present in the room or performed a procedure that generated higher concentrations of respirator secretions, they are at high risk."

The CDC recommends monitoring for the coronavirus until 14 days after the last potential exposure. These people should also be excluded from work during the monitoring period.

Similarly, if a physician or other healthcare professional had prolonged, close contact with a patient with COVID-19 in which the patient was wearing a facemask, but the provider was not, the provider should be actively monitored for the coronavirus and be excluded from work for 14 days after the last exposure.

Physicians and other health professionals who are not using all recommended personal protection equipment and have brief interactions with a patient, such as a quick conversation at a triage desk, are considered low-risk. This is regardless of whether or not the patient with COVID-19 was wearing a face mask. 

Physicians should self-monitor with delegated supervision until 14 days after last potential exposure. No work restrictions for asymptomatic individuals is needed.

If a physician or other health professional walks by a patient with the coronavirus, has no direct contact with the patient or their secretions and excretions, and has no entry into the patient's room, there is no identifiable risk. In this instance, no monitoring or work restrictions are needed.

THE LARGER TREND

The Department of Health and Human Services, through the Centers for Disease Control and Prevention, said last week it is awarding an initial $35 million in a cooperative agreement to states and local jurisdictions which have so far borne the largest burden of response and preparedness activities.

The funds are for immediate assistance for activities such as the monitoring of travelers, data management, lab equipment, supplies, staffing, shipping, infection control and surge staffing, HHS said.

There is another $8 billion in the federal spending package.

Meanwhile, insurers are voluntarily covering the diagnostic testing of the coronavirus, according to the Board of Directors for America's Health Insurance Plans.

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com