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Epidemiology

You Are Safer From COVID-19 In The ICU Than In The Grocery Store

This summer, COVID-19 numbers keep going up. Five months ago, we thought COVID-19 would behave like other respiratory viruses: have peak incidence in the winter and then drop off in the summer. But that has not happened. Across the United States, there is a second surge in new infections and southern states that seemed to be spared from the initial outbreak now have rapidly escalating numbers of new cases. As our hospitals admit record-breaking number of these patients, all of us in healthcare jobs wonder “Are we safe in our workplace?“. It looks like the answer is… we probably are.

In intensive care units full of COVID-19 patients, we are hyper vigilant about using personal protective equipment. Face masks, eye protection and hand sanitizer are mandatory. For patients undergoing aerosol-generating procedures, disposable gowns, gloves, and N-95 masks are added. It turns out that the coronavirus has a hard time penetrating all of that PPE to get to our mouths, noses, and eyes. Infection control procedures work surprisingly well.

The home is a dangerous place

On the other hand, in our homes, grocery store, bars, churches and restaurants, we let our guard down. The masks come off, we don’t use hand sanitizer every 5 minutes, and there are no plastic face shields to protect our eyes. Even worse are those around us who refuse to take any precautions, either because they believe that they are invincible, they are trying to make a political statement, or they are just plain ignorant. During the influenza pandemic of 1918, these people were called “mask-slackers”. Not only were there individuals who refused to adhere to infection control practices, there were entire cities that refused to adhere to these practices. St. Louis was an early adopter of closing schools and businesses whereas Philadelphia did not close businesses and instead held a public parade – the peak death rate in Philadelphia was 257/100,000 whereas the peak death rate in St. Louis was only 58/100,000.

A recent study from JAMA looked at 3,056 healthcare workers at a hospital in Belgium who underwent antibody testing to identify those who had become infected with the COVID-19 virus. All of them additionally completed a survey about exposures. 197 staff were identified as having been infected. But there was no correlation between taking care of COVID-19 patients and becoming infected oneself. Even working in the hospital was not associated with becoming infected. The only correlation was when a healthcare worker had a family member who was infected. The study indicated that healthcare workers who got infected did not get infected from hospital exposures but instead got infected from family members at home. U.S. hospitals are finding the same thing – when healthcare workers are identified as being infected, it is home exposures that are the cause and not patient exposures.

There are steps our hospitals can take

All of us in hospitals feel the risk. Many healthcare workers have decided to just retire or seek other jobs. Others have gone on disability purely due to perceived risk of becoming infected. But we know that strict use of personal protective equipment and hospital visitor limitation works. So what can we do to ensure our staff safety as elective procedures resume and visitors return? Fortunately, there are some specific things that we can do:

  1. Universal masking. Every person in the hospital should be wearing a mask unless they are alone in a room. This means not only doctors and nurses but also visitors and administrative staff. A mask for every person, all the time.
  2. Eye protection during patient care. In addition to face masks, goggles or face shields should be worn whenever a staff member is in a room with a patient.
  3. Hand hygiene every time. Alcohol hand sanitizer needs to be available throughout the hospital and must be used before and after every patient encounter.
  4. Beware of the break room. In hospitals, we often assume it is the patients who could be infected and are thus dangerous to us. However, we are more likely to get infected from a co-worker in the cafeteria, the conference room, or the office suite when we let our guard down by taking off our masks and not using hand sanitizer. It is probably more dangerous to eat in the doctor’s lounge than it is to intubate a COVID-19 patient while wearing PPE. When it comes to who hospital workers get their COVID-19 infection from, in the immortal words of Pogo: “We have met the enemy and they is us“.
  5. Limit visitors. Statistically, the more people that are in the hospital building, the more likely one of them is infected with COVID-19. Some studies indicate that as many as one-third of infected persons have no symptoms so simply screening visitors by symptoms or body temperature will not catch all of those people who can potentially spread the virus.
  6. PCR test all patients. Not only can visitors have asymptomatic infections but so can patients. So the patient coming in with appendicitis, a heart attack, or a bleeding ulcer can also have subclinical COVID-19. Every patient should be treated as if they have the infection until proven otherwise.
  7. Work from home. Healthcare workers can also have asymptomatic infection and so the fewer healthcare workers are in the building, the less likely one of them is going to inadvertently infect someone else. If you can do your job equally well from home, you should not be in the hospital.
  8. Encourage smart behavior outside of the hospital. We cannot control what our healthcare workers do when they leave the hospital but we can at least encourage them to do the right things. Avoid indoor gatherings. Always wear a mask in public. Avoid places where other people do not wear masks. Practice hand hygiene.

The COVID-19 virus is all around us. But it just may be that the safest place to be right now is working in the COVID-19 ICU.

July 19, 2020

By James Allen, MD

I am a Professor of Internal Medicine at the Ohio State University and the Medical Director of Ohio State University East Hospital