Clinicians Dodge Infection as 'Dofficer' Helps With Gear

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APRIL 24, 2020 -- At UW Medicine in Seattle, the center has a "dofficer" who watches healthcare workers go into and come out of rooms where COVID-19 patients are being cared for to help clinicians with safe donning and doffing of protective equipment.

"We have empowered that person to speak up and say stop if clinicians aren't doing it right," Patricia Kritek, MD, an ICU physician and associate dean for faculty affairs at UW Medicine told Medscape Medical News.

Centers in Seattle have an adequate supply of PPE and vigilant use is a matter of life and death, she said.

Of the 9200-plus healthcare workers in the United States who had been infected with COVID-19 by early April, more than half the infections were the result of patient contact, according to a report from the Centers for Disease Control and Prevention (CDC).

And this is likely a serious underestimation of the true numbers. Of the 315,531 COVID-19 cases reported to the CDC by April 9, only 49,370 (16%) indicated whether or not the patient was a healthcare worker.

Although the majority of sick healthcare professionals did not require hospitalization, 184 have been admitted to the intensive care unit (ICU) and 27 have died.

Viciously Infectious

The problem is clear: Personal safety must be a priority in a pandemic as infectious as this one.

The only way overburdened hospitals are going to get through COVID-19 is by abandoning any notion of what was once standard of care and adopting a crisis standards-of-care approach, said Lewis Goldfrank, MD, an emergency physician at NYU Langone Health in New York City, who is chair of the Forum on Medical and Public Health Preparedness for Catastrophic Events.

A 2009 Institute of Medicine report warned that entering a crisis standards-of-care mode is not optional — it is a forced choice, based on the emerging situation, and under such circumstances, failing to make substantive adjustments to care operations "is very likely to result in greater death, injury or illness."

Unfortunately, physicians have not been very good at advocating for their own safety, warned Eileen Barrett, MD, assistant professor of internal medicine at the University of New Mexico in Albuquerque, and Elisabeth Poorman, MD, internal medicine physician in Seattle and chair of Wellness for the King County Medical Society in a webinar for the virtual American College of Physicians Internal Medicine Meeting 2020.

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"Until now, the 'wellness' narrative that is popular among institutions is one about being resilient in the face of an unmanageable work load," Poorman told Medscape Medical News. "But safety and well-being should be the core principle behind this narrative because we know that when providers feel unsafe and unsupported, patients get poor care."

Not having a centralized voice to advocate for physician safety during the COVID-19 pandemic has made the crisis much worse than it needed to be, she said.

No Unified Voice for Safety

in the United States, residents can work for 30 hours straight. "I think at the end of that 30-hour shift in a COVID unit, providers are not going to doff their PPE properly; we know from sleep research that it's these kinds of rote tasks that suffer the most errors," Poorman said.

"I worked in West Africa a lot," Goldfrank explained. There, "people had a buddy system; you put on your gown, your mask, and your goggles and someone watched you carefully to be sure that you did it correctly and there were no flaws in how you did it."

That buddy system has been adopted by hospitals in New York City and elsewhere in the United States. When there is a lethal disease like COVID-19, "you have to do the donning and doffing precisely so that you do not infect yourself in the process," he said.

That has led to a major change in the way healthcare professionals think when caring for COVID-19 patients. Before the pandemic, if someone collapsed in front of them, clinicians would try to resuscitate them without giving it a second thought.

Now, "you are going to put on your gown, your goggles, and your N95 mask," Goldfrank said.

There is No Emergency in a Pandemic

Crisis standards of care means that "if I do not have my stuff on, I can't go and save this person's life because I am going to threaten my own life," he said.

"It's unfortunate that people tend to create a tension between physician well-being and health and patient well-being and health," Barrett reflected.

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"It doesn't need to be, though. When we have healthier physicians, we have healthier patients, and when we have healthier patients, we have healthier physicians," she explained.

"We have to remember that we can't take care of our patients if we can't take care of ourselves. My hope is that one of the things that comes from this terrible time is that nobody doubts whether a person is committed to the care of patients if they raise a concern about safety," Barrett said.

Poorman said she agrees, emphasizing that the core principle of physician safety in this viral crisis boils down to saying no. "Doing nothing may be the hardest thing you ever had to do in your life," she acknowledged.

"But during the Ebola crisis, many physicians did run in to help patients who were crashing, saying, 'PPE be damned, my patient needs me'," Poorman reported.

Then, as an Ebola responder once wrote, "they became infected and they infected others and then they died. They didn’t help anyone after that."

That same responder stressed that "there is no emergency in a pandemic." Let that be a mantra until this is over.

A central tenant, then, for all clinicians is to not become a vector of the disease themselves. This happened in China when healthcare workers did not understand what they were dealing with at first and had no protocols in place to protect themselves or their patients. As a result, initial rates of nosocomial spread in China were very high.

In Italy, an early epicenter of the pandemic, 74 physicians had died by the first week in April, largely because they lacked the PPE needed to keep them safe. And more than 2600 nurses have been infected with COVID-19, according to the International Council of Nurses, which is approximately 10% of all COVID-19 cases reported in that country.

At the beginning of April, Spain was reporting the highest number of COVID-19 infections among doctors and nurses anywhere in the world. At the time, approximately 15,000 healthcare workers were sick or self-isolating, which is about 14% of all confirmed cases of COVID-19 in that country. Spanish physicians and nurses have repeatedly complained that they don't have enough PPE to treat patients safely, and government officials have acknowledged that the lack of PPE might have contributed to the high rate of infection among medical professionals.

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There was never enough PPE in New York City either, Goldfrank added; not at the beginning of the pandemic and certainly not now. Healthcare workers recycle masks and wear the same mask for a whole shift or even for several days because there are not enough resources to go around, he said.

The CDC recently stated that hospital workers can reuse PPE, which would have been "unheard of 4 months ago," he said.

"We're a bit slower getting into a room than we normally would be," Kritek explained, "but we've rewritten our code response to try to facilitate that, and we've also rewritten our code response to make it so that fewer people are going into a room. Only those who absolutely need to be there are allowed in."

New Code of Response

Physicians have also had to initiate earlier and more frequent conversations with patients and families about the utility of CPR and other resuscitative measures in critically ill patients.

Clinicians are even encouraging COVID-19 patients to talk about end-of-life issues with their families before they come to the hospital. "The odds that patients will survive if they are intubated and then have a cardiac arrest are so small that we don't want to do anything that we don't think they are going to benefit from," Kritek explained.

"We're still working on physical distancing in the hospital," she pointed out, "but using PPE effectively and following specific standards as to how we go into and out of rooms has been really important for us here."

Barrett supports a "clustering of care" approach, where the number of consultants who see each patient is limited, doing their work instead by phone or by chart review.

Clustering of care also means that the morning lab draw is no longer done by a phlebotomist, vital signs are not taken by a tech, and the meal tray is not brought in by dietary personnel. Instead, the nurse does all these tasks; even doctors can bring in meal trays if they are going into a room anyway, as Barrett herself has done.

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In her medical center, nurses can switch the medication regimen to coincide with mealtimes and early conversion from IV medication to oral drugs is encouraged to decrease the need for nurses to be going in and out of a room.

Clinicians can also consider running fluids as boluses instead of maintenance fluids, and IV poles can be placed outside the room so nurses can hang things on them without going into the room, Barrett suggested.

Physicians should avoid ordering unnecessary imaging or other forms of testing, and should always progress through their patient load from those who are at no or low risk for COVID-19, through to suspected cases, and then on to confirmed cases, not the other way around.

When PPE does have to be used, Barrett and her colleagues follow the buddy system, with the proviso that people need to be trained first on how to use PPE correctly, as neither donning nor doffing the equipment is intuitive.

Medscape Medical News

Sources

American College of Physicians Internal Medicine (IM) Meeting 2020.

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