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ACEP COVID-19 Field Guide

Table of Contents

Health Care Workers

Special Populations

Authors: Joseph T. Brooks MD; and Aisha T. Terry, MD, MPH, FACEP

As the COVID-19 pandemic continues to spread, health care workers (HCWs), especially those working in the emergency department, face constantly evolving challenges. Working on the front line, emergency department personnel are exposed to large numbers of patients with suspected and confirmed infection. Such exposure, coupled with the reality of emergency department overcrowding and, in some areas, insufficient supplies of personal protective equipment (PPE), puts these providers at high risk. Preliminary data suggest that HCWs who work in high-risk departments (those in which aerosolizing procedures are frequently performed) have a 2.13 times greater risk of being infected with SARS-CoV-2, compared to those who work in other areas of the hospital.1 Unfortunately, data regarding SARS-CoV-2 infection specific to HCWs are still rather limited; however, this section summarizes the available evidence. There is no data to suggest that clinical presentation and treatment differ in HCWs compared to the general population; thus, these topics are not covered in this section. 

Epidemiology

The exact number of worldwide cases of COVID-19 in HCWs is unknown. Estimates from Italy, however, suggest that 20% of HCWs have been infected.2 Data from China indicate that 3,300 HCWs were infected by March 2020.2 Such high rates of COVID-19 infection in HCWs are not surprising, given what was learned from the SARS and H1N1 influenza epidemics. One study demonstrated that in Toronto, Canada, more than half of SARS infections occurred in HCWs.3 Lietz et al demonstrated that during the H1N1 pandemic, HCWs were significantly more likely to develop the disease compared to controls.4

There is limited data on the severity of illness specific to HCWs. In a large study of 72,000 Chinese patients, approximately 14.6% (401) of the 2,748 infected HCWs suffered from severe or critical disease, defined by the presence of septic shock, multiorgan failure, or respiratory failure. Of those 401 patients, 5 ultimately died.5 There is no evidence to suggest that the risk factors for severe illness in HCWs differ from those of the general population. These risk factors include age >65 years, male gender, and the presence of comorbidities.6,7 It has been postulated that younger HCWs are at higher risk for more severe disease compared to non-HCWs of the same age, given their prolonged exposures to high inoculant loads. 

Testing recommendations

Given that HCWs can have extensive close contact with infected individuals, including those who may present with atypical symptoms, the CDC recommends a more conservative approach to testing.8 There should be a low threshold to test HCWs who are symptomatic and have interacted with patients with confirmed infection. Regarding monitoring and work restrictions, the CDC recommends HCWs who were wearing all recommended PPE (surgical or N95 mask, eye protection, gown, and gloves) and had an interaction with a COVID-19 patient self-monitor with oversight from occupational health. HCWs who were not wearing PPE and had contact with a COVID-19 patient should self-isolate for 14 days while continuing to self-monitor for symptoms. 

Unique challenges 

HCWs face several unique challenges during the COVID-19 pandemic. Surges of patients with increasingly severe illness, concerns about PPE supply, constantly changing clinical guidelines, and concern about the health and safety of themselves and their families are just some of the innumerable stressors. 

Such stress poses an immense risk to mental health and well-being. As evidenced during the SARS outbreak, psychiatric morbidity, including but not limited to, depression, anxiety, and suicidality, can occur among HCWs during epidemics.9 One report of 994 medical staff in Wuhan, China, demonstrates almost 25% suffered from mild depression (mean PHQ-9: 9) and 6.2% had moderately severe depression (mean PHQ-9: 15.1), requiring further intervention in the immediate wake of the COVID-19 pandemic.10 In light of these effects on mental health, it is vital for HCWs to feel comfortable reporting mental health challenges and to have easy access to mental health services. 

Furthermore, clear, open communication between hospital administration, governing bodies, and HCWs is needed. Such open communication is of utmost importance, especially in an era when clinical guidelines and policies change frequently. HCWs should be provided daily updates to ensure cohesive functioning of the entire health care system and, equally importantly, to ease anxiety. In addition, many HCWs may need to drastically alter their daily routines. High levels of exposure, coupled with the possibility of asymptomatic transmission, puts HCWs at an elevated risk of transmitting SAR-CoV-2 to their family members or roommates. Hospital administrations and other organizations should assist HCWs in taking the necessary precautions to limit this risk, including providing fresh scrubs before each shift, providing areas for safe, clean storage of belongings while working, and providing hotel rooms or other lodging for HCWs under quarantine. 

References

  1. Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with corona virus disease 2019: A retrospective cohort study in a designated hospital of Wuhan, China [published online ahead of print, 2020 Mar 17]. Clin Infect Dis. 2020;ciaa287. doi:10.1093/cid/ciaa287
  2. The Lancet. COVID-19: protecting health-care workers. Lancet. 2020;395(10228):922. doi:10.1016/S0140-6736(20)30644-9
  3. Booth CM, Matukas LM, Tomlinson GA, et al. Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area [published correction appears in JAMA. 2003 Jul 16;290(3):334]. JAMA. 2003;289(21):2801-2809. doi:10.1001/jama.289.21.JOC30885
  4. Lietz J, Westermann C, Nienhaus A, Schablon A. The occupational risk of influenza A (H1N1) infection among healthcare personnel during the 2009 pandemic: a systematic review and meta-analysis of observational studies. PLoS One. 2016;11(8):e0162061. Published 2016 Aug 31. doi:10.1371/journal.pone.0162061
  5. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA. 2020;10.1001/jama.2020.2648. doi:10.1001/jama.2020.2648
  6. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. People who are at higher risk for severe illness. CDC website. Reviewed 2020 Apr 15.
  7. Grasselli G, Zangrillo A, Zanella A, et al; for the COVID-19 Lombardy ICU Network. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region, Italy [published online ahead of print, 2020 Apr 6]. JAMA. 2020;e205394. doi:10.1001/jama.2020.5394
  8. National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases. Interim U.S. guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (COVID-19). CDC website. Updated 2020 Apr 15.
  9. Maunder R, Hunter J, Vincent L, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168(10):1245-1251.
  10. Kang L, Ma S, Chen M, et al. Impact on mental health and perceptions of psychological care among medical and nursing staff in Wuhan during the 2019 novel coronavirus disease outbreak: A cross-sectional study [published online ahead of print, 2020 Mar 30]. Brain Behav Immun. 2020;. doi:10.1016/j.bbi.2020.03.028

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