Study: Better Controls, Not Testing, Crucial to Worker Safety During Pandemic

By John Palmer

A new study finds that, while voluntary testing of asymptomatic healthcare workers for COVID-19 may help identify positive cases, it’s not the best way to ensure the safety of workers dealing with COVID-19 patients.

The study, “SARS-CoV-2 Screening of Asymptomatic Healthcare Workers,” was published in the July issue of Infection Control & Hospital Epidemiology, the journal for the Society for Healthcare Epidemiology of America.

“Extensive testing of employees does not seem to be cost-effective or necessary when strong symptom screening and infection control policies are in place,” wrote lead author Andrew P. Jameson, MD, FACP, an infectious diseases physician with Mercy Health Saint Mary’s Hospital in Grand Rapids, Michigan. “As hospitals and communities prepare for the next phase of the pandemic, we recommend close monitoring of employee symptoms, rapid access to testing when symptoms develop, strong infection control practices, and broad testing of patients to effectively cohort patients as an alternative to testing asymptomatic employees.”

There is, of course, much debate over what the “next phase” of the COVID-19 pandemic will look like, and whether U.S. hospitals are already seeing a second phase or a continuation of the first wave.

Certain areas of the country are experiencing an increase in the number of COVID-19 cases, while other areas, including the Northeast, have been enjoying a lull in their positive case numbers. However, as colder weather sets in and the population is driven inside, the number of cases is expected to rise as indoor face-to-face interactions increase.

What is not in question is the need to protect healthcare workers from contracting the disease—either from patients or colleagues. After all, both asymptomatic and pre-symptomatic people can transmit COVID-19 without knowing it.

Jameson and his study team developed a protocol to screen asymptomatic workers at Saint Mary’s as a way to determine COVID-19 positivity rates among those who do not develop symptoms. Those tested (by nasopharyngeal swabs) included respiratory therapists, physicians, nurses, and patient care assistants.

Of 499 eligible staff members, 121 took part in the screening, representing about 25% of the eligible workers. All 121 workers were found to be negative for COVID-19.

“The negative results of all tested individuals allowed these personnel to return to work in confidence and also informed the hospital’s decision to not continue routine testing of employees,” Jameson wrote.

So, what did the study prove? While testing asymptomatic healthcare workers might determine positivity and increase confidence among staff, good luck getting them all to agree to be tested. The 25% of eligible staffers volunteering to be tested was much lower than the study authors expected, probably from a combination of people who did not want to get swabbed or who had low trust in the organization’s approach to infection control.

“Regardless, this relatively low uptake does not support routine testing as an effective method to improve workforce confidence or safety,” Jameson wrote.

In other words, there are many other more important things that hospitals should be focusing on to help protect their employees, and it starts with robust intake procedures, monitoring, and use of personal protective equipment (PPE). Consider the following precautionary measures that Jameson says were instituted at Saint Mary’s:

• All patients admitted to the hospital, regardless of symptoms or reason for stay, are tested for SARS-CoV-2
• All patients undergoing surgical procedures are tested 24–48 hours before the operation
• All positive patients are isolated in designated COVID-19 care units
• All COVID-19 care floors have negative-pressure ventilation systems in place
• PPE is required, including surgical masks and universal precautions on all floors, plus gowns and eye protection on COVID-19 units
• N95 mask or PAPR/CAPR use is mandatory for anyone performing aerosol-generating procedures in COVID-19 units
• There is a “no visitors” policy throughout the hospital, absent exigent circumstances
• Universal symptom screening of all staff arriving to work is in effect, and workers are sent home if they present with any symptoms including fever, cough, shortness of breath, chills, body aches, loss of taste, or loss of smell

“In the months since implementation, adherence to the listed protective measures has been central to the safety of the hospital community and has contributed to the lack of positive testing among asymptomatic HCWs,” Jameson wrote. “As statewide regulations and social distancing restrictions begin to relax, it is essential to adequately protect our healthcare workforce.”

The Saint Mary’s study gained the attention of former CDC director Thomas R. Frieden, MD, MPH, who co-authored a letter in Infection Control & Hospital Epidemiology supporting the study’s conclusion and championing the idea that “all healthcare facilities must rapidly and rigorously implement the full hierarchy of established infection controls.”

Frieden added that because many healthcare workers are contracting and dying from COVID-19, “the scale of this epidemic necessitates thinking beyond individual healthcare facilities.”

The full hierarchy of controls he suggested would include the following:

• Source control, or the removal and mitigation of the source of infection. This includes advising patients with minor symptoms to stay home or seek treatment through telehealth. If they must be seen in person, they need to wear masks or be isolated in rooms separate from other patients.
• Engineering and environmental controls. These include changes in airflow and filtration to remove virus particles from the air, as well as the use of UV light and better cleaning and sanitizing practices.
• Administrative controls. These relate to training and the development, implementation, and enforcement of infection control policies and procedures that are written clearly, easily understood by all staff, and posted conspicuously throughout the facility.
• Nothing new to the healthcare community, PPE includes face masks, respirators, face shields, goggles, gowns, and gloves.

“Especially in areas with many cases, most persons with known or suspected COVID-19 could ideally be channeled to designated facilities,” Frieden wrote. “Infection control procedures would still be needed in all facilities, but enhanced efforts could concentrate on COVID-19-designated facilities, and reusable PPE could be safely used, maintained, and disinfected.”

He also said that critical supplies, equipment, and treatments could be allocated to designated facilities more efficiently.

“This would require participation by most or all hospitals in a geographic area, with centralized coordination, but might ultimately reduce this epidemic’s toll on patients, healthcare workers, and society.”

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.