Why and How Should HEALTHCARE WORKERS Be Supported During the Coronavirus (COVID-19) Outbreak?

Severe acute respiratory syndrome coronavirus 2 (the virus is called SARS CoV-2; the disease is called COVID-19) continues to spread globally. More than 200 thousand cases of COVID-19 and around 9 thousand deaths have been reported worldwide. Although estimates vary widely, COVID-19 appears to have a higher mortality rate and to be more contagious than seasonal influenza (flu). While the World Health Organization (WHO) estimates the global mortality rate at 3.4%, South Korea has reported a mortality rate of approximately 0.6%. Vaccine development for COVID-19 and research into medical treatments continue, but this process will take months. Meanwhile, the pressure on healthcare workers around the world continues to increase. In the COVID-19 pandemic, pressure on healthcare workers takes 2 forms: first, the heavy burden of disease that strains healthcare system capacity; and second, the adverse effects on healthcare workers, including the risk of infection. In China, approximately 3000 healthcare workers contracted the disease and at least 22 died. In Italy, as of 17 March, 2629 healthcare workers had contracted COVID-19, accounting for 8.3% of all cases (more than twice the percentage in China). In Bergamo in northern Italy (the Lombardy region), 118 (20%) of approximately 600 family physicians are infected. Cases of transmission to healthcare workers' family members are widely reported. Transmission is known to occur mostly through individuals with symptoms. However, reports also describe individuals who transmitted the disease to more than one family member without having any symptoms. These reports underline the need to prevent cross-infection. Evidence on transmission and death shows the importance of clinical preparedness, active management and protection. Following the recommended guidelines of the US Centers for Disease Control and Prevention (CDC) improves safety. SARS-CoV-2 spreads through droplets and contact. It is not primarily an airborne virus. Therefore, ensuring routine droplet barrier precautions, environmental hygiene and general infection prevention practices has been indicated. To minimize the risk of infection when treating patients with COVID-19, the CDC recommends using personal protective equipment, including a gown, gloves and an N95 respirator plus a face shield/goggles, or a powered air-purifying respirator (PAPR). However, airborne precautions are not used in the daily, routine care of patients with general respiratory illnesses.

Priority Precautions for Healthcare Workers During the Novel Coronavirus Outbreak

Healthcare workers encounter patients without typical symptoms or with very mild symptoms. Among these patients encountered in emergency departments, outpatient clinics, homes and other settings will be patients who are infected but undiagnosed. Widespread use of the recommended barrier precautions (such as masks, gloves, gowns and goggles) by healthcare workers caring for all patients with respiratory symptoms should be the highest priority. Particularly in outpatient centres, N95 masks, respiratory isolation rooms and powered air-purifying respirators (PAPR) are insufficient to allow every patient with respiratory disease to be evaluated appropriately.

Protection from Disease Is Also Possible Without N95 Masks or PAPR

In a study of healthcare personnel across various outpatient practices, medical masks provided to both the patient and the worker providing care were observed to offer protection similar to N95 masks used by healthcare workers routinely caring for patients with respiratory viruses. Following the evidence-based guidelines provided by the CDC for masks, hand hygiene and environmental hygiene improves healthcare workers' safety. Many additional questions and concerns remain, particularly in high-risk areas and clinical settings One such question arises in the emergency department, where crowding is identified as a major concern. Diligence in applying the recommended precautions for all patients with respiratory illness is particularly important.

Approach to a Patient with Respiratory Symptoms

• When the patient arrives, important steps include placing a face mask on the patient, providing tissues, encouraging cough etiquette, ensuring hand hygiene and cleaning surfaces.
• Patients with suspected COVID-19 should be triaged quickly (directed to the appropriate department) and, until placed in an isolation room, kept in a well-ventilated area at least 6 metres away from others and separated from the general population if possible.
• Healthcare workers caring for any patient with respiratory illness should wear a mask with goggles and gloves, as recommended.
• Even when COVID-19 is not suspected, routine use of these precautions and increased environmental (surface cleaning) and personal hygiene are recommended.
• Providing specific training and encouragement on how healthcare workers can ensure their occupational safety may improve their ability to focus on their work.

Strict adherence to guidelines is very important for protecting healthcare workers. Improved hand hygiene and surface decontamination (removal of microbes) are key to safety. Coronavirus can remain viable on surfaces for hours or days (up to 3 hours in aerosols, 24 hours on cardboard and 2-3 days on plastic-steel). However, it is killed with the proper use of disinfectants. Masks, goggles, gloves and other barrier precautions cannot protect healthcare workers who encounter contaminated surfaces and do not wash their hands. Healthcare personnel should focus on meticulous hand hygiene while avoiding work areas harbouring the virus

• Clinical staff should ensure that their work areas, stethoscopes, mobile phones, keyboards, landlines, name badges and other items, with hospital-provided disinfectants or alcohol-based disinfectants used for this purpose,
• are cleaned.
• It is sensible for environmental services workers to increase the frequency of cleaning commonly touched surfaces such as light switches, counters, chair arms, escalator handrails, lift buttons, door handles and knobs.
• Beyond being a technical matter, active decontamination also helps stressed and anxious staff, patients and visitors feel safe.

The Consequences of a Delayed Diagnosis in a Patient with COVID-19 Are Enormous

Contact tracing for exposure to a COVID-19 case is no longer routinely recommended, so healthcare workers should consider themselves at high risk of exposure. Healthcare workers should monitor themselves, report signs of illness and not provide patient care while exhibiting infectious symptoms. Recognizing that COVID-19 symptoms may be mild, the development of pragmatic policies for healthcare workers with respiratory illness should be considered. When healthcare workers show respiratory symptoms, they should not be involved in direct patient care. As testing, vaccination and treatments become available, healthcare workers should be considered a priority for evaluation and treatment. Since worker safety is a high priority, active education on the correct use of barrier precautions and hygiene practices is important. Many healthcare workers have conditions that increase their risk of serious infection or death if they become infected with COVID-19, so organizations will need to decide whether to redeploy such workers, including physicians, away from the highest-risk areas It is impossible to eliminate risk completely, but prudent adjustments may be needed. New areas may require physician and nursing expertise, including telemedicine services, patient advice lines and expanded telephone triage systems. - Related topic: Coronavirus Disease Covid-19 and Remote Healthcare: Telemedicine – Nearly Perfect Recognizing the risk of healthcare worker shortages, organizations are banning staff travel to medical meetings, cancelling conferences, limiting non-essential travel and advising against personal travel if possible. Avoiding travel and crowds may also reduce infection risk. Although healthcare workers accept the increased risk of infection as part of their profession, they often worry about their loved ones' health. They are particularly concerned about transmission within a household that includes children, older adults, or family members who are immunocompromised or have chronic medical conditions. Clearly, more is needed to optimize safety in the current environment. Healthcare workers may wonder whether their family members can receive priority for testing, vaccines and treatment as testing becomes available. Ensuring the care and safety of healthcare workers' family members will help workers focus on their profession and work more effectively. However, concerns about transmitting the virus to family members will also need to be addressed for physicians working on the front line. Conversations with healthcare workers actively working on the front line of the outbreak may help reduce their concerns. These conversations can address protective planning for the home, such as separating living areas and bathrooms, and when such separation should be implemented. Many issues can be discussed among the protocols planned for returning home after a shift, including the benefits of removing shoes, removing and washing clothes, and showering immediately after entering the home. Although these protocols seem sensible, they are optional and not necessarily required, because the evidence on this matter is uncertain. Discussion can include healthcare workers removing their personal clothes on arriving at work and using hospital-provided clothing, and changing back in the same way when returning home. Experts working at the facility can provide guidance on cleaning household surfaces, including effective products and techniques. Long working hours make additional home preparations and extra household cleaning a significant challenge. On the other hand, when managed well, this process can be sensible and reassuring. Recommendations in supportive conversations and guidance should be clear and focus on reducing workers' concerns. All hospital personnel, including caregivers, support staff, administration and preparedness teams, should be clearly informed of the challenges of a prolonged fight against COVID-19. Leaders should emphasize the importance of self-care at the centre of this effort. Transparent and thoughtful communication can strengthen the response. Ensuring that workers feel adequately rested and that essential personal needs are met (such as caring for an older family member) will help maintain individual and team performance in the long term. As the effort continues and weeks turn into months, sufficient food supplies, rest breaks and time to relax will be as important as the protocols discussed and protective supplies provided. Frequent updates through feedback sessions with local managers, and managing the process with brief, clear and measured communication, will help the entire healthcare team remain focused on care and maintain their roles.