A Face Shield Strategy to Reduce COVID-19 Nosocomial Transmission

In previous blog posts, I mentioned the implementation of face shields to prevent nosocomial COVID-19 infection. Over the past few days, I have received many questions from people across the country, so I thought it would be useful to pull everything together in a single post and add some details.

Rationale

As we began to prepare for the pandemic, we assessed our inventory of personal protective equipment (PPE). However, knowing current inventory levels alone is not useful. It's deceiving when you see PPE inventory levels of several hundred thousand items. How could we ever run out, right? This is why your inventory levels must be evaluated in the context of normal demand. Your supply chain folks should be able to tell you how many PPE items are normally used on a daily or weekly basis. Next, you need to determine your expected demand for the outbreak. There is no right answer here as there are too many unknowns. You'll just need to make an educated guess. We determined that our critical level of each PPE item was 12 weeks (84 days) at four times normal demand*, although you could argue that this is an underestimate. Next our supply chain group developed an interactive spreadsheet with each row being a PPE item, and columns showing current inventory; normal demand per day; and days of stock at normal demand, two times normal demand, and four times normal demand. The final column (days of stock at four times normal demand) is color coded as follows: red <84 days, yellow 85-111 days, green >112 days (16 weeks). Once this is done, you will likely be surprised to find that what seemed like an abundance is really not so. When evaluating your levels, you also need to consider that some items are on allocation and you can expect to receive periodic shipments, while others are simply stocked out with no promise of future deliveries.

After reviewing all of the above, the most worrisome thing for us was an inadequate supply of face masks (<84 days at four times normal usage). My biggest fear was that we would overuse them early in the outbreak when few COVID patients are hospitalized, then have none after the surge of COVID inpatients arrived. Many hospitals had extended the use of face masks beyond a single patient encounter, which is a reasonable decision in this time of shortage, but we know that face masks lose their effectiveness when they get wet. Some began to use cloth masks, which is also a problem. So I began to wonder whether face masks could be replaced by face shields.

Why face shields?

• They provide greater facial surface area coverage than face masks by protecting all the facial mucosal surfaces from infectious droplets. 
• Given that the eyes are protected, we can eliminate the need for goggles when a face mask is worn. And we know that healthcare workers are really bad at wearing eye protection.
• They prevent you from touching your face. One of the major drawbacks of face masks is that some people will touch their faces even more to adjust the mask and this poses a risk for autoinoculation by contaminated hands.  
• Face shields are durable, can be cleaned after use, and reused repeatedly.
• Many people (myself included) find face shields more comfortable than face masks.
• Communication is better with shields than with face masks as your face is visible to patients and coworkers. 
• If all of your healthcare workers are shielded, social distancing becomes less important.
• And importantly, this is a device that is diversified across other industries. There is greater availability since the medical supply chain is so stressed at this time.  

Are there any disadvantages compared to face masks? The only one I can think of is the possiblity of a droplet coming in an upward trajectory going under the bottom edge of the shield. Although the probability of this is small, this can be minimized by having the shielded healthcare worker flex their neck when standing over the patient (for example, when performing a physical exam), bringing the bottom edge of the shield closer to the HCW's torso. Moreover, when doing a procedure that normally requires a face mask, we recommend that a mask be worn under the shield anyway. 

A few people have asked what is the evidence that face shields can replace face masks, and those particularly inclined toward methodolatry (the profane worship of the randomized clinical trial as the only valid method of investigation) continue to demand that face shields not replace face masks. Do I have evidence? No. To me, this is just plain common sense--we have a product that is reusable, cleanable, covers more of your face, decreases the risk of autoinoculation, and keeps us from burning through our mask supply. We have hospitals in the US where nurses are using bandanas to protect themselves. In this extraordinary time, I can live without a clinical trial.

Implementation

We quickly found that face shields marketed for medical uses were stocked out. One of our pharmacists went to a local hardware store and found shields used for grinding. We then explored vendors that supply hardware and agricultural products (see more here on the purchasing process). In addition, the University of Wisconsin has a great website that includes diagrams for construction of shields, and Johns Hopkins has a "recipe" available that can be used to create 50,000 shields. We placed the Wisconsin diagrams on the hospital website and several manufacturing firms responded that they could fabricate them for us. In addition, we have had some designed and produced by people interested in 3-D printing. One of our physicians, modified the Johns Hopkins' information and has her kids at home making shields. We also placed on our hospital's website a request for donation of face shields that people have at home, and we received many donations. It has really been a community effort. As our supply of shields grows daily, we deploy them throughout the medical center. At this point, the shields are handed off from one worker to the next as their shift ends, but our ultimate goal is for every person to have one for their personal use. 

Here are the instructions we give to our staff on when to use face shields:

• Wear the face shield with every patient encounter (COVID and non-COVID patients) over a medical mask. Think of it as a new component of standard precautions--every patient, every time.
• For COVID patients (confirmed or suspect), if an aerosol generating procedure is being performed, wear the face shield over an N95 respirator.

To help introduce the concept to our workforce, we produced this video:

We still have some details to iron out, such as the best product to clean the shield, since some products damage polycarbonate. We have had some of the shields break, so fabricating replacement shields to repair them is ongoing. 

Lastly, I have had a number of people who want to purchase their own shield ask me which one I recommend. Over the past two weeks, I have tried many models and have become a face shield connaisseur. If you want to buy your own, I think the best is the Uvex Bionic S8510 made by Honeywell (shown in the photo to the right). It is more sturdy than many other models, provides greater facial coverage (extends laterally on the face to your ears), and is comfortable. What really sets it apart is the V-shaped, downward projecting bottom border of the shield. This allows it to sit close to your upper torso, minimizing the risk of upward trajectory droplets. As an added bonus, from a sartorial standpoint, you'll look top-notch in this one! It's the kingdaddy!

This is probably more than you ever wanted to know about face shields. But it's a crazy time and we hospital epidemiologists are doing things I could have never imagined just a month ago. The bottom line is that by employing face shields we are able to protect our workforce while extending the duration of time that we will have face masks available.

Stay safe and be well!

Mike Edmond

*Addendum: A hospital in New York reported 15-30 times normal demand for face masks.

AG(P)itation

(Apologies to Mike - we usually don't like to step on each other on the blog, but I missed he'd just published another great post!  So don't miss it here!)

So this week, the reality of what's coming started to dawn on many at the medical center. As we start moving from the preparation to the treatment phase of the pandemic, more people have been pulled into the realities of caring for suspected and confirmed COVID patients . . . and stories abound from around the U.S. about how a lot of them have some very strong opinions about PPE:  A healthcare worker who showed up to work in full Ebola gear (no, I'm sure the co-workers felt safe in their "flimsy" masks).  Entire units who mandated masking of everyone after a co-worker was diagnosed with COVID (and had not worked with symptoms).  The sudden interest in and expertise about asymptomatic transmission by folks who never worried about coming to work sick with other viruses before.  Adding to the confusion are the contradicting images (full Tyvek suits in China), messages (a Power Point describing Wuhan experiences that notes SARS-CoV-2 can spread "through eyelashes and hair"), and, sadly, guidance from various authorities:

• OSHA: "Those who work closely with (either in contact with or within 6 feet of) patients known to be, or suspected of being, infected with SARS-CoV-2, the virus that causes COVID-19, should wear respirators."
• CDC: First, the recommended protection included a respirator for all types of patient care.  Then this was revised to: "Put on a respirator or facemask (if a respirator is not available) before entry into the patient room or care area. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol-generating procedure. . .When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19."
• WHO, Canadian Health Authority, and an increasing number of state health departments, including Tennessee:  Gown, gloves, facemask, eye protection (goggles or face shield) unless performing an aerosol-generating procedure, and then use a respirator or PAPR instead of the mask.

I definitely understand and support the need to be cautious, especially when it's early in a new pathogen outbreak, and the protection and safety of healthcare personnel (HCP) has been a major concern of mine and the focus of my career.  But one can easily see how the seeds of confusion have been sown among our HCPs regarding PPE.

No issue has been the bane of my work this week than "aerosol-generating procedures" or AGPs, and as I tried to dive into the science behind these recs, I came away even more confused.  A few quick learnings and thoughts on this issue:

• The term "aerosol" means a very different thing to a true aerosol scientist (whom I imagine I will offend with much of my own ignorance here) and most lay medical people:  To the former, an aerosol is a smaller particle (smaller than a droplet), the smallest of which require a higher level of filtration to protect HCP (as in a respirator).  To the latter, any visible drop of fluid, liquid, spit, etc. is an "aerosol" ("I can see it flying through the air!!"), and as such their perception is that the official lists (more on those in a bit) of AGPs are lacking.  
• The various lists of what might be an AGP vary by organization and even changes within a single organization's guidance.  Some include nebulized medications. Some, like WHO, had nebs on one version of the list in 2007 but removed them in 2009. A brief summary below:

     

• The actual science on what is an AGP and, more importantly, whether they confer a higher risk of transmission of infectious agents is a) very difficult to illustrate (often relying on retrospective recall of patient care activities in infected and non-infected HCP), b) involves some logistically challenging studies (ask Dr. Babcock), and c) has many confounding factors (individual patient issues, use of PPE, etc.).  I refer you to a few excellent papers on the topic HERE and HERE (shout out to our favorite blogger!).  Also see this nice summary in the lay press HERE. 

I imagine, if we all shared our lists of AGPs, there'd be wide disagreement (which is why I didn't tell you mine). Some will have nebulized medications (which always throws the peds clinics into a frenzy). Some don't.  CPAP/Bipap?  Maybe, but the few studies that have examined this often just say "non-invasive ventilation," and 1 study in SARS had a single patient infect 22 HCPs as a driver of that risk.  Is nighttime Bipap setting on the vent the same as rescue Bipap in impending respiratory failure (where there may be more suctioning and bagging of the airway?).  Open suctioning of the airway?  Just try to find any further description of that generic and broad term in any of the guidelines or evidence base. Is a brief (few seconds), pharyngeal suction an AGP? Is it really similar in risk to a deep, persistent need to suction copious lower airway secretions? Clearly no, but they're all "open suction of the airways." I think what we're seeing is that a simple term or list of procedures that is provided in guidance without strong evidence or out of an abundance of caution can have major logistic and psychological impact when trying to implement on the front line.  Also, without more clarity (and more funded science on this topic!), we end up potentially using valuable PPE that was not warranted if no risk exists. 

I'll end by saying, sadly, this is not the first time we've dealt with this issue. For those of us who were hosp epis during the H1N1 pandemic, this exact conversation occurred, albeit with less intensity as the wave of illness didn’t flood the hospitals as much as expected. Our frontline healthcare workers are putting themselves at potential risk by caring for these patients, and they are understandably anxious and scared. Conflicted and confusing PPE recs do them no service, and guidance not rooted in science that leads to inappropriate use of PPE may lead to shortages down the road and more exposed HCP. This pandemic has already started, but perhaps we can finally learn and have more funded science to provide clarity and consistency on these issues that account for the real world nuances of delivery of healthcare. Failure to do so merely puts our HCP at greater risk for the next new pathogen.

Lessons from a Pandemic

Photo by Martin Sanchez on Unsplash

We are in the early stages of the COVID-19 pandemic, but it's already very clear that the Infection Prevention community in the US has never faced such an enormous challenge. Reflecting back on the past two weeks, we have learned many things that will make us better prepared for the long term. My goal is to keep track of these in this blog. So here we go:

1. We are far too reliant on single-use disposable products. Having a large supply of cloth surgical gowns and isolation gowns that can be laundered is essential. I'll comment on disposable face masks below. Less reliance on disposables will also be better for the environment.
   
   
2. The supply chain for medical products needs geographic diversification. It wasn't all that long ago that we had numerous shortages of medications and IV fluids due to the hurricane in Puerto Rico, and now we have this crisis due to concentration of manufacturing in China.
   
   
3. Just-in-time inventory management is not a great idea in healthcare, particularly when the supply chain is rooted in a single geographic area. Most hospitals, especially larger ones, have some strategic stockpile of products, but it's unlikely that any have inventory levels to manage an outbreak that lasts for many months. Hospitals and government (both at the state and federal levels) have a lot of work to do in this area.
   
   
4. We have a new standard for evaluating personal protective equipment (PPE). In the old days (like last year), the standard for evaluating a new PPE product was: is the new product better than currently available products? Today's standard is: is the new product (let's say a bandana to cover your nose and mouth) better than nothing? I'll push that a little further and argue that the new standard should be: is the bandana no worse than nothing? Healthcare workers are very afraid, and I'll freely admit that I'm one of them. We all want to proactively protect ourselves. Even if the bandana is minimally protective, if it provides some level of psychological safety, we need to respect that and allow our workers to wear "homemade" PPE.
   
   
5. Going forward, the new attire standard for healthcare workers should be hospital-laundered scrubs. These should be donned after hospital entry and doffed prior to leaving. This will require that hospitals construct adequate changing and shower facilities. And scrubs should be coupled with a bare-below-the-elbows approach to patient care.
   
   
6. To the greatest extent possible, no-touch technology should be built into hospital design. Sensors that detect a hand wave for door opening are a great advance.
   
   
7. Face shields should and will replace face masks. They provide greater facial coverage and make it physicially impossible to touch your face. And I find them more comfortable than face masks. Sturdier models can be wiped down and reused. I suspect that every healthcare worker will purchase one, just like they purchase a stethoscope. For this outbreak, I am advocating that face shields be worn for every patient encounter since many patients with COVID-19 are minimally symptomatic. It should become a new component of standard precautions.
   
   
8. The community really wants to help us. I have recieved numerous forwarded emails from colleauges who have friends and relatives who want to sew masks or isolation gowns, donate their face shields and N95s, or whatever they can do to play a part in making things better. This is beautiful.
   
   
9. Infection Preventionists are true heroes. They are working around the clock to keep hospitals functioning. These people are the salt of the earth. They work in the background with little recognition and are some of the most committed people I have ever met. Thank you, thank you, thank you!

These are my initial thoughts. More to come. Get some rest and stay well!

Mike Edmond

Practical Strategies for Physicians to Avoid COVID-19 Infection at Work

The physician workforce is one of the most valuable resources of any hospital, and in the midst of the COVID-19 outbreak we need to do everything possible to ensure that physicians stay healthy. Like other hospital epidemiologists, I spend a lot of time thinking about practical ways to reduce the risk of infection. So to that end, I want to offer some suggestions for reducing your risk of acquiring COVID-19 at work.

• Personal infection prevention: I strongly recommend that everyone in clinical areas follow bare below the elbows. This means that there should be nothing on your forearms, including wrist jewelry and wrist watches. This prevents contamination of sleeves and allows you to perform good hand hygiene. Hospital-laundered scrubs, doffed before going home, is optimal. We want to minimize clothing contamination, so I recommend not wearing white coats, cover jackets, or fleece jackets. Neckties are problematic because they frequently touch the patient/patient surroundings and are rarely cleaned. If you feel the need to wear a necktie, tuck it into your shirt. If you wear a long sleeve shirt, roll up the sleeves. Perform hand hygiene like never before (at least before and after every patient contact), and remember to wipe down your stethoscope after each use. Lastly, avoid touching your face.

• Work rooms: Physician work rooms are often small, so we need to think about how to achieve social distancing in these small spaces. One way to do this is to bring your laptop to work and do your documentation in another site to reduce the number of people in the work room. Also, it’s important to declutter these rooms so that housekeeping can come in to clean all the surfaces. It’s very difficult for them to do this when there is clutter everywhere. You should also wipe down your workspace before you use it. Avoid shared foods in work spaces.


• Conservation of personal protective equipment: Supplies of PPE are tight because many of these products are manufactured in China and factories are closed. This means we really need to conserve these items so that we can safely care for COVID patients for what may be an extended duration. At my hospital, we have modified contact precautions for non-COVID patients to not include gowns, since gowns are particularly in short supply. We continue to wear gloves for patients in contact precautions. If you anticipate a splash or spray, wear a gown for any patient. One way to think about this is to ask yourself: would I rather have this gown to care for a C diff patient today, or this gown to care for a COVID patient 6 weeks from now? I think this question puts the issue into perspective. Face masks and face shields marketed for medical use are in short supply, so consider purchasing a face shield from a hardware store. Here is an example of one. This particular model completely covers your face even laterally, and I think provides good protection and is comfortable. If you are a physician in an area such as urgent care or the emergency department, where there are many patients with respiratory symptoms, I would consider wearing the shield the entire shift. Avoid touching the shield, and wipe it down after use. To reduce supplies used, reduce the number of persons entering the patient room to the minimum necessary.


• Workflow: Again, we need to think about social distancing. In teaching hospitals, we tend to travel in packs, and this needs to stop. Consider asynchronous rounding (attending rounds with each intern separately) to avoid congregating in the hallways on rounds. You might also consider batching your duties to the degree that you can and doing more of your documentation at home. Avoid elevators.


• What to do if you become ill: The most important thing is to not come to work if you have fever or new onset respiratory symptoms. If you begin to feel sick at work, remove yourself from patient care as soon as possible. If you don’t have a thermometer (I didn’t have one until a few days ago), please get one, so that you can check your temp at home should you feel febrile. You might also consider purchasing a pulse oximeter to keep at home for self-monitoring in case you become ill.

Please take care of yourself during this difficult time. Patients need us, so let’s do everything we can to stay healthy!

Mike Edmond

COVID-19: Deep Thoughts and a Little Therapy

I’m not really a crier. I mean, sure, there are moments in life that make me a bit misty.  Turn on those first 10 minutes of the movie Up and on go the tears (curse you, Pixar!).  But something happened Friday that made me realize how unusual and stressful these weeks have and will be for those of us in medicine and, in particular, hospital epidemiology. 

I have worked out with a bunch of dudes early mornings, outside (rain or shine) for the past 2 1/2 years. At the end of every workout, there’s a Circle of Trust where the group leader gives thanks to someone or something higher than himself (be he Christian, Muslim, Buddhist, whatever). On Friday, to celebrate my impending 50^th birthday, I led the workout.  At the end, as we gathered, I started to give thanks but had to stop. I could feel this deep ball of tears and emotion well up inside.  Couldn’t speak. Tears flowed. In front of these dudes.  And that’s when I realized, I wasn’t crying because I was turning 50 . . . this was a massive release with people I trust, and it showed me how much the past 2 weeks in particular have affected me (and I imagine many, if not all, of you).

As Mike (see also his excellent post from yesterday) has noted in an email chain, this is likely the most stressful time many of us (save maybe the HIV epidemic in the early ‘80s) have experienced in our hosp epi careers.  I told a friend that it feels like I’m strapped into a massive roller coaster ride (which I hate), climbing up that hill, sensing what lies ahead from the screams of people ahead of us (China, South Korea, Italy, Seattle, San Fran, etc.), and wanting desperately to get off the ride, realizing we cannot. 

This week, as Vanderbilt started testing, the variety of emotions hit hard. Patient #1 is a close friend, a physician, whom I didn’t know had been tested.  He attended a school fundraiser, and by the middle of the week, 10 people from that event were positive.  But I also saw resilience.  Two weeks ago, Nashville and middle Tennessee had the added hit of a massive tornado, affecting many in the area. One of which, my colleague who is the hosp epi at an affiliated community hospital, had to leave his apartment and move to a hotel, most of his and his wife’s belongings locked in a damaged building.  The next day, his hospital diagnosed the first COVID-19 case in TN.  New to the job, he handled this with grace and professionalism, even when he had to borrow a tie for the press conference because his were all locked in the damaged apartment.

This will be a marathon, and I offer some simple advice as this gears up (and I am sure others have more to offer):

• Delegate:  At first, I was hit with every question about this outbreak, from patient education, to clinical management, to employee furlough questions.  As the weeks progressed, more people joined in the fray who could help. I quickly learned what is under my expertise (IP) and what others can handle.  No need to micromanage. You simply can’t.  While there’s a core group working tirelessly on COVID prep, there are also many in our medical center wanting to help.  We’ve used our quality abstractors to assess if clinicians are correctly ordering COVID testing per our guidance.  Our stewardship team to work on treatment options.  And even though many of us are ID physicians, delegate the clinical management of these patients to your ID peers.  Focus on the IP stuff.
• Be decisive:  ID docs are known for their ability to opine, think, review data, which is great.  But right now, the questions and decisions are coming so quickly, we have to make quick decisions.  Some may be wrong; some may change as you learn more. We’re building an assembly line as the cars have already started rolling down the track. Some might fall off, some might not run well, but we have to keep building quickly. Don’t overthink things.  Use the science but avoid the margins.  We won’t find solutions that fit every scenario, as overthinking things can be paralyzing. 
• Develop a bench:  If you’re the only hosp epi around, figure out who you can train up quickly.  Another ID faculty member.  Ideally one who is even keeled, can know when they don’t know the answer and ask for help. 
• Take time out: It’s imperative that we all take breaks from this work, to refresh mentally, spiritually, and physically. Spend some time with your loved ones, even if just for an hour.  Step away from Twitter/Facebook/etc. Go for a run. 
• Deal with your emotions:  Cry in front of people you trust.  Meditate. Write. This is why I’m back on this blog – this is my therapy. 

I’m glad people pushed us to reignite this blog, as the collective insights can help the whole.  As always, we’re open for guest bloggers.  Stay healthy, stay grounded, and, of course, wash your damn hands.

Conserving PPE in the COVID-19 Era

Photo by Ashkan Forouzani on Unsplash

In my 25 years as a hospital epidemiologist, this week was the hardest yet. Last Sunday, we learned of 3 COVID-19 cases in the Iowa City area. As of today, there are 14--that we know of. Because testing is still quite limited, these 14 patients likely represent just the tip of the iceberg. As all of this unfolds, it is like watching a train wreck in slow motion. And looking at the situations in Northern Italy and Seattle, we see that what lies ahead for us is quite scary.

One of the things I have focused on this week is personal protective equipment (PPE). It seems clear that, sooner or later, most hospitals will be in trouble. The PPE supply chain is deeply rooted in China and those factories have closed. That coupled with the just-in-time inventory concept has put all of us in a tough spot. For those of you not yet in the thick of this, I will offer some thoughts that may be of use to you.

Here is my practical strategy:

1. Know your inventory. Have your supply chain folks produce a tabular report of all PPE products used in your institution. In this table, ask them to also include the numbers of each item used in an average week so that you know your baseline utilization.
2. Develop an inventory target that includes projected usage and duration. We decided to set our critical target at 300% of normal usage for 12 weeks duration. This can be calculated from your baseline utilization for each item. On the table, any item's total inventory that is less than 300% normal usage over 12 weeks is coded red. Yellow is set at 12-16 weeks at 300% normal usage, and green is set at >16 weeks at 300% normal usage. We review the PPE inventory table daily at our Hospital Incident Command System meeting. The color coding of the table allows quick interpretation of inventory levels.
3. Critically evaluate your current usage and limit usage of PPE. Remember that we are not in normal times. Once you see how far away your current inventory is from your target inventory, you will rapidly begin to think of things that can conserve PPE. Here are several:
• If you use contact precautions for patients colonized with VRE or MRSA, PLEASE STOP! At best, the utility of this practice is questionable. Ask yourself this question: would you rather have PPE to care for a VRE colonized patient today, or that PPE for a COVID patient 6 weeks from now. 
• If you use contact precautions to isolate patients infected with VRE or MRSA, consider stopping. Numerous hospitals have done that with no ill effect. Ask yourself the same question as in the previous bullet.
• We made the decision this week that for non-COVID contact precautions we would stop the use of gowns, but continue gloves, and stress hand hygiene and bare below the elbows (to minimize clothing contamination).
• Begin re-using items such as face shields (after disinfection) and N95 masks.
• Stop annual N95 fit-testing to avoid the use of masks in the fit testing process.
• Limit the number of visitors.
• For patients in isolation precautions, avoid taking the entire rounding team into the patient room. 
• Limit care of the COVID patient to one nurse and one physician.
4. Send your supply chain staff on a scavenger hunt throughout the hospital to identify PPE that can be reclaimed. There are hoarders out there! In addition, secure your inventory to avoid theft.
5. Dispense PPE to individual hospital/clinic units in smaller increments.
6. Investigate alternative products. For example, we have a supply of old cloth surgical gowns that could be used as isolation gowns if needed. 

I'm sure others have ideas that we have not thought of. If so, please place them in the comment section. 

To my colleagues in the infection prevention community: This is hard. We are tired. And it's only the beginning. But our work is more important than ever. Stay strong! 

Namaste.

What scares you?

I’m on a quick weekend trip for a wedding—a trip made possible only because we have a high concentration of hospital epidemiologists in Iowa City, and we haven’t yet diagnosed* a case of COVID-19 (*like much of the country, we’re behind in testing).

It’s disorienting to go from non-stop response planning questions to connecting with old friends. But of course the questions still came, the most common being: “are you scared by this?” My response was “yes”. Here are the three reasons I gave for my concern (before trying to turn the conversation to other things!), in no particular order:

Our healthcare system lacks surge capacity, and is already overstretched. Large tertiary care centers commonly run at capacity with overflowing emergency departments and patients “orbiting” (awaiting transfer from smaller hospitals for a higher level of care). The proportion of COVID-19 patients requiring admission and ICU-level care will quickly overwhelm US hospitals if spread continues at plausible estimated rates. This will cripple our ability to care not only for COVID-19 patients for all others requiring hospital care.

Residents of long term care facilities (LTCF, including long term acute care, rehabilitation centers, etc.) are extraordinarily vulnerable. We know from experience that once a transmissible pathogen enters a LTCF it spreads quickly, and the experience at the Life Care Center in Washington is terrifying.

The social and economic disruption caused by COVID-19 may kill more than the virus does directly—particularly in countries that have frayed or nonexistent social safety nets (I include the US in the “frayed” category). Job loss, loss of health coverage, homelessness, all carry with them additional morbidity and mortality that will continue long after the COVID-19 pandemic is over.

What do my fears imply for response planning?

Lack of surge capacity requires aggressive approaches to keep all but the sickest patients out of the hospital (telehealth, home health), and developing plans for conversion of some general hospital units to ICU-level care if needed. No surge capacity also strengthens the argument for aggressive social distancing approaches in an attempt to “flatten the curve” of the epidemic (amazingly helpful graphic below, and great Twitter thread here), while admittedly worsening the social/economic disruption problems.

The vulnerability of LTCF residents requires drastic measures to protect these facilities—limiting facility access, screening employees for URI/ILI daily, and reducing social contact in ways that could still allow interaction (computer/tablet visits, etc.). Some may even wish to investigate temporary relocation of some residents (e.g. to family with visiting nurse assistance). LTCFs look more and more like the highest risk environments for COVID-19 (combining transmissibility with case fatality rate).

The social and economic disruptions are the most difficult to address. In the near term, it requires recognizing when some of the more disruptive control strategies are no longer providing a benefit that overrides the ongoing damage to society. As one example, I think we’re reaching a point at which travel restrictions will have diminishing returns. This excellent modeling paper demonstrates the likely benefit of travel bans from China before extensive international spread had occurred. The impact of travel restrictions is likely to be much less now that the virus is so widespread globally. In fact, I think the motivation for many current travel restrictions being implemented in the US is out of fear that the traveler will be subject to home quarantine upon return (and unable to work or contribute to response efforts)—once community spread is documented across the US, the use of home quarantine after travel becomes illogical. Moreover, the whole idea of quarantining healthcare personnel after exposures needs to be abandoned if we hope to have any work force for patient care. CDC recognizes this in recent updated guidance.

OK, now that I’ve revived this recently moribund blog, we’ll have to address some more COVID-19 controversies soon. Or you could just search the site for our 10 year old posts about the H1N1 N95 mask fiasco?