In many parts of the country, as rates of COVID-19 are declining and vaccination coverage is increasing (albeit with substantial variation across the US and the world), reopening has commenced.  Masking requirements and guidelines have relaxed, gatherings have increased, and we’re entering the post-COVID reality.  In healthcare, discussions regarding how to safely relax various interventions put in place during the height of the pandemic are underway:  When do we (should we ever) stop active screening of healthcare workers, patients, and visitors? Can we stop requiring admission and pre-procedural asymptomatic screening testing? How does a fully vaccinated workforce affect this relaxation? Can we safely gather? Do we stop social distancing? Will universal facemask use in clinical areas be the new standard practice from here on out?

Last week, a massive regulatory curveball crashed into this discussion when OSHA released the Emergency Temporary Standard on COVID-19. Catching many facilities by surprise, the new Standard, which many are required to meet within 14 days of publication in the Federal Register, harkens back to Spring of 2020 in many ways.  The requirements do not seem to take into account the declining rates of infection and increasing vaccination coverage and instead read as if rates were still climbing and vaccines were still under clinical trials. As a regulatory branch of the government with “teeth,” OSHA can cite and fine facilities for failure to comply (unlike other parts of the federal government infection prevention experts are also used to following, like the CDC).  In many ways, this makes OSHA’s directives and perspective on interventions the final say, even when evidence may not fully support them.

OSHA’s mission is a very important one: to ensure employers provide a safe working environment and that employees have safeguards in place to minimize/eliminate harm from their working environment.  OSHA standards have paved the way for safe, protected workplaces, and their guidance applies to all types of industries, from manufacturing plants to construction sites to hospitals and clinics. However, OSHA’s approach to healthcare has been criticized for failing to account for patients and potential patient harm in their mission to protect healthcare workers. While at the manufacturing plant, any regulatory requirements put in place won’t harm the widgets being produced, in healthcare, we have to work to ensure protection of the workforce while also accounting for practices that could result in harm to the patients that that workforce serves.

Enter the “ETS,” as it’s (not really) affectionately called. With a massive preamble of 916 pages (one can only imagine how long such a document took to go through gaining internal consensus), the ETS outlines expected practices that must be in place for facilities who may see persons with suspected or confirmed COVID-19.  Some key concerns about the new guidance are as follows:

  • I won’t rehash the mask vs N95 for the care of COVID-19 patients debate, other than to note that this is an issue where the science is still very much in conflict (see recent debate at SHEA and upcoming one at IDWeek 2021 on just this topic). OSHA’s ETS has essentially made the argument moot: N95s must be worn for care of any suspect or confirmed COVID-19 patient – not just with those undergoing an AGP. Imagine the implications of this: now, even fully vaccinated pediatricians, seeing wave after wave of children with URIs this fall, must wear the full COVID-19 PPE for every patient. Every day. If such workers aren’t facing burnout now, that may tip them over the edge. It’s one thing if such conservative use of precautions were necessary; however, that’s unclear, especially in a fully vaccinated person.  Maybe a facemask and eye protection is all that one needs, but that doesn’t matter now.
  • The ETS requires employers to notify employees if a case of COVID-19 is reported in their workspace. The notification is not just to close contacts but to anyone working in the “well-defined” workplace who weren’t wearing a respirator. This seems more burdensome to already stretched occupational health programs, but what’s even more curious is if such notification was important, it is not necessary if the COVID-19 case occurs in a patient in area where care of suspected and confirmed COVID-19 patients occurs. So if alerted to a case of COVID-19 in the sterile processing department, all employees in that area (not just close contacts) not wearing an N95 (why would they be??) must be notified, but if that case happens to have been on one of the clinical units where COVID-19 patients reside, notification is not required.  Hmm . . .
  • Some of the ETS requirements are confusing and vague, such as this statement: “When the employer establishes it is not feasible for an employee to maintain a distance of at least 6 feet from all other people, the employer must ensure that the employee is as far apart from all other people as feasible.”  “Must ensure” is very strong language yet how is this even remotely possible to monitor, enforce, or even set expectations for?
  • The ETS does allow exemptions for fully vaccinated persons, but only in areas where “people with suspected or confirmed COVID-19 are not permitted to enter those settings.” Unfortunately, in healthcare settings, many such persons are coming to the facility for care for those exact symptoms or require urgent medical interventions that cannot be delayed, and prohibiting them from entering the location runs counter to that mission and can result in patient harm. As a result, the fully vaccinated status of the workforce will not matter for many of the requirements.
  • Despite being the most effective interventions to protect the workforce (which has an added benefit of protecting the widgets . . . I mean, the patients too), OSHA does not take a firm stance on requiring COVID-19 vaccination for healthcare personnel.  (In fairness, they do strongly encourage vaccination and require employers to provide time off for vaccine-related symptoms).

Despite my cynical attitude, I do think some of the ETS requirements are very positive: the emphasis on cleaning, ventilation requirements, use of transmission-based precautions, and a much stronger expectation around reporting of employee respiratory illness and staying home when ill. I do, however, worry about the overly burdensome requirements at a time when COVID rates are falling, especially when we enter the fall and our good friends influenza, RSV, and other viruses make a return (but maybe, given the near elimination of those viruses last winter, that’s part of the intended impact of the Standard?).  Interestingly, OSHA opted only to release an ETS regarding COVID-19 for healthcare and not for other industries.  But if COVID-19 is still an occupational risk for workers in healthcare, isn’t it for other industry workers as well? I also realize that the emergence of variants of concern can change the epidemiology of COVID-19 rapidly, but thankfully, vaccination does still provide substantial protection against the currently circulating variants.

So as you scramble to unroll back/reinstitute interventions that had been in place last year and struggle with messaging to the workforce of the new requirements, know you are not alone.  Hopefully, with public comment and more science, the positive aspects of the Standard can be kept while eliminating or revising the more burdensome and arguably non-protective requirements. As Marcia Brady would say, "Sure, Jan . . ."

[This document represents my individual personal views and opinions and are not necessarily the views and opinions of Vanderbilt University Medical Center]


  1. Tom, Thank you for posting this perspective. During a meeting yesterday at my facility to discuss the ETS, one person made the comment that the ETS "feels very much last year". which aligns with what you you wrote (and I agree with!). One of the most problematic (among a number of problems) is the requirement for distancing and plastic barriers....so many plastic barriers....which are impossible to put into place in healthcare settings. This is right up there with temperature screening at entrances with evidence and is far more wasteful in terms of materials, effort, and workflow. It is stunning that there was no feedback period before publishing on the Federal Register AND provides no protection for workers outside of healthcare. Best, John


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