Droplet or Aerosol? Debate Over How COVID Spreads Can Sway Your Hospital’s PPE Policy

Droplet or Aerosol? Debate Over How COVID Spreads Can Sway Your Hospital’s PPE Policy

The droplet vs aerosol question has front-line health care workers caught in the middle as infection control specialists and hospital administrators debate over how the novel coronavirus is spread ― and therefore, what level of protective gear is appropriate.

At issue is the degree to which the virus is airborne ― capable of spreading through tiny aerosol particles lingering in the air ― or primarily transmitted through large, faster-falling droplets from, say, a sneeze or cough. This wonky, seemingly semantic debate has a real-world impact on what sort of protective measures health care companies need to take to protect their patients and workers.

The Centers for Disease Control and Prevention injected confusion into the debate Friday with guidance putting new emphasis on airborne transmission and saying the tiny aerosol particles, as well as larger droplets, are the “main way the virus spreads.” By Monday that language was gone from its website, and the agency explained that it had posted a “draft version of proposed changes” in error and that experts were still working on updating “recommendations regarding airborne transmission.”

Dr. Anthony Fauci, the top U.S. infectious disease expert, addressed the debate head-on in a Sept. 10 webcast for the Harvard Medical School, pointing to scientists specializing in aerosols who argued the CDC had “really gotten it wrong over many, many years.”

“Bottom line is, there’s much more aerosol [transmission] than we thought,” Fauci said. [10-07-2020 UPDATE: On October 5, 2020, the CDC updated its website to state that “under certain conditions, people with COVID-19 seem to have infected others who were more than 6 feet away. These transmissions occurred within enclosed spaces that had inadequate ventilation. Sometimes the infected person was breathing heavily, for example, while singing or exercising.”]

The topic has been deeply divisive within hospitals, largely because the question of whether an illness spreads by droplets or aerosols drives two different sets of protective practices, touching on everything from airflow within hospital wards to patient isolation to choices of protective gear. Enhanced protections would be expensive and disruptive to a number of industries, but particularly to hospitals, which have fought to keep lower-level “droplet” protections in place.

The hospital administrators and epidemiologists who argue that the virus is mostly droplet-spread cite studies that show it spreads to a small number of people, like a cold or flu. Therefore, N95 respirators and strict patient isolation practices aren’t necessary for routine care of COVID-19 patients, those officials say.

On the other side are many occupational safety experts, aerosol scientists, front-line health care workers and their unions, who are quick to note that the novel coronavirus is far deadlier than the flu ― and argue that the science suggests that high-quality, and costlier, N95 respirators should be required for routine COVID-19 patient care.

Dr. Anthony Fauci, the top U.S. infectious disease expert, addressed the debate head-on in a Sept. 10 webcast for the Harvard Medical School, pointing to scientists specializing in aerosols who argued the CDC had “really gotten it wrong over many, many years.”

“Bottom line is, there’s much more aerosol [transmission] than we thought,” Fauci said.

The topic has been deeply divisive within hospitals, largely because the question of whether an illness spreads by droplets or aerosols drives two different sets of protective practices, touching on everything from airflow within hospital wards to patient isolation to choices of protective gear. Enhanced protections would be expensive and disruptive to a number of industries, but particularly to hospitals, which have fought to keep lower-level “droplet” protections in place.

The hospital administrators and epidemiologists who argue that the virus is mostly droplet-spread cite studies that show it spreads to a small number of people, like a cold or flu. Therefore, N95 respirators and strict patient isolation practices aren’t necessary for routine care of COVID-19 patients, those officials say.

On the other side are many occupational safety experts, aerosol scientists, front-line health care workers and their unions, who are quick to note that the novel coronavirus is far deadlier than the flu ― and argue that the science suggests that high-quality, and costlier, N95 respirators should be required for routine COVID-19 patient care.

WHO Issues 5-Point Charter on Health Worker Safety

WHO Issues 5-Point Charter on Health Worker Safety

Although health workers constitute about 3% of the population in most countries, they comprise 14% of COVID-19 cases reported to the World Health Organization (WHO), and in some countries account for up to 35% of COVID cases. WHO Director-General Tedros Adhanom Ghebreyesus noted this in a September 17 statement and added, “The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives.” As “one of the keys to keeping patients safe is keeping health workers safe,” on Thursday the Director-General issued a 5-point charter on healthcare worker safety in conjunction with Patient Safety Day.

The 5-point WHO charter urges its partner countries to:

1. Develop and implement national programs for the occupational health and safety of health workers

WHO recommends that education and training programs for health workers at all levels include health and safety skills in personal and patient safety and that healthcare licensing and accreditation standards incorporate requirements for staff and patient safety. Member countries should also review and upgrade national regulations and laws for occupational health and safety to ensure that all staff members have regulatory protection of their health and safety at work.

2. Protect health workers from violence in the workplace

Promote a culture of zero tolerance to violence against health workers. Labor laws, policies, and regulations need to be strengthened, and all healthcare workers should have access to ombudspersons and helplines to enable free and confidential reporting and support for any health worker facing violence.

3. Improve the mental health and psychological well-being of healthcare workers

Healthcare facilities must establish and maintain safe staffing levels, and ensure fair duration of deployments, working hours, and rest breaks. Mental and social support services, including advice on work-life balance, risk assessment, and mitigation should be readily available to all staff.

4. Protect healthcare staff from physical and biological hazards

Health care systems must implement patient safety, infection prevention and control, and occupational safety standards in all health care facilities. Facilities need to ensure availability of personal protective equipment (PPE), adequate quantity, appropriate fit, and acceptable quality. All facilities should maintain an adequate, locally held, buffer stock of PPE and provide workers with adequate training on appropriate use and safety precautions. Further, at-risk healthcare staff should receive vaccinations against all vaccine-preventable infections, and in the context of emergency response, be given priority access to newly licensed and available vaccines.

5. Connect the dots between policies on patient safety and healthcare worker safety

Institutions should integrate staff safety and patient safety incident reporting and learning systems, and define the linkages between occupational health and safety, patient safety, quality improvement, and infection prevention and control programs.

Regarding the latter point, the charter states that “No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe.”

For more details on the charter see the WHO announcement, “Keep Health Workers Safe to Keep Patients Safe.”

Is It Time to Relax NY ICU Visitor Policies?

Is It Time to Relax NY ICU Visitor Policies?

Before COVID-19 hit New York City, Mount Sinai Morningside Hospital had a flexible, 24-hour visitor policy for patients in the intensive care unit (ICU).

People would visit their loved ones at any hour of the day, coming and going as they pleased. Doctors and nurses said the constant support of family members was beneficial to these gravely ill patients.

Now, per New York State Department of Health guidelines that apply to all areas of the hospital, visitors are limited to one 4-hour session per day, and only one person is allowed at the bedside at a time. At Morningside, that has to be done between the hours of 10 a.m. and 6 p.m. so visitors can undergo temperature and symptom checks before being permitted on the floors.

Morningside ICU physicians and nurses told MedPage Today those visitation policies are too restrictive, especially as staff have become more adept at managing COVID-19 transmission risk.

“It’s particularly challenging for this community because these families have a lot of restrictions,” said Mirna Mohanraj, MD, an ICU physician at Morningside (formerly St. Luke’s Hospital), which predominantly serves minority patients from Harlem and the Bronx. “Not everyone has a flexible job they can leave for 4 hours. They don’t have the financial resources to hire childcare.”

In an emailed statement, the New York State Department of Health said that hospitals “can authorize visits longer than four hours depending on a patient’s status and condition” and noted that labor & delivery patients, pediatric patients, and those with intellectual or developmental disabilities can have a support person at all times.

“This policy remains in place to safeguard and maintain the health and wellbeing of patients, staff and visitors while the need to contain the spread of COVID-19 continues,” the statement read.

The new visitation rules are a vast improvement from the disease peak, when visitors were barred from hospitals altogether and patients died alone. But while the policy may be sufficient for patients elsewhere in the hospital, it poses particular challenges for the ICU, Mohanraj said.

“The ICU is such a dynamic place, things change frequently and unexpectedly,” she said. “It’s traumatic for a family member not to be present when things are changing rapidly.”

Morningside ICU charge nurse Jessica Montanaro, MSN, RN, said while the visitation rules “make sense on regular floors, you have more grave situations [in the ICU]. You’re dealing with death and difficult decisions. In truly grave situations, people need more support. It should be a different situation for the ICU.”

Mohanraj said the literature “shows that having family at the bedside can be beneficial to patients” in the ICU, which is why many ICUs have adopted flexible visitor policies in recent years.

“Family members can provide emotional and psychological support,” she said. “Often, they’re the ones re-orienting patients, moving their legs, alerting the nurses to issues like pain control or a bedpan.”

“They’re also the constant reminder of the full lives that patients had before they got to the ICU,” she added. “And it helps the family develop trust in us as their healthcare team.”

Hospital administrators have allowed exceptions on a case-by-case basis, as called for by the state guidelines. But that means more time spent trying to cut through red tape, and the possibility of request denials.

Eric Gottesman, MD, medical director of the ICU at North Shore University Hospital in Manhasset, New York, which was also hit hard during the COVID-19 peak, said administrators there typically make exceptions to the visitor rule for end-of-life discussions.

“We follow the guidelines but if there’s an emergent issue, we do stray a little,” Gottesman told MedPage Today. “We try to bend, not break.”

Gottesman was similarly accustomed to a liberal visitation policy before COVID-19 hit. The new policy “puts more pressure on us by having to tell patients about the limitations,” he said. “Also, if we’re on rounds and no family member is present to take in the info, we have to come back and do it over.”

So what changes would ICU doctors and nurses like to see?

Family members should be able to stay for longer than 4 hours, Mohanraj said, especially if that person is the patient’s only visitor. That visitor should also be allowed to return to the bedside after they’ve left (right now, once a visitor leaves a hospital floor, they’re not allowed to return).

Finally, Mohanraj said nighttime visits would be especially helpful because ICU patients who experience delirium typically get worse at night, so the additional family support might alleviate related issues.

Safety is the first priority, she said, and thus far preventing transmission among visitors “has been perfectly manageable,” especially as very few patients with COVID-19 remain in the hospital, she said.

ICU providers in New York hospitals say the trauma of seeing families separated during the peak of the crisis has stuck with them, and makes their current push to have family members around more urgent.

In the beginning of the crisis, visitors weren’t allowed unless a patient was imminently dying — but that’s not always easy to call, Montanaro said.

“We had difficult cases where we would allow one family member to come up and stand in the patient’s doorway, say their goodbyes, and then the patient didn’t pass,” Montanaro said.

As policies eased over time, and patients could have two visitors, she recalled a case of a dying mother with three family members who wanted to say goodbye — her husband and two sons.

“That family had to choose which son would say goodbye to their mother,” she said. “So many things about that experience will haunt us for the rest of our lives.”

Nurses Share NYC Frontline Experience in New Book

Nurses Share NYC Frontline Experience in New Book

In March, when New York City staggered under the weight of the COVID-19 outbreak, the images of refrigerator trucks, overwhelmed hospitals, and outdoor triage centers set Amy Kinder’s caregiving instincts afire. On April 5, 2020, the ER nurse left her home in Kokomo, Indiana and joined the thousands of dedicated nurses who came to work on the city’s frontlines. During her 21 days at Coney Island Hospital in Brooklyn, Kinder formed a tight bond with eight colleagues. Now, the nine nurses have described their experience in a new book, COVID-19 Frontliners.

“I remember my first night in the emergency department I was stopped abruptly in my tracks as I was racing down the hallway. My eyes caught movement in one of my rooms. I stopped to ensure what I was seeing. I had a patient actively dying and the patient next to her reached through the rails of the cot and held her hand trying to comfort her. I felt anguish for these patients. They did not know each other, but they were all alone. They had no one but the stranger beside them.” –Amy Kinder, COVID-19 Frontliners

In an interview with the Kokomo Perspective, Kinder said, “We felt like it was important to get the truth out there because you see on the news so many conflicting stories of what’s really happening or what was going on. So we just felt like it was important to get our frontline experience out there so other people really could see and understand what it really was like—because when I was out in New York, [it seemed] like the news sugarcoated what was really going on.”

As they attempted to communicate with non-English speaking patients, Kinder and the other nurses tried to find their footing amid scenes of chaos: “There were patients everywhere, double and triple stacked in rooms, lining the hallways, right up to the nurses’ station.” She added, “I could not believe what I was seeing. How could this be possible? Where did all of these patients come from? I thought to myself, ‘Damn, this is way worse than what I saw on the news.’”

In addition to dealing with the overcrowding and insufficient PPE supplies, Kinder and her colleagues struggled with a shocking volume of mortalities that sometimes included co-workers: “During the hardest time, we learned how to cope in ways we never had before. Not only were we seeing death in our patients but within our own healthcare family. We lost an agency nurse one night at shift change. She was found down in the bathroom. My heart still hurts for this individual’s family.”

When Kinder returned to Kokomo, she found that the experience had left marks on her psyche. Back on duty at the Ascension St. Vincent ER, “Alarms go off, and I flash back to the horror in NYC. I begin to hyperventilate worrying that we are running out of oxygen again or that a patient is in crisis. I have to talk myself down and remind myself of where I am and that I’m no longer in NYC.”

Her 21 days in New York also left Kinder with a sobering awareness of the realities of COVID. “I knew that it was a big deal, but at the same time I wasn’t really sure how big of a deal it was. There’s so much unknown about this dang virus, so I even was on the fence. But then I come home and people are mouthing, and until you’ve been out there and lived it, it hurts to hear people talk like that…”

For more details on Kinder’s experience, see the story in the Kokomo Perspective.

Family Audio Messages Help Johns Hopkins ICU Team Connect with COVID Patients

Family Audio Messages Help Johns Hopkins ICU Team Connect with COVID Patients

Getting to know the critically ill patients they’re taking care of is hard enough for ICU doctors under normal circumstances. But it’s even worse during COVID-19.

Not only are there no visiting family members to give you information, “but the patients are all similar in terms of their medical issues, they’re all on a breathing machine, and many are lying on their bellies,” explained Brian Garibaldi, MD, associate professor of medicine and anesthesiology at Johns Hopkins Medicine and director of the isolation unit at Johns Hopkins Hospital in Baltimore, in a phone interview. “You might go for days without examining the front side of their body, so we’re not seeing their face. That makes establishing connections with patients a little more difficult.”

An Idea From the Chaplain

One day Garibaldi was talking to Elizabeth Tracey, a chaplain at the hospital who also is director of audio production at Johns Hopkins Medicine — someone very familiar with audio recordings. She had an idea: how about if she interviewed patients’ family members and made a recording of what they say? “I could edit it down to a few things families really want their doctors to know about their loved one,” she said. Garibaldi was immediately on board.

In a separate interview, Tracey — who also edits and appears on MedPage Today‘s TTHealthWatch podcast, said she had heard from a chaplain colleague who told her that a physician had said after an extubation of a terminal COVID-19 patient that “I realized I didn’t know anything about this person; I didn’t know if he had children, if he was married. I didn’t know anything.” So why not give the physicians and the rest of the healthcare team personal details — “Do they have a dog? Do they like to play poker? It’s all the things that make them human,” said Tracey.

Tracey said Garibaldi emphasized one thing: “The only way this is going to work is if it’s in the voice of the family member.” So Tracey began calling family members and saying, “Hey, I’m part of the team helping take care of your loved one … Under normal circumstances you’d be here in the ICU telling us your loved one’s story. The team would like to know your loved one better as a person; would you like to spend 15 to 20 minutes talking about them?”

So far, only one person has turned her down since Tracey began doing this in April, and that was because they didn’t like the sound of their recorded voice, Tracey said.

After getting the family member’s permission, she records the phone call and edits the comments down to 2 or 3 minutes; she estimated that she has completed 30 to 40 recordings so far. Currently, the recording is distributed to the medical staff by an administrator at the hospital, although she hopes to eventually get it added as a link in the patient’s electronic health record.

A Message to the Healthcare Team

Tracey also added a second component: the opportunity for the family member to send a recorded message directly to the patient. “I said, ‘if you were talking to your family member, what would you say? Talk to them directly.'”

“They say these things that are just unbelievable,” said Tracey. One mother recorded a message for her adult daughter, whose autistic child the mother was the custodian of. “She says, ‘I want you to know that everything is forgiven,'” said Tracey. “How can you have a more powerful example of love?” Those conversations also are edited down to 2 minutes and played for the patient.

The recordings for the medical staff are very helpful, said Garibaldi. “Just learning the simple things — What would they prefer to be called by if I met them in the grocery story? What hobbies do they like? What favorite music can we program on an iPad to keep them awake and stimulated during the day? Also, learning things like what that person has accomplished in their personal and professional life; it really puts things in perspective, to put their current illness in the context of where they’ve been, where they are, and where they might want to be going.”

Dale Needham, MD, professor of pulmonary and critical care medicine at Johns Hopkins, agreed. He noted that although the medical staff speaks with patients’ family members every day, “those conversations have to be efficient and focused, whereas Elizabeth has the luxury of spending more time, and distilling it into an audio file that we can listen to and understand and easily share.”

For example, Needham said, “we found out that one patient previously had worked at a Smithsonian museum, and we found out that one of our patients likes to tango. And we found out that one of our patients that we wouldn’t have expected — was a DJ” on the weekend, while he had a white-collar job at a law firm during the week.

“This can help us understand who the patient is, and as the sedation is lightened, it helps us interact with them in a more humanized way.” It’s also mutually beneficial because the families are aware that the staff knows a little about their loved one, he added.

“What a Gift She Gave Us”

Barbara Johnson, whose late sister was a COVID-19 patient at the hospital, agreed. “I thought it was an incredible opportunity, given that none of us could see my sister,” said Johnson, of Silver Spring, Maryland, who did a recording for her sister and one for the medical staff. (You can listen to the recordings in the player above; her recording for her sister Beverly is first, followed by the one for the healthcare team at 3:25.)

When she spoke with Tracey for the recording, Johnson said she was thinking about her sister, “What would I have said if I got to talk to her” the day she was intubated? “What a gift Elizabeth gave us.”

Regarding the recording for the medical staff, “I think that when you take away the family from a hospital room, it might be hard for doctors and nurses to relate to the individuals, and the fact that they wanted to was really quite powerful for me,” Johnson said. “I really wanted them to know what made her happy, and if she was there talking to them, what would she have told them? … I also wanted them to know — in case she woke up — that she was the kind of patient that would tell them what they wanted to hear. If she was not feeling well and wanted them to feel good about their job, she would say, ‘I’m doing great.’ So I wanted them to know, just read between the lines.”

Tracey has recruited several dozen additional volunteers — including chaplains and medical residents — to make the phone calls and edit the recordings. She also has expanded the service — which she calls “This Is My Story,” or TIMS — to include other patients in the hospital, since they also aren’t getting visitors during the pandemic. She said she hoped that other hospitals would adopt the practice.

Within the hospital, “there’s definitely a lot of enthusiasm from the medical units and also an enthusiastic response from pediatrics,” she said. “What parent wouldn’t want to record ‘Green Eggs and Ham’ for their kid?”

FL Nurses Protest Unsafe Working Conditions

FL Nurses Protest Unsafe Working Conditions

More than a dozen registered nurses at Blake Medical Center in Bradenton, Florida, protested outside the hospital Friday, the third such protest since the pandemic began, saying hospital owner HCA Healthcare won’t give them N95 masks unless they are working with known COVID-19 patients, and doesn’t tell them when their patients later test positive.

As case counts in Manatee County climb, many patients have been admitted to the 383-bed hospital for other reasons, but later turn out to have COVID-19, said Candice Cordero, a telemetry nurse who works with stroke and cardiac patients in a step-down unit.

“We’re seeing more random patients test positive, and some have symptoms, but some don’t, or some are admitted for one thing, and start having (COVID) symptoms a few days later,” she told MedPage Today.

“We’re having a problem with the hospital being transparent with their numbers, and letting staff know when they’ve been exposed.”

The hour-long protest was called by members of the Blake Medical Center’s bargaining unit of the National Nurses Organizing Committee-Florida, an affiliate of National Nurses United. NNOC said in a news release that it has filed complaints about unsafe conditions at the hospital with the Occupational Safety and Health Administration. The statement said that at least four RNs at Blake have tested positive since late May.

The union further alleged that Blake Medical Center management requires RNs who have been exposed to COVID to continue working until they have COVID symptoms, does not test all patients prior to a procedure or operation, fails to provide PPE replacements for broken masks, and threatens RNs with discipline for raising safety concerns.

Officials for Blake Medical Center eleased this statement in response to the protest:

“In the midst of a global shortage of personal protective equipment (PPE), Blake Medical Center has been doing everything in our power to protect our caregivers and patient care teams throughout the pandemic and equip them to provide safe, effective care to our patients by following or exceeding Centers for Disease Control and Prevention (CDC) protocols.

“We have provided appropriate PPE, including a universal masking policy requiring all caregivers in all areas to wear masks, including N95s, in line with CDC guidance. While we currently have adequate supplies of PPE, we continue to provide safeguards that are consistent with CDC guidelines and help ensure the protection of our colleagues, not only today, but into the future as the pandemic evolves. The NNU fails to recognize the reality all hospitals nationwide are facing, that this pandemic has strained the worldwide supply of PPE, including masks, face shields, and gowns.”

Cordero said that recently one patient “was not properly screened in the ER who should have been on a COVID unit. That potentially exposed several nurses and the other patient in that room.”

When she complained to human resources officials, she said, she “was reprimanded verbally for speaking up and was told that if I did it again, I would receive discipline.”

The hospital should be testing all of its frontline workers regularly, she said. “We’re much more at risk of being exposed while at work than many other jobs out there. We really should be screened better than we are.”

Kim Brooks, who works in an ICU step-down unit for trauma and cardiac patients, assumes all of her patients are infected with COVID-19 and because of that, she said, she has bought her own N95 masks since the hospital won’t buy them for her.

“We know some of the nurses who are on non-COVID units are getting exposed to positive patients and now [some] are getting sick because they didn’t have N95 masks,” she told MedPage Today.

At the very least, the hospital should inform frontline workers when patients ultimately test positive on our floor, “so we can take precautions with our family,” Brooks said.

“Once we find out someone is positive, we do move them to a COVID unit. But sometimes there’s been a situation where that patient has been rooming with a COVID patient, and that patient is sometimes left on our unit to see if they turn out to be positive.”

By Cheryl Clark, MedPage Today

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