Early in the COVID-19 pandemic, emergency physicians and nurses became critically needed to address the ensuing patient care crisis, but they were also scared of the effects of exposure to the virus on them and their families. Many suffered anxiety, depression, and even symptoms of PTSD.¹ Senior staff, at greater risk for severe outcomes, considered early retirement. We knew of colleagues who had died. The U.S. Centers for Disease Control and Prevention (CDC) made recommendations for personal protective equipment (PPE) based on the experience with SARS-CoV and influenza, but it became clear that aerosol transmission occurred and many emergency department (EDs) had shortages of N95 masks and other PPE. Even after vaccination was introduced, waning antibody titers and immune evasion of new variants continued to exact a toll on our frontline workforce. Perhaps worst was not knowing the actual risk of providing emergency care.

A recently published article describes the first prospective surveillance to determine the risk of contracting COVID-19 by doctors and nurses providing emergency care.² This project was conducted during the height of the pandemic and before vaccinations, May to December 2020, at 20 U.S. academic emergency departments. Approximately 1,600 doctors, nurses, and other staff were followed with weekly surveys and serial SARS-CoV-2 surveillance with PCR and serology tests—30,000 person-weeks of surveillance, including over 4,400 intubations—to determine the attributable risk of acquiring COVID-19 through direct patient care by comparing infection rates between clinical and nonclinical ED staff.

The authors found that availability and use of PPE consistent with CDC recommendations was excellent. Most important and reassuring, PPE worked! The overall risk of infection was very low—4.5 percent got a new COVID-19 infection over 20 weeks, approximately 20 per 10,000 person-weeks. That equates to one infection for a single person after working 10 years. Over 40 percent of those staff who were infected never developed symptoms.

But while the overall risk was low, does caring for patients increase our risk, particularly for those who routinely spend prolonged time in rooms or who do aerosolizing procedures, like CPR and endotracheal intubations?

No additional risk associated with doctors providing direct care was found, however, nurses had almost twice the risk compared to non-patient care staff. And while double the small risk is reassuring, this raises the question of whether nurses and others who spend prolonged time in patient rooms could be more safely protected.

Intubating COVID-19 infected patients was also associated with increased risk of acquiring COVID-19. But again, intubations were uncommon and only 7.5 percent of patients who were intubated were found to be SARS-CoV-2 infected, so intubating while wearing appropriate PPE only contributed minimally to personal risk.

The overwhelming risk to emergency staff was, surprisingly, community COVID-19 exposures, particularly at home, where there was 16-fold increased risk of subsequent infection. Further, those staff who did not use masks during life outside the ED when infections were prevalent were at additional risk.

The bottom line, the CDC’s PPE recommendations worked to protect U.S. emergency health care workers during the early phase of a deadly global contagion. Vaccination has taken some edge off our anxieties, but should infections and severe outcomes surge again, careful adherence to PPE recommendations and routine N95 mask use should be considered. Just as most motor vehicle collisions occur close to home, health care workers must remain vigilant when disease activity increases in their communities for this current and any future pandemics.

Dr. Talan is emeritus professor of emergency medicine and medicine/infectious diseases at the David Geffen School of Medicine at UCLA and was co-Principal Investigator of the CODA trial.

Dr. Mohr is professor of emergency medicine, anesthesia critical care, and epidemiology at the University of Iowa.

References

1. Rodriguez RM, Montoy JC, Hoth KF, Talan DA, Harland KK, Tem Eyck P, Mower W, Krishnadasan A, Santibanez S, Mohr N. Symptoms of anxiety, burnout, and PTSD and the mitigation effect of serologic testing in emergency department personnel during the COVID-19 pandemic. Ann Emerg Med. 2021;78:35-43.
2. Mohr MN, Krishnadasan A, Harland KK, Eyck PT, Mower W, Schrading WA, Montoy JC, McDonald LC, Kutty PK, Hesse E, Santibanez S, Weissman DN, Slev P, Talan DA for the Project COVERED Emergency Department Network. Emergency department personnel patient care-related COVID-19 risk. PLOS ONE. 2022 (in press).