San Francisco Chronicle - (Sunday)
Health care can return to normal
As last week’s announcement by the Biden administration — that it intends to end the national and public health emergency declarations for addressing COVID-19 — makes clear: when it comes to the pandemic, we are no longer in a state of emergency.
Nearly every part of society has returned to normal, with a few exceptions. Not much has changed in terms of COVID-19 protocol at hospitals, clinics and nursing homes. While increased caution in these settings is warranted (more than 1 million Americans are in residential nursing homes, many of them medically fragile and older), every policy enacted in the name of COVID-19 mitigation carries a cost, perhaps especially in health care settings.
How do we amend these policies safely, when people in these locations are still dying of COVID-19? We can take a lesson from our experience with HIV.
As health care settings reopened in late spring of 2020 after wide-scale shutdowns (other than emergency services), facilities required universal masking with eye protection for all patient care — in effect treating all patients as if they might have COVID-19. Nearly three years later, many health care settings still require universal masking, by hospital regulation or state health safety rules. Preadmission and pre-procedure testing for the virus and visitor restrictions are still common in several states, including California.
These policies carry significant downsides. Mandatory pre-procedure testing leads to canceled medical treatments, masks impair communication and connection, and visitor restrictions leave vulnerable people alone when they need comfort and logistical help. While restrictions in nursing homes served an important purpose at the beginning of the pandemic, they also resulted in the loss of vital services such as physical therapy and counseling. Restrictions on family visitation and on socialization among residents also worsened dementia and loneliness and hastened the physical deterioration of patients.
We are also witnessing the devastating costs of deferred care: Deaths of despair, such as overdoses, are up precipitously, and hospitals are dealing with a higher ratio of complex patients, worsening hospital bed shortages, and staff burnout is rising. Obesity and diabetes grew during the pandemic, most notably in children, and multiple-yearslong unaddressed mental health conditions are taxing social and health care systems.
Here, we outline a set of strategies to safely phase out COVID-19 mitigation policies that further defer care, hinder communication among doctors, patients and families, worsen staff burnout, and infringe on patients’ and families’ rights. End symptom screening: Allow patients with mild symptoms consistent with COVID-19 (and other winter colds) into health care settings. Symptom screening is nearly ubiquitous in health care settings today. The result is that patients are turned away, rescheduled to telehealth or sent to emergency departments. However, just as we treat patients with HIV without necessarily knowing their infection status, the availability of highly effective personal protective equipment should allow staff to see patients with COVID-19, whether they are seeking care for COVID symptoms or for other ailments. Diverting patients with mild COVID or COVID-like symptoms to the emergency department harms sicker patients who truly need emergency medical care by increasing wait times for all and worsening overcrowding. Open visitations: Hospitals should reinstate patient and family-centered approaches to delivering care by returning visitor policies to pre-pandemic status. Loved ones should be allowed at bedsides and both parents should be permitted to accompany a child or older adult to the emergency room or other medical visit, just as they were pre-2020. Yet, many hospitals are maintaining one-visitor or novisitor policies. A November 2020 report noted that for every two residents of nursing homes who died of COVID-19, another died prematurely of other causes, leading to a 15% excess death rate. Researchers have speculated that lack of visitation contributes to “failure to thrive” because family members help provide care for nursing home residents and hold facilities accountable for delivering needed services. Take precautions: Admission and pre-procedure testing should not be routine. The emergence of HIV in the early 1980s raised intense concern about transmission to staff and patients in medical settings. Routine preoperative testing was common. Eventually, as data became available, the public and health care workers were reassured that there were ways to protect from infection in health care settings. The concept of “standard precautions” was born, in which gloves and other protective gear were added to routine practices where blood or body fluids might be encountered. This approach has made workplace acquisition of HIV (and other blood-borne pathogens) exceedingly rare even though routine preoperative HIV testing is not practiced. Yet, today, many hospitals still require a negative coronavirus test before every procedure. The justification, similar to what was used for HIV, is twofold: testing protects health care workers and other patients from acquiring a coronavirus infection from an asymptomatic patient, and testing protects patients who may have COVID-19 from undergoing procedures because the disease could worsen the outcome of the surgery.
With the widespread availability of personal protective equipment — and given that nearly every American has immunity against severe COVID-19 conferred by vaccination, infection or both — pre-procedure testing is no longer necessary or helpful. On the contrary, the risks associated with canceling surgeries exceed the risk of performing surgery on a patient who may have asymptomatic COVID-19. The Society for Healthcare Epidemiology of America recently acknowledged the unintended consequences of asymptomatic screening when they issued a guideline and press release advising against both pre-procedure and hospital admission testing. Their rationale was endorsed by the American Society of Anesthesiologists. If patients are symptomatic and too sick to have surgery, then they should be rescheduled, as was always the practice.
Make masking optional: Routine use of masks in health care settings has numerous downsides. Elderly patients and children struggle to express themselves and to understand masked providers. The accuracy of rapid stroke assessments fails when subtle facial droops are missed. Patients who are delirious, at heightened risk of aspiration, women giving birth and those in mild to moderate respiratory distress are often still required to mask, prioritizing infection control measures that, according to a study published in Cochrane Reviews, do not even significantly reduce transmission rates, over patient well-being.
Connection, trust and subtle facial expressions are particularly important during certain visits, such as in primary care, oncology and psychotherapy. But masks have been shown to hamper the assessment of subtle facial expressions that provide cues as to patients’ states of mind. In some states, speech therapists are still required to mask, a practice that both therapists and parents have reported poses serious hurdles to effective therapy.
Universal masking in health care settings should be retired and replaced with selective oneway masking, following the model of gloving to protect from HIV exposure via blood. Today, we do not recommend glovewearing for every routine patient encounter because gloves reduce sensation, impede human connection and do not provide significant benefits for noninvasive encounters. Medical grade N95 masks can be distributed at entrances to health care settings for those patients and staff members who are at high risk for severe COVID illness or who are risk averse.
For far too long, the single metric of COVID-19 positivity has dominated our approach to health care policies. Updating COVID-19 health care policies will free up hospital capacity, promote higher quality care by allowing providers to make rational personal protection choices, improve communication among providers, families and patients, and reinstate family members in settings where their presence makes an enormous difference to patients’ quality of life and care. Modern precautions to prevent the spread of HIV do not impede patient care and well-being, and we should not allow COVID-19 precautions to do so either.