The U.S. is now providing over 2 million vaccines per day for COVID-19. Many are asking how or what do we unwind from our pandemic safeguards as vaccines are deployed. In this article from the infectious disease experts at ID Care (adapted from a more comprehensive white paper), we discuss the safeguards that have been put in place for health care systems and hospitals, as well as provide guidance on how to consider reducing some of those safeguards.
Evaluating pandemic safeguard processes
ID Care evaluated pandemic safeguard processes in the regional hospitals in which our infectious disease specialists provide care. These processes include ongoing testing, exposure protocols, strategies for quarantining, patient and staff vacation and travel policies, and the role and degree of personal protective equipment.
Many of these processes were mandated by either New Jersey’s governor through executive order or by rule from the Department of Health. Additionally, based on known methods of transmission, many hospitals implemented additional safeguards for staff and patient care to reduce risk during the pandemic. We then reviewed available evidence for the benefits of the safeguards and benefits of the vaccine to develop guidance on loosening the safeguards.
We examine the opportunities to “unwind” or adjust hospital processes from both perspectives.
Management of staff
Many process changes implemented for staff to mitigate COVID-19 risk have severely impacted workflow and routines, i.e., screening protocols on entry to the facility that may involve thermal screening and questionnaires, mealtime protocols, quarantine protocols on exposure or travel, limits on travel, testing requirements on exposure and modification to optimal PPE usage protocol. While more in-depth discussion of these processes can be found in our ID Care white paper, a few of our key findings include:
- There is little evidence that symptom or thermal screening effectively blocks infected persons from gaining entry to a hospital, since screening protocols short of testing are insensitive and ineffective at identifying people with mild, early or asymptomatic infection (Sars-cov-2 transmission among marine recruits during quarantine; New England Journal of Medicine, 2020). Further, fully vaccinated employees should be allowed to skip the line and enter the building without screening. Using a smart phone identification or an RFID embedded in an ID badge to notify a reader on entry could be easily developed to make the process efficient.
- Breaktime and mealtime are recognized as high-risk activities for transmission of COVID-19. As such, many systems put severe restrictions on them to limit social interaction. We believe that a facility can establish a mealtime routine that allows fully vaccinated individuals to enjoy meal and break time together without the use of masks. Recent CDC guidance on vaccinated individuals provides support for this approach.
- Mask wearing will still be required for the foreseeable future in health care facilities by both vaccinated and unvaccinated persons while caring for patients. The experience with widespread mask wearing and social distancing has resulted in dramatic reductions of other respiratory viruses including respiratory syncytial virus (RSV) and influenza (Weekly U.S. Influenza SURVEILLANCE Report, 2021). As a result, there are good public health reasons to continue this practice even outside the COVID-19 concerns.
Management of vaccinated patients
Several areas of process have likewise been altered related to patient care. This includes routine testing for admission to a hospital, testing of all patients prior to an operative procedure and limits on visitors of patients in the hospital. A number of these practices are no longer necessary, including routine testing of asymptomatic patients who have received both doses of the vaccine, testing for admission to a hospital and testing prior to elective procedures.
If a person is symptomatic, testing should proceed as clinically indicated. There may be a role for routine SARS CoV2 antibody testing on admission. There are many routine testing procedures for hospitalized patients including CBC and chemistry testing which acts as a baseline and as a warning for unexpected clinical disease, e.g., chronic renal failure. It also provides an opportunity to vaccinate a non-immune individual. Health systems should consider routine SARS CoV2 antibody testing on admission.
Visitation can be expanded to allow fully vaccinated persons to visit, upon showing proof of vaccination. The duration of immunity is unknown at this point, but based on the early results, is seems prudent to allow visitation for up to one year.
These concepts provide a summary framework for considering how to unwind our COVID-19 protection stance in the setting of widely available vaccination. Challenges to broad adoption come from the unknown, related to the novel nature of the infection and limited long-term information on vaccine risk, durability of immunity and risks posed by variants that continue to evolve.
Nonetheless, we need to move forward to modify our procedures based on what we do know to lead our communities in the unwinding process. The accumulating evidence indicates that the vaccine indeed will protect for serious illness and provide dramatic reductions in transmission. As a result, restrictions in place can be relaxed for vaccinated individuals. The time to act is now.
This content is adapted from a white paper authored by ID Care infectious disease experts Ronald G. Nahass, MD, MHCM, FIDSA, and Edward J. McManus, MD, FACP.
Nationally recognized for infectious disease specialty services, ID Care provides infectious disease care, wound care, infusion care and travel care across nine outpatient locations throughout New Jersey. It also serves hundreds of health care facilities throughout the state, providing vital care to ensure the health of health care workers and the patients they serve. If you have any questions on ID Care services or would like to consult with an expert on designing or implementing a customized program for your facility, please call 908-281-0221 or visit ID Care Partners today.