My 2 cents on ending mask requirements in hospitals

People who follow my blog or follow me on Twitter will not be surprised that I disagree with the decisions made by some hospitals to end mask requirements in healthcare facilities. In fact, I previously wrote a blog piece as to why.

However, I also realize that health care leaders are dealing with very challenging situations and enormous pressures to end their requirements, especially when others in their service area end theirs. So, while I may not have agreed with the decisions, I certainly would have provided them with advice that might have helped them better formulate their new policies and communicate their decisions to the community. Perhaps lessons from some hospitals or health systems that have already announced their decisions might help those considering such a move.

Timing

When I ran a health system and had to make decisions that I knew were likely to upset some people (in other words, almost every decision I made), I always tried to understand why my decision might upset those people and how it might negatively impact them, so that I could consider whether I could come up with a solution that would mitigate that harm resulting from the decision. In this case, I suspect that many people would celebrate the end to masks, as they have already abandoned masks long ago, if they ever adopted them in the first place. So, who would potentially be negatively impacted by the decision and why?

Well, I can tell you from the people that I talk to who some of these people are – those who are at high risk and have therefore been doing all that they can to protect themselves and those who are not at high risk but are concerned about getting infected or getting infected again and potentially transmitting the infection to someone they love who is at high risk.

So, the first thing I would have advised is acknowledge these folks and their concerns. One concern many have is that their last booster was in September or October and they know that their protection is likely waning by now. It is widely anticipated that the FDA Commissioner and CDC Director may authorize another booster for these high-risk patients in roughly 1 week. Let me repeat that – one week.

It was a missed opportunity to not state something like: “Out of concern for the health and well-being of our most vulnerable patients, this new policy will not go into effect for two weeks (for example) to allow those who wish to be boosted an opportunity to do so before this new policy goes into effect. In fact, we will be offering vaccinations [at these locations and at these times with priority for those at high risk or scheduled hospital visits or procedures].”

I can tell you that I talk to immunocompromised patients all the time who seek out my advice. They have felt that society has abandoned them for the past three years, which is largely true, but they always felt that at least their health care providers would protect them. Nothing in the messaging I have seen from several organizations acknowledged these patients nor expressed concern for them. The statement above could have helped at least show a little sensitivity towards them.

Rationale

Be as transparent as you can be and if you can’t or won’t share the rationale, then tell the audience that; don’t provide an alternative rationale that is not true or accurate.

In every public statement I have seen, the rationale begins with a less than convincing argument or even misinformation, usually something to the effect of low community transmission rates, or a decline in community transmission rates or a “review of the latest COVID-19 data.” In each case, I have then looked up the community transmission levels in the locale of those hospitals and health systems, and to my surprise (to clarify, I am not surprised by the community transmission levels I saw, but by the fact that those organizations would characterize those transmission levels as low or as any justification that masks are no longer needed) the levels are not at all consistent with what the hospital or health system is offering as its rationale.

Now these are pretty sophisticated health care organizations. Its not like they don’t know how to interpret the data correctly. It generally would lead me to conclude that they either have other data or other reasons, but for some reason don’t want to be transparent about it. I think that is a mistake. First, if you use a rationale that is demonstrably false, you gaslight those who know better and you are losing credibility and trust. It is hard to regain either once lost.

This is particularly regrettable at a time when there are so many who are promoting misinformation and disinformation and convincing the public that they are knowledgeable experts. When those in the public who want to know the facts so that they can make their own health decisions don’t know who to trust, they have always been able to turn to their doctor and/or local hospital. If they can no longer trust their doctor and their hospital to give them the facts and truth, then I fear where they will turn to for their advice. Worse, those hospitals and health systems lose the high ground to call out other misinformation and disinformation being spread in their communities.

There have been many times when my leaders have not been able to agree to a recommendation on a challenging issue.  In those cases, I had to make the decision knowing that I would please some and disappoint others who I worked with everyday and greatly respected and cared for. Those are difficult decisions to make. But, in each case, I would acknowledge the different points of view, thank them for their input and then carefully explain my decision including my reasoning. Obviously, I would never know whether I reached the right decision for days, months or years, but in every case, those who were disappointed with my decision always knew that I carefully considered all the input and could at least understand my reasoning, even though they still might have reached a different conclusion were they the CEO.

Given what we have been through this past three years, I can understand that leaders may be reluctant to deliver what some will consider to be bad news. I would advise these leaders that reasonable people understand that difficult decisions have to be made, and they can accept those decisions better if leaders will treat them like reasonable people and tell them the reasons behind the decision and don’t insult them by misrepresenting the reasons or sugar-coating them. And, as for the unreasonable people, there is nothing you can tell them that will make them change their minds, so just focus on the reasonable people (who despite what you might conclude from social media, is still the majority of people).

Don’t throw in extraneous and irrelevant reasons in an attempt to buttress an already weak rationale.

Each of the public announcements or pronouncements I saw made reference to declines in other respiratory viruses, with one organization going so far as to pronounce an end to the flu season! As to the latter, again, why state something that is verifiably false? Although influenza transmission has declined significantly, this influenza season is not officially over and there are still more than one thousand people hospitalized in the US with influenza, so avoid stating things that will merely undercut your credibility. Either tell us your real reasoning, or tell us that you cannot share your reasoning with us, but don’t make stuff up.

Now, why do I say that you shouldn’t throw in the fact that other respiratory virus transmission has gone down to buttress your rationale for ending your mask requirement? Because now you have just told the public that respiratory virus transmission in the community is a material factor in deciding whether to require masks or whether to end masking. There is a new variant in the US that is causing serious problems in some other countries. If that variant does the same thing in the US in, say July (when the influenza season really will be over) and there are many patients being admitted to the hospital with COVID-19, staff are getting sick, the spread of COVID to hospitalized patients has increased and you now want to explain to the public why masks are being required, when asked why you are reinstating masks since there are very low levels of circulation of other respiratory viruses, do you now have to twist yourself in knots explaining why that really doesn’t matter after all? And, in November or December, when there is a large circulation of respiratory viruses, but no significant new surge from SARS-CoV-2, what is your reasoning then for not implementing a mask requirement, when a reporter or the public questions why low circulation of respiratory viruses is a reason for ending mask requirements, but high levels doesn’t seem to be a basis for implementing mask requirements?

Empathy

There seems to be a widespread deficiency of empathy. The public statements I have read have been short in length and lacking in any acknowledgement or consideration for those who will now be in fear for their safety in one of the few places they rely to keep them safe.

My advice would have been to acknowledge this fear and impact, especially when I see language in some statements such as “this has been a very thoroughly considered decision.” Maybe it was, but if you don’t address “the elephant in the room,” those who are in fear are not going to believe that it was thoroughly or carefully considered.

When you are taking something away (as some of those who are at high risk will perceive this), then tell them what you are doing to mitigate that loss or help make up for it as an acknowledgement that you know that this decision may be placing them at additional risk. For example, can you provide any reassurance that xx% of our patient care staff are fully vaccinated and up-to-date? Or can you state that only those who are can go maskless, but other staff who are not will continue to be required to mask (as is commonly done in handling influenza vaccinations)? Or can you state that all staff are screened for temperature and symptoms daily? Or is there still testing of all new admissions to the hospital? Is there any periodic testing of staff? Can you at least explain to the public what changes you have made in ventilation, filtration and/or air treatment? What about special accommodations for those who are at high risk? For example, can you provide a clinic or urgent care facility where you will keep masking in place that they can access for care? Can you offer high risk patients a separate waiting area that has high rates of air exchanges and HEPA filtering and where everyone in that room is required to wear masks? I think most of the immunocompromised and high-risk patients I talk to would see this as a sign that at least the health care facility cares about their health conditions and is trying to find a compromise to balance the competing interests of those who can’t wait to be rid of masks and those who feel that their lives may very well depend upon them.

In other words, the message solely conveying we are going mask optional is very different than we are ending the mask requirement, but at the same time, we understand that without masks, high risk patients will now be at higher risk in the hospital than in their homes, so we are making these additional accommodations for them. Empathy goes along way, even when you feel unable to fully address someone’s concerns.

For the love of God, please have someone who is not intimately involved in the decision read your statements and policy before you publish them.

I have been in this situation countless numbers of times. I have been working on some document very hard and very long, I have read it twenty times, and I think it makes perfect sense to me. The problem is that you have blinders on. Especially, when it is a big change, a change that you know is risky or a change that you know is going to upset some people. Then, I get my assistant to read it, my editor to read it, a board member to review it, or if it is not confidential or sensitive, I may have my wife read it. It is amazing how many times I thought I was saying one thing and the person took it the other way or they catch a glaring omission. Sometimes, they find that I wrote something stupid.

So, could that have helped these hospitals and health systems? Absolutely. What are some examples?

Amazingly, but probably because those who drafted these documents just assumed this to be the case, while all of these public documents mention that there will be some circumstances where masking will still be required (e.g., in a bone marrow transplant unit or in a long-term care facility), not one of them states that patients with probable or confirmed COVID-19 and their visitors and their caregivers will be required to mask! Of course, there are situations in which the patient cannot be masked, but this is an obvious concern to those who are at high risk who may have to receive care in a health care facility. Why not just come out and reassure these folks?

Here’s another example. One policy that I saw stated: “Symptomatic visitors are discouraged from visiting.” WHAT!?!?! So, someone is burning up with fever and having frequent coughing fits and you’re going to tell them, “We would discourage you from visiting, but ultimately, it’s your choice”?

One final point, since I think I have made my point. In one document I read explaining some of the areas of the hospital where masking will still be required, it stated something to the fact of “masks will still be required in our operating rooms,” at which point I sprayed the coffee in my mouth all over my laptop. Good heavens, while I was just beginning to try to come to grips with the idea that you aren’t going to require masks in a hospital, now you imply to me that you considered whether to continue wearing masks in the operating room!?!! I didn’t even realize that was a possibility until you pointed that out.

Be internally consistent

This is one of the most frequent problems I see when I review hospital policies. This was a flagrant problem with visitor policies early in the pandemic. As an example, many hospital policies would allow for a visitor with a laboring mother, but not with a patient who had undergone surgery and is still woozy from the anesthesia and pain medications.

What I now see is announcements that generally state something to the effect that “patient safety is our highest priority.” In one case, a health system offered the statement that: “Masks have been, and continue to be, an effective tool for preventing the spread of infections by respiratory route.” But, “we are ending our mask requirement!” What!?!? How does that make any sense when you just said nothing is more important than keeping your patients safe and masks are effective at doing so?

Anticipate questions from patients, families and the public.

• If a patient contracts COVID while in the hospital, will you tell the patient and their family?
• If a patient was exposed while in the hospital, e.g., a nurse caring for the patient yesterday is out sick today and tests positive for SARS-CoV-2, will you notify the patient and family?
• If a patient was exposed, will you do serial testing of the patient?
• Are you still quarantining infected staff members and isolating close contacts? Will staff returning to work after 5 days of isolation for COVID-19 still be required to mask for at least an additional 5 days or does mask optional apply to them as well?

• How will you know if your decision was wrong?

While there certainly may be real-life circumstances for making this decision, few experts in the field would be able to say that the decision is consistent with the science or evidence at present. So, what steps are you taking to monitor the impact of this decision and to identify quickly if the decision results in patient harm? Will you be tracking nosocomial COVID-19 before and after the decision and making that data available to the public? Will you report the outcomes of nosocomial SARS-CoV-2 infections? Will you be monitoring infections among especially vulnerable patients in the hospital and in the immediate period post-discharge, such as neonatal ICU patients, newborns, young children, pregnant women, etc.? Will you be monitoring infection rates among staff? What change in metrics would cause you to revert back to mask requirements?

Many people, like me, were experiencing shock and awe with these announcements. Being honest; being as transparent as you can be about the real rationale for the decisions, including sharing data where applicable; not trying to distract us with irrelevant and extraneous reasons for the decision; demonstrating empathy for those who will be negatively impacted by the decision, particularly if you can also offer some alternative measures that you can adopt to mitigate the potential harms resulting from the decision you are making; not overlooking the obvious; avoiding stating stupid things; and being internally consistent will make a huge difference in delivering a message that is going to be controversial and upsetting to some. An additional nice touch, especially when you can’t be sure that things might not get worse with your decision, is to simply acknowledge that, explain how you will monitor the situation to identify quickly if things are getting worse, and what you do in that event.