Many Hospitals May Regret Their Decision to Relax COVID Precautions

Those that read my blog, follow me on Twitter or listen to me on the radio will not be surprised that I have been critical of some hospitals making a decision to end masking and certain other COVID mitigation measures in hospitals during a pandemic with an airborne virus that has a much higher risk to patients who are infants or elderly, and even those who are not elderly, but have certain comorbidities or underlying states of immunocompromise – in other words, the very types of people that are admitted to hospitals.

Although I have many reasons for my criticism, two of the main reasons were (1) this feels like further abandonment of high-risk patients, especially those that are immunocompromised and (2) many of the communications about these decisions were very poorly done, illogical, or in some cases, based on demonstrably incorrect facts or assessments. In almost every case, even if the push to end these protections of staff and patients was just too hard for leaders to resist, there would have been much better ways that the change could have been implemented and communicated to help acknowledge and address the fears of many patients, like those who contact me on a regular basis for advice. I fear that this has further eroded trust in hospitals.

There are now two new studies that may cause some hospitals to reconsider their decisions, or at least regret those decisions to end most of their precautions. I have no doubt that more are coming.

One is a research letter that was published today in the Journal of the American Medical Association Internal Medicine: Discontinuation of Universal Admission Testing for SARS-CoV-2 and Hospital-Onset COVID-19 Infections in England and Scotland | Global Health | JAMA Internal Medicine | JAMA Network.

It has been a common practice in the U.S. and many other countries to test every patient admitted to the hospital for COVID during the pandemic, given that COVID may be the cause of their illness, but also because we know that people can be infected, but pre-symptomatic and contagious. This practice was to protect staff and other patients.

Many U.S. hospitals have stopped this routine testing recently; however, England and Scotland ended their requirement for hospitals to perform this routine testing on August 31 and September 28, 2022, respectively.  Researchers reviewed data from those countries before and after the change in routine testing (July 1, 2021, and December 16, 2022) to determine hospital-acquired cases of COVID-19 before and after routine testing ended, considering a patient to have acquired their infection from within the hospital if the patient first tested positive 7 or more days following hospital admission.

In Scotland, there was a 41% relative increase in hospital-acquired COVID cases following the end of routine patient testing and in England, there was a 26% relative increase in hospital-acquired COVID cases. In fact, in both cases, the rate of increase in in-hospital transmission of COVID exceeded the rate of increases in community transmission. This should not be surprising. Guess where people go when they are sick, including with COVID-19?

This study does not report on the outcomes of hospital-acquired COVID, but we know from other studies that the mortality rates for these patients far exceeds the case fatality rates among the general population, again, something that should not be surprising.

The other study of note examined the risk for Long COVID in health care workers in Brazil: Risk factors for long coronavirus disease 2019 (long COVID) among healthcare personnel, Brazil, 2020–2022 | Infection Control & Hospital Epidemiology | Cambridge Core.

This study looked at health care workers (HCWs) that worked in a health system in Brazil and experienced laboratory-confirmed, symptomatic COVID-19 between March 1, 2020 and July 15, 2022. Subjects were divided into study participants if they met the criteria for Long COVID using the CDC’s criteria or into the placebo group if infected, but they did not have Long COVID.

Shocking as to the magnitude, of 7,051 HCWs diagnosed with COVID-19, 1,933 (27.4%) developed long COVID. Let that sink in- during a time with many health care professional worker shortages, more than 27% of these HCWs developed Long COVID following their COVID infection. 51.8% of those with Long COVID had 3 or more symptoms. The authors noted that the risk of developing Long COVID increased if the worker had 2 or more infections (i.e., 1 or more reinfections). They also noted that those workers who had received at least 4 doses of COVID vaccine had significantly reduced chances of developing Long COVID following a breakthrough infection.  

During this pandemic, we have witnessed unprecedented increases in anti-science and antivax movements, significant disinformation campaigns, and unprecedented losses of trust in public health. Historically, hospitals have been sources of reliable and accurate health information and places where patients and their families have had a great deal of trust that when hospitalized, hospitals would help them and protect them from harm. In all my years of leading hospitals and health systems, I have always dedicated my efforts to enhancing quality and patient safety, including the safety of our employees.

Unfortunately, decisions by hospitals to broadly abandon infection control practices will statistically harm staff and patients if the results of these studies and others are applicable to American hospitals and health care workers. Unfortunately, I fear that the consequences will be severe – loss of trust and credibility, increased harms to patients, increased morbidities in the workforce with resultant loss in productivity and increase in employee health care and disability costs, increase in liability costs, among other things, and of course, all of this is likely to contribute to long-term increase in health care costs, the opposite of the direction that our health care delivery systems should be driving our country.