Calculating Return-to-Work COVID-19 Policies Is a Balancing Act for Hospitals

When it comes to staffing hospitals, public and private health care officials strive to reach a balance between the safety of HCPs and the ability of institutions to function properly, especially during COVID-19 surges. The issue came to the fore last December when the Centers for Disease Control and Prevention (CDC), with an eye on critical staffing shortages in the health care industry, which has lost about 20% of its workforce since the beginning of the COVID-19 pandemic, shortened the recommended isolation time for health care workers exposed to COVID-19 in high-risk situations from 10 to 7 days (Sharon Ward-Fore, MS, MT[ASCP], CIC, FAPIC, a member of the Infection Control Today® [ICT®] Editorial Advisory Board [EAB], clearly spelled out the dos and don’ts of the recommendations in a Q&A in January).

Recently, Infection Control Today® spoke with Graham M. Snyder, MD, MS, medical director for Infection Prevention and Hospital Epidemiology at University of Pittsburgh Medical Center, and associate professor, Division of Infectious Diseases at University of Pittsburgh School of Medicine about a study on this topic. Snyder was the lead author on the study titled “Health care personnel early return-to-work program after higher-risk SARS-CoV2 exposure: A learning health system quality improvement project,” published in the American Journal of Infection Control (AJIC). Snyder says, "In this quality improvement study, the lesson was in the learning."

National Nurses United, a union representing more than 175,000 members, immediately pushed back agaomst the study, arguing that the recommendation puts nurses on the front lines of the COVID-19 wars in jeopardy. And despite a recent minor uptick in hiring in the health care sector, hospitals and other health care facilities must still deal with staffing shortages.

Investigators with the University of Pittsburgh Medical Center wanted to see just what the effects of shortened quarantines might be. They concluded that HCPs can safely return to work (RTW) after 7 days of quarantine if they test negative for COVID-19 on days 5 to 7.

“To optimize employee health, patient safety, and health care capacity, extraordinary efforts are needed to address contingency and crisis planning to mitigate staffing shortages before the next wave of COVID-19 cases,” investigators reported in the study. “Implementing an HCP early RTW program is one strategy to increase staffing availability and therefore reduce burden of staffing shortages on the health care workforce, while maintaining a low risk of SARS-CoV-2 transmission.”

The observational study included HCP working at a 40-hospital integrated health care system in central Pennsylvania in which employees faced a higher risk of either workplace or non-household community exposure to COVID-19 in 4 or fewer days. HCPs could return to work 8 days after exposure “if they remained asymptomatic through day 7 with day 5-7 SARS-CoV-2 nucleic acid amplification test result negative,” the study states.

Investigators tracked 384 HCPs between January 4 and June 25, 2021, who followed the recommendations. Of the 384 participants, 333 (86.7%) remained asymptomatic. Of these, 323 (97%) tested negative and were thus eligible to return to work.

“Median day of early RTW was 8 (range 6-9, IQR 8-8),” the study states. “Mean days saved from missed work was 1.84 (SD 0.52). A total of 297 (92%) HCP did RTW ≤ 10 days from exposure and days saved from missed work was 546.48.”

Investigators note that COVID-19 may last for years, and Omicron might not be the last variant to emerge and challenge health care systems. The way those systems can meet future challenges will be to be as fully staffed as possible. The 10-day quarantine was established as a “conservative” way to manage risk of exposure to COVID-19, the study notes. While the CDC offers quarantine recommendations, many hospitals and other health care facilities will use different standards.

That’s a point made recently by Linda Spaulding, RN-BC, CIC, CHEC, CHOP, an infection prevention consultant and another ICT® EAB member, when she said that “if nurses are still sick at day 5, they shouldn’t be coming back to work yet. But they’re feeling pressure by their hospital to return to work because of the nursing shortage.”

Spaulding added that infection preventionists can’t provide much help to stressed nurses. “IPs can listen to the nursing staff but they’re pretty much powerless if the administration [of a hospital] is requiring them to return to work,” says Spaulding. “From what I hear from nurses, they’re going to try hard to take care of patients with COVID-19. But as soon as this surge is over, they’re going to leave nursing and if there’s another surge, we’re going to have even less staff than we have now.”

Investigators in the AJIC study state that the system they use builds in flexibility.

“We were able to flex the 7-day quarantine period in the program back to a 10-day quarantine period when staffing constraints eased and resume the 7-day early RTW program when the pandemic surged again,” the study states. “As a learning health system, we used these findings to inform new methods for Employee Health specimen collection, including a program for symptomatic self-testing with results typically available within 1 day.

Investigators concluded that "adaptability is critical in pandemic response, as is real-time evaluation of interventions like the early RTW program. Outcomes from this program were reviewed no less than weekly to ensure a safe work environment for HCP and safe patient care.”

Snyder also mentions in the interview that a new study is coming soon on how quickly HCWs can come back if they are sick and contagious. The investigators are looking at the HCWs returning as soon as 5 days.