May 27, 2020

Nationwide, cities and states are starting to lift stay-at-home orders put in place to stop the spread of Covid-19. Writing for the New Yorker, Atul Gawande outlines the five strategies his hospital, Mass General Brigham and Women's Hospital, has employed to limit transmission of the disease.

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'A drug cocktail'

Gawande writes that Mass General Brigham has 75,000 employees, which is more people than in 75% of U.S. counties. "In April, two-thirds of us were working on site," he writes. "Yet we've had few workplace transmissions."

The reason? A layered approach Gawande likens to "combination therapy—like a drug cocktail. … Skip one, and the treatment won't work. But when taken together, and taken seriously, they shut down the virus."

The 5 strategies for safely reopening

1. Consistent hygiene

Washing your hands "is essential to stopping the transfer of infectious droplets from surfaces to your nose, mouth, and eyes," Gawande writes, "But frequency makes a bigger difference than many realize."

For instance, he cites a study conducted at a military boot camp that found that requiring hand-washing five times a day reduced medical visits for respiratory infections by 45%. And still other research, on the SARS outbreak of 2002, found that washing hands more than 10 times each day reduced infection rate by at least 55%.

"The key … is, washing or sanitizing your hands every time you go into and out of a group environment, and every couple of hours while you're in it, plus disinfecting high-touch surfaces at least daily," Gawande writes. But he cautions that this step—while necessary—is, like all the others he outlines, not enough to stand alone; in fact, he cites research showing that "environmental transmission may account for as little as six percent of [C]ovid-19 infections."

2. Keeping physical distance

In addition to frequent handwashing, Gawande writes that Mass General Brigham has introduced rules to make sure staff and patients maintain physical distance from each other. For example, Mass General Brigham has asked people to maintain distance on escalators and waiting in line for elevators. Those elevators, which Gawande writes "used to carry more than 20," are now limited to four passengers at a time.

The hospital is also making all internal meetings, visits with patients, and team huddles virtual when possible. And when face-to-face encounters are unavoidable, the hospital relies on Plexiglas barriers and increased physical distance between work stations, he writes.

Spending less time around people who have Covid-19 can also reduce a person's risk of developing the disease, Gawande writes. "We don't know exactly how long is too long, but less than 15 minutes spent in the company of an infected person makes spread unlikely."

However, Gawande again cautions that distance alone is an insufficient barrier to infection. "It has now become well recognized that, under the right conditions of temperature, humidity, and air circulation, forceful coughing or sneezing can propel a cloudburst of respiratory droplets more than twenty feet," he writes, adding, "six feet was simply a choice guided by practicality."

3. Screening employees, patients, and visitors for Covid-19 daily

Mass General Brigham also mandates that everyone entering the hospital confirm they have no symptoms of Covid-19. For instance, as an employee, Gawande writes that he logs onto a website to confirm he doesn't have any Covid-19 symptoms. After doing so, "[a] green pass on my phone indicates no symptoms and grants me access to the hospital," he writes. "Otherwise, I can't work. In that case, the website directs me to call our occupational-health clinic and arrange for possible testing."

And while Gawande acknowledges that anyone could lie in self-screening for symptoms of Covid-19, that occurrence—at least at Mass General Brigham—has been minimal to nonexistent. "Through the first week of May, symptoms, often mild, prompted more than 11,000 staff members to stay home and receive testing," Gawande writes. "Fourteen hundred of them tested positive for SARS-CoV-2 and avoided infecting patients and colleagues."

Nonetheless, Gawande also points out that testing alone is insufficient—particularly for people infected with Covid-19, who are not showing symptoms.

4. Consistent wearing of masks

The delayed onset of symptoms is one reason Mass General Brigham adds another preventive measure to the mix: The hospital requires every employee to wear a disposable surgical mask. According to Gawande, a study published last month in Nature that found that, when worn properly and with the right fit, surgical masks can block 99% of respiratory droplets expelled by Covid-19 patients or those with influenza.

Even double-layered cotton masks, much like what many people make at home, have the ability to block respiratory emissions, Gawande writes. And in fact, according to Gawande, a review of research suggests if at least 60% of the population wore masks that were 60% effective at blocking respiratory emissions, the Covid-19 epidemic could be stopped.

But masks alone are an imperfect solution, Gawande explains. That's because supply cannot meet demand, especially for N95 masks, and people often wear poorly fitting masks or, because they cannot breath comfortably through cloth ones, move them under their nose or otherwise reduce their efficacy, he writes.

5. Change the culture

Ultimately, according to Gawande, since none of these preventive measures are perfectly effective in isolation, it's the fifth pillar—culture—that's perhaps the most critical, especially when trying to figure out how to implement Mass General Brigham's workplace regimen beyond the hospital walls. It's also perhaps the most difficult measure to address, because changing culture requires people care not only about their own safety, but the safety of others.

Recalling Mass General Brigham's ongoing efforts in this regard, he writes, "This requires absorbing detailed practices that keep us from transmitting germs in a given setting—like the rule at the operating table that, once you're scrubbed in, you never let your hands fall below your waist." He adds, "Even more, this requires developing norms about how to address lapses in rules, so you can comfortably call one another out when you see a standard slipping and still enjoy working together."

There is still a lot to learn about which practices are most effective at stemming the spread of the new coronavirus, Gawande writes. He notes, "The four pillars of our strategy—hygiene, distancing, screening, and masks—will not return us to normal life, but, when signs indicate that the virus is under control, they could get people out of their homes and moving again." He concludes, "[A]nswers will come only through commitment to abiding by new norms and measuring results, not through wishful thinking" (Gawande, New Yorker, 5/13; Dyrda, Becker's Hospital Review, 5/21).

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