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To the Editor:
As the COVID-19 pandemic continues to plague communities across the United States, healthcare institutions are attempting to balance the availability of frontline staff available to take care of COVID-19 patients.
Frontline staff (defined as those who may directly interact with patients) may fall into a “high-risk” category and need to be appropriately removed from taking direct care of COVID-19 patients. This includes persons aged 65 years and older, or those with underlying chronic lung disease, moderate to severe asthma, serious heart conditions, immunocompromised, severe obesity (more than 40 BMI), diabetes, chronic kidney disease undergoing dialysis, and liver disease.1 Other frontline staff may themselves become COVID-19 patients or be quarantined due to exposures in the workplace. In the state of Maryland, the governor issued a stay-at-home order on March 30, 2020 but included exceptions for employees of essential entities, including healthcare workers. Prior to the order, Johns Hopkins Medicine (JHM) had shifted to remote learning, adopted expansive telework policies, and decreased all but COVID-19-related and essential research functions.
For JHM employees who were categorized as essential, appropriate precautions such as personal protective equipment (PPE) where appropriate, altered schedules to minimize personal contact, and education on preventive hygiene and social distancing was occurring. JHM anticipated that employees categorized at “high-risk” would request work restrictions (accommodations) to minimize or avoid work around COVID-19. In total, there were 179 accommodation requests (about 1.5% of the employees) from March 13, 2020 to May 1, 2020 received at the main JHM institution in East Baltimore, the vast majority of which (95%) had clinical contact. The requests appeared in a bell-shaped epidemiological curve with the peak during the first week of April whereas the epidemic peak of COVID-19 cases in Maryland is projected to occur on April 20, 2020.2
The likelihood of filing a request increased with age and employment duration (years) as anticipated. However, other aspects were not anticipated. We found that there was disproportionate number of requests submitted by female employees (Rate Ratio 1.14 for females vs 0.53 for males compared with the JHM population). There were half of employees (50.9%) that did not mention an underlying “high-risk” medical risk factor as a reason for seeking an accommodation. In addition, accommodation requests earlier in the epidemic tended to have no underlying high-risk medical condition (Fig. 1), but rather concerns for COVID-19 infection risk itself, suggesting that the anxiety of contracting COVID-19 infection and the psychological impact of the pandemic might play a role in these accommodation requests.
Due to the rising number employees without underlying conditions seeking accommodations, JHM has established a new multidisciplinary committee comprised of occupational health, human resources, and legal counsel, to review all accommodation requests, with representatives from the Department of Hospital Epidemiology and Infection Control (HEIC) available for consultation if needed. The committee considers the employee's medical condition(s), work environment and responsibilities, workplace precautions including required use of PPEs, scientific evidence, and requested accommodation in order to provide greater standardization and apply best practices in assessing each request. This new process is intended to help improve the efficiency and streamline the evaluation of the increasing number of requests being received, while providing consistency.
The anxiety of contracting COVID-19 infection and the psychological impact of the pandemic among frontline staff has been discussed in the recent literature.3–8 It appears from our assessment of accommodation requests that healthcare workers require additional training to understand the true risk of exposure in a hospital environment where environmental controls (increased air exchanges, terminal cleaning, etc), universal PPE, symptom screening, Reverse transcription polymerase chain reaction testing are applied to reduce risk of exposure to minimal levels. This training should be a top priority of hospital leadership.
Our findings may carry implications as institutions begin to reopen since they provide quantifiable evidence of the fear of COVID-19 among clinical staff. As hospitals start to consider a return to normal operations, providing reassurance to all employees of a safe return to work will be paramount. This includes creating a clear strategy to hear, protect, prepare, support, and care for employees.3,6,7 In addition, leadership should provide regular transparent multimedia messaging on the actions that are being taken to protect the staff and their families, patients, and any visitors at the hospital.
1. CDC. People Who Are at Higher Risk for Severe Illness. Available at: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-higher-risk.html.
Accessed May 5, 2020.
3. Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA
2020; doi: 10.1001/jama.2020.3972.
4. Chen Q, Liang M, Li Y, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry
5. Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to Coronavirus Disease 2019. JAMA Netw Open
2020; 3:e203976doi: 10.1001/jamanetworkopen.2020.3976.
6. Santarone K, McKenney M, Elkbuli A. Preserving mental health and resilience in frontline healthcare workers during COVID-19. Am J Emerg Med
2020; doi: 10.1016/j.ajem.2020.04.030.
7. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA
2020; doi: 10.1001/jama.2020.5893.
8. Tsamakis K, Rizos E, Manolis AJ, et al. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med