Emergency department personnel patient care-related COVID-19 risk

Abstract

Objectives: Emergency department (ED) health care personnel (HCP) are at risk of exposure to SARS-CoV-2. The objective of this study was to determine the attributable risk of SARS-CoV-2 infection from providing ED care, describe personal protective equipment use, and identify modifiable ED risk factors. We hypothesized that providing ED patient care increases the probability of acquiring SARS-CoV-2 infection.

Methods: We conducted a multicenter prospective cohort study of 1,673 ED physicians, advanced practice providers (APPs), nurses, and nonclinical staff at 20 U.S. centers over 20 weeks (May to December 2020; before vaccine availability) to detect a four-percentage point increased SARS-CoV-2 incidence among HCP related to direct patient care. Participants provided monthly nasal and serology specimens and weekly exposure and procedure information. We used multivariable regression and recursive partitioning to identify risk factors.

Results: Over 29,825 person-weeks, 75 participants (4.5%) acquired SARS-CoV-2 infection (31 were asymptomatic). Physicians/APPs (aOR 1.07; 95% CI 0.56-2.03) did not have higher risk of becoming infected compared to nonclinical staff, but nurses had a marginally increased risk (aOR 1.91; 95% CI 0.99-3.68). Over 99% of participants used CDC-recommended personal protective equipment (PPE), but PPE lapses occurred in 22.1% of person-weeks and 32.1% of SARS-CoV-2-infected patient intubations. The following factors were associated with infection: household SARS-CoV-2 exposure; hospital and community SARS-CoV-2 burden; community exposure; and mask non-use in public. SARS-CoV-2 intubation was not associated with infection (attributable risk fraction 13.8%; 95% CI -2.0-38.2%), and nor were PPE lapses.

Conclusions: Among unvaccinated U.S. ED HCP during the height of the pandemic, the risk of SARS-CoV-2 infection was similar in nonclinical staff and HCP engaged in direct patient care. Many identified risk factors were related to community exposures.

Fig 1. Screening and enrollment.

The final analysis cohort had 1,673 participants who contributed 29,825 person-weeks of observation. Baseline Positive COVID-19 was defined as a positive reverse-transcription polymerase chain reaction (RT-PCR) or a positive SARS-CoV-2 anti-nucleocapsid IgG antibody, and any HCP with a positive baseline test was withdrawn and replaced in the surveillance cohort. ED, emergency department; HCP, health care personnel; APP, advanced practice provider.

Fig 2. Occupational and community COVID-19 infection risk in emergency department health care personnel, United States, May–December 2020.

This graph shows the percentage of participant epochs with each of the a priori-defined risk factors. Risk factor definitions are summarized in S1 Table. CDC, Centers for Disease Control and Prevention, CDC; AGP, aerosol-generating procedures; PPE, personal protective equipment; HCP, health care personnel.

Fig 3. Adjusted COVID-19 infection risk in emergency department health care personnel stratified by job type and intubation, United States, May–December 2020.

These graphs show the unadjusted and adjusted attributable risk point estimates, and error bars show the upper and lower bounds of the 95% confidence intervals. Adjusted estimates account for household and community COVID-19 exposure, number of in-hospital COVID-19 cases, and community COVID-19 incidence. A. Risk of HCP COVID-19 infection shown within each of three job categories. B. Risk of HCP COVID-19 infection shown within categories of risk and intubation/cardiac arrest care risk assigned within each participant time-epoch. Note that risk was assigned at the epoch-level, so one participant may have contributed epochs in the intubation risk category when intubations were performed and in the non-intubation risk category when no intubations were performed. Not intubating represents the risk in epochs during which no intubation or cardiac arrest care was reported. Intubating, not COVID-19 represents the risk in epochs during which only non-COVID-19 intubations or cardiac arrest care was reported. For nurses, all intubation and cardiac arrest care is represented in this category since no stratification was performed. Intubating, COVID-19 represents risk in epochs during which any RT-PCR-confirmed COVID-19 patients had intubation or cardiac arrest care. APP, advanced practice provider. cases per 10,000 person-weeks, number of COVID-19 infections identified per 10,000 person-weeks of observation.