Hospital return-to-work practices for healthcare providers infected with severe acute respiratory coronavirus virus 2 (SARS-CoV-2)

Abstract

A survey of academic medical-center hospital epidemiologists indicated substantial deviation from Centers for Disease Control and Prevention guidance regarding healthcare providers (HCPs) recovering from coronavirus disease 2019 (COVID-19) returning to work. Many hospitals continue to operate under contingency status and have HCPs return to work earlier than recommended.

Throughout the coronavirus disease 2019 (COVID-19) pandemic, minimizing the risk of transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) from healthcare providers (HCPs) to patients has been a priority. Most data indicate that for immunocompetent individuals infected with SARS-CoV-2, recovery of viable virus and risk of transmission from person to person is minimal by day 10 of illness. ^1,2

The Centers for Disease Control and Prevention (CDC) has issued guidance for HCP to return to work under normal and contingency (crisis) standards (Table 1). ^3,4 Briefly, under normal conditions, afebrile HCPs who had mild-to-moderate illness and have symptomatically improved can return to work after 10 days, or after 7 days with negative test(s). ³ HCPs with more severe illness or with underlying immunosuppression can return to work after isolation for 10 days to 20 days or after at least 2 negative tests at least 48 hours apart. ³ During surges of the COVID-19 pandemic, healthcare facilities instituted various measures to maintain staffing and essential functions. The CDC issued guidance (updated September 23, 2022) detailing strategies to mitigate HCP staffing shortages that included staff hiring and schedule changes, development of alternative care sites, cancellation of nonessential procedures, and allowing HCPs with SARS-CoV-2 infection to return to work earlier (Table 1). ⁴ We conducted a survey to evaluate current practice and potentially assist organizations in navigating changes in the return-to-work policy.

Table 1. Centers for Disease Control and Prevention Recommended Return-To-Work Practices for Healthcare Providers Infected With SARS-CoV-2 During Normal and Contingency Standards

Note. HCP, healthcare provider; RTW, return to work.

^a If antigen test used, should test on day 5 and again 48 h later.

Methods

From a previously established email-based list-serve of hospital epidemiologists, we invited 1 representative from each US-based nonfederal, acute–care hospital or health system to respond to a 50-question survey between March 1, 2023, and March 15, 2023. ⁵ The survey was formatted in Microsoft Office 365 (Microsoft, Redmond, WA), developed by iterative revisions by the authors, and explored rationale for hospital return-to-work practices (see the full survey in the Supplementary Materials online). Respondents could reply anonymously. The survey was considered a quality improvement protocol not requiring individual informed consent by the local institutional review board.

Results

Of the 44 hospital epidemiologists invited to participate, 25 completed the survey (response rate, 57%). Standard operations were in place at 11 hospitals (44%), whereas 14 respondents (56%) noted contingency status operations. Only 4 respondents (16%) noted that their hospitals were adhering to CDC recommendations for operation in noncontingency (noncrisis) status, whereas 21 (84%) related that they were not adherent to CDC return-to-work guidance. Of the 4 hospitals that reported adhering to CDC guidance under standard operations, concern for nosocomial transmission of SARS CoV-2 potentially associated with early return to work was cited as the chief reason for adherence. One institution related that it was under regulatory or legal requirement to adhere to CDC guidance. In the text comments, several respondents noted that other means to preserve staffing (eg, cancellation of elective procedures, reassignment of staff, etc) were not being done. No hospital reported operating under contingency (crisis) standards of care.

Return-to-work practices varied widely from institution to institution, and none of the facilities appeared to be strictly adherent to CDC guidance. Specific return-to-work practices are summarized in Table 2. Whether operating under contingency status or not, 88% of facilities allowed HCPs with asymptomatic or mild-to-moderate illness to return to work in 5–7 days, usually without a requirement for testing. Most facilities (64%) required HCPs to universally mask until completion of their isolation period. Most facilities (76%) did not require HCPs to change work practice (eg, avoid immunosuppressed patients) after returning to work. All facilities monitored for nosocomial transmission of SARS-CoV-2, and none noted transmission associated with HCPs returning to work. Although not specifically pertinent to the return-to-work policy, 10 facilities (40%) had universal masking policies in place, 14 (56%) required masks in selective settings, and mask use was optional in 1 facility (4%).

Table 2. Return-To-Work Practices in 25 US Hospitals and Healthcare Systems for Healthcare Providers Infected with SARS-CoV-2

Note. RTW, return to work; HCP, healthcare provider; PPE, personal protective equipment.

Discussion

Well into the fourth year of the COVID-19 pandemic, SARS-CoV-2 continues to cause substantial morbidity and mortality. Many hospitals and clinics are heavily populated with patients at increased risk of adverse outcomes due to advanced age or underlying comorbid conditions. ⁶ Therefore, particularly early in the pandemic, many institutions required HCPs with COVID-19 to avoid returning to work until testing negative for SARS-CoV-2 or completing a prolonged isolation period. Subsequently, hospitals adopted time-based return to work at 10 days. However, to maintain critical services during COVID-19 surges, most hospitals resorted to contingency (crisis) standards that allowed for earlier return to work. ⁴ More recently, as vaccination increased, treatment options improved, severe cases decreased, and national public health measures were relaxed, many HCPs and hospital administrators questioned the stringent return-to-work criteria.

Our survey demonstrated that hospital return-to-work practices vary widely and that most diverge from CDC guidance. Possible reasons for this divergence from recommendations are of great interest. First, despite the perception that the pandemic is over, hospitals remain under great stress regarding workforce, necessitating contingency procedures and early return to work for HCPs. Furthermore, healthcare facilities are under financial duress ⁷ and are unwilling to limit activities that are revenue generating (eg, cancellation of elective procedures) to alleviate staffing pressures. Second, despite data indicating that a substantial proportion of HCPs have high levels of viral shedding at day 5 of illness, there is a perception that transmissibility is limited. Most facilities, whether or not they are operating in contingency status, allow HCPs to return to work after 5 days of isolation. ⁸ The facts that data are limited and that questions continue concerning duration and significance of viral shedding and its correlation with transmissibility point to profound deficiencies in our ability to study critical questions and resolve important practical issues, particularly during times of national emergency. Third, there is belief that HCPs recovering from COVID-19 and who return to work early do not pose a risk for nosocomial transmission if they wear a mask or a N-95 respirator. The fact that we continue to debate the importance and effectiveness of respiratory personal protective equipment in preventing viral transmission at this stage of the pandemic indicates deficiencies in our investigative capacity. ⁹ However, analysis and study of these issues has been made more challenging by a “moving pandemic target” influenced by population immunity, emergence of viral variants, and shifting availability of resources such as testing capacity and drug and vaccine supply.

Our survey results have profound implications regarding the authority and credibility of public health agencies. Most academic medical centers and large health systems responding to our survey are not adhering to CDC guidance. Before the pandemic, this widespread nonadherence would not have been observed. The variability in practice may suggest a need for evidence-based, practical guidance and the need for public health agencies (ie, CDC), research-based agencies (ie, NIH, AHRQ, NSF, etc), and academia to partner and collaborate to answer pressing and practical questions in a timely manner.

Our study had several limitations. The survey was limited in sample size and was directed toward academic medical centers and large healthcare systems, thus limiting its generalizability. There was no independent validation of data. Although all respondents noted that nosocomial transmission of SARS CoV-2 was monitored, details regarding surveillance methods were not sought (eg, use of viral sequence data to ascertain patterns of transmission), and underdetection or underreporting is possible. Finally, this is a rapidly changing landscape and institutional practices are in constant evolution as facilities respond to changing conditions; thus, our results will be quickly outdated.

In conclusion, our findings indicate substantial deviation between CDC return-to-work guidance for HCPs with COVID-19 and points to profound issues of how we deal with ambiguity in times of outbreaks and pandemics.