Public health specialists explain how well she mitigated risk for herself, her patients, and her family

Wouldn’t it be nice, as you go about your confusing, nerve-wracking, coronavirus-avoiding days, to have an epidemiologist on call to answer your many questions? Consider the Covid Audit the next best thing. This project, a collaboration between Elemental and the Epidemiology Covid-19 Response Corps at the Boston University School of Public Health, asks real people to keep a diary about what they’re doing to avoid Covid-19 and gives friendly feedback from the Response Corps team on actions you can take to support public health — and your own. This week’s reviewers are response corps members Sarah Lincoln and Ivanna Rocha, graduate students in the Master of Public Health program at BU, under the supervision of Eleanor Murray, ScD, assistant professor of epidemiology at BU.

Our diarist is a nurse manager on an acute psychiatric unit at a hospital in Missouri. She lives with her husband — a chef who recently returned to work at an upscale restaurant — and her 13-year-old daughter. “This entire time was and continues to be incredibly stressful for my husband and me,” she says. With her husband furloughed for nearly eight months, “I was anxiously working a ton of overtime in a place where everyone was basically holding their breath waiting for the worst of a pandemic to come crashing down at any moment. Oh, and did I mention we were newlyweds when all of this happened too? It’s really been a hell of a year.” She kept a diary for a few days late in 2020, describing the precautions she took at home and at work.

Day one, 3 p.m.

I wake up around 3 p.m. To be clear, I work 12-hour overnight shifts as a nurse manager on an inpatient psychiatric unit within a hospital, so my day starts later than most. Despite waking in the afternoon, I still complete typical morning tasks like making coffee and putting on some scrubs fresh out of the dryer.

As a rule of thumb, once in my scrubs I avoid being in public because these days my boring navy blue uniform attracts stares. And I get it, the average person is anxious enough about the state of the world in general without me making everyone wonder how infectious I might be. Also, trust me when I say I’m genuinely concerned about bringing anything the public might have onto my units.

Ivanna Rocha: It’s unfortunate that this stigma has fallen over health care workers in some areas. The diarist is right to be concerned about possibly bringing anything into her units. The SARS-CoV-2 virus, which causes Covid-19, does not survive very long on soft surfaces like fabric, but Covid isn’t the only thing that could be brought into (or taken out of) a hospital environment. Only wearing scrubs inside the hospital can be a good infection control practice in general.

I work on a psychiatric unit, where patients spend most of their time sharing space in a large, open dayroom — and may not have the insight to socially distance. Plus, if Covid-19 cases do arise, we don’t have the capacity for medical interventions like in-room oxygen therapy. This means that making a concerted effort to come into the units clean is paramount. So instead of running errands or grabbing an early dinner like I might have in the past, I hang out around the house letting my teenage daughter force me to watch TikToks I don’t understand until I leave for work.

Sarah Lincoln: By choosing not to run errands or go out for an early dinner, she is minimizing her contact with other people and essentially decreasing her risk of getting infected. This is a great way for anyone to decrease their overall risk of exposure. We can think of this process like making a “contact budget.” Similar to how a financial budget works, a contact budget is a limit of the number of people you come in contact with based on how much risk you can “afford.” If you’ve “spent” all your contacts that you’ve budgeted for in a given period of time, stay home! As a nurse, the total number of contacts the diarist can “afford” is relatively low, and the number of contacts she “spends” at work uses up most of her budget.

It’s also worth noting that although the diarist takes great care to limit contact and exposure for herself so as to avoid infecting others, she is still living in a household with other people who have relatively high contacts. It may be worth discussing as a family whether there are ways for her daughter or husband to lower their contact budgets. Reducing the overall level of contacts for their household could allow the diarist to feel more comfortable running errands.

Day one, 6 p.m.

Once I arrive at work, as dictated by procedure, I put on my level three mask and protective eyewear while still in my car. After gearing up, I head into my building, immediately take my temperature, and then log that temperature into an online tracking document.

This screening tool is an enormous Google Document where every staff member attests that they are without Covid signs and symptoms and then records their temperature so that members of leadership can track trends in real time. Also, worst-case scenario, if I’m reviewing the screening log as folks are coming in and I catch a staff member who is febrile, I can send them off the unit immediately. Ideally, I can get them back in their car even before they make contact with patients. In a perfect world, this keeps staff who have symptoms consistent with Covid from being around peers and patients, even if they do manage to make it into the building.

Ivanna Rocha: This is interesting; why are they screening people after they have already entered the building? Especially considering how the screening tool is online and can be submitted remotely, it would make more sense for the hospital staff to take their temperature and log their symptoms at home or in their car before they got inside at all. It’s good that they seem to have a broad symptom checklist though because fever does not always present in symptomatic cases. Relying on just temperature checks is not specific enough and can potentially miss symptomatic cases that don’t have fever.

After all the screening and masking, I head into a nursing shift report meeting where all the staff present are wearing PPE and have stated they are asymptomatic. Even with the measures each person was asked to take upon arriving to the building, during nursing report, there are still roughly seven staff in a room together with the door closed due to patient privacy concerns. This is unfortunately normal practice and was the subject of much consideration at the beginning of the pandemic. The option we settled on was changing the location of shift report to a much bigger room than the one in which it was held previously.

Report lasted half an hour and then we got started with direct patient care which was uneventful and required a ton of hand-washing. Additional steps taken on the units to prevent transmission between staff include staggering break times so that only one staff is in the breakroom at a time and spreading nursing staff out in the nurses station.

Ivanna Rocha: These precautions all make perfect sense to adapt distancing recommendations in a setting that is necessarily indoors. There’s no way to effectively hold meetings outside of the hospital, so moving to a large room while still wearing masks does well to compensate for that. Keeping a single staff member in break rooms at any given time also makes perfect sense. While it may seem lonely, most transmission from within hospitals has come from break rooms. Health care workers wear PPE to protect themselves and patients in units halls, but would let their guard down during breaks, where co-workers mutually place each other at risk due to close proximity and lack of masks.

Day two, 6 a.m.

After my shift ends, I leave the hospital still wearing my PPE and head to my car where I take off my mask and eyewear. Typically, I make sure to leave those items in the car along with my work bag, badge, and unit keys, rather than letting any of them touch my countertops or even the inside of my purse.

After I unload my face and pockets, I drive straight home, again without stopping anywhere. When I arrive at home I take off my shoes and sanitize my hands at the door before I go inside. I strip off my scrubs upon entering the house (you’re welcome, neighbors) and change into sleepwear. Once I manage to rid my body of anything I decide is “gross,” I wash my face and hands, brush my teeth, and climb into bed.

When Covid first started, I was taking off my scrubs immediately inside the door, putting them in a trash bag, and walking straight into a hot shower before moving around the house. After we started requiring every patient to have a negative Covid swab prior to being admitted to the unit I relaxed a little and gave my dry skin a break from the constant hot showers. Unfortunately, I’ve started thinking I may need to reconsider that stance thanks to the current surge of Covid in the Midwest. Mostly because I’m concerned now that asymptomatic staff are the ones I need to start worrying about.

Sarah Lincoln: The diarist seems to maintain a reasonable balance of precautions here. If she chooses to go back to the constant showering, I want to note that the temperature of the water is not the key component of the washing. The key here is really the soap and water together which lifts and removes germs. Using lukewarm water to shower or wash hands is just as effective at removing germs and can be less irritating to the skin.

Even though my odds of coming in contact with a Covid patient are higher than my husband’s in his work at the restaurant, I think my job is almost safer than his because I’m aware of a person’s Covid status and my facility has worked hard developing protocols and acquiring PPE for staff coming in contact with Covid patients. Also, since many restaurants don’t offer PTO and the culture is very much one that looks down on calling in to work, it’s not uncommon for restaurant staff to work sick. Which makes sense when you consider the crushing pressure that comes with not feeling like you have the option of being sick because you can’t afford to feed your family if you’re not at the tableside making cash tips from your guests who may very well also be sick.

Many restaurant owners and staff have become outspoken advocates for loosening the few, small restrictions we have here in our area in hopes that their business would increase if they didn’t have to require masks and could seat more diners. It’s been incredibly heartbreaking and incongruous for me to see the news features and social media posts of restaurant workers who I care about and am fully aware are just trying their best to save their life’s work when I know that what they’re asking could lead to the death of more people.

Ivanna Rocha: I agree with the diarist’s opinion of her work being safer than her husband’s. It’s true that she works in a setting that does have more Covid-19 patients. People who are infected get treatment at a hospital after all. However, her job requires PPE use, screenings, and precautions, and her unit does not focus on Covid-19 care. Her husband works in a restaurant whose managers are free to choose whether or not PPE is required of their staff; how many customers to serve at any one time, and whether they need to have masks on; whether tables are set close together or far apart. For a restaurant that chooses to seat patrons, there’s always a risk of wait staff coming in contact with the virus from customers, who then come in contact with kitchen staff. Her husband lacks any real control over the safety of his situation other than his own choice to follow recommended precautions. The same can be said for grocery cashiers, retail workers, public transit workers, teachers, and so on.

Day two, 12 p.m.

It’s Monday, so my daughter needs a ride to her junior high school. She’s enrolled in her school’s hybrid learning model, so she completes online work most days of the week and goes to in-person classes on Monday and Thursday.

Since my husband and I work outside the home, I worry that my kid will be the student who shows up to school bringing pestilence with her. I can see her walking the hallways like a Gen Z version of one of the Four Horsemen of the Apocalypse except there’s no horse, just anxiety and Ariana Grande perfume and scrunchies. But despite my frontline staff-associated guilt and fears, like a lot of parents I’m also concerned about what this period of strange but necessary isolation may be doing to kids who are in highly social stages of their development.

My daughter is an only child who can’t go a few hours without talking to her friends. With all that’s at stake, I can’t decide if the most selfish thing to do is send her to school two days a week where she could be an asymptomatic vector of disease, or to expect a precocious teenage girl to hang out in her room completely alone for over a year while she tries to passively learn iambic pentameter and atomic bonds from a computer screen.

Sarah Lincoln: I don’t think it’s selfish at all. Isolation is a very real problem for childhood development right now, especially for very small children. I think it’s important for the diarist’s daughter to be able to have some in-person interaction. That being said, there is a middle ground between spending two days at school every week and completely isolating in her room indefinitely. If she opted out of in-person schooling, she could probably “afford” the contacts involved in regular meetups with a small group of friends, which would likely have less interaction and risk than being at a school with large groups of other people.

Ivanna Rocha: I would be more concerned about the possibility of her daughter bringing in the virus home from her peers than of her taking it with her to school. The diarist and her family have clearly been very conscious of their choices and take every opportunity to reduce their risk to the best of their ability. Though this is true, there’s no telling what choices the families of other students are making, and what exposures other children who interact with her daughter have had.

Day three, 2 p.m.

I head to the hospital, this time as a patient at the dermatology clinic. As required, I come to my appointment wearing a mask and unaccompanied by any visitors. Once I hit the door I have my temperature taken, answer questions about signs and symptoms, and sanitize my papery hands.

The nurse completing the screening also asks me which clinic is expecting me, then slaps a name tag labeled with my desired location on my shirt. This additional step was added in June once our outpatient offices reopened. This labeling of patients with the name of their intended destination is meant to discourage folks from wandering and indicate to staff that the individual is meant to be in the building.

Checking in every patient at the door has also been important because we have a high homeless population in our area, and prior to the pandemic, it wasn’t uncommon for folks experiencing housing instability to (understandably) come hang out in the hospital to get out of the weather and use the facilities. Since it’s no longer safe for them in the buildings with the influx of Covid patients at the hospital, we’ve had to work closely with the local homeless coalition to find better options for this population. Our organization even teamed up with the city and other groups in the community to rent out an entire motel where Covid-positive patients who are housing insecure can stay while they heal rather than asking them to return to crowded shelters and camps. I like this fact and it makes me feel hopeful. So that, even when I feel like working in health care during a global pandemic is burning me out, thinking about our patients tucked away safe makes me feel like maybe most folks are trying their best.

But none of that has anything to do with my dermatology appointment which only lasted 15 minutes and was wildly uneventful. I returned home immediately after my appointment since I felt like I had been out in the wild too long and a trip to the pharmacy for skin cream would have been pushing my luck.

Day four, 6 p.m.

I arrive at work on Wednesday and start the shift just as I had on Sunday. That is until around 8 p.m. when nursing staff start completing the first round of four-hour vital signs and a patient is found to have symptoms consistent with Covid.

I immediately call the house supervisor (the nurse leader in charge of coordinating all the beds and staff in the hospital) to have the patient transferred to the emergency department. Unlike on our big, open unit with adjoining rooms, in the ED our patient could quickly be isolated to a room equipped with the appropriate medical devices for his developing situation. Don’t get me wrong, our unit does a lot of really good work with psychiatric patients in mental health crises, but art therapy isn’t going to do much for someone with a blood pressure that is quickly headed into the toilet.

Once the patient is safely off the unit I make easily 20 phone calls and activate a safety response at the administrative level. Once everyone above me on the pay scale has been paged and woken up I begin contract tracing patients and staff who had been at work over the last several days. The unit is also closed to any further admissions while we assess the potential for staff and patient exposure. We encourage patients to relax and journal in their rooms until further notice and nursing staff spend the rest of the night wiping down everything in sight.

Over the next several days, patients and staff are all Covid tested. Staff are required to retest seven days after the result of their initial swab. Occupational health also calls all the staff at home to screen them for symptoms and anyone with even the vaguest of symptoms is taken off the schedule and told to quarantine until the result of their Covid swabs comes back. The units are systematically cleaned with UV lights during this time and the specific unit that the symptomatic patient was admitted to is closed to admissions for a week. We hope that this would allow for the discharge of patients and subsequent deep cleaning of the rooms they vacated. Thankfully, the situation turns out as well as I could have hoped and all other patients are found to be negative. But I really don’t care to ever do it again.

Ivanna Rocha: The diarist’s team had a quick and appropriate response to a Covid patient appearing in their unit. There are a couple things to note that may have been performed better though. The team seems to have tested for Covid very soon after the initial exposure. The best time to detect an active infection is five to six days after initial exposure. Exposed individuals should then be follow-up with for symptoms and retesting up to 14 days after exposure. It’s also not clear if the patients were retested the same way staff were; they should be considered for close follow-up as well.

Sarah Lincoln: The diarist is obviously very invested in protecting others, but it doesn’t seem like she has much time to take care of herself. Her dedication to caring for others does not go unnoticed! I can’t even begin to imagine the amount of pressure she is under during this time as a health care worker. The rest of us need to do a better job of doing our part to stay healthy to lessen the burden on health care workers by continuing to stay home, socially distance, and wear a mask.

Update: Vaccination week

We caught up with the diarist after vaccines began rolling out to health care workers in her state. Here’s what she had to say.

I got my first round of Covid vaccine earlier this week! Since our patients are such a vulnerable population we were one of the first hospitals in my area to get the Pfizer vaccine. The first day it was available the nursing staff and providers on the designated Covid units went to get theirs and there was a lot of excitement. The next day the rest of us frontline staff had the option to go get vaccinated and I went first thing in the morning.

To put anyone who’s nervous at ease, it feels just like a flu shot — if not even a little less of a sting — and I’ve had no complications at all. Some nurses did joke that if there was a serious complication they hoped it would cause them to grow an extra arm or two so they could keep up during busy shifts a little easier. Otherwise, our attitudes are positive and it feels like a light at the end of the tunnel.