Hospitals and health care workers are at the frontline of the fight against Covid-19. In recognition of this, citizens of countries like the United Kingdom and Italy have staged a weekly applause for doctors, nurses and carers. A report by the Data Evaluation and Learning for Viral Epidemics group (DELVE) of the Royal Society in the UK has found that these workers and institutions are particularly vulnerable when it comes to contracting Covid-19. They found that nine out of 10 health and care workers who caught the coronavirus contracted it at work and one in five patients hospitalised with Covid-19 had caught the virus while on a ward in a hospital. The data also suggested that health workers are six times more likely to contract Covid-19. The Wall Street Journal has identified the weak points in hospitals that the virus exploits and says the gaps leave hospitals âheavily reliant on personal protective equipmentâ. This knowledge of what other countries have experienced could help South Africa to ensure that hospitals do not become super-spreaders of Covid-19 or act as revolving door for the virus between hospitals and local communities. – Linda van Tilburg
Hospitals struggle to contain Covid-19 spread inside their walls
By Russell Gold and Melanie Evans | Photographs by Taylor Glascock for The Wall Street Journal
The University of Illinois Hospital in Chicago thought it was ready when the pandemic reached its emergency room in early March.
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Staff wearing protective gear whisked the first coronavirus patient into isolation, allowing the hospital to stay open for urgent operations. âWe have response plans in place to minimize any continued risk to patients, staff or students,â the university said in a campuswide letter.
Those plans were no match for the virus. Within a month and a half, three staff members â two nurses and an operating-room technician â died from Covid-19.
By mid-June, more than 260 of the hospitalâs nurses, clerical staff, custodians and technicians had tested positive for the coronavirus, nearly 7% of workers represented by unions. And then a fourth staff member died of Covid-19.
Itâs impossible to know how most of the people got infected. But it is likely the virus spread inside the nearly 500-bed hospital, Susan Bleasdale, its head of infection control, said in an interview. She said the hospital investigated staff deaths but declined to discuss the findings, citing privacy.
In the fight against the coronavirus, the nationâs hospitals are a refuge for the sickest. Yet despite their intensive efforts, hospitals also are a place where the virus sometimes spreads.
Nationwide, hospitals have identified 5,142 coronavirus infections apparently acquired inside hospitals from May 14 to June 21, according to figures provided to The Wall Street Journal by the Centers for Disease Control and Prevention. The figure could be higher; the reporting is voluntary.
Those are just cases in patients. The CDC hasnât publicly reported in-house infection of the staffs of hospitals.
University of Illinois Hospital declined to say how many patient infections it thinks were transmitted internally.
Although a small fraction of all cases, coronavirus infections spread inside hospitals pose an obstacle to the institutionsâ ability to fully reopen and persuade people theyâre safeâa step eventually needed both for public health and for hospitalsâ finances.
Hospitals try to prevent the spread of disease inside their walls on several fronts. They have protocols to isolate infected patients, buildings engineered to reduce viral spread, teams to monitor for outbreaks and multiple grades of protective gear. The virus has exploited weaknesses in each defense, according to interviews with doctors, nurses, respiratory therapists and infection-prevention specialists at two dozen hospitals around the country.
Buildings with limited space for isolation force hospitals to re-engineer on the fly. Monitoring is frustrated by the coronavirusâs ability to incubate for up to two weeks, and to pass silently from infected people who have no symptoms. Limited and inaccurate tests meant hospitals were at times unable to identify contagious patients.
All these gaps have left hospitals heavily reliant on personal protective equipment, which for months wasnât available in sufficient quantity and is still being rationed by many hospitals.
At many medical centers, including University of Illinois Hospital, the strategy from the pandemicâs outset was to cleave into two parts, one for Covid-19 patients and one for everyone else.
The CDC recommended physical separation and also having a dedicated coronavirus staff. That has proved harder to do.
University of Illinois Hospital, while separating Covid-19 patients from others, allows physicians, nurses, technicians and custodial staff to float in and out of Covid-care zones, employees said. Nurses from both sections of the hospital change in shared locker rooms before and after shifts. A spokeswoman for the hospital said it tried to have a dedicated staff for Covid units but didnât dispute that some personnel floated from a Covid unit to a non-Covid one.
Dr. Bleasdale told others as early as the end of March that the virus seemed to be spreading inside University of Illinois Hospital. In an email to infection-control doctors around the country, she wrote: âWe have gone to universal masking and not due to pressure but due to nosocomial transmissionââmeaning spread inside a hospital.
âI have staff who are coming to work ill that are not identified and then I have sick staff and patients,â her email said.
The hospitalâs small infection-control staff, whose job is to determine the route of disease transmission and trace contacts, was quickly overwhelmed by the number of employees who got sick. Although the CDC said hospitals stretched thin should forgo this time-consuming task, Dr. Bleasdale added temporary staff members to do contract tracing.
The need to scan paper case records into computers hobbled the effort. New software eventually helped, but the push to trace viral exposure in employees didnât fully get going until around April 20, according to employees. By then, several staff members were infected with the coronavirus and potentially spreading it inside the facility.
One was Joyce Pacubas-Le Blanc, a 53-year-old nurse on the night shift in the sixth-floor neurosurgical unit.
Also on the sixth floor, the hospital converted a medical-surgical unit to Covid-19 care.
People who worked with the Covid unitâs patients received some of the hospitalâs limited supply of N95 respirator masks. Across the floor, neurosurgery staff members wore less-protective surgical masks.
Ms. Pacubas-Le Blanc died on April 23.
PHOTO: EILEEN FAJARDO-FURLIN
âEveryone has asked, âHow could this have happened?ââ said Bhumika Puklin, a nurse who worked with her. âWe are the clean unit. She didnât float to the Covid unit.â
Ms. Puklin, like others on the staff, said she didnât hear about infected and hospitalized coworkers from hospital administration. Word passed on social media and the work floor, they said.
The hospitalâs Dr. Bleasdale said when officials become aware of an employee testing positive, they notify those who work with the person if needed. Coworkers are notified if they are âin contact with the COVID-positive individual while they were symptomatic,â she said. She said that practice began with the hospitalâs first Covid-19 case.
Ms. Pacubas-Le Blanc could have become infected outside of the hospital. Wherever she got it, she could have spread it at work before developing symptoms.
Four days after Ms. Pacubas-Le Blancâs death, Juan Martinez died. He was an operating-room technician on the third floor, preparing trays of surgical tools.
Mr. Martinez, 60, often ate lunch with Maria Lopez, a nurse who worked in the third-floor operating unit.
Ms. Lopez had returned to work in early April after knee surgery, and she came home upset that she was mingling with nurses from emergency-room and intensive-care units who treated coronavirus patients.
âShe was still in the same areas, breathing the same air. She was pretty pissed off about that,â said her daughter, also named Maria Lopez.
A little more than a week after returning to work, the 63-year-old developed a slight cough and a raspy voice. She went to work, then to the occupational-health department for a test; it came back positive.
Her symptoms quickly worsened. She died of Covid-19 on May 4, seven days after her friend Mr. Martinez.
The younger Ms. Lopez said her mother was vigilant about hand washing, wore a mask when buying groceries and stayed home as much as possible.
Six weeks after this cluster of deaths, another hospital employee died of Covid-19: Phlebotomist Edward Starling, age 61, on June 17.
Some hospitals have made extensive efforts to trace viral exposure among their employees. Others say infections are so widespread it doesnât make sense to commit the resources.
âContact tracing is pretty difficult because there are so many people with Covid,â said Michele Saysana, chief quality and safety officer of Indiana University Health in Indianapolis, at which she said about 460 of 35,000 employees have tested positive. The hospital is increasing its testing capacity.
Frustration with infection-control practices has boiled up in several hospitals. In Los Angeles, a doctor at Ronald Reagan UCLA Medical Center told leaders of UCLA Health, of which it is a part, that an intern working with heart patients tested positive and other workers reported symptoms not long after. âInfection control did not get involved at all in identifying contacts, undermining faith in the system,â said the doctorâs email.
UCLA Health didnât comment on whether the infection-control team was involved in tracing. It said there was no evidence the virus spread and staffers in close contact with the intern ultimately tested negative. UCLA declined to say how many employees tested positive or how many patients had apparent in-house infections, if any.
Pinning down hospital-acquired infections is difficult because of the time the virus can incubate before symptoms appear. To be certain an infection occurred in a hospital, the federal government asks hospitals to report only infections appearing in patients who had been hospitalized for two weeks or more.
Such a standard means âyouâre going to miss a vast majority of hospital-acquired infections,â said Ashish Jha, director of the Harvard Global Health Institute.One hospital system, Legacy Health in Portland, Ore., investigates infections in patients who have been there only four days, said an official of the hospital system. It said it hadnât identified any patients infected in the hospital. It said three of its employees became ill after exposure on the job.Juan Martinez Jr., a surgery technician at University of Illinois Hospital in Chicago, survived Covid-19. His father, surgery technician Juan Martinez Sr., died of virus there.
Hospitals typically have at least one room outfitted with ventilation that pulls in air, known as negative pressure, to keep germs from wafting into hallways. With Covid-19 patients, the CDC recommended negative-pressure rooms for those needing procedures that aerosolize the virus, such as intubation.
Some hospitals raced to add more negative-pressure space, using plywood, duct tape, temporary walls and portable fans and filters. Others reconfigured ventilation on certain hospital floors, or re-engineered whole buildings.
Researchers at University of Nebraska Medical Center found the coronavirus in hallway air outside negative-pressure Covid-19 rooms. The Omaha hospital revamped its ventilation system to protect people in hallways by creating negative air flow there, too. It has identified four employees and one patient who likely became infected in the hospital.
In recent weeks, many hospitals have moved to resume procedures they postponed in March and April, launching advertising campaigns to let patients know the hospitals are open and safe. Delayed treatment is a risk, and patients shouldnât be afraid of emergency rooms, their executives say.
Hospitals are creating Covid-designated clinics to isolate infected patients when possible. They are screening anyone entering buildings and have stepped up cleaning efforts for the return of uninfected patients.
Said Dr. Richard Fogel, chief clinical officer of hospital system Ascension: âWe need to be in a heightened state of readiness.â
Write to Russell Gold at [email protected] and Melanie Evans at [email protected]
