By Marie Rosenthal, MS

The same rules that apply to everyone else outside a hospital—hand hygiene, not touching the face, wiping surfaces and social distancing—should apply on the wards, but wearing personal protective equipment (PPE) properly is paramount, according to experts.

Most health care workers effectively wear goggles, a mask, a gown and gloves inside the room of a patient with COVID-19, but they may not be as diligent about their PPE and hand hygiene outside the patient rooms.

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Yet, COVID-19 is likely to be on many surfaces throughout the ward, not just in the patient rooms. “One reason why our health care workers are going to get sick is that they’re not paying attention to the fact that this virus lives for hours on surfaces,” said James A. McKinnell, MD, an infectious disease specialist at Harbor-UCLA Medical Center in Los Angeles.

Consistent and proper handwashing is more important now than ever because it is a main vehicle of transmission. “Some of our health care workers are lax about hand hygiene,” Dr. McKinnell admitted.

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“We have a behavioral issue here where health care providers think they know how to wash their hands. They think they know how to use hand sanitizer, and they think they know how to use PPE. And I would challenge all of those assumptions,” agreed Gregory A. Poland, MD, MACP, FIDSA, FRCP (London), the Mary Lowell Leary Emeritus Professor of Medicine, Infectious Diseases, and Molecular Pharmacology and Experimental Therapeutics and a distinguished investigator of Mayo Clinic in Rochester, Minn. (Click here to watch Dr. Poland teach Jimmy Kimmel how to wash his hands.)

You Are What You Wear
The face mask is particularly problematic. Paper medical masks are meant to be used once and thrown away when leaving a patient’s room, but with the shortage of equipment, people are wearing them all day. 

Virus concentrates on the outside of the mask, explained Dr. McKinnell, who is also an assistant professor of medicine at the David Geffen School of Medicine at UCLA and an investigator at the Lundquist Institute.

They pull it down over their chin to talk, to drink, because they cloud their glasses or just because they are uncomfortable, and once they do, they contaminate their fingers with a highly concentrated virus. 

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Then they walk over to the keyboard to check the electronic health record, make notes or order medication, and they have contaminated the keyboard. Any surface they touch—door knobs, desks, counters, their phones—can become contaminated by SARS-CoV-2 after they touch their face masks, even if they are wearing gloves.

In addition, they’ve broken the barrier, and now the virus is on their scrubs or chin, as well as their fingers, and if they touch their face, they can self-inoculate with SARS-CoV-2.

“You see pictures of people walking around with a surgical mask where the top strap has been untied. And the mask is dangling over their chest. Well, that’s not proper mask technique and doffing at all,” said Dr. Poland, who is also the director of the Mayo Clinic’s Vaccine Research Group.

After a while, they forget where that mask has been. It’s not too surprising, especially right now. Health care workers are under a lot of stress and fatigue because of COVID-19.

“I think they know how to don their equipment, but doffing is a real problem, and the more tired you get the more mistakes you can make in doffing,” Dr. Poland said.

For people who have to brown-bag their masks and reuse them, many hospitals are offering sterilizing options, such as placing them under UV lights. At a minimum, handwashing after the mask is put away should be done. Dr. Poland said one problem with reusing a mask is that perspiration and moisture from the wearer’s breath reduce the efficacy of the mask.

Leave Your Face Alone
Dr. McKinnell said if a health care worker is going to wear a mask all day, leave it in place, and really important, each person should be very conscious about touching his or her face. 

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Most people touch their faces frequently throughout the day, and medical personnel are no exception. One observational study of medical students at the University of New South Wales, in Australia, found that on average students touched their face about 23 times per hour—that’s hundreds of times during a shift. About 44% of the time, they touched their mouth, nose or eye (Am J Infect Control 2015;43[2]:112-114).

Since it is an unconscious habit, it is very difficult to break, but everyone who works in a hospital must make it a conscious act and be very aware of where they put their hands, according to Dr. McKinnell. His personal rule right now is, “I do not raise my hands above my shirt collar or below my belt without washing my hands.”

One way to protect yourself from COVID-19 is to remember how SARS-CoV-2 is spread. Many people are worried about airborne transmission, because the virus can linger in the air for a bit before it falls to various surfaces, but that’s not the way the virus is transmitted, Dr. McKinnell reminded. 

“The ‘sneeze zone’ is 6 feet, and that’s based on how far the droplets spread, but this is not airborne transmission,” Dr. McKinnell said. People touch contaminated surfaces and then touch their face. 

Anything that breaks that transmission cycle is worthwhile. Something as simple as closing patient room doors can help keep some of the virus in the room, instead of on the ward.

Environmental cleaning is also an important component. There should be a “deep, deep cleaning” of patients’ rooms, and regular wiping of all touched surfaces is imperative, according to Dr. Poland. (It wouldn’t be a bad idea to leave a box of disinfecting wipes by all keyboards that are used on the COVID-19 ward, he suggested.)

In addition, many hospitals are mandating taking daily temperatures of staff every day. Dr. Poland said his facility takes temperatures twice a day because no one wants an employee with a fever in the hospital.

Social Distancing
A hospital ward is a workplace, and people are social beings and creatures of habit, but these habits have to change, the experts said. People like to have that cup of coffee before rounding or enjoy the comradery of eating lunch with their colleagues on the unit. They gather together before the shift starts to talk about the night before. 

If the virus is on the ward, it’s probably in other areas of the hospital, too, so Dr. McKinnell said he doesn’t eat or drink in the hospital now, and no one should be eating or drinking on the unit anymore.

In addition, they really need to practice social distancing as much as possible, the ID doctors said.

Even rounding needs to be thought through, according to Dr. Poland. “Therein lies the balance,” Dr. Poland said. “People have to learn, they have to see these cases, but do you necessarily need to have everybody in every room? We need to think through that [during this pandemic].” 

In addition, Dr. McKinnell said to be careful when using the restrooms in the hospital because a person’s scrubs are their first barrier to infection. PPE is not 100% effective in preventing the virus from getting on a person’s skin, so clothing is another layer of protection. If you have to unbutton or unzip your pants, you’ve exposed your skin to potential virus. 

He suggested washing your hands before and afterward.

Don’t Bring Your Work Home
No one wants to bring COVID-19 into their home, and there are steps health care workers can do to minimize the risks of doing this.

If the hallways and counters outside a COVID-19 patient’s room are contaminated, staff should expect the entire hospital to be contaminated because there is no way to know who didn’t wash their hands before they entered another area of the hospital (J Hosp Infect

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2020 Apr 4. [Epub ahead of print]. doi: 10.1016/j.jhin.2020.03.036). So, Dr. McKinnell considers the entire hospital as a red zone.

And he uses the red, yellow, green stoplight system to guide his day. Dr. McKinnell thinks in terms of zones: The hospital is the red zone; his car and his garage are the yellow zones; and his home is the green zone. 

He practices all the advice given earlier in this article while in the red zone. 

When he leaves the hospital, he enters the yellow zone, and no one in his family is allowed in the yellow zone. He enters his home through his garage, where he undresses to his boxers, cleans his hands with hand sanitizer, and then immediately enters the house and takes a shower. 

“I haven’t touched my face. I haven’t touched my hair. I haven’t done anything extra. I walk immediately to the shower and take a full shower. Now, I am decontaminated, and now I can kiss my wife. Now, I can have a meal. Now I can relax because I’m decontaminated in my green zone,” Dr. McKinnell said.

“These are legitimate, reasonable and feasible things to do and are what I call contextually appropriate layers of protection,” Dr. Poland said.

Showering at the hospital and leaving worn scrubs there is also a reasonable action to take, especially if you don’t have a garage or mudroom to change into before entering the house, Dr. Poland said, and health care workers should leave all bagged masks, stethoscopes, brief cases, etc. in the hospital, or at least in the trunk of the car. 

Leaving them on a passenger seat is a good way to make a yellow zone a red zone, according to Dr. McKinnell.

“We ought to be in scrubs. We go into the facility, we change in the scrubs, we wash our hands properly,” Dr. Poland summarized. “We are donning and doffing PPE properly, ideally watching each other doff our PPE and care for patients so that we don't make mistakes—they're extremely easy to make. Try to not adjust your mask or scratch your face or rub your eyes for eight hours.

“And then when you’re done with work, sanitize your hands, your stethoscope, take your scrubs and lab coat off, leave them there; shower if you can, change into street clothes and go home,” he said, adding that some of his colleagues have opted to stay in a hotel room rather than go home.