Dr. Atul Gawande: The 5 standards to safely lift lockdowns require commitment, not 'wishful thinking'

Cities and states across the U.S. are lifting lockdowns and navigating the slow return to a more normal life, which includes opening nonessential businesses and allowing for more contact between people outside of the home.

How can they do this safely? Atul Gawande, MD, chair of Haven's board of directors and a surgeon at Brigham and Women's Hospital in Boston, penned an article for The New Yorker outlining how Mass General Brigham kept two-thirds of its staff on-site in April with few workplace COVID-19 transmissions and what organizations across the U.S. can do to safely reopen.

He advises thinking about the approach to safely reopening as a "combination therapy — like a drug cocktail" that includes the familiar elements of hygiene measures, regular COVID-19 screening, social distancing and wearing masks. All elements, he wrote, are essential for limiting the spread of the disease.

Five key standards for a safe reopening:

1. Regular hand-washing and surface sanitization. Dr. Gawande pointed to a military boot camp study that found hand-washing five times per day led to a 45 percent reduction in medical visits for respiratory infections.

"The key is, washing or sanitizing your hands every time you go into and out of a group environment, and every couple of hours while you're in it, plus disinfecting high-touch surfaces at least daily," he wrote.

2. Maintain physical distance. Most Americans are familiar with the 6-foot rule to prevent COVID-19 transmission, and Mass General Brigham has new rules to ensure staff and patients keep their distance. The hospital has asked people to stay a set distance apart on escalators and in line for the elevator, which is limited to four people at a time. Internal meetings, patient visits and team huddles are now virtual whenever possible, even when the others on the call are just down the hall.

The amount of time someone is exposed to an individual who tested positive for COVID-19 makes a difference. "We don't know exactly how long is too long, but less than 15 minutes spent in the company of an infected person makes spread unlikely," wrote Dr. Gawande.

3. Daily screening of all employees, patients and visitors. Mass General Brigham requires anyone entering the hospital to confirm they do not have any signs of the disease, which would include a fever, cough, sore throat, shortness of breath, taste or smell loss, nasal congestion, or a runny nose. He wrote that mild symptoms are the most important to screen for since fevers are present in COVID-19 symptomatic patients less than half the time in the early days of infection.

Dr. Gawande wrote he can use his phone to log in to a website and confirm that he doesn't have any of the symptoms before entering the hospital. Then, testing can quickly confirm whether symptomatic people have the virus, and they can notify those who have come into close contact with them. If individuals have a negative result, they can return to their normal life after their fever is over.

4. Continuously wearing masks. Asymptomatic individuals or those who have just started to show symptoms of COVID-19 can spread the virus, which has made social distancing and wearing masks critical to stopping the spread. Mass General Brigham requires all employees to wear disposable surgical masks and provides masks to all patients on-site. He also pointed to a study that shows surgical masks were three times better at blocking the "outward transmission of respiratory viruses" than homemade cloth masks.

To conserve supplies, the hospital is limiting workers to one mask per day and is decontaminating masks for reuse with a machine that creates a hydrogen-peroxide vapor that allows the mask to keep filtration for up to 20 cycles.

5. Changing the culture. Without everyone adhering to the strict standards that are typically reserved for the hospital operating room, the virus has a greater chance to spread. "This requires absorbing detailed practices that keep us from transmitting germs in a given setting — like the rule at the operating table that, once you're scrubbed in, you never let your hands fall below your waist," wrote Dr. Gawande. "Even more, this requires developing norms about how to address lapses in rules, so you can comfortably call one another out when you see a standard slipping and still enjoy working together."

Dr. Gawande noted that changing the culture is the toughest part of maintaining standards because it requires people to care about the safety of others as well as themselves, and it is essential as lockdowns are lifted.

"There is still much more to learn, such as whether we can safely work at less than six feet apart if everyone has masks on (the way nurses and patients do with one another) and for how long. But answers will come only through commitment to abiding by new norms and measuring results, not through wishful thinking," he wrote.


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