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Doctors don't have the guidance we need for this pandemic

Doctors don't have the guidance we need for this pandemic

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You already know the story: In about a month, the national coronavirus pandemic has exploded to more than 300,000 confirmed cases. In Wisconsin, where one of us practices general surgery, cases have increased from a few hundred to more than 2,000 in roughly two weeks. In a hospital that typically has 15 to 20 patients in medical intensive care beds, now those beds are full, and patients are spilling out into makeshift intensive care units. Medical personnel face extreme risk because we deal with the sickest patients with the highest viral load. Research shows that larger viral doses lead to more severe symptoms and a higher likelihood of death. While we put on brave faces, we quietly confess to each other that we are scared to go to work. We are afraid of infecting our families.

And by now, you know that while the number of doctors, nurses and other staff remains constant, our patient load grows while our supply of gloves, masks, face shields, gowns and ventilators is rapidly depleting. While we will continue to fulfill our oath, despite the resource challenges and despite the risk of infection, there's something that can make our jobs more manageable that we can't provide ourselves - something that some of the government entities and hospital accreditation agencies that oversee medical practice are failing to provide: standards.

In normal times, these entities - including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Department of Health and Human Services - regulate everything, including but not limited to how far apart hospital beds should be to how long a nurse's shift can be to how close to treatment rooms the cafeteria should be. These standards and guidance are essential to ensuring that the hospital functions to provide a healthy, safe and comfortable environment for patients, visitors and staff.

That's how, over time, the practice of medicine in this country has earned the trust of patients and their families. No system is foolproof, but the standards that hospitals and medical practitioners follow, and that the accreditation agencies grade us on, ensure that safety protocols are being followed and care is consistent. They work because an easily available and accepted process is developed by experts and used across systems. For instance, standards prevent surgeons from replacing the wrong hip by requiring that the correct site of surgery is carefully marked preoperatively with a surgical pen. Standards help minimize medical errors and prevent harm to patients.

But so far, in the covid-19 crisis, these agencies have failed to offer doctors and nurses comprehensive, evidence-based standards for sufficient protection of patients and themselves. The CDC, for example, has based its personal protection recommendations on inaccurate estimates of the supply of personal protective equipment (PPE). PPE is frequently relocated to different places in the hospital, making counting supplies difficult. Recommendations should be based on the necessary level of protection, not supply currently available. JCAHO supports using masks made at home, despite scientific findings that they are inadequate. Compared with surgical masks, cloth masks can lead to increased risk of infection. The CDC's National Institute for Occupational Safety and Health has told us, as recently as March 27, that N95 masks, which were considered single-use before the pandemic, should be saved in plastic bags and reused. Reusing masks lessens their protection over time, and the contaminated mask can spread the virus to other surfaces. The message coming from these authoritative institutions is that health-care providers contracting and spreading this disease is an acceptable risk.

Clearly, we've never dealt with a situation like this before. The coronavirus outbreak spread quickly across the country and around the world, and everyone is scrambling to catch up. But that's not an excuse for abandoning safe standards. While physicians and hospital staff work overtime to catch up with treatment, agencies and accreditation organizations must also work overtime - to catch up, to come up with effective guidance and then figure out how to get it implemented and re-sourced. While we're in hospitals all over the country doing our jobs, the people in Atlanta or Washington have to do their jobs.

Tell us, step-by-step, what is the safest way to put on and remove PPE? What kinds of gowns and masks are safe, in terms of both design and materials? Importantly, what kinds aren't safe? Which patients should we test? Who should we treat in the hospital, and who should we send home? How do we get a rapid and accurate test? Once this is all figured out, where will the supplies come from, and who will get them first? Doctors know how to treat illness, but in an all-hands-on-deck situation, we can't take time out from treating patients to synchronize best practices around the country.

On Friday, President Donald Trump, in charge of the entire federal apparatus, said that at home, "people can just make something out of a certain material" if they want to wear masks. That's a suggestion, not a standard. And it applies to the general public, not the needs of medical professionals.

We have pleaded for policies to guide care in the time of covid-19, but have mostly heard silence. A recent phone call to JCAHO requesting guidance resulted in a request for an email submission promising a response in five to ten business days. Doctors don't have that kind of time. The ad hoc solutions we are forced to experiment with in the absence of such standards are undoubtedly increasing the spread of this disease. Most alarmingly, this is increasing the infection rate among physicians, nurses and respiratory therapists. We may see shortages of the specialists who care for ICU patients and operate ventilators before we run out of those resources themselves. We have seen hospital workers locking up and hiding their supply of masks to protect this precious resource, even from hospital colleagues.

While the body of scientific knowledge to inform such standards is certainly incomplete, it is rapidly expanding with an explosion of collaborative research. The SARS and MERS outbreaks can serve as the foundation for these guidelines. One thing doctors learned during these crises was that "a shortage of masks could pose a risk to health workers." We can also apply lessons learned from other countries that have flattened the curve, such as South Korea, which used contact tracing, extreme social distancing and frequent, rapid, comprehensive testing.

Every day, medical standards reduce errors and help front-line clinicians apply the best evidence when making decisions for their patients. This is critically important, even when doing something as routine as a yearly checkup. In the current crisis, the need for standards is even greater to provide a safe and effective working environment for hospital staff and patients. Standards keep us from causing irreparable harm, such as replacing the wrong hip. Standards will keep us from contracting covid-19 and spreading it to patients and our families.

Standards save lives.

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Morris is a trauma and acute care surgeon at the Medical College of Wisconsin.

Charles is a researcher and trauma/critical care surgeon at the University of North Carolina at Chapel Hill.

Tignanelli is a researcher and trauma/critical care surgeon at the University of Minnesota.


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