Who are essential workers for patient safety?

In 2020, as a consequence of COVID-19 our hospital and many others around the globe discovered more “essential workers” in their ranks than they had appreciated in the past.

“Essential Worker” can be defined as one “who conducts a range of operations and services that are typically essential to continue critical infrastructure operations.” ¹ In healthcare, during the COVID-19 pandemic the US Centers for Disease Control defines frontline essential workers as the subset likely to be at greatest risk for work-related exposure to SARS-CoV-2, because their work-related duties must be performed onsite and their duties involved being in close proximity to the public or co-workers. ²

In the public mind, and perhaps those of many hospital administrators, essential workers include professionals and other clinical staff, like physicians, nurses, nursing assistants, respiratory therapists and medical technicians, as well as aides and ward clerks. In the past, less attention has been paid to other members of the healthcare workforce, including those in maintenance, environmental services (EVS), food service, patient transport, and security, among others.

Early in 2020, during hospitals’ precarious early attempts to treat COVID-19, it became apparent that many of these less visible workers were also essential for maintaining the safety of both patients and health care workers. This work exposed them to increased personal risk, as well anxiety and fear for themselves, and for taking the infection home to their families. A majority of these relatively low-wage workers are members of disadvantaged minority groups. ³

Building and construction workers worked with amazing speed to convert existing hospital rooms and entire units to accommodate growing numbers of COVID-19 patients. They followed exacting requirements to create negative pressure rooms with the required airflow requirements, medical gas and electrical systems. This contributed greatly to protecting patients, staff and visitors from exposure to infectious material. Their work was essential to maintain the safety, sanitation and operation of hospitals.

The work done by environmental services (EVS) workers on the timely cleaning and disinfecting of surfaces became a top priority during the pandemic. This required extra effort on the part of workers to relearn routines and protocols, and increase the frequency of cleaning.

Laundry workers keep medical facilities running by washing soiled linens, gowns and uniforms, often working in spaces that have poor ventilation, lack of physical distancing and variable access to Personal Protective Equipment (PPE).

Patient transport workers transfer COVID infected patients and patients-under-investigation between hospitals, wards, testing and procedures. This requires both speed and care to avoid nosocomial spread.

For the safety of all, security workers are needed to maintain order during times when patients or visitors are sometimes distressed, non-compliant and even combative, as well as to intervene in crises of many kinds.

Other categories of workers have assumed a central role in patient safety. Prior to the pandemic, the term “supply chain” was rarely uttered by any medical person. Since then, rolling shortages developed for virtually every kind of PPE - powered air purifying respirators (PAPRs), surgical and N-95 masks, face shields, gowns, hand sanitizer, and disinfectants. This has led to daily reports from supply chain managers to incident commanders and top executives.

At Johns Hopkins, it is less surprising that hospital safety officers have been important in maintaining patient safety during the past year. However, part of the job description was rewritten to create the role of PPE Safety Officer. Their role was to work on COVID-19 units to help front line workers maintain safety and infection control in their never-ending use of PPE. They also worked closely with patient transport staff to assure that no infections were transmitted during that process.

An additional group that transitioned from the status of nice-to-have to need-to-have were the mental, emotional and spiritual help (MESH) programs in the hospital. MESH offered 24-hour service via multiple modes and channels from wellness, spiritual care, psychological first aid, and employee assistance programs and psychiatry, providing a continuum of support for staff wellbeing. ⁴ Early discussions made it clear that greater efforts were needed to reach less visible workers in the health system. Many were not aware of these programs, as they did not use electronic mail or read hospital leaflets. Even when they had heard of them, they never called, stating “I didn’t think those things were for us.”

The relationship between patient and worker safety has been explored for over two decades.^5,6 It was given greater visibility during the pandemic with its adoption as the theme of World Patient Safety Day 2020. ⁷ A silver lining of the pandemic has been our increased awareness of less visible yet still essential workers that do so much to maintain patient safety.

In this issue of the Journal a few papers touch on themes related to the need for a broad interdisciplinary approach if we are to succeed in improving safety. Sarawasthula and colleagues describe several potential failure points for COVID-19 patients undergoing tracheostomy that could endanger medical personnel. These include problems in multiple domains including proper PPE use, transport, and intraoperative equipment failure. ⁸

Owodunni and colleagues involved nurses at several levels, physicians, nurse practitioners, and physician assistants to implement a patient-centered educational bundle to reduce venous thromboembolism. ⁸ Information technology staff were instrumental in delivering the intervention.

The thematic analysis of Coroner’s reports by Leary and colleagues also suggested concerns at many levels of the health system. These included issues with individuals, teams, communication and culture, systems issue and lack of resources, all of which might harnessed to improve patient safety and quality of care. ¹⁰

At this moment in history there is a chance to use this insight to improve the culture of safety in health care. It is time that we pay more than lip service to involving the multiple disciplines and professions in healthcare that are essential to patient safety. This recognition can increase understanding and respect for all of those workers and what they contribute. Frequent and better targeted communication of this expectation will be needed. And, as many hospital workers tend to live in the communities surrounding hospitals, greater respect can lead to increased trust. This in turn provides hope for greater equity both within and beyond the bounds of our health centers.