Masking Approaches in Healthcare Should Be Reconsidered, Experts Say

Healthcare facilities should reconsider their approaches to masking, a group of public health experts argued.

“As health care systems navigate this next phase of the pandemic, different approaches could be considered that place patient safety first and integrate masking as part of routine health care policies,” wrote Eric Chow, MD, MPH, of the University of Washington in Seattle, and colleagues in an Annals of Internal Medicine commentary.

“We should be mindful of continuing areas of uncertainty while integrating the lessons learned into our hospital-based practices to prevent harm to vulnerable patients rather than reverting to suboptimal prepandemic behaviors,” they added.

While rates of severe COVID-19 have decreased, severe outcomes attributable to COVID-19 are still occurring, the authors noted. “Deaths disproportionately affect older persons, those with underlying comorbidities, and those experiencing long-standing inequities in care,” they wrote. “Furthermore, we are only just beginning to understand and measure the postacute and long-term ramifications of SARS-CoV-2 infections, even among persons with asymptomatic or mild acute illness.”

The fact that most people have stopped masking while returning to their regular activities “provides further rationale to integrate precautions, such as masking, as part of general practice to protect patients, especially those who are most vulnerable to severe disease,” Chow and co-authors observed. “Masking also remains an important mitigation measure to protect the health of our healthcare workforce, including those who are at high risk for severe disease. Preventing [healthcare worker] infection is vitally important in maintaining the capacity of an already severely strained healthcare system.”

Prior policies assumed that patients with active infection are identified, tested, and isolated appropriately, the authors pointed out. “Yet it is estimated that asymptomatic and pre-symptomatic cases account for the majority of SARS-CoV-2 spread,” they wrote. “These findings mean that it is not possible to consistently identify patients and [healthcare workers] who are capable of transmitting virus, especially as hospitals discontinue universal SARS-CoV-2 admission testing.”

Chow and colleagues recommended four possible approaches for returning to masking:

• Across healthcare spaces year-round
• In targeted settings, such as transplant, oncology, and geriatric units, where risk is highest for those patient populations
• In specified months during the local respiratory viral season
• When community burden of respiratory viruses approaches a critical threshold, although appropriate metrics will need to be defined

The authors noted that, in the state of Washington, “regional health care organizations issued a joint consensus to extend universal masking in patient care spaces of healthcare facilities, with plans to update this policy through a regional approach to masking as the pandemic continues to evolve … By developing a cross-systems healthcare masking agreement, facilities addressed patient safety through a collaborative and supportive approach that can take into account regional variations in community respiratory viral burden.” Because of variations in healthcare settings, the joint consensus allowed each facility “to tailor policies to their own unique spaces, such as determining what constitutes public or patient care spaces.”

Georges Benjamin, MD, executive director of the American Public Health Association, liked the authors’ idea of formalizing a mask protocol. “We have learned a lot about the role masks play in mitigating the risks for acquiring a range of infectious respiratory diseases during the COVID pandemic,” Benjamin said in an email to MedPage Today. “Going forward, we need to develop a more formal risk-based approach to infection control, of which masks are one part of the formula.”

The mask-wearing issue “is definitely something to keep an eye on, and I would postulate that it’s very location- and site-dependent,” said Peter Silver, MD, MBA, chief quality officer and associate chief medical officer at Northwell Health, a health system in the metro New York City area with 21 hospitals and 850 ambulatory health facilities.

“We currently don’t have a mandate in place at Northwell although we are encouraging it in high-risk areas — as was recommended by the authors,” Silver said in a phone interview. “In high-volume areas such as emergency rooms, we’re strongly encouraging staff to wear masks and most are, but it’s not a mandate.” Mask-wearing also is required of staff members in some very high-risk population areas, such as cancer units and bone marrow transplant units.

The number of COVID-positive patients being admitted to Northwell has increased over the last 4 to 6 weeks, he noted, “but people are coming in not for COVID; they’re being admitted for other conditions and coincidentally have COVID. The number of people critically ill from COVID is virtually zero … so severity is still quite low in our patients.”

But the situation could easily change, Silver said. “We have to see what happens with these new variants … We’re taking it not only a week at a time but a day at a time, and if we need to get to [mandatory masking], we will.”

However, “I’m kind of hoping that we don’t,” he said, adding that mask-wearing does have its downsides “in terms of the change in the relationship between patient and provider when masks are involved — the inability to see somebody’s face, the depersonalization is really very significant. We saw that during COVID, and we saw the positive effects among our providers and our patients when masks were no longer required.”