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Brigham and Women’s COVID-19 cluster illustrates challenges in controlling infection

Experts say leadership, vigilance, and culture change are needed, along with more space to gather and eat at safe distances

Medical assistant Abigail Libman swabbed a patient at a drive-through testing at Brigham and Women's Hospital in April.
Medical assistant Abigail Libman swabbed a patient at a drive-through testing at Brigham and Women's Hospital in April.Craig F. Walker/Globe Staff

When Dr. Doug Salvador heard about the cluster of COVID-19 cases at Brigham and Women’s Hospital, his first reaction was one of sympathy. “Our hearts go out to the staff and patients and leaders who are dealing with it right now,” he said.

Salvador, chief quality officer at Baystate Health, had dealt with a similar outbreak at the Springfield hospital in July, and knows how arduous it can be — and also how a concerted effort can swiftly contain the spread.

Like the Brigham, Baystate quickly tested hundreds of people. Baystate eventually identified 36 employees and 25 patients who became infected as part of the cluster, and immediately stopped transmission.

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The lessons from Baystate are strikingly similar to the issues emerging in the Brigham outbreak, which as of Friday had affected 19 employees and nine patients. They illustrate the common challenges that hospitals face in controlling a wily and unfamiliar foe.

The Springfield hospital learned that it needed to scrupulously monitor use of masks and eye protection, encourage and enable workers to report even the mildest symptoms, and provide enough space to eat and gather without crowding.

“A big piece of this is leadership and culture,” Salvador said.

The virus has been spreading at conferences and weddings, in churches, bars, prisons, and homeless shelters. But despite being filled with sick people and frenetic activity, hospitals see few outbreaks and typically can quickly contain them.

But such events clearly do happen, including in Massachusetts.

In addition to Baystate and the Brigham, a small cluster occurred at Tufts Medical Center in the spring but none since then. Additionally, Beth Israel Deaconess Hospital – Plymouth had a cluster this month affecting 12 patients and 16 staffers, with no new cases since Sept. 12; and New England Baptist Hospital is contending with a recent cluster involving five patients and 19 staffers, with no new cases seen since Wednesday.

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“The hospital is a really safe place to be, especially compared to many places people are going,” said Dr. Shira I. Doron, an infectious disease physician and hospital epidemiologist at Tufts Medical Center. The number of outbreaks is small considering the "millions and millions of hospital admissions during the course of the pandemic.”

The cluster at Brigham was recognized lastweek, after an employee and a patient tested positive, and the infection spread among other patients and staffers working in two units in the Braunwald Tower.

At Baystate, the outbreak started among a group of employees, who then spread it to patients. Many of those employees had come to work with mild symptoms that they attributed to other things — just as employees at Brigham and Women’s thought they had allergy symptoms.

“You’ve got to shift that culture of medicine, 150 years of physicians and nurses believing they can’t let their patients down, can’t let their colleagues down. We’ve always considered that a virtue,” Salvador said.

Since the outbreak, Baystate said hospital officials are happy to see increases in people calling in sick, he said.

In a series of Tweets on Friday, Dr. Neha Limaye, a resident at the Brigham, pointed out obstacles for employees.

“At many hospitals,” she wrote, “getting test results can still take up to 72 hours. While waiting for your results you may have to miss up to three days of work, burdening the rest of your team and affecting patient care… If they need us to keep working, they have to test us regularly and rapidly.”

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Another aspect of human nature that bedevils infection control efforts is a phenomenon known as “drift,” Salvador said. As people avoid infections by adhering to safe practices, they can lose sight of the true risk. Slight deviations from infection-control protocols become normal, like driving 72 miles per hour in a 65-mile-per-hour zone. “I drove 72 and I didn’t crash. Now I’m going to drive 90,” Salvador said.

By July, the COVID-19 surge in Massachusetts had eased; hospitals were no longer packed with COVID-19 patients. “People had gotten a little more comfortable that things were going well,” Salvador said. “There had been a laxity in some of the infection control practices,” particularly in wearing of face masks and social distancing.

“We realized that it’s hard to wear a mask all day on your shift,” he said. Sometimes people pushed them down to take a breath.

That was even a bigger issue during meal breaks, when workers obviously have to take off their masks to eat, but may not have always had room to stay six feet apart.

Baystate now requires its managers to regularly round in the hospital making note of every lapse they observe, recording it on an app. This prompts the managers to correct any problems, and enables the hospital to detect any signs of “drift.”

“A lot of this is vigilance. Are we living in that safe space or have we drifted?” Salvador said.

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At Tufts, Doron said, a patient seen in an outpatient area unexpectedly became positive for COVID-19. “We asked everyone who had been in contact with that person whether they had been wearing masking and eye protection,” Doron said. When it became clear that everyone had done so, “they all got to experience that sigh of relief” that reinforced the importance of those measures.

But the issue of finding space for employees to gather, confer, and eat, without getting too close, has been a major challenge.

“An ongoing concern since the outset of the pandemic is the fundamental nature of the healthcare environment, which isn’t well-designed to maintain physical distancing,” Dr. Sharon Wright, senior medical director of infection control and hospital epidemiology at Beth Israel Deaconess Medical Center, said in an email.

At Baystate, Salvador said, the administration looked for “every nook and cranny” that could be used to free up more space for work and meals. With meetings going virtual, conference rooms could be repurposed as break rooms. Tents were set up outside for breaks, although that can’t last past November.

At Tufts, Doron said, the hospital leaders have been going from break room to break room with tape measures, putting signs on doors, and affixing stickers to show how the furniture should be arranged.

Another difficult cultural change is getting all employees to monitor each other, pointing out any lapses, said Dr. David Weber, an infectious diseases specialist at the University of North Carolina and a board member of the Society for Healthcare Epidemiology of America. That includes encouraging lower-ranking workers to admonish superiors — to enable, say, a surgical technician to alert a senior surgeon that a face shield is up — another tough, against-the-grain imperative, he said.

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“It’s very hard to maintain 100 percent compliance 100 percent of the time,” Weber said, and yet hospital outbreaks remain uncommon. “To expect perfection in a hospital when we don’t expect it anywhere else society is not fair.”




Felice J. Freyer can be reached at felice.freyer@globe.com. Follow her on Twitter @felicejfreyer.