Few questions are of greater concern to emergency health personnel these days than how they can protect themselves from COVID-19.

It is an issue loaded with nuance. Much depends on such factors as how someone works in the emergency department (ED), what procedures they perform, what specific practices they use when performing those procedures, and how often they are exposed.

Nonetheless, a multidimensional study that seeks to capture all these complexities is well underway, with the goal of delivering solid answers to nurses, physicians, and even many nonclinical personnel who staff EDs across the United States.

In the COVID-19 Evaluation of Risk in Emergency Departments (COVERED) project, investigators from UCLA and the University of Iowa are aiming to identify which practices and which pieces of personal protective equipment (PPE) make the most difference in preventing personnel from acquiring COVID-19.

The Centers for Disease Control and Prevention (CDC) is funding the project with a $3.7 million grant, enabling researchers to enroll and follow participants at 20 academic medical centers.

The project is a collaboration between EMERGEncy ID NET, a CDC-supported network of 12 EDs studying emerging infectious diseases, and the National Emergency Airway Registry (NEAR), a multicenter group studying the intubation of patients in the ED.

“The question of how we protect healthcare workers is something that we have been interested in throughout the COVID-19 pandemic,” explains Nicholas Mohr, MD, MS, clinical professor of emergency medicine, anesthesia - critical care, and epidemiology at the University of Iowa and co-principal investigator of the COVERED study. “Through the two national networks, we pulled together this collaborative with the goal of really having a national platform to be able to understand what the risk is of COVID-19 transmission to healthcare workers across sites around the country.”

To understand the granularity of this investigation, Mohr says 1,600 participants have been divided into four groups:

  • emergency physicians who perform endotracheal intubation in patients with confirmed COVID-19 infections;
  • emergency physicians who do not perform endotracheal intubations;
  • emergency nurses;
  • nonclinical ED staff.

Specifically, Mohr notes there are about 800 physicians, 400 nurses, and 400 nonclinical staff participating in the study.

“They tell us information every week about their use of PPE and how many patients they are taking care of in certain risk groups. They’re also telling us what their practices are around certain procedures,” he shares. “For instance, one of the procedures we are very interested in is endotracheal intubation, which involves putting people on ventilators. We know that is a high-risk practice. We also know that it is a life-saving procedure.”

Mohr states that from prior work involving severe acute respiratory syndrome and Middle East respiratory syndrome, researchers know those who performed endotracheal intubations were at significantly higher risk of contracting these coronavirus infections.

Consequently, when participants in the COVERED study perform endotracheal intubations, they are asked to provide information such as what type of equipment they used, how they used the equipment, how long they were in the room, what types of countermeasures they were using, what types of PPE they were wearing, and other patient-specific details.

Collect Samples

Similarly, regarding CPR, Mohr notes participants are reporting how it is performed, whether people are performing CPR in special rooms in their ED, whether specific filters are used to protect clinicians, or whether special masks are used. “All of that information is helping us to understand what the risk is throughout the study period,” he says.

Furthermore, in addition to inputting data, participants are providing blood samples and nasal specimens regularly. This will enable investigators to determine which participants have been exposed to COVID-19 and which participants have developed the disease over the course of the study.

Specifically, participants submit blood and nasal samples at the start of the study, at week two, and then at week four. After that, participants submit samples for testing every four weeks for a 20-week period. However, Mohr stresses participants are reporting on what their exposures are every week. “They log in to the system [we have created], and tell us how many patients they have seen and what kind of procedures they have done,” he says. “Then, with certain procedures, even every day they are telling us about those procedures and about the equipment they used.”

By collecting information at the time of possible exposure, investigators believe the data quality is much better than what has been collected during previous studies. The authors of that work asked participants to recall well after the fact what they were doing and how they were practicing at the time when they might have been infected.

The nonclinical participants in the study include reception staff, clerks who page, financial services people, and some social workers, depending on their specific job.

“We [are following] a cohort of people who work in the area of the ED, but who don’t go into patient rooms or provide clinical care and aren’t within six feet of patients routinely,” Mohr says. “We have tried to take into consideration how different staff function within each institution, but we really wanted people who are within an ED but don’t have patient-facing care responsibilities.”

Under such criteria, environmental services staff are not part of this study because this is a group that faces different types of risk than nonclinical staff investigators are following. “The [environmental services sector] is clearly a higher-risk group,” Mohr notes.

In addition to specific data points about individuals, COVERED investigators also are collecting information from participating facilities about whether they are experiencing shortages of PPE, and whether they are sanitizing PPE that was originally intended for single use. “We are certainly capturing a window of time where physicians and nurses are taking care of patients with COVID-19, and we are tracking ... how health systems have responded to those challenges dynamically,” Mohr says. “That is something we can include in our analysis as we try to understand what the risk factors are.”

Analyze Data

With so much information to distill, interpreting the results will involve a fair amount of complexity.

“We are collecting more than a thousand data points from each of our 1,600 participants. In the course of the project, we are collecting blood and nasal specimens seven times from all of these participants, which [amounts to] almost 12,000 COVID-19 tests,” Mohr says. “As the study goes on, we have people enrolled in the cohort who continue to be diagnosed with COVID-19. That is the type of information we will be using to really try to nail down what the quantifiable risk is, and how we can reduce that risk to certain healthcare providers in the future.”

Despite the complexity involved, investigators anticipate they will be able to share their results this fall. For ED personnel eager to learn how they can most effectively protect themselves, that may seem too late. Mohr argues that from a biomedical research standpoint, the COVERED study has unfolded lightning-quick.

“The way this project has rolled out has just been unprecedented. From the time we first had the idea and started talking with the CDC to the time we had a funded project was just three weeks,” Mohr reports. “Even from the time that our study had been funded until the time we launched and enrolled participants was just another four weeks.”

While it may feel like the study is plodding along, it is moving much faster than any other large public health surveillance project, at least in terms of trying to understand a pandemic while it is happening, according to Mohr. “The opportunity to be able to test healthcare workers prospectively during the course of the pandemic while we collect this really detailed data is a once-in-a-generation opportunity for us to learn how to take care of patients better in the future,” he says. “But it is something that really requires a little bit of time to pass so that we can understand what those exposures are and how those translate into risks.”