Healthcare workers may be vigilant with personal protective equipment (PPE) around COVID-19 patients, but inadvertently expose themselves to colleagues when they take breaks, socialize, and eat, said Connie Steed, MSN, RN, CIC, FAPIC, director of infection prevention and control at Prisma Health in Greenville, SC.

“When we have seen clustering, our drill-down investigations have identified that, typically, our healthcare providers are not being exposed by patients infected with COVID-19,” she said recently at the IDWeek 2020 conference, held Oct. 21-25. “When they are with patients, they follow protocol. What we have found is that our healthcare providers will relax a little bit when they’re in the break room, even though the guidelines say they need to socially distance and keep their masks on unless they are eating or drinking. That, many times, does not occur. Therefore, they expose each other to a provider who is asymptomatic.”

PPE Fatigue Contributes

Part of the problem is healthcare workers are experiencing PPE fatigue and may be tempted to removed gear for brief respites when possible.

“Our providers are tired,” Steed noted. “In organizations across the country, there have been reports of significant outbreaks related to providers laxing off on PPE. Not necessarily on COVID-19 wards, but on the regular units where they take care of patients they don’t suspect have [the virus]. We need to really pay attention to what our providers are doing, not only when they are in the room caring for the patient, but also outside of that environment when they take their mask down when they are talking to someone because their voices are muffled.”

Steed’s hospital has adopted a “200% accountability” campaign encouraging healthcare providers to be role models. “COVID-19 is a pandemic and it is still here,” she said. “We have flu coming, and we need to clean our hands and wear our masks. We are going to be communicating in different ways — nonverbally — when we observe providers not following a rule. Hopefully, this useful help will mitigate some of their risk.”

Collaboration between employee health and infection prevention is critical. “Make sure that your occupational health department and team have updated guidance,” Steed said. “Make sure that when they see clustering of healthcare provider infections that they contact infection prevention and control so you can undertake an investigation and figure out what is going on. Assess your organization’s exposure management process, and continue to alter it and change it as need arises.”

PPE lapses in break rooms and during meals has been an ongoing issue, but leaders are using several tactics to address the problem. “What we have done that has probably had the biggest impact is actually go to the area and talk to the providers who are using the space,” Steed said. “If they are not using it properly, help them change it. We have brought engineering in and removed chairs and moved things to socially distance them. Some of our facilities and departments have posted the maximum number of individuals who can take a break in that space, based on the size. That seems to have worked.”

Intervention and observations must occur during all shifts if exposures are to be prevented. “We have found that after hours we need to have someone who goes around and observes,” she explained. “We have also set up some locations where providers have a huge community room space. There are hand hygiene rubs on every table, and the limit is two people per table. We also have changed some of our waiting rooms throughout the organization, where they are closer to the unit so they can eat and drink. They are more apt to use those because it is closer to where the patients are. We have also set up areas outside. People enjoy going out to eat, and it gets them out in the fresh air and the risk is less.”

With PPE fatigue and other issues undermining worker protections, facilities need to restore the sense of urgency that hit the healthcare system with the pandemic’s emergence.

“From what I hear as I talk to people around the U.S., we have to ensure access to PPE and training,” Steed said. “We need to make sure that the PPE denial or laxity we are seeing now is turned around.”

New CDC Training

The Centers for Disease Control and Prevention (CDC) has launched on online, interactive training network on infection control aimed at both frontline healthcare workers and other personnel.

“Project Firstline [is] a comprehensive infection control program designed to help prevent the spread of infectious diseases in U.S. healthcare settings,” the CDC states. “Project Firstline will reach healthcare workers in all healthcare settings, including hospitals, outpatient clinics, dialysis centers, and nursing homes. Core training is posted to address immediate workforce infection control training needs, delivered via short and accessible training videos. The site also includes practical tools to support everyone working in a healthcare facility as they implement infection control protocols and procedures throughout their workday.”1

The training should help clarify and reinforce CDC guidelines on COVID-19 and other infectious threats. “Their focus is on frontline providers and staff, and I think that this is long overdue,” Steed noted. “It’s hard and challenging many times to grasp the rationale of basic IP prevention practices.”

The educational materials include concise 10-minute videos that do not require a certain level of training or educational background to understand. They offer interactive features through periodic “knowledge checks” during training.

“If you look at what they have online, they have a general one on hand hygiene, and then their focus right now is long-term care and dialysis,” says Steed. “I think that in the future they will get into some other topics. Right now, their focus is on COVID, the basics of hand hygiene, and things like that.”

Steed has shared the training on long-term care and dialysis with staff in her facility. “I see them using it as support and validation for what needs to be done,” she said. “These short videos are excellent. They can be used at a staff meeting and are accessible from any computer.”

Regarding PPE, Michael Bell, MD, deputy director of the CDC’s Division of Healthcare Quality Promotion, recently gave an overview in a webinar hosted by one of the project’s sponsors, the American Medical Association. There are some questions and confusion regarding masks, N95 respirators, or the lack thereof.2

“Full disclosure: We are painfully aware of the supply chain challenges that many of the facilities are experiencing,” Bell said. “It is a very frustrating situation in the context of something like the COVID-19 pandemic.”

Given the supply limitations, particularly of N95s, Bell said the CDC resorted to crisis standards.

“There are certain things where you should always be using an N95, assuming you have them,” he explained. “There are currently recommendations that say if, for any reason you are not able to use respirators in a single-use disposal kind of way, we have available crisis standards that are not intended to be normal practice.3,4 But if you are up against the wall and you are needing to do something, we have suggestions for how to extend the use of respirators. In other words, keep them on and going from patient to patient, or, if you are absolutely out, using surgical masks as a temporary alternative. They are not as good, but they are definitely better than nothing.”


  1. Centers for Disease Control and Prevention. Project Firstline: CDC’s national training collaborative for healthcare infection prevention and control.
  2. American Medical Association. Episode 3: Project Firstline: CDC’s new national training collaborative for infection control. Oct. 29, 2020.
  3. Centers for Disease Control and Prevention. Strategies for optimizing the supply of N95 respirators. Updated June 28, 2020.
  4. Centers for Disease Control and Prevention. Strategies for optimizing the supply of facemasks. Updated June 28, 2020.