Discussion

Early in the COVID-19 pandemic, HCP concerns about COVID-19 exposure resulted in broad application of overly cautious practices without differentiation between high- or low-exposure activities. Although pandemic responses necessitated changes in hospital operations (eg, cancelling nonurgent surgeries) to accommodate COVID-19 patients and HCP provided lifesaving care to innumerable patients, our results show that concerns about transmission risk added to procedure delays, cancellations, modifications, and unnecessary PPE use, adversely affecting HCP physical well-being and patient care delivery.

Procedural delays and unexpected cancellations were reported across a wide spectrum of transmission risk, including among those with minimal respiratory transmission risk. Many studies have shown the serious consequences of COVID-19–associated delays on surgical, cancer, cardiac, or diabetes care, underscoring the need to limit COVID-19 prevention practices to those that are truly necessary. ^{Reference Joung, Nelson and Mullett3–Reference Johnson, Waddimba, Ogola, Fleshman and Preskitt6} Preprocedural testing contributed to care delays in large numbers of patients, most of whom did not have COVID-19. ^{Reference Srinivasan, Gohil and Abeles7} Although clinical circumstances can warrant delaying surgery due to COVID-19, positive tests often resulted in reflexive cancellations despite the fact that positive PCRs often indicate convalescent disease and that many surgeries can be safely performed with appropriate PPE. This strategy has remained active in many facilities despite lower frequency and severity of COVID-19 in the postvaccine era and despite highly effective IP protocols. ^{Reference Talbo, Hayden and Yokoe8}

Concerns about aerosolization were similarly pervasive and included avoidance of noninvasive respiratory treatments not known to produce infectious aerosols. Standardized definitions of AGPs that constitute true pathogen transmission risk are needed to prevent exposure concerns from driving broader definitions that could have had untoward consequences. In addition, studies demonstrating real-world effectiveness of PPE and standardized IP processes are needed so that pandemic scenarios do not potentiate unnecessary fear and actions to avoid exposures.

The use of “extra” prevention practices beyond evidence-based strategies can undermine current standards for high-quality, safe patient care and the invaluable HCP care provided in the setting of a pandemic. ^{Reference Alarfaj, Foula and Alshammary9,Reference Galanis, Vraka, Fragkou, Bilali and Kaitelidou10} Our findings of clinical practice modifications suggested that HCP concern about COVID-19 exposure superseded adherence to well-vetted clinical and IP guidelines. We also found that extra PPE layers compromised HCP visibility, mobility, and function with unintended effects on both patient care and HCP health. Investments in HCP education on IP concepts to reduce harms that can inadvertently arise from overuse of precautions are needed.

This study had several limitations. The survey design captured anecdotal experience from a convenience sample of US hospital IP leaders. We did not assess the persistence of these early pandemic experiences, and emotional drivers of such experiences were inferred.

In summary, we found multiple examples of HCP modifying PPE and clinical practices with detrimental effects on patients and HCP across many hospitals, likely driven by excessive caution to avoid exposures. These findings have important implications for pandemic planning and response, including the need to emphasize balanced approaches to precautions, to prioritize HCP educational campaigns to manage safety concerns, and to generate an evidence base that can guide appropriate IP practices.