To the Editor:
Because of the combined stressors of critically ill patients, limited resources, and increased personal risk, the well-being of frontline health care workers has emerged as an issue of critical importance in the coronavirus disease 2019 (COVID-19) pandemic.1 , 2 To better understand these conditions and their effects, we surveyed a nationwide cross-section of emergency medicine attending and resident physicians.
We obtained a convenience sample of US emergency physicians through the Emergency Medicine Residents’ Association e-mail distribution list. The survey included questions covering 4 topics: demographics, workplace environment, COVID-19 exposure, and a validated instrument on burnout and professional well-being, the Stanford Professional Fulfilment Index. Survey data were collected from April 29 to May 13, 2020.3
Approximately 7% of survey recipients opened the survey email with 443 participants beginning the survey. We excluded 75 incomplete submission and 72 submissions by medical students leaving 296 completed surveys for analysis. Further demographic information can be found in Appendix E1 (available online at http://www.annemergmed.com). Regarding pandemic work conditions, 39% of respondents were moderately or extremely concerned for their safety in the workplace (Appendix E1 [Table 2], available online at http://www.annemergmed.com). Personal protective equipment reuse was reported by 93% of respondents. Two thirds (66%) of respondents reported that they had rationed medical resources other than personal protective equipment; among this subset, 69% had rationed medications, 39% had rationed noninvasive ventilation, and 21% had rationed ventilators. Of all respondents, 26% reported having had symptoms of COVID-19, 26% had been tested, and 7% had tested positive for it. Median Professional Fulfilment Index scores were consistent with work exhaustion and burnout.
We report several key differences in measures for respondents practicing in self-reported COVID-19 hot spots. Not surprisingly, a greater proportion of physicians in hot spots had rationed medical resources compared with non–hot spot respondents (82% versus 56%) (Table 1 ). Of physicians in hot spots who had rationed resources, 35% had rationed ventilators compared with 10% of non–hot spot respondents. Emergency physicians in hot spots also had a higher positive test-result rate for COVID-19: 40% of those tested in hot spots tested positive, whereas 17% of those tested had positive results in non–hot spots. The kind of COVID-19 test used was not specified by respondents.
Table.
Work environment and COVID-19 exposure stratified by hot spot.
| Hot Spot |
Difference in Proportion (95% CI) | ||
|---|---|---|---|
| Yes, N=114, |
No/Unsure, N=180 |
||
| No. (%) | No. (%) | ||
| Adequate supply of personal protective equipment | |||
| No | 40 (35) | 55 (31) | 4.5 (–6.5 to 15.6) |
| Yes | 74 (65) | 125 (69) | |
| PPE reuse | |||
| No | 5 (4) | 16 (9) | 4.5 (–1.1 to 10.1) |
| Yes | 109 (96) | 164 (91) | |
| Equipment reused∗† | (N=109) | (N=164) | |
| Glasses/goggles/face shields | 97 (89) | 148 (90) | 1.3 (–6.2 to 8.6) |
| Surgical mask | 45 (41) | 112 (68) | 27.0 (15.3 to 38.7) |
| N95/p100/etc | 102 (94) | 160 (98) | 3.9 (–1.2 to 9.1) |
| Gowns | 34 (31) | 32 (20) | 11.7 (1.1 to 22.3) |
| Rationing of resources‡ | |||
| No | 21 (18) | 79 (44) | 25.7 (15.5 to 35.9) |
| Yes | 93 (82) | 100 (56) | |
| Items rationed∗† | (N=93) | (N=100) | |
| Ventilator | 32 (34) | 8 (8) | 26.4 (15.4 to 37.4) |
| Noninvasive ventilation | 43 (46) | 33 (33) | 13.2 (0 to 26.9) |
| Medication | 66 (71) | 67 (67) | 4.0 (–9.1 to 17.0) |
| Staff attention | 69 (74) | 49 (49) | 25.2 (12.0 to 38.4) |
| Other medical supplies | 52 (56) | 41 (41) | 14.9 (1.0 to 28.9) |
| Dedicated COVID-19 area of ED‡ | |||
| No | 47 (42) | 60 (34) | 8.4 (–3.2 to 19.9) |
| Yes | 65 (58) | 119 (67) | |
| Are you aware of any existing institutional policies regarding the residents’ role in the care of known or suspected COVID-19 at your hospital(s)?‡ | |||
| No | 35 (31) | 61 (34) | 3.6 (–7.4 to 14.5) |
| Yes | 79 (69) | 117 (66) | |
| Are residents permitted to provide face-to-face care for patients with known or suspected COVID-19 at your institution?‡ | |||
| No | 4 (4) | 22 (12) | 9.0 (3.1 to 15.0) |
| Yes | 109 (96) | 153 (88) | |
| Are residents permitted to intubate patients with known or suspected COVID-19 at your institution?‡ | |||
| No | 20 (18) | 51 (29) | 11.1 (1.3 to 20.9) |
| Yes | 91 (82) | 124 (71) | |
| Are residents staffing the dedicated COVID-19 area?† | |||
| No | 5 (8) | 28 (24) | 16.5 (6.3 to 26.8) |
| Yes | 59 (92) | 87 (76) | |
| Is resident staffing of the COVID-19 area of the ED voluntary?† | |||
| No | 53 (90) | 66 (76) | 14.0 (2.1 to 25.8) |
| Yes | 6 (10) | 21 (24) | |
| Is attending physician staffing of the COVID-19 area of the ED voluntary?† | |||
| No | 10 (83) | 36 (78) | 5.1 (–19.1 to 29.3) |
| Yes | 2 (17) | 10 (22) | |
| How have your work hours been affected by the COVID-19 pandemic in the last 4 wks? | |||
| Work less | 21 (18) | 67 (37) | |
| Work hours have not changed | 64 (56) | 98 (54) | |
| Work more | 29 (25) | 15 (8) | |
| Unnecessary exposure to possible or confirmed COVID-19 patient?‡ | |||
| No | 77 (68) | 133 (75) | 7.2 (–3.5 to 17.9) |
| Yes | 37 (33) | 45 (25) | |
| What was the situation(s)?∗† | (N=37) | (N=45) | |
| Possible COVID-19 patient | 24 (65) | 39 (87) | 21.8 (3.4 to 40.1) |
| Confirmed COVID-19 patient | 26 (70) | 14 (31) | 39.2 (19.2 to 59.2) |
| Have you provided in-person care for patients who have tested positive for COVID-19? | |||
| No | 4 (4) | 17 (9) | 5.9 (0 to 11.4) |
| Yes | 110 (97) | 163 (91) | |
| Have you had any symptoms of COVID-19 unexplained by other illnesses or cause(s)? | |||
| No | 74 (65) | 144 (80) | 15.1 (4.5 to 25.6) |
| Yes | 40 (35) | 36 (20) | |
| Have you been tested for COVID-19? | |||
| No | 76 (67) | 143 (79) | 12.8 (2.3 to 23.3) |
| Yes | 38 (33) | 37 (21) | |
| Did you test positive or negative?† | (N=37) | (N=38) | |
| Positive | 15 (40) | 5 (14) | 26.0 (6.9 to 45.0) |
| Negative | 23 (61) | 32 (87) | |
| Have you been asked to self-quarantine at any point because of test results, symptoms, travel, or exposures?∗ | |||
| Symptoms | 23 (20) | 15 (8) | 11.8 (3.4 to 20.2) |
| Travel | 3 (3) | 9 (5) | 2.4 (–1.9 to 6.7) |
| Exposure | 7 (6) | 17 (9) | 3.3 (–2.8 to 9.4) |
| Test results | 5 (4) | 5 (3) | 1.6 (–2.9 to 6.1) |
| Not asked to self-quarantine | 80 (70) | 144 (80) | 9.8 (0 to 20.1) |
| Has a family member or loved one tested positive for COVID-19? | |||
| No | 93 (82) | 158 (88) | 6.2 (–2.4 to 14.8) |
| Yes | 21 (18) | 22 (12) | |
| (N=21) | (N=22) | ||
| Within 2 wk before diagnosis | 7 (33) | 5 (23) | 10.6 (–16.1 to 37.3) |
| Within 2 wk after diagnosis | 6 (29) | 2 (9) | 19.5 (–3.3 to 42.2) |
| No contact | 13 (62) | 17 (77) | 15.4 (–11.8 to 42.5) |
CI, Confidence interval; PPE, personal protective equipment.
Totals greater than 100% because more than 1 answer permitted.
Denotes questions that were not presented to all participants but only to select ones according to answers to previous answers. Percentages for these columns represent the percentage of the sample who were in the hot spot or were not in it.
Question presented to all participants but not all responded; if greater than or equal to 5 participants did not respond, revised n=hot spot and n=not hot spot are noted.
Our survey suggests that a concerning proportion of emergency physicians have rationed medications, critical interventions, and basic personal protective equipment during the pandemic. These findings underscore a fact that is intuitive yet warrants emphasis: when COVID-19 caseloads exceed relative clinical capacities, both the safety of physician and the quality of patient care become compromised. Building rapidly scalable clinical capacity and controlling the rate of pandemic spread are critical to avoid future compromise as additional hot spots emerge.
Acknowledgments
The authors acknowledge the Emergency Medicine Residents’ Association (EMRA) Board of Directors for their support of the study; EMRA staff members Todd Downing and Cathey Wise, who facilitated survey distribution; and the residents and faculty of University of Cincinnati and Penn State at Hershey Medical Center for their input with survey design and content.
Footnotes
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Drs. Zalesky, Dreyfus, and Davis hold leadership positions with the Research Committee of EMRA. Cincinnati Center for Clinical and Translational Science and Training grant support (1UL1TR001425-01) allowed access to REDCap.
Supplementary Data
Supplementary Tables and Methods
References
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Supplementary Materials
Supplementary Tables and Methods