Correlation of the COVID-19 Infection and Outcomes with Workload among Emergency Healthcare Workers in an Iranian Referral Hospital

1. Introduction

The novel coronavirus pneumonia disease 2019 (COVID-19) outbreak spread out the entire world and became a terrible tragedy. Since the Health Care Professionals (HCPs) carry almost all the burden as the first line and have tolerated a lot of morbidities and mortalities, it is a top priority to prevent intra-hospital transmission ( 1 ). Ample documents have shown that the COVID-19 virus is transmitted via droplets, small 5-10 μm particles, in direct person-to-person contacts ( 2 , 3 ). Although observing social distancing, staying at home, as well as wearing a face mask can reduce the risk of infection ( 4 ), HCPs were subjected to more task load and hours at the workplace ( 5 ). Reports demonstrated that the burden of COVID-19 on HCPs was high COVID-19, raising concerns for global health. Furthermore, COVID-19 infections among HCPs affect personnel’s sick leave ( 7 ). As the HCPs are in the first line of fighting COVID-19, the negligence of their safety as well as their insufficient Personal Protective Equipment (PPE) can easily transmit the disease to others and pose a threat to the healthcare system. Hence, the lack of PPE puts HCPs in danger of infection and more COVID-19 viral loads ( 8 ).

Although plenty of infected cases in Iran are HCPs, there was not enough scientific evidence to demonstrate the estimated cases so far, especially in major hospitals in Iran. Therefore, at Baqiyatollah Hospital in Tehran, the main referral center in Iran, we gathered informative data, including laboratory data, from COVID-19-infected HCPs. This data provided insight into the clinical features of the coronavirus.

It is well accepted that laboratory markers, such as serum erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, increase during inflammatory events. These factors can activate the complement system and raise phagocytosis ( 9 , 10 ). Numerous studies have reported that severe COVID-19 patients expressed significantly higher ESR and CRP levels than their non-severe counterparts ( 11 , 12 ). The current study can be of high importance due to the lack of information regarding the HCP population as the front line of COVID-19 disease in Iran.

2. Materials and Methods

2.1. Data collection

The present study was conducted on 58 HCPs with COVID-19 in the Baqiyatallah Hospital as a reference hospital (Emergency Ward). Data were collected during the first year of the COVID-19 pandemic from February to November 2020. The required data were collected from HCPs, including medical doctors, nurses, healthcare assistants, and administrative personnel. We assessed HCPs who had a positive test result of real-time reverse transcription-polymerase chain reaction (PCR) performed by oropharyngeal swab. Besides, based on the Iranian National Committee for COVID-19, we included patients with a history of COVID-19 manifestations along with Ground-Glass Opacity (GGO) alone or GGO accompanied with consolidation in chest computed tomography (CT) scan. The researchers documented demographic characteristics, symptoms, and underlying health conditions of HCPs, as well as family members' exposure to affected HCPs prior to COVID-19 confirmation. All samples were working in different parts of the Emergency Room (ER). The factor of PPE employment was also considered. The main symptoms (e.g., fever, cough, dyspnea, myalgia, anorexia, and sore throat) were recorded. We calculated the length of stay (LOS) and the interquartile range (IQR) in the present study. The length of stay is a critical indicator of the efficiency of hospital management. To elaborate, a decrease in the number of inpatient days leads to reduced risk of infection and medication side effects, as well as improvement in the quality of treatment. The IQR is the range of values that resides in the middle of the scores. The difference between the upper and lower quartile is known as the IQR. The formula for calculating the interquartile range is as below:

Interquartile range = Upper Quartile – Lower Quartile = Q­3 – Q­1

, where Q1 is the first quartile and Q3 the third quartile of the series ( 13 ).

2.2. Ethical Considerations

The current retrospective study was approved by the Research Ethics Committee of Baqiyatallah University of Medical Sciences, Tehran, Iran (IR.BMSU.REC.1399.240).

2.3. Statistical Analyses

The current data were analyzed using the SPSS software (IBM. SPSS Statistic., version 24.0). The qualitative variables were analyzed using Pearson's chi-square test. Quantitative variables were presented as mean ± standard error of mean (SEM), while qualitative variables were described as frequency and percentage.

3. Results

This study was performed on 58 HCPs of Baqiyatallah Hospital with an age range of 20-59 years. Most cases (n=42, 72.4%) were in 30-49 age group. Among these individuals, 14 subjects (24.1%) were women. Nine (15.5%) individuals had close contact with confirmed COVID-19 patients. In this study, 6 (10.3%) patients were confirmed for COVID-19 by positive PCR tests, 18 (31%) by radiographs (CT scan), and 34 (58.7%) by both positive PCR test and CT scan. Regarding the ward type, 51 (13.1%) patients were the personnel of COVID-19 wards, 43 (11.1%) were the personnel of COVID-19 intensive care unit, and 46 (11.8%) were COVID-19 emergency department personnel.

In our study, HCPs who were on working shifts at the hospital between 30 and 59 h/week contributed to the highest frequency (n=29, 50%). Among the different parts of emergency departments, HCPs who worked in the COVID-19 ICU had the highest rate of infection (72.41%). Table 1 gives information about the frequency of cases (n=58) working in the different sections of the emergency ward of Baqiyatallah Hospital.

The median (IQR) of hospital LOS was 8 days for all patients. The LOS for 34.2% of patients was 1-3 days. Information on sick leave (for COVID-19) is presented in table 2. Only 38 (65.5%) individuals were hospitalized, all of whom were discharged in good condition. There was no death in total. Eleven patients (19%) had more than one underlying disease. Hypertension, diabetes mellitus, irritant gas inhalation injury, coronary artery disease, and hypothyroidism were present in 3 (5.2%), 3 (5.2%), 2 (3.44%), 1 (1.72%), and 1 (1.72%) patients, respectively. Among the underlying diseases, hypertension, diabetes mellitus, and irritant gas inhalation injury were the most common ones. The hospital LOS did not significantly associate with the patients’ comorbidities.

As shown in table 3, of initial symptoms, fatigue (89.7%), muscle pain (84.5%), chilling (79.3%), fever (77.6%), and headache (72.4%) were the most common complaints.

The results of the chest CT scan, which was performed for 51 patients, revealed that all of them had pulmonary involvement in favor of COVID-19. Twelve (21.8%) patients had GGO alone, and 20 (35.7%) had patchy GGO. Lung involvement was mostly reported bilaterally (70.6%) (Table 4). The CT criteria of patients did not significantly associate with the comorbidities. Of the 58 individuals with COVID-19 infection, 33 (57.9%) utilized PPE. Based on current data, the high level of laboratory results was as follows: CRP (53.4%), D-dimer (39.7%), aspartate transaminase and alanine transaminase (34.5%), lactate dehydrogenase (32.8%), ESR (32.8%), prothrombin time (29.3%), lymphopenia (25.9%), creatine phosphokinase (24.1%). In the multivariable analysis, high levels of liver enzymes (P=0.04) and lymphopenia (P=0.01) were significantly associated with LOS. Furthermore, high levels of the patient’s ESR (P=0.022, Pearson chi-square=7.668, df=2) and CRP (P=0.006, Pearson chi-square=10.189, df=2) were significantly associated with lung involvement. The hospital LOS was not significantly associated with the patient’s gender, age, and the type of ward.

4. Discussion

From February 2020 to November 2020, we investigated the hospital database for 58 patients with COVID-19 among the emergency HCPs in Baqiyatallah Hospital in Tehran, Iran. In our hospital, we assessed both symptomatic and asymptomatic HCPs and found that 58 staff were positive for COVID-19 infection. Several studies have reported that HCPs are highly exposed to the COVID-19 infection. In the observational cohort study conducted by Iversenet et al. (2020) to investigate the incidence of infection among the HCPs in Denmark, 1,163 out of 29,295 screened personnel were detected with COVID-19 positive tests. They reported that frontline HCPs in hospitals, including nurses and medical students, were effectively more involved than other HCPs. They also found that the risk of COVID-19 in HCPs was related to exposure to infected patients ( 8 ). Similarly, in a study by Rivett et al., in a UK teaching hospital, of 1,032 asymptomatic HCPs evaluated for COVID-19 infection, 3% were positive. The researchers of the mentioned study noted that people could transmit viruses to others ( 14 ). Furthermore, Kluytmans-van den Bergh et al. evaluated the incidence of COVID-19 among the HCPs of 52 different Dutch hospitals. Of 9,705 HCPs with fever and respiratory symptoms, 6% were positive, accounting for 1% of all staff ( 15 ).

In the present study, HCPs who were on working shifts at the hospital between 30 and 59 h/week formed the highest frequency (n=29, 50%). Moreover, in our study, nurses formed the highest percentage of COVID-19 infection (44.8% of total cases). Our findings were in line with those of a study by Villar et al. demonstrating that nurses spent more time with COVID-19 patients ( 16 ). Additionally, our hospital nurses were under stress because they had to encounter a novel and not well-recognized virus. None of the nurses in our study worked in a similar situation to the COVID‐19 pandemic and they had to adjust to this new condition in a short period. Maybe this is why nurses are more likely to become infected ( 17 , 18 ). Therefore, education and training should focus on increasing HCPs knowledge of COVID-19 infection.

There are various protocols from different countries for PPE access. To give an example, based on a study by Holland et al., all emergency physicians should wear N-95 masks, disposable gloves, isolation gowns, and face shields. Furthermore, avoiding hand-to-face contact is a beneficial measure ( 19 ). The results of A considerable number of prospective observational studies in the UK and USA have revealed that the risk of COVID-19 increased among HCPs with inadequate PPE or reused PPE ( 20 ). In the current study, 57.9% of the infected personnel utilized PPE, such as medical or N95 masks, gowns, gloves, and shields. Hence, one of the probable reasons for the transmission of the disease among HCPs would be their failure to use PPE properly or not observing hand hygiene precautions closely. The second probability of transmission might be not using PPEs during the rest time. Therefore, we suggested that failing to follow the PPE protocols was one of the critical factors that could increase the prevalence of the COVID-19 infection among HCPs.

In our study, the most prevalent comorbidities were diabetes and hypertension. However, the hospital LOS did not significantly associate with the patients’ comorbidities. Similar to our results, Rees et al. also concluded that disease severity was not associated with LOS.

The findings of our research were also indicative of the existence of a relationship between high levels of patient ESR and CRP and longer LOS. We also found that age and gender had no effect on LOS, which is a critical factor in predicting hospital resource needs. Previous results also suggest that neither age nor gender affects LOS ( 13 ). Despite some similarities, our results showed that LOS and its associated factors were different from that published in the literature. For instance, Rees et al. found that every 1-year increase in age was correlated with a rise in patients' LOS ( 21 ). This discrepancy in the findings is not surprising due to the still incomplete knowledge of the COVID-19 infection.

One of the limitations of the present study was related to the restricted sample size from a single center; as a result, the data analysis cannot be representative of the characteristics of COVID-19 healthcare workers. Furthermore, since the study was limited in scope, it might have biases to the analysis. It was revealed that HCPs who had more working shifts were more infected and the ICU of the emergency ward was the most infected part of the ER.

Failure to follow PPE protocols is one of the critical factors that can increase the prevalence of COVID-19 infection in HCPs. Therefore, this critical factor should be addressed by administrative health officials. Most of the HCPs were under 40 years old, which might be justified by the higher frequency of this age group in emergency personnel. Moreover, in the present study, nurses accounted for the highest number of COVID-19 infections. HCPs who had more working shifts were more infected, and the Chemical, Biological, Radiologic, Nuclear, and Explosive section was the most infected area of the ER.

Acknowledgment

Thanks to financial support, guidance and advice from the "Clinical Research Development Unit of Baqiyatallah Hospital (Tehran, Iran) ".

Authors' Contribution

Study concept and design: M. J. B.

Acquisition of data: A. V.

Analysis and interpretation of data: Z. B.

Drafting of the manuscript: Z.B.

Critical revision of the manuscript: M. J. B and Z. B.

Statistical analysis: Z.B.

Ethics

It is declared that all ethical considerations were taken into account in the preparation of the submitted manuscript.

Conflict of Interest

The authors declare that they have no conflict of interest.

Funding

None

References

1. Kalantar SH, Mortazavi SJ, Bagheri N, Manshadi SA, Moharrami A, Ariamloo P, et al. Prevalence of Coronavirus Disease-2019 among Healthcare Workers in Imam Khomeini Hospital Complex in Tehran, Iran. JOTER. 2020; 6: 30-32.
2. Demirjian A, Singh C, Tebruegge M, Herbert R, Draz N, Mirfenderesky M, et al. Probable vertical transmission of SARS-CoV-2 infection. Pediatr Infect Dis J. 2020; 39: 257-60.
3. Goldberg L, Levinsky Y, Marcus N, Hoffer V, Gafner M, Hadas S, et al. SARS-CoV-2 infection among health care workers despite the use of surgical masks and physical distancing—the role of airborne transmission. OFID. 2021; 8(3):ofab036.
4. Wang Y, Tian H, Zhang L, Zhang M, Guo D, Wu W, et al. Reduction of secondary transmission of SARS-CoV-2 in households by face mask use, disinfection and social distancing: a cohort study in Beijing, China. BMJ Glob Health. 2020; 5:e002794.
5. Shoja E, Aghamohammadi V, Bazyar H, Moghaddam HR, Nasiri K, Dashti M, et al. Covid-19 effects on the workload of Iranian healthcare workers. BMC Public Health. 2020; 20: 1-7.
6. Dzinamarira T, Murewanhema G, Mhango M, Iradukunda PG, Chitungo I, Mashora M, et al. COVID-19 prevalence among healthcare workers. A systematic review and meta-analysis. Int J Environ Res Public Health. 2022; 19: 146.
7. Park SH. Personal protective equipment for healthcare workers during the COVID-19 pandemic. JIC. 2020; 52:165.
8. Iversen K, Bundgaard H, Hasselbalch RB, Kristensen JH, Nielsen PB, Pries-Heje M, et al. Risk of COVID-19 in health-care workers in Denmark: An observational cohort study. Lancet Infect Dis. 2020; 20: 1401-8.
9. Yaseri M, Mortazavi Khatibani SS, Naeimi A, Fayazi HS. Association between C-Reactive Protein Test Result and Clinical Characteristics in Patients with COVID-19. Med Lab J. 2022; 16(6):20-5.
10. Rainer TH, Chan CPY, Leung MF, Leung W, Ip M, Lee N, et al. Diagnostic utility of CRP to neopterin ratio in patients with acute respiratory tract infections. J Infect. 2009; 58(2):123-30.
11. Gershov D, Kim S, Brot N, Elkon KB. C-Reactive protein binds to apoptotic cells, protects the cells from assembly of the terminal complement components, and sustains an antiinflammatory innate immune response: implications for systemic autoimmunity. J Exp Med. 2000; 192(9):1353-64.
12. Coster D, Wasserman A, Fisher E, Rogowski O, Zeltser D, Shapira I, et al. Using the kinetics of C-reactive protein response to improve the differential diagnosis between acute bacterial and viral infections. Infection. 2020; 48(2):241-8.
13. Angulo FJ, Finelli L, Swerdlow DL. Estimation of US SARS-CoV-2 infections, symptomatic infections, hospitalizations, and deaths using seroprevalence surveys. JAMA network open. 2021; 4(1):e2033706- e2033706.
14. Rivett L, Sridhar S, Sparkes D, Routledge M, Jones NK, Forrest S, et al. Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission. Elife. 2020; 9: e58728.
15. Kluytmans-van den Bergh MFQ, Buiting AGM, Pas SD, Bentvelsen RG, van den Bijllaardt W, van Oudheusden AJG, et al. Prevalence and clinical presentation of health care workers with symptoms of coronavirus disease 2019 in 2 Dutch hospitals during an early phase of the pandemic. JAMA Netw Open. 2020; 3: e209673.
16. Villar RC, Nashwan AJ, Mathew RG, Mohamed AS, Munirathinam S, Abujaber AA, et al. The lived experiences of frontline nurses during the coronavirus disease 2019 (COVID‐19) pandemic in Qatar: A qualitative study. Nurs Open. 2021; 8: 3516-26.
17. Park CL, Russell BS, Fendrich M, Finkelstein-Fox L, Hutchison M, Becker J. Americans' COVID-19 stress, coping, and adherence to CDC guidelines. J Gen Intern Med. 2020; 35: 2296-2303.
18. Mo Y, Deng L, Zhang L, Lang Q, Liao C, Wang N, et al. Work stress among Chinese nurses to support Wuhan in fighting against COVID‐19 epidemic. J Nurs Manag. 2020; 28: 1002-9.
19. Holland M, Zaloga DJ, Friderici CS. COVID-19 Personal Protective Equipment (PPE) for the emergency physician. Vis J Emerg Med. 2020; 19: 100740.
20. Nguyen LH, Drew DA, Graham MS, Joshi AD, Guo CG, Ma W, et al. Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study. Lancet Pub Health. 2020; 5: e475-83.
21. Rees EM, Nightingale ES, Jafari Y, Waterlow NR, Clifford S, Pearson CA, et al. COVID-19 length of hospital stay: a systematic review and data synthesis. BMC Med. 2020; 18: 1-22.