key: cord-0717303-qrri3gzu
authors: Parmasad, Vishala; Keating, Julie A.; Carayon, Pascale; Safdar, Nasia
title: Physical Distancing for Care Delivery in Healthcare Settings: Considerations and Consequences
date: 2020-12-24
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2020.12.014
sha: f10e29a231f537211ffd4b22ca8d690c9d2abbb9
doc_id: 717303
cord_uid: qrri3gzu

As healthcare systems explore new ways of delivering care for patients with and without COVID-19, they must consider how to maintain physical distancing among healthcare workers and patients. Physical distancing in high complexity systems such as healthcare is particularly challenging and may benefit from a human factors and systems engineering perspective. We discuss challenges to implementing and maintaining physical distancing in healthcare settings and present possible solutions from a human factors and systems engineering perspective.

With few evidence-based pharmaceutical interventions approved for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), healthcare workers and patients need effective and reliable methods to mitigate viral transmission in healthcare settings. Physical distancing, also known as social distancing, is an effective non-pharmaceutical intervention that involves maintaining a distance in the physical space between individuals to decrease viral transmission. 1 Public health agencies currently recommend a physical distance of 2 meters (6 feet) to decrease SARS-CoV-2 spread. 1, 2 There is growing acknowledgement that SARS-CoV-2 aerosols can also spread via the airborne route in some circumstances, and in those situations, physical distancing of more than 2 meters may be warranted. [ 2 ] In healthcare settings, while physical distancing is critical to prevent SARS-CoV-2 transmission, , [ 3 ] it poses challenges and may produce unanticipated negative consequences. The complexity of healthcare institutions thus requires a systems approach. Here we present recommendations to mitigate the negative consequences of physical distancing in healthcare institutions, using a human factors and systems engineering framework.

Healthcare systems are highly intricate sociotechnical environments that function by integrating multiple individuals in the performance of tasks using varied technologies, in delimited physical environments, under specific and often challenging organizational conditions.[ 4 ] One example of a human factors and systems engineering approach, the Systems Engineering Initiative for Patient Safety (SEIPS) model of healthcare work systems (Figure 1 ), comprehensively incorporates all work system elements (i.e., external environment, technology/tools, tasks, organization, and person). The SEIPS model enables the identification of modifiable factors within individual work systems which can affect care processes and outcomes. [ 5, 6 ] The core human factors principles of the SEIPS model include its systems orientation, person-centeredness, and design-driven improvements.[ 7 ] SEIPS is especially wellequipped to understand and adapt healthcare work systems to physical distancing requirements given its successful application to occupational health and safety and quality improvement initiatives in various care healthcare settings. [ 5, 6 ] In Table 1 , we use the SEIPS model is used to identify challenges of physical distancing interventions in healthcare settings, their potentially negative consequences, and possible mitigation approaches.

The rapidly evolving literature on the current COVID-19 pandemic has highlighted that the traditional 6-foot physical distancing recommendation should be interpreted in the context of emerging data on the physics of respiratory emissions. 2, 8 The 6 foot distance does not account for the effect on viral particle spread of environmental conditions such as ventilation, airflow patterns or types of activity, or patient specifics (e.g. viral load of emitter, duration of exposure, individual susceptibility), 2 nonetheless, keeping a minimum of 6 feet distance is an important strategy among the suite of NPI solutions for preventing SARS-Co-V2 transmission.

Physical distancing falls within two tiers of the traditional NIOSH/CDC occupational hierarchy of controls, preventing exposure by eliminating the hazard in some circumstances, and improving administrative controls in others. The SEIPS model provides a framework for integrating physical distancing recommendations in the healthcare work-system, in Table 1 . The model also allows us to identify the range of stakeholders and actors involved in implementing effective physical distancing: healthcare administrative leadership, clinicians, physical plant, infectious disease teams, and cleaning and environmental control staff. The challenges related to integrating physical distancing recommendations are outlined below.

First is the challenge posed by space limitations. This can be mitigated to some degree by the construction of alternative spaces (e.g. external tents for ED triage), the reassigning of existing spaces to meet needs (e.g. offices for call-rooms), and the cohorting of confirmed COVID-19 patients in shared rooms if necessary.

The second challenge is the efficient and continued provision of care. For example, one human factors and systems engineering measure to reduce pandemic exposure involves decreasing the total number of persons frequenting healthcare settings by postponing nonurgent patient appointments, reducing the numbers of on-site HCW, and restricting visitors.

Potential negative consequences of these interventions may impact HCW and patients in all care settings. Outpatients whose care has been deferred may experience deterioration in their medical conditions, while inpatients may experience less attentive and integrated care. The remaining on-site HCW might also be negatively affected by decreases in supportive care, e.g.

nursing, leading to lowered efficiency.

A third challenge relates to the psychological consequences of physical distancing on patients and HCW. Physical isolation can have severe mental health consequences on already ill patients, due to fewer interactions with HCW and visitors in a pandemic. Measures to increase the feasibility of physical distancing in healthcare settings can also decrease the psychological supports for the remaining HCW, leading to increased stress and burnout.

Many of these challenges can be alleviated by using technology to our advantage within SEIPS work system components (Table 1) . Ultimately, all measures and strategies should be evaluated within the context of individual work systems to determine their feasibility. In the context of an evolving pandemic, there is likely to be no "one size fits all" suite of solutions to the challenges of effectively mitigating viral transmission in healthcare settings. The holistic systems approach of the SEIPS framework is useful to describe the interactions between work system components that are important for integrating physical distancing interventions, maintaining healthcare delivery, and anticipating potential unwelcome consequences.

The COVID-19 pandemic has disrupted healthcare delivery in an unprecedented manner, the effects of which will be long-lasting. Physical distancing will remain an important 

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