Where masking currently stands in hospitals

After the end of the COVID-19 public health emergency in May, hospitals largely moved away from masking requirements for both patients and staff. Currently, masking rules vary by hospital, with some only requiring them on a case-by-case basis while others require them around certain vulnerable patients, such as those who are immunocompromised.

Now, as COVID-19 cases rise again, some hospitals are reinstating mask mandates. For example, Kaiser Permanente Northern California has reinstated a mask mandate for staff in its Santa Rosa facilities and is encouraging visitors to also wear masks. United Health Services and Upstate Medical Hospitals in New York have also implemented mask mandates, as has UMass Memorial Health in Massachusetts.

Some hospitals, including Stony Brook Medicine, have asked their staff to wear masks, but do not intend to reinstate a mandate for visitors or patients. Others, such as the University of Rochester Medical Center, have said they currently have no plans to reinstate mask mandates.

Hospitals are taking different approaches on a return to masking

Although many health experts say they expect masks to come back at some point, the timing and specific requirements will largely depend on individual hospitals.

Unlike the early days of the pandemic, "there is basically no guidance from the top now," said Saskia Popescu, an epidemiologist and infection-prevention expert at the University of Maryland School of Medicine. Although CDC provides recommendations on when to mask, they're currently tailored to the general public rather than hospitals.

While more specific guidance from CDC or local public health authorities could still be announced, it's assumed that "each hospital is supposed to have its own general plan," said Chanu Rhee, an associate hospital epidemiologist at Brigham and Women's Hospital.

Currently, many hospitals are monitoring viral spread to determine when to implement masking policies. However, it is difficult for hospitals to determine a true rise in cases and what it could mean for their resources and workforce.  

COVID-19 tracking is more patchwork now since many parts of the country no longer regularly monitor or report new cases, especially since many people are either not testing or only testing at home. Although wastewater monitoring can provide some insight into rises in cases, not all areas closely track this measure.

To make up for this lack of data, some hospitals have turned to their own in-house data tracking to determine when masks should be reinstated. For example, Duke University Hospital is considering requiring masks when respiratory viruses account for between 2% and 4% of ED and urgent care visits. At UVA Health, leaders are considering requiring masks when 1% to 2% of employees call out sick.

"It really doesn't take much to have an impact on our ability to maintain operations," said Costi David Sifri, UVA Health's director of hospital epidemiology. However, he also noted that he doesn't "know if those are the right numbers." Just like data from the general public, hospital data may not always be accurate.

Other hospitals with a baseline level of masking have developed a system to return to universal masking if needed.

For example, UChicago Medicine has a color-coded system that goes from teal (masking for high-risk patients, those with symptoms, and those who request it) to red (everyone masks up everywhere). Each week, leaders meet to assess the situation based on community and internal metrics and adjust the organization's masking requirements accordingly.

Although many hospitals plan to determine masking requirements on their own, others are planning to take a more coordinated approach. In North Carolina, Duke is working with both the University of North Carolina at Chapel Hill and North Carolina State University to enact tandem policies.

Similarly, several regional healthcare organizations in Washington state have announced plans to align their masking policies as COVID-19 cases continue to rise. The Veterans Health Administrations has also developed guidance on how to add mitigation policies across its facilities.

Overall, "[a] bespoke approach to hospital masking isn't impractical," The Atlantic writes. "COVID waves won't happen synchronously across communities, and so perhaps neither should policies."

At an individual-level, health experts say that people at high risk of severe disease may want to consider masking again as COVID-19 cases and hospitalizations continue to rise.

"People 65-plus and people who are immunocompromised should strongly consider masking during flu, RSV, COVID season while in indoor public spaces," said Céline Gounder, editor-at-large for public health at KFF Health News. "And for everyone else — it all depends on what their risk tolerance is." (Wu, The Atlantic, 9/6; Hollowell, Becker's Clinical Leadership, 9/6)

To help hospital leadership teams pressure test the comprehensiveness of their COVID-19 response and check for blind spots, we created this scenario planning guide in collaboration with health systems and internal experts. This information should be used as a supplement to, rather than a replacement for, any guidance you receive from federal, state, or local officials.