Hospitals are reporting inordinately high “burn rates” of personal protective equipment (PPE), as healthcare personnel are exposed to nonstop media coverage of panicked shoppers and grim-faced public health officials.
“Our PPE is flying off the shelves,” said Michael Anne Preas, RN, senior director of Infection Prevention and Hospital Epidemiology at the University of Maryland Medical Center in Baltimore. “Our burn rate is so much higher than our actual need rate because of the public perception that everyone is going to die. There is this perception among our healthcare force that COVID-19 is going to be their demise.”
Preas commented on the situation at a recent infection control advisory committee meeting at the Centers for Disease Control and Prevention (CDC). Some level of fear can be ascribed to the lack of infection prevention training in many healthcare personnel, said Michael Bell, MD, deputy director of the CDC Division of Healthcare Quality Promotion.
“We have major gaps in infection transmission training and teaching, ranging from medical schools to nursing schools,” he said. “I hate to say it, but what we are seeing now is the result of a very long problem of neglecting that part of our education.”
One of the lessons of this pandemic is that infection control education should be emphasized in all medical and nursing training.
“I think we need to be asking ourselves what should we be doing for our existing staff, and also for the people coming through this process, to make sure for the next one of these — and there will be a next one — we don’t have such a heavy lift to do,” Bell said.
However, some of the fear and concern expressed by healthcare workers may be their perception that they do not have sufficient supplies of PPE in their facilities to protect themselves while treating patients.
National Nurses United found evidence of this in a recent survey of 1,000 registered nurses in California.1 The survey found that:
- Only 27% of respondents said there is a plan in place to isolate a patient with a possible novel coronavirus infection. Another 47% reported they don’t know if there is a plan.
- Overall, 73% percent reported that they have access to N95 respirators on their units. In addition, 47% reported access to powered air purifying respirators (PAPRs) on their units.
- Only 27% reported that their employer has sufficient PPE stock on hand to protect staff if there is a rapid surge in patients with possible coronavirus infections.
A common theme in pandemic planning is ensuring a supply of PPE, which means frequently talking to distributors and clamping down on hoarding and indiscriminate use within facilities.
“When the virus first started surfacing, everybody wanted an N95 [respirator], and as you and I know, you probably saw boxes, cases, or pallets of N95s going out the back door,” said Skip Skivington, MBA, vice president of healthcare continuity and support services at Kaiser Permanente. “We have heard incredible stories of people willing to pay $100 of their own money for a box of — not even N95s — surgical masks. We are seeing the burn rate on our surgical masks going up much higher. We have put in pretty aggressive techniques to try to control the flow.”
Similarly, JoAnn Shea, ARNP, MS, COHN-S, director of employee health and wellness at Tampa General Hospital, decided with her colleagues to secure supplies to ensure they were not being used indiscriminately or taken home. Some are put out in each needed area, but unit managers have the full inventory under lock and key.
In another conservation measure, workers who use N95 respirators for tuberculosis (TB) patients were given plastic bags to cover and reuse them, allowing reuse with the same patient for up to 12 hours. This practice cannot be done for COVID-19, because it can spread from contact and surfaces as well as droplets.
“Before, everybody was putting on the N95 [for TB patients] and then throwing them away,” Shea says.
Likewise, fit-testing for N95s has been expanded to groups not normally targeted for such respiratory protection, like physical rehabilitation workers and clinicians caring for pregnant women and newborns.
“Just in case we get a pregnant mom or infant with coronavirus, we did just-in-time training for [healthcare personnel],” she says. “Also, not all of our security guards were fit-tested. They had a few designated [who] could go into a patient’s room, but now because of this we have fit-tested all of the security guards.”
Respirator fit-testing also was done in all 17 ambulatory care clinics, where patients with respiratory symptoms are being screened on the phone if possible. “We had to increase our fit-testing quite a bit,” Shea says.
In assessing mask and respirator use in the hospital, Shea and colleagues found a lot of staff were wearing N95 respirators in areas and situations where the gear is unnecessary. The respirators are primarily indicated for suspected TB cases, who are placed in airborne isolation rooms.
“At any one time, we have two or three airborne precautions patients with potential TB,” she says. “Most of them are rule-out patients. Last year we had six TB patients out of 232 with potential TB. So, most were not TB, but you have to wear the N95s.”
However, efforts to limit the number of workers going into the room can preserve respirators, for example when physicians take a large group of medical students into an airborne isolation room.
“We are asking the medical staff to only have people go into the room who have to care for the patient,” Shea says.
CDC guidelines for extending respirator supplies for the emerging novel coronavirus include excluding or limiting patient visitors and consider cohorting patients or staff.
“Another strategy is to limit face-to-face encounters with the patient. For example, healthcare personnel may consider bundling care activities to minimize room entry,” said Marie de Perio, MD, an epidemiologist at the CDC’s National Institute for Occupational Safety and Health. Speaking at a CDC webinar on extending supplies of respiratory equipment, de Perio said use a standard face mask — not an N95 respirator — as source control on a suspected COVID-19 patient. Regarding cohorting, when single patient rooms are not available, patients with confirmed COVID-19 may be placed in the same room, she said.
“Cohorting healthcare personnel means assigning designated teams to provide care for all patients with confirmed or suspected novel coronavirus,” she said. “This is another strategy that may limit the number of healthcare personnel exposed and who need to use N95s, and it also limits the number of personnel that need to be fit-tested.”
In general, CDC guidelines recommend that healthcare facilities:2
- Minimize the number of healthcare personnel (HCP) who need to use respiratory protection through the preferential use of engineering and administrative controls.
- Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air-purifying respirators, powered air-purifying respirators) where feasible.
- Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable.
- Prioritize the use of N95 respirators for those HCP at the highest risk of acquiring infection or experiencing complications of infection.2
“In times of increased demand and decreased supply, consideration can be made to use N95 respirators past their intended shelf life,” the CDC recommends.
The equipment may degrade under such conditions, and a visible inspection and seal check should be done by the user before donning the equipment. In addition, the CDC allows extended use of N95 respirators on cohorted patients.
“Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters,” the CDC states. “Extended use may be implemented when multiple patients are infected with the same respiratory pathogen and patients are placed together in dedicated waiting rooms or hospital wards.”
- National Nurses United. Nation’s hospitals unprepared for COVID-19. Feb. 28, 2020. https://www.nationalnursesunited.org/press/nations-hospitals-unprepared-covid-19
- CDC. Strategies for optimizing the supply of N95 respirators. Updated Feb. 29, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html