Two different national surveys have found widespread shortages of personal protective equipment (PPE) and other critical hospital supplies as the United States battles the highest number of COVID-19 cases in the world. The findings come amid reports of novel coronavirus infections and deaths in healthcare workers, including at least one emergency physician and one nurse.1,2 There were also anecdotal reports of healthcare workers quitting work or threatening to do so if they are not going to be protected.

As this story was filed, there were reports of manufacturers ramping up PPE production, generating some hope that the chaotic situation could be resolved as the pandemic entered a critical and deadly phase in the United States.

The Association for Professionals in Infection Control and Epidemiology (APIC), which conducted a national survey of infection preventionists (IPs), is demanding the federal government act to protect both patients and frontline healthcare workers.

“This is simply unacceptable,” said APIC CEO Katrina Crist, MBA. “Shortages of critical PPE and disinfection supplies are jeopardizing our ability to safely treat patients and protect healthcare workers, who put their lives on the line every day.”

APIC issued a call to action along with its survey results at a March 27, 2020, press conference.

“APIC is urging the federal government to act now,” Crist said. “We are asking for clear communication. We need clarity on when the supplies are coming — when and where. So, in addition to asking the federal government to use all of the powers at their disposal to increase the supply — especially of respirators — we need clear communication.”

Similar findings were revealed in an Inspector General (IG) report of a phone survey conducted in late March.3

“Hospitals reported that widespread shortages of PPE put staff and patients at risk,” the report stated. “Hospitals reported that heavier use of PPE than normal was contributing to the shortage and that the lack of a robust supply chain was delaying or preventing them from restocking PPE needed to protect staff. Hospitals also expressed uncertainty about availability of PPE from federal and state sources and noted sharp increases in prices for PPE from some vendors.”

Likewise, the IG report found a demand for clear and consistent communication, as “inconsistent guidance from federal, state, and local authorities posed challenges and confused hospitals and the public.”

Hospitals reported that it was sometimes difficult to remain current with Centers for Disease Control and Prevention (CDC) guidance, which has been evolving as the dynamics of the pandemic change, the IG report noted. For example, healthcare workers are particularly concerned about a change in the CDC recommendations, which said wearing a surgical mask with a face shield for COVID-19 patients was acceptable if N95 respirators were unavailable. The CDC said the action was temporary, in part to save N95s for aerosol-generating procedures. (See Figure 1.)

Conflicting Guidance, Misinformation

Respondents to the IG report cited “conflicting guidance from different government and medical authorities, including criteria for testing, determining which elective procedures to delay, use of PPE, and getting supplies from the national stockpile. Hospitals also reported concerns that public misinformation has increased hospital workloads (e.g., patients showing up unnecessarily, hospitals needing to do public education) at a critical time.”

Although more rapid tests are coming on the market, the IG survey reflected some of the confusion and mixed messaging on coronavirus testing, which has gone through a series of exasperating changes, from largely unavailable, announced and delayed, and then rolled out as if anybody could be tested. A shortage of testing reagents, swabs, and viral transport media followed in some areas, exacerbated by concerns of using scarce PPE during testing that is needed by frontline staff.

“Hospitals reported that they were unable to keep up with COVID-19 testing demands because they lacked complete kits and/or the individual components and supplies needed to complete tests,” the IG report found. “Additionally, hospitals reported frequently waiting seven days or longer for test results. When patient stays were extended while awaiting test results, this strained bed availability, PPE supplies, and staffing.”

The testing issue also created a bottleneck in the continuum, as some long-term care facilities were refusing to take in hospital discharges until they had a negative COVID-19 test.

“Hospitals reported needing items that support a patient room, such as intravenous therapy poles, medical gas, linens, toilet paper, and food,” the IG survey found. “Others reported shortages of no-touch infrared thermometers, disinfectants, and cleaning supplies. Isolated and smaller hospitals faced special challenges maintaining the supplies they needed and restocking quickly when they ran out of supplies.”

Running on Empty

The APIC survey of IPs was conducted between March 23 and March 25, netting 1,140 responses in all states and the District of Columbia. Of those, 233 (20%) reported their facilities had no respirators and an additional 317 (28%) said they were “almost out.” Nearly half (49%) of the respondents said they do not have enough face shields and 13% are completely out. Regarding mask supply, nearly one-third (31%) of respondents are almost out or completely out.

APIC called for immediate activation of the Defense Production Act, a 1950 law that gives the federal government broad powers to direct production of critical materials.

“The federal government must act now to produce more PPE and coordinate distribution where it is needed most,” said APIC president Connie Steed, MSN, RN, CIC, FAPIC. “Every minute wasted puts more lives at risk. We are asking healthcare providers to risk their own health and their families’ health to care for us.”

Supplies in the U.S. Strategic National Stockpile have been dispensed in some areas, but the consensus is that these reserves will not be sufficient and new production on a mass scale is needed to meet the novel coronavirus threat. APIC sought clarity on this issue and other aspects of the pandemic response.

“There seems to be some con-fusion about the distribution and even in some pockets of the country, how to get access to the stockpile,” said Steed, director of infection prevention and control at Prisma Health in Greenville, SC. “The role of the IP as a coach, mentor, and leader in our hospitals has never been more important. I know, as a frontline infection preventionist in the facilities where I work, how challenging this role is, but it is vital for us to help our providers every day to get through this trying time.”

APIC President-Elect Ann Marie Pettis, RN, BSN, CIC, FAPIC, is director of infection prevention at the University of Rochester, NY.

“In New York hospitals, we are being overrun with COVID-19 patients,” Pettis said at the press conference. “Given how rapidly this virus is spreading, other states and facilities will soon face the same situation. Our survey shows that the supply shortages are widespread throughout the country. Every hospital out there is concerned about putting patients and healthcare workers at unnecessary greater risk.”

The situation could create a crisis of confidence in healthcare workers, she adds. “The situation is causing health-care personnel to lose faith in our guidance as IPs, as well as losing faith in the whole healthcare system,” she says. “How can we ask healthcare workers to take care of us when we really are not taking care of them?”

The Rochester community has stepped up to donate masks and create homemade ones for the hospital, she says. The donations have created a stockpile for the facility that will be drawn on as needed if medical masks run out, Pettis says.

“We are holding on to those and with the idea that our first use would be for loved ones that have to come in and see a COVID patient or for patients themselves,” she said. “We would send patients home with one of the homemade masks — we launder those before we hand them out.”

The hospital has adopted the increasingly common practice of wearing surgical masks over N95 respirators, which protects them from getting contaminated and preserves future use.

“Eventually we could come to using the homemade masks even for our staff,” Pettis said. “We hope it does not come to that because we don’t know what the efficacy of those masks would be. But desperate times call for desperate measures.”

Fear and Science

Some practices may have to be based less on science than the mitigation of fear, Pettis added.

“As this ramps up, our staff is getting understandably more and more fearful,” she said. “We’re probably going to institute universal masking. In other words, every time staff come into work, we are going to offer them a new mask each day whether they are taking care of COVID patients or not. We are hoping soon to provide one N95 mask to everybody that would like that one. Again, it’s not scientific, but we have to give them the feeling that they are safe because their families are so worried about them coming to work.”

Torree McGowen, MD, FACEP, an emergency physician at St. Charles Medical Center in Bend, OR, is starting to see the first wave of coronavirus infections in her area.

“I am definitely concerned,” she says. “My husband is immunosuppressed, so I shower and change clothes before I leave work. I am trying very hard to stay away from my family and we are strictly socially isolating. I am not going anywhere but work, home, and then the bare minimum that we need to do [in the community].”

Will some healthcare workers consider their safety and that of their families a higher priority than reporting for duty and caring for COVID-19 patients?

“My prayer is that doesn’t happen,” Steed said. “I think our healthcare providers are resilient and many of them went into this field to care for others. I trust — if we do everything we can, which is what APIC is trying to do — if we protect our healthcare workers, they will be more comfortable caring for sick patients. That’s why taking action now is so vital. We don’t want to end up with healthcare providers refusing to work.”

Although personal risk is part of the high calling to healthcare, those who deliver it day in and day out are by no means immune to fear. “We have the same fears that everybody else has,” says Wendy Dean, MD, CEO and co-founder of Moral Injury of Healthcare in Carlisle, PA. “We have been kind of acculturated to manage the risk and the fear of the work that we face. We face all kinds of infectious risks all the time. The difference is that typically when we are facing those, they are known entities. We know what the algorithms are for treatment or for mitigation. The difference for coronavirus is that we don’t know any of that. It is an outsized risk, and as with anything else, we are more comfortable dealing with the known — even if it is high-risk — than dealing with the unknown. But we are going to face down that risk and do our jobs, because that is what we have trained to do.”

REFERENCES

  1. American College of Emergency Physicians. ACEP mourns loss of first emergency physician to COVID-19. Published April 1, 2020. https://www.emergencyphysicians.org/press-releases/2020/4-1-20-acep-mourns-loss-of-first-emergency-physician-to-covid-19
  2. Saliba E. ‘There's only going to be more’: NYC nurse dies after contracting coronavirus. NBC News. Published March 26, 2020. https://www.nbcnews.com/health/health-care/there-s-only-going-be-more-nyc-nurse-dies-after-n1169586
  3. U.S. Department of Health and Human Services. Office of Inspector General. Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020. https://oig.hhs.gov/oei/reports/oei-06-20-00300.pdf