A SHEA survey of its research network hospitals in the United States and Canada found that strategies to maintain safety while preserving supplies and delivering care included:

• extended use of disposable respirators beyond one day;
• respirators worn in combination with masks (surgical, cloth) to preserve them;
• storage of disposable respirators by the user in a paper bag between uses;
• reprocessing of disposable respirators via hydrogen peroxide vapor, ethylene oxide, ultraviolet irradiation, or moist heat treatments;
• extended use of disposable gowns;
• self-production of personal protective equipment (PPE), test kits, and testing materials.

In April 2020, the SHEA Research Network collected survey responses from healthcare epidemiologists at 69 healthcare facilities, including 58 from the United States and Canada, and 11 located internationally. “In the ‘other’ field in a question about self-producing test components, 13% of facilities wrote in that they were self-producing PPE, such as face shields and gowns, due to shortages,” the authors report. “A quarter of facilities were self-producing testing components, such as swabs, transport media, and collection tubes.”

The survey did not assess the time and resources that were required to research and implement these strategies.

“However, the burden of doing this across settings, types of procedures, patients, healthcare roles, and local circumstances represents substantial opportunity cost at a time when healthcare facilities were under strain to prepare for, mitigate, and respond to the pandemic,” the authors noted. “These challenges also include implementing unfamiliar practices for [healthcare personnel], such as long durations of extended use of disposable respirators and gowns.”

In a finding that informs this self-reliant approach, 40% of respondents said their supply of respirators was “limited” or at “crisis level.” Nine (15%) respondents assessed their supply as “sustainable for the pandemic,” and 27 (45%) said it was “adequate for the current situation.”

Approximately two-thirds of facilities reported receiving ethical guidance from their institutions regarding PPE contingency strategies, potential therapies for COVID-19, patient triage, equipment modifications, and visitor policies.

“Only about one-third of survey participants had received ethical guidance from states and professional societies in these areas,” the authors reported. “PPE contingency strategies was the topic that facilities said they had most frequently sought and received ethical guidance.”

Regarding testing, 52 (81%) of 64 facilities reported having access to in-house testing for COVID-19. Among 51 facilities that indicated the turnaround time for COVID-19 diagnostic test results, 22 (43%) reported it was less than six hours; 10% reported a range of seven to 12 hours; 10% reported 13 to 24 hours; and 18% reported longer than 24 hours.

Overall, 18 respondents (26%) indicated that they self-produced test components because of shortages. Of these, 13 (72%) produced viral transport media, 11 (61%) made their own viral collection swabs, and three (16%) produced collection tubes as a result of shortages. “The vast majority (81%) reported having access to in-house testing for COVID-19,” they concluded. “Sixty-four percent of facilities reported testing asymptomatic patients prior to certain procedures.”

AMA Pleads for PPE

In a related development, the American Medical Association (AMA) sent a letter on June 30, 2020, to federal emergency officials expressing “ongoing concern over the availability of PPE, specifically for clinicians in office-based settings.”²

“We understand that PPE and other critical infection control supplies have been directed towards COVID-19 hotspots and to facilities treating infected patients, and we have supported the Administration’s efforts to send supplies where they are most needed,” the AMA states. “However, as non-hospital-based physicians return to work and reopen their practices, the need for these supplies is rapidly expanding to other care sites.”

Although many physician practices have been shuttered in the transition to telemedicine, in-person visits are returning as offices reopen.

“While it is critical to the long-term viability of these practices to resume office visits, the serious threat of COVID-19 infection persists and it is essential that physicians and their staff institute proper infection control protocols and procedures in their practices,” the AMA emphasized. “However, strains on the supply chain for PPE and disinfectant products continue, and they simply are not readily available from the usual sources our physicians use. We are hearing significant and growing concern from our member physicians that they cannot secure needed supplies to safely reopen and that they are unsure where to turn for further guidance and assistance.”

The AMA suggested the Federal Emergency Management Agency create a “clearinghouse on a regional, state, or local level to provide such information to providers in one easy-to-access location.”

REFERENCES

1. Calderwood MS, Deloney VM, Anderson DJ, et al. Policies and practices of SHEA Research Network hospitals during the COVID-19 pandemic. Infect Control Hosp Epidemiol 2020; June 23. doi:10.1017/ice.2020.303. [Online ahead of print].
2. American Medical Association. Letter to the Federal Emergency Management Agency. June 30, 2020. https://searchlf.ama-assn.org/undefined/documentDownload?uri=/unstructured/binary/letter/LETTERS/2020-6-30-Letter-to-Gaynor-re-PPE.pdf