PPE Strategies for the COVID-19 Era

The supply of personal protective equipment (PPE) has been uncertain since the start of the COVID-19 pandemic. Months into this healthcare crisis, supply chains are unpredictable as reports of shortages continue. Follow these key strategies for managing PPE:
 

1. Assess supply and burn rate
2. Reduce use of PPE
3. Extend the life of existing PPE
4. Become resourceful to increase supply

Assess Your Supply

The first step in developing a strategy for providing PPE must start with assessing your current inventory and burn rate. The Centers for Disease Control and Prevention (CDC) offers a PPE Burn Rate Calculator that estimates how long your remaining supply of PPE will last based on your average consumption rate.

Part of supply assessment should also include operating room (OR) volume, according to Kyle B. Enfield, MD, FCCM, Director of the Special Pathogens Unit at the University of Virginia. “We are doing daily ‘OR huddles’ to meet on how many surgical cases are scheduled for that day and to assess how that will impact PPE needed for COVID-19 patient rooms.”

At McAllen Medical Center, a community hospital in Texas, staff learned quickly that they were burning through PPE at an alarming rate once they started to see an increase in patients with COVID-19. To help better assess usage, all PPE supplies were consolidated into a storeroom that was staffed by a gatekeeper who tracked the supply for units each day. That exercise provided much better understanding of the hospitals burn rate and—importantly—how each unit differed.

The most important aspect of assessing your supply—Deal with the reality and don’t make assumptions. “If you think you have an order coming, don’t count on it until it physically arrives,” said Dr. Enfield. “Count on your current supply and nothing else.

Reduce Use

Once hospitals have assessed their PPE supply chains, they should implement strategies to reduce the use of PPE without impacting the qualify of care delivered to patients. This often means finding unique ways to limit the number of staff who must don PPE and reducing the need to enter patient rooms unnecessarily.

SCCM’s must-read guide addresses these strategies with real-world examples. Configuring ICUs in the COVID-19 Era is based on experiences from 16 hospitals and their clinicians and other staff members who provide frontline COVID-19 care.

The guide offers strategies that can reduce PPE use, including:

• Developing new processes of care, such as moving monitoring and medication delivery outside the patient’s room
• Rethinking the delivery of respiratory care, pharmacy, and medication management
• Emplacing new processes to protect staff from aerosolized virus contact

Having operated as an Ebola treatment center, Dr. Enfield’s hospital was well positioned to implement such strategies early in the pandemic and build on successes. “We’ve installed huge 48-inch monitors in the room so clinicians can see them without entering a patient’s room. And our ventilator monitors are moved outside the room, so the respiratory therapist doesn’t have to enter unless it’s necessary,” he said.

The hospital was also able to rapidly build on its existing telemedicine system, putting a computer tablet in every patient room. Patients and caregivers can contact each other easily through a secure link—no room entry required. “We’ve also used it to watch the team prone a patient and be an extra eye for safety issues. The telemedicine component provides an extra level of observation,” he added.

In addition to the detailed examples published in the ICU configuration guide, check out these PPE management strategies from the SCCM COVID-19 Rapid Resource Center and beyond.

• This webcast discusses integrating pharmacists into critical care rounds using telemedicine.
• This article, published in the Journal of Cardiothoracic and Vascular Anesthesia, proposes a procedure for CPR in the ICU that minimizes the number of personnel in the immediate vicinity of the patient. It was shared on this thread in the COVID-19 Discussion Group, where others have been sharing their experiences and innovative ideas to augment ICUs.
• These microlearning presentations and questions address specific topics:
  • Extended Use of Personal Protective Equipment for COVID-19
  • What is recommended regarding the use of personal protective equipment when caring for patients with known or suspected COVID-19?
  • When PPE resources are scarce, which aspect of PPE is most important for healthcare workers’ protection?
  • What are your thoughts on recycling PPE?
  • What PPE are your frontline staff currently using: regular masks, N95s, powered air-purifying respirators, hair covers? What are your challenges with PPE?
  • How is PPE allocated in your hospital? How are decisions made as to when to reuse it and when to discard it
  • What is the current evidence for PPE recommendations and what are some of the conservation strategies being used?
  • What is your perspective on personal safety and PPE availability for nurses?
  • When is a cloth mask, as opposed to a surgical mask, appropriate when dealing with COVID-19 patients or non-aerosol-generating procedures?
  • Non-FDA Approved Respirators

Optimize PPE to Extend Use

In July, the CDC published a continuum of options on what to do when PPE supplies are stressed, running low, or absent. The guidance for PPE generally advises that, in crises, hospitals cancel all elective and non-urgent procedures that typically require PPE. Crisis protocols for specific types of PPE—specifically N95 respirators—call for strategies such as these:

• Using respirators beyond the manufacturer-designated shelf life
• Using respirators approved under standards used in other countries (such standards may not be as rigorous and PPE could be counterfeit)
• Reusing N95 respirators
• Prioritizing the use of N95 respirators by activity

  The CDC’s guide calls out best practices for gowns, eye protection, gloves, and face masks, but to be clear: During any procedure that involves aerosolization, clinicians should use an N95 respiratory mask and eye cover.

Access the Full CDC Guide

How to Obtain More PPE

If you are concerned about supplies of PPE in your area, several organizations can help you or your hospital source this important resource:

• Direct Relief
  • Since January, Direct Relief has delivered more than 12 million N95 and surgical masks, more than 4 million gloves, more than 1 million face shields and tens of thousands of protective suits and other items to help safeguard healthcare workers. SCCM has partnered with Direct Relief on several donation efforts to provide PPE and other supplies to ICUs in hard-hit areas.
• Project N95
  • Project N95 is the National Critical Equipment Clearinghouse for PPE and critical equipment. Frontline and healthcare organizations report their critical equipment needs and suppliers submit information about the products they have available. Then Project N95 conducts sourcing due diligence on all suppliers and products. 
• #GetUsPPE
  • #GetUsPPE is a grassroots movement founded by physicians and medical researchers on the frontlines of the COVID-19 pandemic. It matches need with donated supplies of PPE.
• MasksOn
  • MasksOn provides face shields adapted from snorkel masks for healthcare providers to use as PPE. These reusable face shields are not FDA-cleared or FDA-approved and may be used only when FDA-cleared masks are unavailable; they are designed to provide full-face, sealed protection in which incoming air passes through a standard 15-mm bacterial/viral filter.
• ActionPPE 
  • ActionPPE is a collaborative effort to bring PPE to communities by using group buying power. Launched in South Carolina by the Charleston County Medical Society, many other state medical organization have now joined to give their members the opportunity to connect with reputable and certified PPE suppliers.

Ensure That PPE Is Used Properly

Having an adequate supply of PPE is not helpful if it is not used correctly. Again, look to Configuring ICUs in the COVID-19 Era for guidance on providing donning and doffing best practices, including:

• Assigning zones or designated areas for donning and doffing
• Having a trained observer to ensure safety
• Developing protocols that align with efforts to preserve PPE supplies (e.g., sterilization of N95 masks

“Early on, we conducted in-person training with a pictorial guide each time someone went in and out of a room with PPE. We now have a simplified version of that as our staff have become more educated. We still have buddy checks to ensure the gown goes on correctly, gloves go over the wrist, masks are fitted, etc.” said Dr. Enfield. “Anyone learning or unexperienced still must go through the full training.”

Remember, when it comes to PPE, complacency can kill. Stay vigilant about donning and doffing protocols, and think about the everyday PPE used throughout the hospital. Your cloth or surgical masks are PPE; they should be worn with accordance to proper protocols.

How SCCM Is Addressing PPE Needs

SCCM has provided donations of medication and PPE to hospitals hardest hit by COVID-19 outbreaks. These donations were made possible through a partnership with Direct Relief. Learn more about the supply donations SCCM has made possible.

Most recently, SCCM provided 30 hospitals throughout Arizona, Texas, and Florida with powered-air purifying respirators (PAPRs) and ICU medications. 

“We received an email from SCCM asking if we had a need for supplies. We were surprised and thankful for the outreach. Having these donations is one less thing to worry about. It’s amazing what one email can do,” said Bianca Cruz, BCPS, PharmD, a clinical pharmacy specialist at McAllen Medical Center. “This is an answered prayer during a dark time in my community. These donations will also mean so much to other healthcare providers at my institution.”

SCCM has also been urging action on the national level to increase PPE supplies and sound the alarm on shortages.

In April, SCCM joined 45 specialty organizations stating that PPE is a fundamental expectation for all healthcare professionals. In May, SCCM, as part of the Critical Care Societies Collaborative, called for the activation of the Defense Production Act to produce sufficient PPE. In July, SCCM surveyed its members again about PPE supplies so it can better communicate the latest on-the-ground situation to government leaders and others.

Having proper PPE supply is essential not only to the physical health of critical care clinicians at great risk of contracting and spreading COVID-19 but also to their well-being and mental health. Not having adequate PPE is a contributing stressor at a time when clinicians are being tested on the front lines of this crisis.