Latest / The SHEA Podcast / COVID-19: PPE: Conservation & Shortages, 3/26

Transcript

COVID-19: PPE: Conservation & Shortages, 3/26 · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:21
  SPEAKER_02: I am Dr.
• 0:22
  SPEAKER_02: David Bannock, Associate Professor of Medicine and Hospital Epidemiologist at the University of Connecticut School of Medicine Yukon Health, and I'll serve as the moderator for today's podcast.
• 0:31
  SPEAKER_02: Shay is excited to launch the fifth episode of this podcast series, COVID-19 updates of what we know now.
• 0:36
  SPEAKER_02: Today's episode will focus on PPE conservation and shortages.
• 0:41
  SPEAKER_02: Please be aware that discussion on this podcast does not reflect Shay's perspective, but facilitates the communication in multiple different perspectives and experiences as we go through this challenging time together.
• 0:51
  SPEAKER_02: Our speakers for today's podcast are Dr.
• 0:53
  SPEAKER_02: Marcy Drees from Christiana Care Health System and Dr.
• 0:56
  SPEAKER_02: Claire Rock from Johns Hopkins Hospital.
• 0:58
  SPEAKER_02: Thank you both for joining us today.
• 1:00
  SPEAKER_02: Before we hear from our speakers, I wanted to get started with a brief news and guidance update.
• 1:05
  SPEAKER_02: At this point, we have widespread community transmission in the United States.
• 1:09
  SPEAKER_02: As of yesterday, there are 44,183 total cases in the United States and 544 deaths, and 54 jurisdictions across the United States are reporting cases, including all 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S.
• 1:23
  SPEAKER_02: Virgin Islands.
• 1:24
  SPEAKER_02: There are several updates since last week's podcast to bring attention to.
• 1:29
  SPEAKER_02: First is the invocation of the Defense Production Act, which is supposed to create domestic manufacturing capacity in order to address the ongoing shortages of personal protective equipment in the United States.
• 1:39
  SPEAKER_02: Institutions are attempting to conserve and reuse personal protective equipment, adopting various strategies.
• 1:44
  SPEAKER_02: And there are shortages across the country of N95 respirators, surgical face masks, hand sanitizer, test kits, and squads to perform collection of specimens for COVID-19 testing.
• 1:56
  SPEAKER_02: And the CDC now has published strategies for optimizing the supply of personal protective equipment, including eye protection, isolation gowns, face masks, and N95 respirators.
• 2:06
  SPEAKER_02: So I want to introduce our speakers for today's podcast, Dr.
• 2:10
  SPEAKER_02: Rock and Dr.
• 2:10
  SPEAKER_02: Drees.
• 2:11
  SPEAKER_02: Thank you both for joining.
• 2:12
  SPEAKER_02: So the first question I wanted to raise for both of you is really what are the challenges that you're facing at your institution when it comes to local PPE conservation and the shortages that you may be encountering?
• 2:23
  SPEAKER_00: Sure, David.
• 2:24
  SPEAKER_00: It's Claire Locke here.
• 2:26
  SPEAKER_00: I think many of us are facing similar circumstances that are very hard for hospital epidemiologists and infection preventionists to deal with.
• 2:35
  SPEAKER_00: Usually we're in a situation when we're trying to encourage people to use personal protective equipment to prevent transmission of organisms on units.
• 2:44
  SPEAKER_00: And now we're in a situation where there's a shortage of the appropriate personal protective equipment needed to prevent against transmission of COVID-19 amongst our healthcare worker staff.
• 2:55
  SPEAKER_00: And I think this presents huge challenges for us.
• 3:00
  SPEAKER_00: Like many others, we had anticipated that the COVID-19 epidemic was coming and had stockpiled a great deal of PPE ready for the scenario of a pandemic which we find ourselves in.
• 3:15
  SPEAKER_00: I don't think anybody really anticipated the amount and the speed at which personal protective equipment would be used when there was a lot of anxiety related to COVID-19 in the early days of the epidemic.
• 3:30
  SPEAKER_00: And some of that has contributed a little bit to the shortages that we now see ourselves in.
• 3:36
  SPEAKER_00: I think that there's lots of sound recommendations that we can try and give to our healthcare workers to try and overcome these types of situations.
• 3:46
  SPEAKER_00: And the relatively straightforward ones are basically to make sure that they're bundling care when they're entering into any contact precaution room, whether that's one that requires respiratory protection or one that just requires contact isolation.
• 4:04
  SPEAKER_00: And that's really to preserve the PPE across the wide range of contact precaution and other rooms that we see.
• 4:11
  SPEAKER_00: So limiting the personnel going in and out of rooms and really bundling the care is one key way to do that.
• 4:18
  SPEAKER_00: The other thing is really not having trainees pre-round on patients and really not having any medical students or nursing students and limiting the resident interaction with the patients.
• 4:29
  SPEAKER_00: And then other things such as using phones and technology and other communications to be able to communicate in and out to the patient rooms.
• 4:38
  SPEAKER_00: I think the other thing that's key is the conservation of PPE and how we champion that in our different healthcare settings.
• 4:48
  SPEAKER_00: We're basically doing a concept that the people that truly need popper hoods or N95s with face shields, those people that are caring for known COVID patients or suspect COVID patients have what they need.
• 5:02
  SPEAKER_00: And then for the other areas where really they're not caring for people that are known COVID-positive patients or persons under investigation, really thinking through the procedures that those people are doing and the interactions that they're having with these asymptomatic patients and triaging to allocate some PPE where appropriate.
• 5:23
  SPEAKER_00: And what we are asking people to do is if they have that a paper hood, they're writing their name on that pepper hood and they're reusing that paper hood basically until it no longer functions.
• 5:34
  SPEAKER_00: And similar with N95 and surgical face masks, so really it's for the reuse of the person, and they can continue to reuse until it's soiled or they're finding difficulty breathing.
• 5:46
  SPEAKER_00: What we have done is given our providers what we're called 3P packs.
• 5:51
  SPEAKER_00: So it's basically a bunny pack with two face masks and a visor, and then an area that they can put an N95 in if they're bit tested.
• 6:01
  SPEAKER_00: And this is really to allow people to feel safe when they're going from unit to unit, where they may come across a person under investigation that they have their N95 with them if they're bit tested.
• 6:12
  SPEAKER_00: And so that has helped alleviate some of the anxiety that I think we're all seeing across our frontline healthcare workers.
• 6:19
  SPEAKER_02: Thank you.
• 6:20
  SPEAKER_02: Dr.
• 6:20
  SPEAKER_02: Drees, would you mind sharing some of your thoughts on this particular question?
• 6:24
  SPEAKER_01: So I would agree with Claire that you need to do all of the things that she mentioned around limiting the number of staff that need to go into a room.
• 6:33
  SPEAKER_01: We've been able to really accelerate a lot of our telemedicine use.
• 6:38
  SPEAKER_01: For example, we've had telemedicine for our virtual ICU that's used only at night, but we can use those same devices during the day to allow for virtual consults.
• 6:48
  SPEAKER_01: And so I think using the existing technology that we have creatively, you know, we have a virtual primary care practice that we're pulling into use for monitoring of healthcare workers who are potentially exposed.
• 7:01
  SPEAKER_01: It's been very exhilarating in a way to start to see everybody come together to accelerate a lot of the things that we could have been doing before, now that there is this crisis.
• 7:12
  SPEAKER_01: I think, you know, the big challenge is balancing fear among all the healthcare workers, especially those that are at the front line.
• 7:21
  SPEAKER_01: They know that those of us that are making these decisions are not necessarily at the front line.
• 7:25
  SPEAKER_01: And so they feel very exposed and not necessarily protected.
• 7:30
  SPEAKER_01: So we've been very careful around how we communicate and that you know our healthcare worker safety is our first and foremost priority, and making sure that people understand that even though on the news they see people in Tyvek suits or they see people with face masks in public, that there is a rationale for why we're not recommending those things and making sure that we try to be ahead of it.
• 7:54
  SPEAKER_01: That said, we have a very large and geographically diverse healthcare system, and there are lots of little pockets of people doing things that we may not necessarily know.
• 8:05
  SPEAKER_01: You know, for example, we've been really limiting our N95 use to aerosolizing procedures.
• 8:11
  SPEAKER_01: I found out today that we're having radiology in some areas where we're doing routine chest x-rays with N95s, and I only found out about this because they tried to order more and were denied.
• 8:22
  SPEAKER_01: So keeping a tight control over your supply chain, getting to know your supply chain leaders really closely has been fundamental.
• 8:29
  SPEAKER_01: And we've had to severely restrict who can even order different types of PPE because the orders were coming in fast and furious from areas that had never wanted or needed this.
• 8:40
  SPEAKER_01: So one of the things we've really struggled with is the process for fit testing.
• 8:44
  SPEAKER_01: As many people know, the process for quantitative fit testing destroys an N95.
• 8:50
  SPEAKER_01: And so we had early in January kind of halted our routine fit testing process just because we knew that this was going to be an issue.
• 8:59
  SPEAKER_01: But as this has accelerated, you know, we've recognized that the staff that are taking care of COVID patients and the staff who may take care of undifferentiated patients.
• 9:08
  SPEAKER_01: So we've had to back away from no fit testing to making sure that those staff are protected.
• 9:15
  SPEAKER_01: The people are coming out of the woodwork asking for fit testing.
• 9:18
  SPEAKER_01: And so it's had to be not occupational safety's decision, but they've referred it back to infection prevention to say, does this unit really need fit testing?
• 9:27
  SPEAKER_01: I think where we struggle now is around some of the procedure-based specialties like dentistry, ENT, who are working right in the nose and mouth and are potentially aerosolizing, and they're not necessarily feeling safe.
• 9:42
  SPEAKER_01: So we're having to move toward more universal use of N95s for those procedures just because we really want those staff to be safe.
• 9:52
  SPEAKER_01: So the other complicating issue has been about a year and a half ago, we had converted over to a newer model of N95 because the older ones were being discontinued.
• 10:02
  SPEAKER_01: And what we're getting from the state stockpile now is the older version that we used to use.
• 10:06
  SPEAKER_01: And so we've had to go back and refit test people.
• 10:10
  SPEAKER_01: So unfortunately, we've had to burn through more N95s because of that.
• 10:14
  SPEAKER_01: We looked at the qualitative way to fit test, which has not been our practice for many, many years.
• 10:21
  SPEAKER_01: Our computer systems don't support that in terms of being able to track it adequately, and we can't even get the supplies necessarily to be able to convert over to qualitative fit testing, which again would not destroy a respirator.
• 10:35
  SPEAKER_01: So while that is one of the CDC's recommendations for conservation, we've not found that one practical.
• 10:40
  SPEAKER_01: But I think it really has just gone back to understanding who really needs to take care of these patients.
• 10:46
  SPEAKER_01: So it is challenging all of our current processes.
• 10:49
  SPEAKER_01: The other thing I would add is as we've been shutting down other elective procedures, we have a lot of extra staff that we're paying that don't really have much to do anymore.
• 10:59
  SPEAKER_01: So we've had to repurpose many of these people to help with fit testing, help employee health take calls, monitor PPE use and teach.
• 11:08
  SPEAKER_01: So again, being creative with how trained people can just be repurposed to meet some of these other needs has been part of the process as well.
• 11:16
  SPEAKER_02: Thanks.
• 11:16
  SPEAKER_02: I think you really speak to those challenges and also uh some of the strategies, including things like conservation strategies and everything you can do to optimize uh the available PPE to be used when it's needed.
• 11:28
  SPEAKER_02: So I want to go back to another question that's uh been explored.
• 11:32
  SPEAKER_02: There's been a lot of interest in alternatives to traditional PPE, including homemade masks, and that's been something that we hadn't anticipated necessarily, but is something that we're facing on a day-to-day basis.
• 11:44
  SPEAKER_02: So, Dr.
• 11:45
  SPEAKER_02: Rock, can you share um any of your experience with alternatives to traditional PPE?
• 11:50
  SPEAKER_00: So we are looking at various different options, and one of the very heartening things that we've seen is a lot of people donating different types of personal protective equipment, particularly respiratory personal protective equipment, to our instant command and supply chain center.
• 12:08
  SPEAKER_00: We're gathering all that PPE and trying to understand the limitations.
• 12:14
  SPEAKER_00: What we are focusing on is having adequate PPE for our healthcare providers that are taking care of patients, both known COVID positives and those that are under investigation with tests pending.
• 12:27
  SPEAKER_00: But we also have other needs.
• 12:29
  SPEAKER_00: So we are exploring with our applied physics lab to really think outside the box about what type of PPE we could make more widely available that would protect during the process of aerosolization and during regular care when airborne PPE is advised.
• 12:47
  SPEAKER_00: And so we are exploring different options of masks that could meet that requirement and also be comfortable for healthcare workers to use and also that would be cleanable and reusable.
• 12:59
  SPEAKER_00: And so we're optimistic that there's people really paying close attention to this and coming up with prototypes, etc.
• 13:06
  SPEAKER_00: We are also exploring the um concept, as you say, of the homemade masks.
• 13:11
  SPEAKER_00: We are looking at that in the in not as well, not currently in a situation that we would use those masks during patient care, but more if we were to go to a concept of universal masking, that those homemade masks or masks that are made of cloth would be ones that would be used in break rooms or when people are walking down the corridor, or really any scenario where they're not doing patient care.
• 13:39
  SPEAKER_00: And really the purpose of those masks is for the person who's wearing it, so they're keeping any potential burden of respiratory secretions that they have away from others.
• 13:50
  SPEAKER_00: And so, despite lots of efforts at social distancing, um, some of it is still challenging with healthcare worker teams.
• 13:57
  SPEAKER_00: And so we're exploring using those masks in that way and getting a production.
• 14:03
  SPEAKER_02: That's great.
• 14:03
  SPEAKER_02: So it sounds like you're looking at a lot of different alternative options outside of the traditional PPE.
• 14:08
  SPEAKER_02: You know, I share your experience that we've we've actually had a very nice outpouring of donations of PPE from some of our university laboratories and even some non-university related laboratories that have PPE that they've donated to our hospital.
• 14:22
  SPEAKER_02: I think that's really a way that the community can help support the healthcare providers during this challenging time.
• 14:27
  SPEAKER_02: So, uh Dr.
• 14:28
  SPEAKER_02: Drees, do you have any other experiences that you'd like to share regarding alternatives to traditional PPE?
• 14:34
  SPEAKER_01: So, similarly, we are getting a lot of donations of all different types and quality.
• 14:39
  SPEAKER_01: I would definitely recommend that you have your top leaders who have lots of connections in the community to reach out to any and all alternatives.
• 14:48
  SPEAKER_01: We, you know, we're getting a number of donations from dentists.
• 14:52
  SPEAKER_01: Most of their offices are closed and they are willing to donate their PPE in this time of need.
• 14:57
  SPEAKER_01: As far as the homemade masks, I think, you know, we're certainly getting those types of donations, and we're not saying no, but there is evidence that cloth or or cotton mask may even be worse than nothing at all.
• 15:10
  SPEAKER_01: So we are not recommending those for healthcare worker use.
• 15:14
  SPEAKER_01: You know, we may end up using those for visitors, or if we come to the point where there really is nothing else, we may end up using those, but we're hoping not to.
• 15:24
  SPEAKER_01: We are working through a process of trying to identify medical grade material, like surgical gowns, for example, that could have the same protective quality as the FDA-approved masks and get our seamstresses to use that sort of material instead of cotton.
• 15:40
  SPEAKER_01: So I'm aware of some other healthcare institutions that have been able to do that, and we're just in the process of trying to stand that up as well.
• 15:47
  SPEAKER_02: One area that I think has been a bit of a challenge is the communication piece in trying to collaboratively work with frontline healthcare providers on the PPE strategy while supporting healthcare worker safety and acknowledging the limitations with supply and the role of conservation.
• 16:07
  SPEAKER_02: Can you share some of your experiences with that communication piece and what you have found to be effective at your hospital?
• 16:15
  SPEAKER_00: I think this is a huge challenge because we all know that we need our frontline healthcare workers to feel safe and to feel that the institution that they're working in is completely supporting them and giving them what they need.
• 16:29
  SPEAKER_00: What I would say is the communication can never be too much.
• 16:35
  SPEAKER_00: I feel like you know, getting the hospital epidemiologists and the infection preventionists out speaking to different groups, obviously, in keeping with social distancing, is key because they need to hear the messages that are coming from us and they need to hear in person and they need to be able to ask questions and have that interaction, and that helps them to feel supported.
• 16:59
  SPEAKER_00: I think that the very important thing is that the hospital epidemiologists and infection prevention are linking very closely with the chief medical officer and chief nursing officer.
• 17:10
  SPEAKER_00: So similar messages are coming out in similar ways, and so that there's a unified message about the conservation strategy, and that is critically important, even though that message may change, that the leadership of the hospital or the institution are all on the same page, and then there's other ways to get communications out.
• 17:31
  SPEAKER_00: We've done a lot of emails, and actually the emails are having a huge open rate, but we're looking at other things like doing videos really just to give the high-level facts, and then they're referred to our webpage, intranet, for more specific details.
• 17:47
  SPEAKER_00: But I think that helps people to feel that there's a connection.
• 17:50
  SPEAKER_00: The other thing that I think is critical is using, we have the Rise team, but the various teams that can help with resilience and to really help coach and cancel the frontline staff as they're dealing with difficulties of feeling anxious about returning to family, feeling anxious about communicating with their family, feeling a distance with the other healthcare workers that they're working with on the unit when they're in personal protective equipment and social distancing in break rooms, etc.
• 18:20
  SPEAKER_00: We can use our other groups to help support our healthcare workers so that they really understand that we're all doing our very best in this difficult situation to support them.
• 18:31
  SPEAKER_02: You've emphasized a lot of the strategies that we've tried to use as well.
• 18:35
  SPEAKER_02: One area that I think you can't emphasize enough is the face-to-face and sort of being present on the units.
• 18:41
  SPEAKER_02: Literally, our whole team has been rounding throughout the hospital and trying to provide in-person discussion and answer questions that come up.
• 18:49
  SPEAKER_02: Um, because it it's tough the frontline personnel are getting information from all different sources, and there's you know justifiable anxiety regarding the situation.
• 18:58
  SPEAKER_02: So I think that face-to-face approach is really critical and then coupled with um you know the other uh strategies that you mentioned.
• 19:04
  SPEAKER_00: I completely agree.
• 19:06
  SPEAKER_00: What we're saying to our infection prevention team, we're getting out onto our units to talk with the frontline, is that it's okay to say that you don't know the answer right now and that you'll come back and speak with the incident command or leadership and get back to them.
• 19:19
  SPEAKER_00: But the important thing is that we're listening to their concerns and then we're getting whatever appropriate information we need and then returning it to the frontline people just to close that loop.
• 19:29
  SPEAKER_01: So we're doing a lot of the same things.
• 19:31
  SPEAKER_01: We have tried to encourage people to use our intranet.
• 19:36
  SPEAKER_01: And one of the problems we were having is that people weren't taking the time to look at the internet, they were calling IP.
• 19:43
  SPEAKER_01: And sometimes this was happening night shift, so we really had to get some messaging out through nursing to remind people to use the portal, use the FAQs that are up there, because good majority of the questions that IP was getting over and over again were easily available and findable there.
• 20:01
  SPEAKER_01: So we've really tried to use that as the source of truth.
• 20:05
  SPEAKER_01: Internally, we had started with kind of a COVID working group.
• 20:09
  SPEAKER_01: It quickly became very big and unmanageable.
• 20:12
  SPEAKER_01: We were meeting three times a week, and then we've really started to use our incident command structure, which you know is a little bit modified because normally that's used for a disaster of limited duration, like a hurricane or something like that.
• 20:25
  SPEAKER_01: This obviously is different, but that group is really very high-level people that can make decisions at the moment and start to communicate them out.
• 20:33
  SPEAKER_01: So that is a group that's been meeting daily for the last two or three weeks now.
• 20:37
  SPEAKER_01: We too have been making videos.
• 20:39
  SPEAKER_01: Um, we've been rounding, we've been having IPs come in on the weekends to help out when there's been a lot of anxiety on the units.
• 20:46
  SPEAKER_01: Our nursing education staff has been phenomenal in terms of creating content.
• 20:52
  SPEAKER_01: They've been creating videos, they've been creating job aids and other infographics.
• 20:57
  SPEAKER_01: And they also were rounding kind of nonstop over the weekend at night, trying to hit all staff and really just trying to re-emphasize that proper PPE use and discourage misuse and overuse.
• 21:09
  SPEAKER_02: I agree 100%.
• 21:11
  SPEAKER_02: So the last thing I wanted to bring up was cleaning and conservation of PPE.
• 21:16
  SPEAKER_02: I was wondering if either of you could uh share strategies that you have either explored at your institution or implemented that is a little outside of what's the typical practice is.
• 21:26
  SPEAKER_02: There's a lot of discussion about disinfection of N95 respirators.
• 21:30
  SPEAKER_02: And have you either moved in that direction or started considering uh what that might look like in the future?
• 21:36
  SPEAKER_00: There are some strategies with UV and other disinfection mechanisms.
• 21:41
  SPEAKER_00: We have not really explored using that process.
• 21:44
  SPEAKER_00: We're more focused on trying to put our efforts into focusing our healthcare workers on the correct processes of cleaning copper hoods, the correct process of storing the N95s and face masks, and then focusing our efforts on trying to increase our future supply.
• 22:00
  SPEAKER_02: Okay.
• 22:00
  SPEAKER_02: I think that sounds like a good approach at this stage.
• 22:03
  SPEAKER_02: Um, and every institution is going to be different in the way that they're approaching these kinds of topics.
• 22:08
  SPEAKER_02: Dr.
• 22:08
  SPEAKER_02: Dries, do you have anything else to add in this area?
• 22:12
  SPEAKER_01: So regarding the UV disinfection of PPE, you know, I think we're all at the point now where we're looking for any possible way to conserve and reuse.
• 22:22
  SPEAKER_01: And I think, you know, we've really been focusing on conservation up until this point.
• 22:27
  SPEAKER_01: However, we're at the point where we have to think about the fact that we could run out and trying to prevent that.
• 22:32
  SPEAKER_01: So the University of Nebraska actually has a very detailed protocol for how to UV disinfect N95s.
• 22:40
  SPEAKER_01: And it's a fairly complex process because you want to try to get the same N95 respirators back to the same staff.
• 22:47
  SPEAKER_01: And so we have not yet done that, but we do have UV machines, and or we're in the process of setting up a way to zap the regular surgical masks.
• 22:55
  SPEAKER_01: And again, we're not planning on recirculating those now, but kind of keeping that as a last ditch, you know, it's I think it's better than nothing and it's better than cloth masks.
• 23:04
  SPEAKER_01: And then we are working through how would we replicate the University of Nebraska protocol for the N95s.
• 23:11
  SPEAKER_01: So as far as environmental services, you know, how much daily cleaning is necessary is really being debated.
• 23:18
  SPEAKER_01: And if it's really just cleaning up spills and emptying trash, I think nursing can do that as part of their work when they're already in the room in PPE and we can try to prevent another set of PPE being used.
• 23:31
  SPEAKER_01: And of course, we are, you know, working through the process of extended use.
• 23:35
  SPEAKER_01: So for EVS going in and out of rooms, you know, maybe they just leave the same things on and not don and off after every room.
• 23:42
  SPEAKER_01: Like what would be our normal process?
• 23:45
  SPEAKER_02: All right, thanks for sharing.
• 23:46
  SPEAKER_02: So thank you very much to our speakers for sharing your perspectives and experiences, and a sincere thank you from Shay to all the frontline healthcare providers for all that you are doing to protect us and to contain the spread of this outbreak.
• 23:57
  SPEAKER_02: This podcast can be accessed on Shay's online education center, Learning CE, under the Rapid Response Program.
• 24:03
  SPEAKER_02: You'll also find additional resources such as the recorded webinar, Healthcare Facility Outbreak Preparedness.
• 24:09
  SPEAKER_02: This concludes this episode of the Rapid Response Podcast.
• 24:12
  SPEAKER_02: Thank you for tuning in.