Strategies for PPE During COVID – 19

Healthcare systems across Central Virginia and the United States are experiencing personal protective equipment (PPE) supply chain challenges. Due to decreases in PPE exports from impacted countries and increases in demand as a result of the COVID-19 outbreak, manufacturers of select types of PPE- including N95 respirators and facemasks- are reporting increased volume of orders and challenges in meeting order demands . While plans are underway to surge PPE manufacturing globally, current impacts include delayed shipping and reduced fulfillment of PPE orders across all healthcare provider types and geographic regions.

Hierarchy of Infection Control Practices

The Central Virginia Healthcare Coalition (CVHC) is continuing to monitor and share information regarding the supply of PPE with healthcare organizations in the region. However, CVHC has no mechanism to affect the vendor prioritization, fulfillment, or distribution of PPE orders on behalf of its stakeholders. The Commonwealth of Virginia has requested release of PPE from federal stockpiles to augment supplies in primary and outpatient care settings. However, no disposition on that request is available at this time. Healthcare organizations should continue to contact their primary PPE vendor for updates on order status. For awareness, a consolidated listing of additional PPE vendors and their contact information has been attached to this message. As this situation remains fluid and dynamic, please continue to share information regarding PPE availability, needs, and shortages with CVHC by posting on the VHASS COVID-19 Event Log using your login to VHASS.

PPE Burn Rate Calculator

This is a spreadsheet-based model that provides information for healthcare facilities to plan and optimize the use of PPE for response to coronavirus disease 2019 (COVID-19). We recommend downloading and saving the PPE burn rate calculator spreadsheet to your computer before opening the spreadsheet. Taking this step will open the spreadsheet in Excel rather than your web browser (CDC).
 Personal Protective Equipment (PPE) Burn Rate Calculator 

Contingency and crisis strategies are based upon these assumptions:

  1. The facility understands its PPE inventory and supply chain.
  2. The facility understands their PPE utilization rate.
  3. The facility has been in communication with their Regional Healthcare Coalition. (If you have not requested PPE from CVHC and you are located in our region please use this form)
  4. Facilities have already implemented other engineering and administrative control measures including:
    • Reducing the number of patients going to hospitals or outpatient settings
    • Excluding non-essential HCP from entering patient care areas
    • Reducing face-to-face HCP encounters with patients
    • Excluding visitors to patients with confirmed or suspected COVID-19
    • Cohorting patients and HCP
    • Maximizing use of telemedicine
  5. The facilities have provided HCP with required education and training, including having them demonstrate competency with donning and doffing, with any PPE ensemble that is used to perform job responsibilities, such as patient care.

Eye Protection

What are the Conventional Capacity Standards?

Use eye protection according to product labeling and local, state, and federal requirements.

What are the Contingency Capacity Strategies?

Selectively cancel elective and non-urgent procedures and appointments for which eye protection is typically used by HCP.

Shift eye protection supplies from disposable to re-usable devices (i.e., goggles and reusable face shields).

Implement extended use of eye protection.

What are the Crisis Capacity Strategies?

Cancel all elective and non-urgent procedures and appointments for which eye protection is typically used by HCP.

Use eye protection devices beyond the manufacturer-designated shelf life during patient care activities.

Prioritize eye protection for selected activities

Consider using safety glasses (e.g., trauma glasses) that have extensions to cover the side of the eyes.

Exclude HCP at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients.

Designate convalescent HCP for provision of care to known or suspected COVID-19 patients.

What is extended use of eye protection?

The practice of wearing the same eye protection for repeated close contact encounters with several different patients, without removing eye protection between patient encounters. Extended use of eye protection can be applied to disposable and reusable devices.

What is reprocessing?

Reprocessing is the act of cleaning an item and reusing it again. Always adhere to recommended manufacturer instructions for cleaning and disinfection.

What are the recommendations if a disposable faceshield is reprocessed?

A disposable faceshield should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on.

When should eye protection be removed and reprocessed?

If it becomes visibly soiled or difficult to see through

When should eye protection be discarded?

If it is damaged (e.g., face shield can no longer fasten securely to the provider), if visibility is obscured and reprocessing does not restore visibility.

How do I reprocess single use disposable face shields?
  1. While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe.
  2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution.
  3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue.
  4. Fully dry (air dry or use clean absorbent towels).
  5. Remove gloves and perform hand hygiene.

Isolation Gowns

What are the Conventional Capacity Standards?

Use isolation gown alternatives that offer equivalent or higher protection.

What are the Contingency Capacity Strategies?

Selectively cancel elective and non-urgent procedures and appointments for which a gown is typically used by HCP.

Shift gown use towards cloth isolation gowns.

Consider the use of coveralls.

Use of expired gowns beyond the manufacturer-designated shelf life for training.

Use gowns or coveralls conforming to international standards.

 

What are the Crisis Capacity Strategies?

Cancel all elective and non-urgent procedures and appointments for which a gown is typically used by HCP.

Extend use of isolation gowns

Re-use cloth isolation gowns

Prioritize gowns 

What is reprocessing?

Reprocessing is the act of cleaning an item and reusing it again. Always adhere to recommended manufacturer instructions for cleaning and disinfection.

What is considered extended use of isolation gowns?

Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious diagnoses transmitted by contact (such as Clostridioides difficile) among patients. If the gown becomes visibly soiled, it must be removed and discarded as per usual practices.

Can I re-use cloth isolation gowns?

Cloth isolation gowns could potentially be untied and retied and could be considered for re-use without laundering in between.

However, for care of patients with suspected or confirmed COVID-19, HCP risk from re-use of cloth isolation gowns without laundering among:

  • single HCP caring for multiple patients using one gown is unclear
  • among multiple HCP sharing one gown is unclear.

The goal of this strategy is to minimize exposures to HCP and not necessarily prevent transmission between patients. Any gown that becomes visibly soiled during patient care should be disposed of and cleaned.

Can I launder cloth reusable gowns?

Reusable (i.e., washable) gowns are typically made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be safely laundered according to routine procedures and reused. Care should be taken to ensure that HCP do not touch outer surfaces of the gown during care.

  • Laundry operations and personnel may need to be augmented to facilitate additional washing loads and cycles
  • Systems are established to routinely inspect, maintain (e.g., mend a small hole in a gown, replace missing fastening ties), and replace reusable gowns when needed (e.g., when they are thin or ripped)
What happens if we run out of gowns?

Consider using gown alternatives that have not been evaluated as effective.

In situation of severely limited or no available isolation gowns, the following pieces of clothing can be considered as a last resort for care of COVID-19 patients as single use. However, none of these options can be considered PPE, since their capability to protect HCP is unknown. Preferable features include long sleeves and closures (snaps, buttons) that can be fastened and secured.

  • Disposable laboratory coats
  • Reusable (washable) patient gowns
  • Reusable (washable) laboratory coats
  • Disposable aprons
  • Combinations of clothing: Combinations of pieces of clothing can be considered for activities that may involve body fluids and when there are no gowns available:
    • Long sleeve aprons in combination with long sleeve patient gowns or laboratory coats
    • Open back gowns with long sleeve patient gowns or laboratory coats
    • Sleeve covers in combination with aprons and long sleeve patient gowns or laboratory coats

Reusable patient gowns and lab coats can be safely laundered according to routine procedures.

Facemasks

What are the Conventional Capacity Standards?

Use facemasks according to product labeling and local, state, and federal requirements.

  • FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures.
  • Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.
What are the Contingency Capacity Strategies?

Selectively cancel elective and non-urgent procedures and appointments for which a facemask is typically used by HCP.

Remove facemasks for visitors in public areas 

Implement extended use of facemasks 

Restrict facemasks to use by HCP, rather than patients for source control.

What are the Crisis Capacity Strategies?

Cancel all elective and non-urgent procedures and appointments for which a facemask is typically used by HCP.

Use facemasks beyond the manufacturer-designated shelf life during patient care activities.

Implement limited re-use of facemasks.

Prioritize facemasks for selected activities.

What are the recommendations to extend use of facemasks?

The practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters.

  • The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
  • HCP must take care not to touch their facemask. If they touch or adjust their facemask they must immediately perform hand hygiene.
  • HCP should leave the patient care area if they need to remove the facemask.
What are the recommendations to re-use facemasks?

Limited re-use of facemasks is the practice of using the same facemask by one HCP for multiple encounters with different patients but removing it after each encounter. 

  • The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
What facemasks can be re-used?

Facemasks that fasten to the provider via ties may not be able to be undone without tearing and should be considered only for extended use, rather than re-use.

Facemasks with elastic ear hooks may be more suitable for re-use.

How should I store a facemask to be re-used?

Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag or breathable container.

What if no facemasks are available?

Exclude HCP at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients

Designate convalescent HCP for provision of care to known or suspected COVID-19 patients

Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask

Consider use of expedient patient isolation rooms for risk reduction.

Consider use of ventilated headboards

HCP use of homemade masks

N95 Respirators

What are the Conventional Capacity Standards?

While engineering and administrative controls should be considered first when selecting controls, the use of personal protective equipment (PPE) should also be part of a suite of strategies used to protect personnel.

The use of alternative to N95 respirators:

Use alternatives to N95 respirators where feasible. These include other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators (PAPRs) where feasible. All of these alternatives will provide equivalent or higher protection than N95 respirators when properly worn. NIOSH maintains a searchable, online version of the certified equipment list identifying all NIOSH-approved respirators.

NIOSH approves other filtering facepiece respirators that are at least as protective as the N95. These include N99, N100, P95, P99, P100, R95, R99, and R100.

Elastomeric respirators are half-facepiece, tight-fitting respirators that are made of synthetic or rubber material permitting them to be repeatedly disinfected, cleaned, and reused. They are equipped with exchangeable filter cartridges. Similar to N95 respirators, elastomeric respirators require annual fit testing. Elastomeric respirators should not be used in surgical settings due to concerns that air coming out of the exhalation valve may contaminate the sterile field.

PAPRs are reusable respirators that are typically loose-fitting hoods or helmets. These respirators are battery-powered with blower that pulls air through attached filters or cartridges. The filter is typically a high-efficiency particulate air (HEPA) filter. Loose-fitting PAPRs do not require fit-testing and can be worn by people with facial hair. However, PAPRs should not be used in surgical settings due to concerns that the blower exhaust and exhaled air may contaminate the sterile field.

What are the Contingency Capacity Strategies?

Use of N95 respirators beyond the manufacturer-designated shelf life for training and fit testing

Extended use of N95 respirators

Limited re-use of N95 respirators for tuberculosis

What are the Crisis Capacity Strategies?

Use of respirators beyond the manufacturer-designated shelf life for healthcare delivery

Use of respirators approved under standards used in other countries that are similar to NIOSH-approved N95 respirators

Limited re-use of N95 respirators for COVID-19 patients

Use of additional respirators beyond the manufacturer-designated shelf life for healthcare delivery

Prioritize the use of N95 respirators and facemasks by activity type

What are the recommendations to extend use of N95 respirators?

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. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted (e.g., housed on the same hospital unit).

What are the recommendations to re-use N95 respirators?

There is no way of determining the maximum possible number of safe reuses for an N95 respirator as a generic number to be applied in all cases. Safe N95 reuse is affected by a number of variables that impact respirator function and contamination over time. However, manufacturers of N95 respirators may have specific guidance regarding reuse of their product.

  • Use a cleanable face shield (preferred) or a surgical mask over an N95 respirator and/or other steps (e.g., masking patients, use of engineering controls), when feasible to reduce surface contamination of the respirator.
When should I discard my N95 respirator?

Following use during aerosol generating procedures.

If it is contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients.

Following close contact with any patient co-infected with an infectious disease requiring contact precautions.

What steps should I take to reduce contact transmission when I re-use a N95 respirator?

Secondary exposures can occur from respirator reuse if respirators are shared among users and at least one of the users is infectious (symptomatic or asymptomatic). Thus, N95 respirators must only be used by a single wearer.

  • Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly.
  • Clean hands with soap and water or an alcohol-based hand sanitizer before and after touching or adjusting the respirator (if necessary for comfort or to maintain fit).
  • Avoid touching the inside of the respirator. If inadvertent contact is made with the inside of the respirator, perform hand hygiene as described above.
  • Use a pair of clean (non-sterile) gloves when donning a used N95 respirator and performing a user seal check. Discard gloves after the N95 respirator is donned and any adjustments are made to ensure the respirator is sitting comfortably on your face with a good seal.
What if no N95 respirators are available?

Exclude HCP at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients

Designate convalescent HCP for provision of care to known or suspected COVID-19 patients

Use a face shield that covers the entire front (that extends to the chin or below) and sides of the face with no facemask

Consider use of expedient patient isolation rooms for risk reduction.

Consider use of ventilated headboards

HCP use of non-NIOSH approved masks or homemade masks

What precautions should I take prior to using an expired N95 respirator?
  • Visually inspect the N95 to determine if its integrity has been compromised.
  • Check that components such as the straps, nose bridge, and nose foam material did not degrade, which can affect the quality of the fit, and seal and therefore the effectiveness of the respirator.
  • If the integrity of any part of the respirator is compromised, or if a successful user seal check cannot be performed, discard the respirator and try another respirator.
  • Users should perform a user seal check immediately after they don each respirator and should not use a respirator on which they cannot perform a successful user seal check.

Reference

https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html

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