By Evan M. Benjamin, MD, MS; Mary Brindle, MD, MPH; Sue Gullo RN, MS; and Saranya Loehrer, MD, MPH

In the past few weeks, the global pandemic attributed to COVID-19 has taken root in the United States. As our health care systems, scientists, and society mount preparedness and response efforts, one issue seems of paramount importance — how to keep patients, and those within health care settings who care for them, safe.

Personal protective equipment (PPEs), such as masks, gloves, and isolation gowns, are vital to minimize the risk of exposure to the virus for all who are attending to the health and well-being of COVID+ or presumptive positive patients in various care settings. The rapidly diminishing supply of PPEs available for the health care workforce, coupled with challenges with the supply chain, has understandably caused widespread concern and could considerably hinder our ability to ensure the safety of those who have committed to the health and safety of others.

Many health care organizations have not faced a global shortage and supply chain disruption of this magnitude before. Undeterred, they have partnered with policymakers, innovators, businesses, and the public to attempt to ensure an adequate supply of PPEs are available to all who need them in health care settings. Until these efforts ramp up sufficiently to meet the needs, current supplies continue to diminish forcing many health care organizations to make difficult decisions about how to conserve existing supplies.

We want to share some common approaches that many systems are currently taking in the hopes that they will be helpful to your efforts. The ideas below are taken from interviews, writings, and exchanges amongst health care organizations in the US and from the important lessons provided by our colleagues around the world. We recognize that many of the actions listed do not have the benefit of Level I evidence; they are the result of health care organizations trying to logically address an unprecedented and rapidly evolving situation. Our goal is to share these ideas in the spirit of collective learning and improvement.

We have put the PPE conservation strategies into three buckets: Restrict, Reduce, and Reuse.

Restrict

Visitors

Restrict all visitors with possible exceptions (one visitor per hospitalized infant or child, one companion for active L&D, one per hospice patient, etc.).

Minimize the number of entrances to health care settings and screen all visitors for symptoms. Create standardized workflows for screening and communication to visitors. Consider identifying an internal Patient and Family Liaison Team to maintain communications with families and reduce the burden on clinical staff.

Minimize exposure to personnel

Consider specific units or areas for Persons Under Investigation (PUI) and COVID+ individuals with dedicated care teams.

Work across disciplines as a team. Develop and utilize a basic checklist prior to patient encounters:

• Determine if the patient needs to be seen and by whom. Ask: Can we minimize the number of care providers in the room?
• Review all equipment and supplies needed before entering the room.
• Bundle as many tasks together as possible (e.g. if two people are required, ensure they can group and complete all necessary tasks at one entry. Labs can be drawn by clinicians once in the room instead of phlebotomy, etc.)

If feasible, have care teams do some of the routine cleaning after patient care so that environmental services only does terminal cleans.

Minimize the use of transport staff by having PPE-clad receiving team retrieve patient from PPE-clad care team.

Access to PPEs

Keep PPEs in centralized locations with individuals from quality or infection control departments responsible for distribution.

Reduce

Reduce demand for PPEs by:

Eliminating elective surgeries and procedures

Some guidance is available for managing COVID-19 in surgical systems and limiting non-essential surgeries and procedures. Work with your local government and regional care partners to coordinate.

Minimizing unnecessary face to face encounters

Create office visits with alternative sites for “respiratory fever clinics” and non-infectious disease complaints.

Scale telehealth capabilities to convert as many non-essential face to face visits as possible for both respiratory complaints and for non respiratory issues. Recent changes to payment, technology, and licensure should aid in this effort.

Reducing potential for viral exposure through

• Physical controls to separate and cohort COVID+ patients
• Isolating PUIs with proper ventilation systems
• Putting surgical masks on PUI and COVID+ patients except when in isolation
• Avoiding entering the patient’s room for unnecessary patient care. For example, some systems have started to keep IV pumps outside the patient room by using IV extension tubing to provide access to investigate alarms and change medication.

Measuring

Develop an inventory system to identify high use areas and ensure appropriate use. Accurate inventory will allow mobilization to high risk areas when inventory is low and mitigate rationing.

Other potential considerations being explored include:

• Limiting use of N95 masks to only procedures where respiratory secretions can be aerosolized, including intubation for PUI or COVID+ individuals. Use loop surgical masks for all other encounters. Read the latest guidelines on keeping the coronavirus from infecting health care workers.
• Limiting use of loop masks to only encounters with patients on droplet precautions such as PUI or COVID+ or other flu like illness investigations.

Using “intubation runners” to do all the intubations on COVID-19+ patients. Develop an intubation checklist to standardize equipment needs and to minimize waste. Consider including individual intubation kits/boxes to prevent contamination.

Re-Use (and extend)

In the case of critical shortages, some systems have attempted to use novel approaches such as:

• Extending wear of N95s and facemasks from patient to patient with the clinician changing gown and gloves between patients.
• Re-using their N95 up to 5 times if it has been covered by a facemask and is clean and not wet or soiled. Masks are stored in a paper bag with 5 checkbox notations on the outside of the bag.
• Sterilization of PPE with UV light or a 3 hour ozone disinfection (however evidence of the ability of these techniques to eliminate the virus and maintain PPE effectiveness is not yet determined).

For all such approaches, consider developing a chart for staff with clear guidelines regarding what items should be used by whom and under what circumstances in addition to when they can be re-used and/or parameters for extended use.

Conclusions

The provision of PPE is an essential aspect of our health care system throughout the pandemic. Having appropriate supply and proper use will continue to be a top priority for health systems. All health systems will need to adapt to a rapidly changing environment, and these strategies may help to conserve PPE. Having a clear PPE strategy during the COVID-19 pandemic will keep our patients and health care workers safer. Visit www.ariadnelabs.org/coronavirus for additional resources for clinicians and the community.

Evan M. Benjamin, MD, MS

Ariadne Labs at Brigham Health and Harvard T.H. Chan School of Public Health, Boston, MA

Mary Brindle, MD, MPH

Ariadne Labs at Brigham Health and Harvard T.H. Chan School of Public Health, Boston, MA

University of Calgary, Calgary, AB

Sue Gullo RN, MS

Ariadne Labs at Brigham Health and Harvard T.H. Chan School of Public Health, Boston, MA

Saranya Loehrer, MD, MPH

The Institute for Healthcare Improvement

Header illustration by Olga_Z / iStock