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APRIL 06, 2020 -- With COVID-19 case numbers exploding, an overshadowed aspect of the personal protective equipment (PPE) crunch is whether healthcare workers are able to use it properly — including taking it on and off without contaminating themselves or others.
Each day they report to their jobs, healthcare workers across the nation are anxious, unsure of what type of and how much PPE will be available and whether it will provide enough protection from the novel coronavirus that causes COVID-19.
With PPE scarce, infection control is an evolving mix of science and make-do necessity. And as it's starting to appear that all healthcare workers — not just those in clinical capacities — will need PPE, hospitals are scrambling to ramp up training on proper PPE donning and doffing.
Whether PPE actually protects is dependent on the user, said Harvey Fineberg, MD, PhD, chair of the National Academies' Standing Committee on Emerging Infectious Diseases and 21st Century Health Threats. "You have to use it properly," Fineberg told Medscape Medical News.
Gloria J. Brigham, EdD, MN, RN, director of nursing practice at the Washington State Nurses Association, a union, said training isn't always occurring. "We've heard from our constituents that there is a lot of inconsistency in whether key care providers were trained and tested prior to this event," Brigham told Medscape Medical News. She added, "There probably is still inconsistency on whether people are fit tested for the equipment."
A radiologic technician who performs bedside procedures in the rooms of COVID-19 patients at New York University's 591-bed Winthrop Hospital in Minneola described a constantly shifting landscape that undermined confidence. He received training before the pandemic and was fit tested for an N95 mask. But when he came in for his most recent shift, he was handed a different style of N95, and it felt looser. It appeared to be a different size, "which is a little concerning to me," said the tech, who did not want his name used.
The person giving out the PPE said the mask offered sufficient protection. But neither the tech nor other staff were fit tested for the new N95s, and some have taken to taping down the nose bridge or the chin area of the mask to get a better seal, he said.
"The instructions and rules change every day," he continued. Despite years of saying they were prepared for a pandemic, "in reality, when it came down to this actually happening, it seems like so many things went out the window," he said.
At the University of Wisconsin, in Madison, infection control staff are trying to make sure that training doesn't slip through the cracks. The state is not yet a hotspot, but "we're starting to ramp up," said Nasia Safdar, MD, PhD, medical director of infection control and prevention for UW Hospital and Clinics in Madison.In a single week at the end of March, 1400 clinicians and staff went through training at the university's simulation center, according to a news release. The training included watching a short video and then undergoing a 20-minute tutorial in which they donned and doffed PPE while being monitored, Safdar told Medscape Medical News.
Currently, anyone involved in direct care — nurses, physicians, and ancillary staff — are receiving the training, but Safdar envisions that many others will eventually go through the program. "We may have to redeploy people who currently may not be in a setting where they need to use PPE," she said.
Getting It Right Is Not Easy
Several studies have shown that it's not always easy to use PPE even when there's no emergency.
A 2018 study in the United Kingdom showed that even after going through simulator training, contamination was commonplace. Using fluorescent simulants of body fluids detected with ultraviolet light, the researchers saw that workers were frequently contaminated, either through a failure of the PPE ensemble itself or because of post-doffing errors.
Similarly, Shannon L. Lockhart MD, FRCPC, and colleagues at the universities of British Columbia and Ottawa recently reported results of a simulation study in which a mannequin was made to cough during anesthesia induction. Using fluorescent powder to simulate infectious material, the researcher detected contamination on clinicians' scrubs, as well as on their neck, wrist, lower pants, and shoes.
Although infection with the novel coronavirus, SARS-CoV-2, is not believed to be transmitted through the skin, "these areas of soilage increase the risk for self-contamination (eg, during doffing) via mucous membranes," the authors write.
As a result of the findings, the Canadian hospitals involved in the study have changed PPE recommendations. It is now recommended that disposable surgical gowns be used instead of reusable gowns; that double high-cuffed gloves are to be used instead of single gloves; that head covering consisting of a surgical hood with ties be used; and that knee-high shoe coverings be used.
"An additional finding has been how the doffing process must be specific to the combination of PPE chosen and that it must be practiced," Lockhart and colleagues write.
A study from Wuhan, China, that's in preprint but has not yet been peer reviewed suggests that workers might contaminate the environment just by taking off PPE. In a sampling of various environments, the researchers found that some of the highest viral concentrations were in PPE removal rooms. "The virus aerosol deposition on protective apparel or floor surface and their subsequent resuspension is a potential transmission pathway and effective sanitization is critical in minimizing aerosol transmission of SARS-CoV-2," they write.
A recent report from the US National Academies notes that although it might be difficult to "re-suspend particles of a respirable size," it's possible that "fomites could be transmitted to hands, mouth, nose, or eyes without requiring direct respiration into the lungs.from the US National Academies notes that although it might be difficult to "re-suspend particles of a respirable size," it's possible that "fomites could be transmitted to hands, mouth, nose, or eyes without requiring direct respiration into the lungs."
A study by Singapore researchers that was published in the Annals of Internal Medicine supports the idea that healthcare workers might unwittingly contaminate the environment if they are not cognizant of how to use PPE.
The researchers tested the face shield, gown, and N95 mask of a worker who had held and fed a 2-month-old infant who had tested positive for the novel coronavirus but was asymptomatic. Viral DNA was not detected on the PPE, but it was found on the bed rails, the bed, and a table that was 3 meters from the bed. The presumption was that the worker came into contact with virus shed through tears or drool and then infected the environment, the researchers said."Our data also reaffirm the importance of hand hygiene when caring for infants with COVID-19 and potentially in helping to reduce environmental virus contamination," they write.
Best Practices for PPE Use, Reuse Lacking
The evidence as to what type of PPE works best in which circumstances and which training is most effective is almost nonexistent, according to the Cochrane Collaboration.
"We still need randomised controlled trials to find out which training works best in the long term," concluded the authors of a 2019 systematic review. "We need better simulation studies conducted with several dozen participants to find out which PPE protects best, and what is the safest way to remove PPE."
The current sky-high PPE burn rate — which Brigham calls "unimaginable," noting that one Washington facility went through a month's supply in 4 days ― has forced hospitals to do things they'd never consider under normal circumstances, such as asking workers to reuse masks multiple times or find ways to clean and reuse both N95 masks and surgical masks.
"There are not any guidelines from the Centers for Disease Control and Prevention [CDC] on cleaning and reusing those face masks," said Brigham. The CDC has issued guidelines for extended use ― for instance, on how to take them on and off and how to store them for later use without contaminating them.
Many experts are desperately trying to come up with ways to sanitize PPE. JAMA issued a call for ideas on conserving PPE that has generated hundreds of responses. On March 29, US the Food and Drug Administration approved emergency use of a system manufactured by Battelle Memorial Institute, based in Columbus, Ohio, that can decontaminate an N95 up to 20 times.
But in the absence of solid evidence, healthcare workers are struggling to manage fear and mistrust.
At Jacobi Hospital in the Bronx, New York City, nurses protested outside the facility on March 28 after being told they would have to use the same N95 masks for a week and were given surgical masks to place over the N95, according to the New York Post.
To conserve N95s at the University of Wisconsin, users are being told to also use a face shield as an extra layer of protection, Safdar said. "None of this is by any means ideal," she said, adding that the goal, based on work from the University of Nebraska Medical Center, would be to discard the mask after a single use. Wisconsin is also exploring ways to sanitize the N95s.
The Long Island–based radiologic technician said that in mid-March, he and others who come into close contact with patients were told they could discard their N95s after attending to each patient. That policy lasted a week. "The second week, they told us you need to reuse the masks for the whole week" and to also use a single plastic face shield, he said.
Each person who received an N95 was also given a paper bag and a cubby in which they were to store the mask when they were not on shift. The masks were not decontaminated and were often used every day, he said.
The policy has changed again; now N95s and face shields are given out every other day ― a policy that perhaps reflects an increase in supply.
"I really thought that everyone would be more prepared for this situation," he said. "And it's scary because it almost seems like they're not."