Conserving PPE in the COVID-19 Era

Photo by Ashkan Forouzani on Unsplash

In my 25 years as a hospital epidemiologist, this week was the hardest yet. Last Sunday, we learned of 3 COVID-19 cases in the Iowa City area. As of today, there are 14--that we know of. Because testing is still quite limited, these 14 patients likely represent just the tip of the iceberg. As all of this unfolds, it is like watching a train wreck in slow motion. And looking at the situations in Northern Italy and Seattle, we see that what lies ahead for us is quite scary.

One of the things I have focused on this week is personal protective equipment (PPE). It seems clear that, sooner or later, most hospitals will be in trouble. The PPE supply chain is deeply rooted in China and those factories have closed. That coupled with the just-in-time inventory concept has put all of us in a tough spot. For those of you not yet in the thick of this, I will offer some thoughts that may be of use to you.

Here is my practical strategy:

1. Know your inventory. Have your supply chain folks produce a tabular report of all PPE products used in your institution. In this table, ask them to also include the numbers of each item used in an average week so that you know your baseline utilization.
2. Develop an inventory target that includes projected usage and duration. We decided to set our critical target at 300% of normal usage for 12 weeks duration. This can be calculated from your baseline utilization for each item. On the table, any item's total inventory that is less than 300% normal usage over 12 weeks is coded red. Yellow is set at 12-16 weeks at 300% normal usage, and green is set at >16 weeks at 300% normal usage. We review the PPE inventory table daily at our Hospital Incident Command System meeting. The color coding of the table allows quick interpretation of inventory levels.
3. Critically evaluate your current usage and limit usage of PPE. Remember that we are not in normal times. Once you see how far away your current inventory is from your target inventory, you will rapidly begin to think of things that can conserve PPE. Here are several:
• If you use contact precautions for patients colonized with VRE or MRSA, PLEASE STOP! At best, the utility of this practice is questionable. Ask yourself this question: would you rather have PPE to care for a VRE colonized patient today, or that PPE for a COVID patient 6 weeks from now. 
• If you use contact precautions to isolate patients infected with VRE or MRSA, consider stopping. Numerous hospitals have done that with no ill effect. Ask yourself the same question as in the previous bullet.
• We made the decision this week that for non-COVID contact precautions we would stop the use of gowns, but continue gloves, and stress hand hygiene and bare below the elbows (to minimize clothing contamination).
• Begin re-using items such as face shields (after disinfection) and N95 masks.
• Stop annual N95 fit-testing to avoid the use of masks in the fit testing process.
• Limit the number of visitors.
• For patients in isolation precautions, avoid taking the entire rounding team into the patient room. 
• Limit care of the COVID patient to one nurse and one physician.
4. Send your supply chain staff on a scavenger hunt throughout the hospital to identify PPE that can be reclaimed. There are hoarders out there! In addition, secure your inventory to avoid theft.
5. Dispense PPE to individual hospital/clinic units in smaller increments.
6. Investigate alternative products. For example, we have a supply of old cloth surgical gowns that could be used as isolation gowns if needed. 

I'm sure others have ideas that we have not thought of. If so, please place them in the comment section. 

To my colleagues in the infection prevention community: This is hard. We are tired. And it's only the beginning. But our work is more important than ever. Stay strong! 

Namaste.