From Crisis to Confidence: Returning to Normal Standards of Care

Since the outbreak of the pandemic last year, healthcare clinicians and staff have been forced to play by their facilities’ crisis playbooks—particularly with regard to the use of PPE. As the COVID-19 outbreak occurred across the U.S. and the world, PPE shortages compelled hospitals and other healthcare facilities to adopt PPE crisis standards of care in order to address the need for clinician and staff protection.

CDC interim infection control recommendations for COVID-19 reflected the reality of the severe short supply of certain items of PPE. The emergency guidance included operational considerations for PPE in the context of these significant global supply shortages.¹

Eight months into the pandemic, a survey conducted by the Association for Professionals in Infection Control and Epidemiology (APIC) found that 73% of infection preventionists reported their facility was still using PPE crisis standards of care for respirators, 68% for face masks, and 76% for face shields or eye protection. This means healthcare personnel were having to reuse or employ extended use of PPE which was intended for single use.²

“N95 respirators, face masks, exam gloves and isolation gowns are all labeled for and intended for one-time use,” said Allison Pearsall, Senior Global Product Manager-Healthcare, Honeywell. “They were designed to be changed in between each patient and procedure, or immediately if they become soiled or wet. That’s in accordance with the guidance in support of infection control protocols developed by the CDC and the Association of PeriOperative Registered Nurses (AORN). This is to help protect the patient and caregiver from the risk of unintentional contact transfer of pathogens via the PPE.”^3,4

Over the course of the COVID-19 pandemic, healthcare professionals have been operating under high stress, and the lack of PPE and inadequate ramp-up by the industry to address their changing needs in the first months of the event undoubtedly contributed. The inability to follow the protocols that healthcare professionals were trained on has likely added to the fear and stress. The psychological and physical toll that elevated stress takes on nurses and doctors is well documented.

As noted in the journal Healthcare Finance, "Not only are frontline healthcare workers experiencing the sickness, death and devastation of the pandemic on a daily basis – and in some cases doing so with limited staffing and resources – but they are also repeatedly putting themselves at risk for infection."⁵

The Gradual Process of Returning to Normalcy

As the need for heightened protection for healthcare professionals continues for the foreseeable future, the good news is there is a greater supply of N95 respirators, fluid-resistant face masks, protective apparel, and eye and face protection available now than at any time in the past year.⁶  As more PPE becomes available, it is time to begin to consider restoring usual infection control practices where possible.

In its guidelines, the CDC states that re-using PPE should only apply to extraordinary circumstances. Once the supply has been re-established, hospitals should return to usual practices.⁷ Disposable PPE is designed to be used one time. For example, AORN Recommended Practice for Surgical Attire confirms that healthcare workers should don a new mask before each procedure and replace or discard the mask once removed or if it becomes wet or soiled.⁴ The length of wear in terms of particle loading time, in addition to the relative humidity, has been shown in studies to affect the filtration efficiency.  Disposable respirators and face masks become moist from the user's exhalation. In addition, an analysis published by the British Journal of Anaesthesia reported that nearly half of all N95 masks worn by anesthesiologists during the COVID–19 pandemic fail fit tests after four days of reuse.⁸

Everyone Has a Role to Play

After operating in crisis mode for so long, returning to the customary infection control practices of changing PPE in between each patient and procedure will require a bit of a leap of faith that suppliers will be able to support the demand. In recent months, domestic manufacturers have made significant, dramatic improvements in terms of adding manufacturing capacity. Honeywell’s additional production capability added as many as 70 million or more N95 respirators per month to the domestic N95 supply. Other manufacturers have also invested in capacity upgrades.

The current shortage of nitrile exam gloves is expected to continue into 2022. However, supplies of gowns, N95 respirators, face masks and face shields have increased significantly to help meet the increased demand. Additional supply of PPE solutions from reputable manufacturers should now be considered as the key to restoring usual infection control protocols. Healthcare facilities should urgently consider adding more brands to their formularies in order to achieve inventory levels to rescind extended use and re-use protocols. The take-away for those on the front lines should be that it is now, or soon will be, possible to ease back into normal standards of care for some items.

Graduated Return to Conventional Standards

To help healthcare professionals manage serious and extreme situations, the CDC created three strata to describe surge capacity. These three levels help facility administrators respond appropriately based on the extent of the surge.

• Conventional capacity refers to the facility’s engineering, administrative and personal protective equipment (PPE) controls that should already be implemented in general infection prevention and control plans in healthcare settings.

• Contingency capacity are measures that may be used temporarily during periods of expected shortages. While the existing PPE supply may satisfy the facility’s current or anticipated utilization rate, there may be uncertainty as to whether the future supply will be adequate.

• Crisis capacity strategies should only be implemented after considering and implementing conventional and contingency capacity strategies. Facilities can consider crisis capacity strategies when the supply is not able to meet the facility’s current or anticipated utilization rate.⁹

As healthcare organizations consider the question of when and how to begin the process of stepping down from crisis to contingency to conventional status, the CDC suggests considering the following three factors:¹⁰

1.    The expected number of patients and PPE that should be worn by HCP (healthcare providers) providing their care

2.    The number of days’ supply of each PPE type currently remaining at the facility

3.    Whether or not the facility is receiving regular resupply with its full allotment

More than re-stocking inventories, we must re-build confidence

Given the emotional and physical strain on front-line clinical workers and the supply chain constraints, it is easy to understand why healthcare professionals may be hesitant to adopt a business-as-usual attitude. Re-building their confidence in the system, so that they feel safe about returning to their conventional standards of care, will take more than just time. It will take an ongoing commitment from all levels of the supply chain to ensure healthcare professionals have the protection they need for any demand surge.

At Honeywell, our recent investments in creating more domestic manufacturing capacity are just the start. We continue to work with our suppliers, distributors, and healthcare partners to identify and address gaps in the supply chain and develop new PPE solutions that allow clinicians to work more safely and comfortably. We invite you to track our progress and stay up to date on the latest PPE and supply chain strategies by visiting us at: https://sps.honeywell.com/us/en/campaigns/safety/personal-protective-equipment-for-healthcare-workers

Sources:

¹Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-US Healthcare Settings; CDC, website; November 19, 2020

https://stacks.cdc.gov/view/cdc/97532

²Covid-19 infection prevention survey; APIC, survey; December 2020

https://apic.org/news/national-survey-shows-healthcare-facilities-implementing-ppe-crisis-standards-of-care/

³Operational Considerations for Personal Protective Equipment in the Context of Global Supply Shortages for Coronavirus Disease 2019 (COVID-19) Pandemic: non-US Healthcare Settings, March 18, 2021 https://stacks.cdc.gov/view/cdc/111311

⁴RP First Look: New recommended practices for surgical attire  https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1016/S0001-2092(14)01101-6

⁵COVID-19-related mental health issues could have long-term effects on healthcare workers; Healthcare Finance News; January 26, 2021

https://www.healthcarefinancenews.com/news/covid-19-related-mental-health-issues-could-have-long-term-effects-healthcare-workers

⁶CSCMP’s Supply Chain Quarterly; PPE availability improves, but supply chain still constrained; April 2, 2021

https://www.supplychainquarterly.com/articles/4571-ppe-availability-improves-but-supply-chain-still-constrained

⁷Strategies for Optimizing the Supply of Facemasks; CDC, website; November 23, 2020

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/face-masks.html

⁸British Journal of Anaesthesia; Probability of fit failure with reuse of N95 mask respirators; June 26, 2020

https://bjanaesthesia.org/article/S0007-0912(20)30480-3/fulltext

⁹Strategies for Optimizing the Supply of Facemasks; CDC, website; November 23, 2020  https://www.cdc.gov/coronavirus/2019-ncov/hcp/

¹⁰Strategies for Optimizing the Supply of Facemasks; CDC, website; November 23, 2020  https://www.cdc.gov/coronavirus/2019-ncov/hcp/