key: cord-0953436-me6eqd5o
authors: Rebmann, Terri; Alvino, Rebecca T.; Holdsworth, Jill E.
title: Availability and Crisis Standards of Care for Personal Protective Equipment During Fall 2020 of the COVID-19 Pandemic: A National Study by the APIC COVID-19 Task Force
date: 2021-03-26
journal: Am J Infect Control
DOI: 10.1016/j.ajic.2021.03.015
sha: 14d3b5fd70f157008fba3cd6fa580c1fdc546cee
doc_id: 953436
cord_uid: me6eqd5o

BACKGROUND: The COVID-19 pandemic resulted in personal protective equipment (PPE) shortages in spring 2020, necessitating crisis protocols. METHODS: An online survey was administered to all Association for Professionals in Infection Control and Epidemiology members in October, 2020 to assess PPE availability and crisis standards utilized in fall, 2020. RESULTS: In total, 1,081 infection preventionists (IP) participated. A quarter lacked sufficient disinfection supplies, N95s, isolation gowns, and gloves; 10 – 20% lacked eye protection and hand hygiene supplies. Significantly more were reusing respirators than masks (65.6% vs 46.8%, respectively; p< .001); a third (32.0%, n=735) were re-using isolation gowns. About half (45.9%, n=496) were decontaminating respirators. Determinants of believing current PPE re-use protocols were safe and evidence-based included the IP being involved in developing COVID-19 protocols (both), having respirator reuse protocols that involve ≤ five reuses (both), using reusable respiratory protection (both), decontaminating respirators (perceived safe), and not reusing masks (perceived safe; p < .05 for all). CONCLUSIONS: Although most healthcare facilities had adequate PPE in fall 2020, PPE supply chains were still disrupted, resulting in the need to reuse or decontaminate PPE. Ongoing gaps in PPE access need to be addressed in order to minimize healthcare associated infections and occupational illness.

SARS-CoV-2, the virus that causes COVID-19 disease, was identified in early 2020 and quickly led to a pandemic. Within just a few months of the pandemic, many hospitals and healthcare facilities reported personal protective equipment (PPE) and infection prevention supply anticipated and actual shortages. 1, 2 This required healthcare facilities to begin utilizing crisis capacity strategies to conserve PPE. Healthcare facilities were forced to implement strategies to reuse, conserve and prioritize the use of eye protection, isolation gowns, masks, and N95 respirators (i.e., to implement crisis standards of care (CSC) related to PPE). 3, 4 A national study conducted in March 2020 found that many hospitals and healthcare facilities were running dangerously low or even out of face shields, N95 respirators, hand sanitizer, and disinfection supplies. 2 Soon after findings from this study were made public, the Defense Production Act was activated, which included provisions to ramp up production of PPE and other critical supplies. 5 In late spring, the Centers for Disease Control and Prevention (CDC) released guidelines for optimizing PPE supply during the COVID-19 pandemic. 4 These guidelines were designed to provide evidence-based strategies for CSCs for PPE, such as long-term and re-use of PPE. Despite activation of the Defense Production Act and release of the CDC's PPE crisis standard protocols, about half of healthcare facilities continued to report PPE shortages through the summer of 2020 and beyond. 6 A study conducted by the American Nurses Association found that about 79% of nurses felt unsafe due to PPE shortages and the associated use of PPE CSCs. The purpose of this study was to assess PPE availability in fall 2020 of the COVID-19 pandemic and PPE CSCs implemented.

A link to an online questionnaire was provided to all members of the Association for Professionals in Infection Control and Epidemiology (APIC) via email newsletters sent to members. The survey was administered through Gravity Forms ® , an online survey software program. The CSCs and other protocols related to PPE, such as their use of universal masking or eye protection; use of reusable respiratory protection; practices related to reuse of respirators and masks; and respirator decontamination strategies. Ten items assessed participants' attitudes and beliefs about the pandemic.

APIC staff collected the data and then shared with the authors to conduct a secondary data analysis. The Saint Louis University Institutional Review Board determined that this was not human subjects research.

The Statistical Package for the Social Sciences (SPSS  ) 27.0 was used for all analyses. Each PPE type, hand hygiene, and infection prevention supply was recoded into a dichotomous variable, with running a bit low, almost out, and have none = "no", and have plenty and have sufficient amount = "yes".

Descriptive statistics were reported for all questions. All comparisons across dichotomous groups were assessed using a chi square, such as to detect differences between those who agreed with an attitude and belief statement and whether or not they had implemented CSCs for mask use. Proportions tests were used to evaluate differences in agreement between attitude and belief questions. Regional participation percentages were compared using a chi square goodness of fit test based on US census data. A hierarchical logistic regression was used to determine predictive models for believing their PPE reuse protocols are safe and evidence-based, and that they have adequate PPE. A Hosmer and Lemeshow goodness-of-fit test was used to determine good model fit for each regression. Only final models are reported. A p value of .05 was used as the cut off for statistical significance for all analyses.

In all, 1,081 infection preventionists completed the survey. Almost all were female (94.5%, n=990), and over 40 years of age (79.7%; Table 1 ). Participation was slightly higher among IPs in the Midwest and slightly lower than expected among IPs in the South and West compared to U.S. census data (X 2 =11.6, p< .05; Table 1 ). The vast majority (80.0%, n=859) work at a single facility; all others Crisis Standards of Care During COVID-19 covered than more one facility type. Over half (58.9%, n=638) work in a hospital. A quarter (25.1%, n=198) worked at the smallest sized facility with  50 beds; 17.6% (n=139) worked at the largest-size facility with  500 beds (Table 1) .

Current PPE and infection prevention supply availability was assessed; details are provided in Table 2 . About a quarter lack sufficient disinfection supplies, N95s, isolation gowns, and gloves ( Table 2 ).

Between 10 -20% lack sufficient eye protection, hand sanitizer, and hand soap ( PPE availability was found to vary by facility type. LTCFs, ambulatory care, and home care were significantly less likely to report having sufficient respirators compared to other facility types (X 2 =18.5, p< .01). Critical access hospitals and ambulatory care facilities were less likely than other settings to have sufficient masks (X 2 =18.5, p< .01). Hospitals, LTCFs, and urget care were more likely to have sufficient face shields compared to all other sites (X 2 =18.6, p< .01). Ambulatory care and critical access hospitals were less likely to have adequate gloves (X 2 =15.9, p=.01). Isolation gown and goggle availability did not vary by facility type.

Almost all healthcare facilities are implementing a universal masking policy for employees and visitors (99.4% and 98.4%, respectively). About a third of IPs (29.9%, n=323) reported that their facility reserves N95s for aerosol-generating procedures (AGPs); 64.0% (n=687) reserve N95s for all known or suspected COVID-19 patients and/or AGPs. A small percentage (6.6%, n=71) reported that they only have access to masks and do not use N95s for any medical care. About two-thirds of participants (63.2%, n=683) reported that their facility is using some type of reusable respiratory protection. About half (56.5%) have had some staff use a powered air-purifying respirator (PAPR) for respiratory protection;

22.2% (n=240) have used elastomeric respirators. About a third of IPs reported that their facility has used respirators that are not certified by the National Institute for Occupational Safety and Health (NIOSH); 28.2% have used respirators that exceeded their shelf life. A small percentage reported using KN95 respirators or some other type of non-NIOSH certified respirator in the past three months (4.3% and 1.4%, respectively). About two-thirds (67.5%, n=730) have implemented a universal eye protection protocol for all staff; a quarter (25.8%) only use eye protection with COVID-19 patients, and 6.7% (n=72) allow the healthcare personnel to decide when to wear a face shield or goggle. No facilities implemented a universal eye protection protocol for patients or visitors. Approximately half (56.5%, n=611) have visitors of COVID-19 patient wear eye protection; 43.5% (n=470) only have visitors wear eye protection if they are unable to wear a mask.

About two-thirds (65.6%, n=709) reported that their healthcare facility is currently reusing respirators. Of those reusing respirators (n=709), two-thirds are allowing 5 reuses (37.4%) or as many as possible (38.6%) before providing staff a new respirator. Almost all facilities that are reusing respirators are having staff store the used respirator in a brown bag or other breathable container (90.9%, n=637); 3.9% are using an unsealed plastic baggie or container, 1.1% are hanging the respirator, and 4.1% allow staff to choose their storage method. Of those facilities reusing respirators (n=709), half (49.5%, n=351) are providing staff with more than one respirator so that they can be rotated and not worn two days in a row. Significantly more facilities are reusing respirators compared to reusing masks (65.6% vs 46.8%, respectively; p< .001). Of those reusing masks (n=506), more than half (56.7%) have staff wear the mask as many times as possible before donning a new mask; 16.8% require five reuses, and 12.8% reuse a mask only once. About 20% (19.2%, n=208) reported that their healthcare staff resorted to wearing a homemade mask at some point during the pandemic because their facility had run out of respirators and masks. About a third (32.0%, n=735) are currently re-using isolation gowns or have done so in the past three months. Of those re-using gowns (n=346), half (50.9%) are re-using cloth gowns; 46.2% are re-using synthetic/traditional isolation gowns.

About half of all facilities (45.9%, n=496) reported using some form of respirator decontamination currently or in the past three months. The two most commonly reported forms of respirator decontamination were vaporous hydrogen peroxide and ultraviolet germicidal irradiation (UGVI; 24.1% and 19.0%, respectively; Table 3 ). The frequency of other types of respirator decontamination are outlined in Table 3 . Of those decontaminating respirators (n=496), 16.3% (n=81) are stockpiling the decontaminated respirators for possible future use rather than returning them to staff. About 20% (17.9%, n=193) are having respirators decontaminated off-site. Of those using off-site decontamination (n=193), a third (34.2%) are returning the respirators to general stock rather than providing staff their own previously used respirator.

Crisis Standards of Care During COVID-19

The vast majority of IPs have been involved in developing their facility's COVID-19 response protocols and believed their healthcare colleagues trust their opinion about infection prevention (85.8% and 85.5%, respectively; Table 4 ). More than three-quarters of IPs (79.1%, n=855) reported being concerned about the impact of medical supply shortages on their facility related to the pandemic and influenza season (Table 4 ). Significantly more were concerned about medical supply shortages this year compared to previous years because of the pandemic (84.3% vs 79.1%, p < .001; Table 4 ). Almost threequarters (71.9%, n=777) were concerned about their facility's healthcare surge capacity during the current influenza season and COVID-19 pandemic (Table 4 ). Approximately half were concerned about their facility's ability to provide safe patient care and/or protect healthcare personnel during the current influenza season and COVID-19 pandemic (53.7% and 51.2%, respectively; Table 4 ). IPs whose facility was currently using CSC protocols for masks reported significantly more concern about the impact of medical supply shortages, healthcare surge capacity, and the ability to provide safe care or protect healthcare personnel compared to those who are not using CSCs for masks (Table 4 ). Most IPs (86.6%, n=936) believed their facility is currently providing adequate PPE for their staff, although IPs using a mask CSC protocol were less likely to believe this ( Table 4 ). Predictors of believing their facility is currently providing adequate PPE for their staff included the IP being involved in developing COVID-19 protocols, not having worn homemade masks at some point, not having used respirators that exceeded their shelf life, having respirator reuse protocols that involve five or fewer reuses, and not current reusing masks (p < .05 for all; Table 5 ). All other demographic variables and attitude and belief statements,including CIC status, were not significant predictors.

Three quarters of IPs (74.5%, n=805) believed their facility's current PPE re-use protocols are safe; there was no relationship between this belief and using a mask CSC protocol ( Table 4) .

Determinants of believing their facility's current PPE re-use protocols are safe included the IP being involved in developing COVID-19 protocols, having respirator reuse protocols that involve five or fewer Crisis Standards of Care During COVID-19 reuses, using reusable respiratory protection, using any form of respirator decontamination, and not currently reusing masks (p < .05 for all; Table 5 ). Fewer than three-quarters (70.8%, n=765) believed their PPE reuse protocols are evidence-based ( Table 4 ). Predictors of believing their PPE reuse protocols are evidence-based included the IP being involved in developing COVID-19 protocols, having respirator reuse protocols that involve five or fewer reuses and using reusable respiratory protection.

The findings of this study indicate that IPs are reporting better access to PPE and infection prevention supplies in fall, 2020 compared to a similar study conducted with APIC members in spring 2020. 2 However, disinfection supplies, N95s, isolation gowns (including cloth and washable), and gloves continue to be lacking and remain the PPE most often in insufficient supply. This data reflects findings from other COVID-19-related studies examining PPE access throughout the pandemic. For example, Greene and Gibson 7 found that 16.8% -18.8% of sampled LTCFs experienced a PPE shortage during June through July 2020 of the COVID-19 pandemic, with N95s and isolation gowns most likely to be in shortage. McGarry et al. 8 found that 20.7% of participating LTCFs reported a severe PPE shortage, defined as one week or less of available supply, with N95s and isolation gowns being reported as the frequent PPE in shortage. The General Accountability Office reported on November 30, 2020 9 that while entities and organizations in most states could fulfill requests for supplies, constraints continued on certain items, including nitrile gloves, which are preferred over latex gloves in healthcare due to their puncture-resistant nature. This sustained shortage of PPE and disinfection supplies across healthcare facilities remains a concern, as these supplies are critical to protect healthcare personnel and patients from exposure and infection. As of January 30, 2021, the CDC reported that 387,901 healthcare personnel had become infected with COVID-19, resulting in 1,325 deaths. 10 Gowns worn in healthcare, such as isolation and surgical gowns, are chosen based on the barrier protection level afforded by that material and the action to be performed, such as used when providing care to a patient in isolation versus during a surgical procedure. Traditional isolation gowns are not made of cloth and are considered to be single-use items. It is not known whether there was an increased risk of occupational illness for those facilities that were forced to switch to cloth/washable gowns instead of traditional isolation gowns. Additional research is needed to learn how PPE and disinfection supply shortages may contribute to these infections during this pandemic, but research has found that a large percentage of nurses felt unsafe working during the pandemic due to PPE shortages. 11 Findings from this study indicate that the ongoing and intermittent supply challenges have resulted in a number of healthcare facilities implementing PPE contingency and crisis protocols in an attempt to preserve their supplies. Almost 90% of IPs in this study reported perceiving that they have an adequate PPE supply, but only when compromises were made regarding PPE use. Approximately three-quarters of healthcare facilities in this study reported implementing crisis standards for PPE, including N95s, masks, eye protection, and isolation gowns. The CDC defines crisis capacity strategies as "strategies that can be used when supplies cannot meet the facility's current or anticipated PPE utilization rate". 4 Extended use, reuse, and decontamination of respirators, use of respirators beyond their designated shelf life, extended use of isolation gowns and masks, and prioritizing PPE to patient care activities of higher risk to healthcare personnel are some strategies that CDC recommends to prolong PPE supplies. 4 In this study, about 20% of IPs reported that healthcare personnel at their facilities needed to wear a cloth mask at some point during the pandemic due to lack of single-use mask supplies, a practice that the CDC indicates should be the last resort after all other options have been exhausted. 4 This demonstrates the extreme lack of PPE availability during the pandemic.

An interesting finding from this study is that use of crisis standards for masks was strongly associated with IP concerns about patient and healthcare worker safety. IPs whose facilities are currently applying crisis protocols for masks reported significantly more concern about the impact of medical supply shortages, healthcare surge capacity, and the ability to provide safe care or protect healthcare personnel compared to those who are not using crisis standards for masks.. These concerns for healthcare worker safety related to supply shortages and their implications are substantiated by other research from this pandemic. For example, Sharma et al. 12 found that there was a higher likelihood for emotional distress and burnout among intensive care unit personnel reporting insufficient PPE access, these healthcare personnel were 5.82 times more likely to feel like their hospital could not keep them safe. Norful et al. 13 identified PPE stressors, including access to supplies and transmission risk by healthcare personnel to their families, as a theme in their qualitative study of healthcare personnel examining stress during the early part of the COVID-19 pandemic in the US. PPE crisis standards may also have an impact on healthcare associated infections. 14 In one study, extended use of an underlayer of PPE was found to be associated with an outbreak of Candida auris, a multidrug resistant yeast that can cause invasive infections. 15 Additional observational studies to understand how using PPE within crisis standards could impact other healthcare-associated infections and occupational exposures and infections would help in understanding potential consequences to implementing these protocols.

A notable finding from this study is that nearly one-quarter of IPs do not believe their PPE reuse protocols are safe and about a third do not believe they are evidence-based. However, when the IP was involved with developing COVID-19 PPE protocols, they were significantly more likely to believe their PPE protocols were safe and evidence-based, and to report having adequate PPE for staff. In a 2016 paper by Bubb et al. 16 This study is the first to assess the extent to which U.S. healthcare facilities are currently implementing crisis standards related to PPE, such as reuse of masks and N95s and respirator decontamination. Although recommendations around these practices are evolving, it is critical to assess what is currently being implemented and IPs' attitudes and beliefs about these practices. However, study limitations must also be noted. There is a potential risk of responder bias. Participants may have been more involved than non-responders in developing PPE crisis standards or COVID-19 response at their facilities, which could lead to bias. Finally, because only APIC members were invited to participate, these findings do not reflect all U.S. healthcare facilities and likely better represent hospitals compared to LTCFs and other healthcare settings that are less likely to have an APIC member IP. Additional studies would be needed to better determine PPE crisis standards implemented in nonacute care facilities.

This study found that, although most US healthcare facilities reported having adequate PPE, hand hygiene products, and disinfection supplies in fall, 2020, this was due to the high frequency of PPE crisis standards being implemented. PPE supply chains were still disrupted, resulting in the need to reuse or decontaminate PPE in order for healthcare facilities to have adequate PPE. These practices may result in unsafe work and healthcare environments and an increased risk of healthcare-associated and/or occupational infections among patients and healthcare personnel. Ongoing gaps in PPE access need to be addressed in order to minimize healthcare associated infections and occupational illness. * 0 = have none; 1 = almost out (unsure if current supplies will last until replacements arrive); 2 = running a bit low (more has been ordered but we should have enough until it arrives); 3 = have sufficient amount (crisis standards of care are in place, but we have enough); 4 = have plenty (no crisis standards of care in place; PPE are single use items) 

Governor Cuomo Holds a Briefing on New York's COVID-19 Response

Availability of personal protective equipment and infection prevention supplies during the first month of the COVID-19 pandemic: A national study by the APIC COVID-19 task force

Challenges and solutions for addressing critical shortage of supply chain for personal and protective equipment (PPE) arising from Coronavirus disease (COVID19) pandemic -Case study from the Republic of Ireland

Centers for Disease Control & Prevention. Summary for Healthcare Facilties: Strategies for Optimizing the Supply of PPE during Shortages

Trump invoked the Defense Production Act

ANA Survey of 14K Nurses Finds Access to PPE Remains a Top Concern

State Actions and Shortages of Personal Protective Equipment and Staff in U.S. Nursing Homes

Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic. Health affairs

COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal Response

?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fcases-updates%2Fcases-in-us.html#health-care-personnel

ANA Survey of 14K Nurses Finds Access to PPE Remains a Top Concern

Healthcare professionals' perceptions of critical care resource availability and factors associated with mental well-being during COVID-19: Results from a US survey

Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States

Impact of SARS-CoV-2 on hospital acquired infection rates in the United States: Predictions and early results

Candida auris Outbreak in a COVID-19 Specialty Care Unit -Florida

APIC professional and practice standards