Time to Update Personal Protective Equipment Protocols?

During the first surge of the coronavirus disease 2019 (COVID-19) pandemic in March 2020, infection preventionists (IPs) had to figure out how to use/reuse single use personal protective equipment (PPE) and train staff to do the same. IPs had to change their message from “please don’t reuse that” to “please don’t discard that just yet.” This was not normal, and everyone knew it. The sheer volume of patients infected with COVID-19 drastically changed everything healthcare personnel (HCP), especially IPs, knew about PPE used to protect their health and safety while caring for patients.

In response to these nationwide PPE shortages, the US Centers for Disease Control and Prevention (CDC) developed an entire section on its website dedicated to strategies for optimizing PPE supplies titled “Optimizing Supply of PPE and Other Equipment During Shortages.”¹ It describes how patient surge, defined as “the ability to manage a sudden increase in patient volume that would severely challenge or exceed the present capacity of a facility” can be used to help monitor PPE use for facilities experiencing shortages. There is a quick reference chart that summarizes the CDC’s strategies to optimize all PPE, providing detailed strategies for N95 respirators, facemasks, gowns, and gloves. It also includes links to the CDC’s full guidance documents on optimizing supplies. It is a very detailed chart meant to be implemented sequentially, based on conventional, contingency, and crisis capacity, which is clearly spelled out. Every IP should have this readily available.

Burn Rate

In addition to the quick reference summary chart, the CDC, in collaboration with the National Institute for Occupational Safety and Health (NIOSH), developed the Personal Protective Equipment (PPE) Burn Rate Calculator.² The calculator was designed to help estimate how many days a PPE supply will last given current inventory levels and PPE “burn rate” or consumption. Originally a spreadsheet-based model that helped healthcare facilities plan and optimize their use of PPE for response to COVID-19 in the initial surge, it is now also available as an app for both iOS and Android, called the “NIOSH PPE Tracker App.”³

To use the calculator, you enter the number of full boxes of each type of PPE in stock (gowns, gloves, facemasks, surgical masks, respirators, and eye protection/face shields) and the total number of patients at your facility. The tool calculates the average burn rate for each type of PPE entered in the spreadsheet. This information can be used to help estimate how long the remaining supply of PPE will last, based on the average burn rate. Using the calculator can help facilities make order projections for future needs. This is a really handy app for anyone to have who orders supplies, especially supply chain and unit managers, as we again begin to experience PPE shortages.

Although IPs generally have limited involvement with supply chain, it might be worthwhile to find out more about supply chain and how it works so you can understand the process of bringing in products. This knowledge might help answer questions when you are rounding on your areas and questions about supplies that come up from HCP. Knowing who the person is who keeps your areas stocked with supplies is also a very valuable relationship to nurture.

And don’t forget what happened in the first surge of COVID-19-positive patients. To conserve PPE for use by HCP on the frontlines, the CDC provided guidance on methods to reduce PPE use for patients on transmission-based precautions such as contact precautions for multidrug-resistant organisms (MDROs)—specifically vancomycin-resistant Enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA).⁴ Typically, contact precautions is the single use of gown and gloves when caring for patients who are either colonized or infected with one or more MDRO. But during the first COVID-19 surge, a “bundled” approach for patient care, to not using some PPE at all, with an emphasis on glove use and hand hygiene, was recommended by the CDC for HCP caring for patients in isolation precautions other than COVID-19. Much about the previous use of PPE in many facilities was deferred until supplies were replenished or COVID-19 patient volumes decreased to manageable levels.

Comprehensive

Historically, PPE has been used to “break the chain” of transmissible disease. But PPE alone cannot reduce organism transmissions. A comprehensive program that includes antimicrobial stewardship, hand hygiene, chlorhexidine bathing, a cleaning and disinfection program of the patient environment and equipment, and decolonization, where appropriate, should be considered as a “bundled approach” to preventing transmissions.⁵ The initiation of isolation precautions should be considered by the infection control program based on local, state, regional, or national recommendations, and be of clinical and epidemiologic significance for that particular hospital or region.

Last, healthcare institutions should have a process in place to remove isolation precautions since the necessary duration of contact precautions for patients treated for infection with an MDRO, but who may continue to be colonized with the organism at one or more body sites, remains an unresolved issue.⁶

According to the latest updated CDC guidelines “Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006,”⁷ contact precautions can be discontinued when 3 or more surveillance cultures for the target MDRO are repeatedly negative over the course of a week or 2 in a patient who has not received antimicrobial therapy for several weeks, especially if there is:

1. absence of a draining wound,
2. no profuse respiratory secretions, or
3. no evidence implicating the specific patient in ongoing transmission of the MDRO within the facility.

But being able to do this is a lot harder than it might seem. Issues with frequent admissions and transfers within and outside of facilities, and monitoring antibiotic use makes this especially difficult, so patients sometimes remain on contact precautions for MDROs like VRE and MRSA indefinitely, despite the best efforts by IPs.

Stay on Top of It

Those facilities that have been performing some kind of surveillance on VRE and MRSA transmissions during COVID-19 should look at their data. The ability to compare transmission data for patients on contact precautions using the recommended full complement of PPE versus transmissions for patients on contact precautions when PPE was being utilized differently or not at all, would be very valuable information for a healthcare facility to have.

Now would be the time to determine the value of how PPE is used for contact precautions, with facility level data regarding patient transmissions—one of the main reasons for PPE use.

Your facility could reap the benefits of lower costs, higher patient and staff satisfaction, a greener future for our planet, and a method to always have enough PPE on hand. But remember to audit this process and track transmissions. As most IPs know, practices drift. So, stay on top of it! 

SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago. She is also a member of Infection Control Today®’s Editorial Advisory Board.

References:

1. ^{Centers for Disease Control and Prevention. Optimizing Supply of PPE and Other Equipment during Shortages. Centers for Disease Control and Prevention website. Updated July 2020. AccessedNovember 6, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html}
2. ^{Centers for Disease Control and Prevention. Personal Protective Equipment (PPE) Burn Rate Calculator. Centers for Disease Control and Prevention website. Updated April 7, 2020. Accessed November 6, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html}
3. ^{National Institute for Occupational Safety and Health. Personal Protective Equipment. NIOSH PPE Tracker App. National Institute for Occupational Safety and Health (NIOSH) website. Updated June 2020. Accessed November 6, 2020. https://www.cdc.gov/niosh/ppe/ppeapp.html}
4. ^{Centers for Disease Control and Prevention. Clinical Questions about COVID-19: Questions and Answers. Centers for Disease Control and Prevention website. Updated November 18, 2020. Accessed November 20, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html#Infection-Control}
5. ^{Young K, Doernberg S, Snedecor RF, Mallin E. The things we do for no reason: Contact Precautions for MRSA and VRE. Hosp. Med. 2019 March;14(3):178-180 | 10.12788/jhm.3126}
6. ^{Centers for Disease Control and Prevention. Management of Multi-Drug Resistant Organisms in Healthcare Settings – Duration of Contact Precautions. Updated February 15, 2017. https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf}
7. ^{Centers for Disease Control and Prevention. Management of Multi-Drug Resistant Organisms in Healthcare Settings Updated February 15, 2017https://www.cdc.gov/infectioncontrol/pdf/guidelines/mdro-guidelines.pdf}
8. ^{The Effect of Hospital Isolation Precautions on Patient Outcomes and Cost of Care: A Multi-Site, Retrospective, Propensity Score-Matched Cohort Study.J Gen Intern Med. 2017 Mar; 32(3): 262–268. Published online 2016 Oct 17. doi: 10.1007/s11606-016-3862-4}