Conservation Of Personal Protective Equipment Research Articles

Family physicians’ responses to personal protective equipment shortages in four regions in Canada: a qualitative study

BackgroundDespite well-documented increased demands and shortages of personal protective equipment (PPE) during previous disease outbreaks, health systems in Canada were poorly prepared to meet the need for PPE during the COVID-19 pandemic. In the primary care sector, PPE shortages impacted the delivery of health services and contributed to increased workload, fear, and anxiety among primary care providers. This study examines family physicians’ (FPs) response to PPE shortages during the first year of the COVID-19 pandemic to inform future pandemic planning.MethodsAs part of a multiple case study, we conducted semi-structured qualitative interviews with FPs across four regions in Canada. During the interviews, FPs were asked to describe the pandemic-related roles they performed over different stages of the pandemic, facilitators and barriers they experienced in performing these roles, and potential roles they could have filled. Interviews were transcribed and a thematic analysis approach was employed to identify recurring themes. For the current study, we examined themes related to PPE.ResultsA total of 68 FPs were interviewed across the four regions. Four overarching themes were identified: 1) factors associated with good PPE access, 2) managing PPE shortages, 3) impact of PPE shortages on practice and providers, and 4) symbolism of PPE in primary care. There was a wide discrepancy in access to PPE both within and across regions, and integration with hospital or regional health authorities often resulted in better access than community-based practices. When PPE was limited, FPs described rationing and reusing these resources in an effort to conserve, which often resulted in anxiety and personal safety concerns. Many FPs expressed that PPE shortages had come to symbolize neglect and a lack of concern for the primary care sector in the pandemic response.ConclusionsDuring the COVID-19 pandemic response, hospital-centric plans and a lack of prioritization for primary care led to shortages of PPE for family physicians. This study highlights the need to consider primary care in PPE conservation and allocation strategies and to examine the influence of the underlying organization of primary care on PPE distribution during the pandemic.

A Dispatch Screening Tool to Identify Patients at High Risk for COVID-19 in the Prehospital Setting.

IntroductionEmergency medical services (EMS) dispatchers have made efforts to determine whether patients are high risk for coronavirus disease 2019 (COVID-19) so that appropriate personal protective equipment (PPE) can be donned. A screening tool is valuable as the healthcare community balances protection of medical personnel and conservation of PPE. There is little existing literature on the efficacy of prehospital COVID-19 screening tools. The objective of this study was to determine the positive and negative predictive value of an emergency infectious disease surveillance tool for detecting COVID-19 patients and the impact of positive screening on PPE usage.MethodsThis study was a retrospective chart review of prehospital care reports and hospital electronic health records. We abstracted records for all 911 calls to an urban EMS from March 1–July 31, 2020 that had a documented positive screen for COVID-19 and/or had a positive COVID-19 test. The dispatch screen solicited information regarding travel, sick contacts, and high-risk symptoms. We reviewed charts to determine dispatch-screening results, the outcome of patients’ COVID-19 testing, and documentation of crew fidelity to PPE guidelines.ResultsThe sample size was 263. The rate of positive COVID-19 tests for all-comers in the state of Massachusetts was 2.0%. The dispatch screen had a sensitivity of 74.9% (confidence interval [CI], 69.21–80.03) and a specificity of 67.7% (CI, 66.91–68.50). The positive predictive value was 4.5% (CI, 4.17–4.80), and the negative predictive value was 99.3% (CI, 99.09–99.40). The most common symptom that triggered a positive screen was shortness of breath (51.5% of calls). The most common high-risk population identified was skilled nursing facility patients (19.5%), but most positive tests did not belong to a high-risk population (58.1%). The EMS personnel were documented as wearing full PPE for the patient in 55.7% of encounters, not wearing PPE in 8.0% of encounters, and not documented in 27.9% of encounters.ConclusionThis dispatch-screening questionnaire has a high negative predictive value but moderate sensitivity and therefore should be used with some caution to guide EMS crews in their PPE usage. Clinical judgment is still essential and may supersede screening status.

Behind the mask: extended use of surgical masks is not associated with increased risk of surgical site infection

PurposeCOVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI).MethodsA single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded.ResultsFour hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation.ConclusionExtended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.

X-Rays through the Looking Glass: Mobile Imaging Dosimetry and Image Quality of Suspected COVID-19 Patients

Background: This paper aims to evaluate the clinical utility and radiation dosimetry, for the mobile X-ray imaging of patients with known or suspected infectious diseases, through the window of an isolation room. The suitability of this technique for imaging coronavirus disease 2019 (COVID-19) patients is of particular focus here, although it is expected to have equal relevance to many infectious respiratory disease outbreaks.Materials and Methods: Two exposure levels were examined, a “typical” mobile exposure of 100 kVp/1.6 mAs and a “high” exposure of 120 kVp/5 mAs. Exposures of an anthropomorphic phantom were made, with and without a glass window present in the beam. The resultant phantom images were provided to experienced radiographers for image quality evaluation, using a Likert scale to rate the anatomical structure visibility.Results and Discussion: The incident air kerma doubled using the high exposure technique, from 29.47 μGy to 67.82 μGy and scattered radiation inside and outside the room increased. Despite an increase in beam energy, high exposure technique images received higher image quality scores than images acquired using lower exposure settings.Conclusion: Increased scattered radiation was very low and can be further mitigated by ensuring surrounding staff are appropriately distanced from both the patient and X-ray tube. Although an increase in incident air kerma was observed, practical advantages in infection control and personal protective equipment conservation were identified. Sites are encouraged to consider the use of this technique where appropriate, following the completion of standard justification practices.

Compounding sterile products during a personal protective equipment shortage.

PurposeTo describe our pharmacy department’s plan for conservation of personal protective equipment (PPE) during the coronavirus disease 2019 (COVID-19) pandemic to ensure continued availability of sterile compounded products.SummaryPPE shortages impacted hospitals throughout the nation in the early months of the COVID-19 pandemic response. The PPE requirement for sterile compounding and need to maintain supplies within the pharmacy cleanroom are often overlooked. A sustained supply of PPE is critical to ensure an uninterrupted supply of compounded medications to our patient population. Multiple conservation strategies, including staffing changes, communication, adjustments to training, and even reuse of select PPE, can assist with conservation.ConclusionPPE in pharmacy cleanrooms is critical for the continued provision of sterile compounds with appropriate beyond-use dates and effective patient care. Pharmacy departments must employ multiple conservation strategies to ensure PPE is available for continued compounding of sterile products, and early planning and implementation of conservation strategies are key.

Challenges in communication, prognostication and dialysis decision-making in the COVID-19 pandemic: implications for interdisciplinary care during crisis settings.

Using case vignettes, we highlight challenges in communication, prognostication, and medical decision-making that have been exacerbated by the coronavirus disease-19 (COVID-19) pandemic for patients with kidney disease. We include best practice recommendations to mitigate these issues and conclude with implications for interdisciplinary models of care in crisis settings. Certain biomarkers, demographics, and medical comorbidities predict an increased risk for mortality among patients with COVID-19 and kidney disease, but concerns related to physical exposure and conservation of personal protective equipment have exacerbated existing barriers to empathic communication and value clarification for these patients. Variability in patient characteristics and outcomes has made prognostication nuanced and challenging. The pandemic has also highlighted the complexities of dialysis decision-making for older adults at risk for poor outcomes related to COVID-19. The COVID-19 pandemic underscores the need for nephrologists to be competent in serious illness communication skills that include virtual and remote modalities, to be aware of prognostic tools, and to be willing to engage with interdisciplinary teams of palliative care subspecialists, intensivists, and ethicists to facilitate goal-concordant care during crisis settings.

Achieving Health Equity: Examining Telehealth in Response to a Pandemic

The coronavirus disease 2019 (COVID-19) pandemic necessitated social distancing mandates, the conservation of personal protective equipment, and the prioritization of health care resources, thus prompting the rapid scale-up of telehealth services. The COVID-19 pandemic illustrates the importance of taking a broader view of health policy that facilitates the optimal conditions in which patient-centered care occurs and health equity is pursued. This article examines the use of telehealth during the pandemic as a case for demonstrating the necessity for advanced practice nurses to engage in broad policy initiatives to address social determinants of health care.

Cancer Management During the COVID-19 Pandemic in the United States: Results From a National Physician Cross-sectional Survey.

Objectives:The coronavirus disease 2019 (COVID-19) has significantly impacted health care delivery across the United States, including treatment of cancer. We aim to describe the determinants of treatment plan changes from the perspective of oncology physicians across the United States during the COVID-19 pandemic.Methods:Participants were recruited to an anonymous cross-sectional online survey of oncology physicians (surgeons, medical oncologists, and radiation oncologists) using social media from March 27 to April 10, 2020. Physician demographics, practice characteristics, and cancer treatment decisions were collected.Results:The analytic cohort included 411 physicians: 241 (58.6%) surgeons, 106 (25.8%) medical oncologists, and 64 (15.6%) radiation oncologists. In all, 38.0% were practicing in states with 1001 to 5000 confirmed COVID-19 cases as of April 3, 2020, and 37.2% were in states with >5000 cases. Most physicians (N=285; 70.0% of surgeons, 64.4% of medical oncologists, and 73.4% of radiation oncologists) had altered cancer treatment plans. Most respondents were concerned about their patients’ COVID-19 exposure risks, but this was the primary driver for treatment alterations only for medical oncologists. For surgeons, the primary driver for treatment alterations was conservation of personal protective equipment, institutional mandates, and external society recommendations. Radiation oncologists were primarily driven by operational changes such as visitor restrictions.Conclusions:The COVID-19 pandemic has caused a majority of oncologists to alter their treatment plans, but the primary motivators for changes differed by oncologic specialty. This has implications for reinstitution of standard cancer treatment, which may occur at differing time points by treatment modality.

Use of the ADKAR® and CLARC ® Change Models to Navigate Staffing Model Changes During the COVID-19 Pandemic

In early 2020, hospitals faced unprecedented patient volumes resulting from the COVID-19 outbreak. Nurse executives at a faith-based, not-for-profit health care system quickly responded to ensure safe staffing, conservation of personal protective equipment, and implementation of infection prevention strategies. A significant challenge was safe staffing for the expected patient surge. To address this, a team of nurse executives utilized the ADKAR change model to guide a transition from primary to team nursing. The processes varied between hospitals, but core principles and implementation strategies were the same. This article discusses the quick, but methodical, journey one health care system experienced.

Protocols for Personal Protective Equipment in a COVID-19 Medical Shelter.

The coronavirus disease 2019 (COVID-19) has greatly impacted health-care systems worldwide, leading to an unprecedented rise in demand for health-care resources. In anticipation of an acute strain on established medical facilities in Dallas, Texas, federal officials worked in conjunction with local medical personnel to convert a convention center into a Federal Medical Station capable of caring for patients affected by COVID-19. A 200,000 square foot event space was designated as a direct patient care area, with surrounding spaces repurposed to house ancillary services. Given the highly transmissible nature of the novel coronavirus, the donning and doffing of personal protective equipment (PPE) was of particular importance for personnel staffing the facility. Furthermore, nationwide shortages in the availability of PPE necessitated the reuse of certain protective materials. This article seeks to delineate the procedures implemented regarding PPE in the setting of a COVID-19 disaster response shelter, including workspace flow, donning and doffing procedures, PPE conservation, and exposure event protocols.

Engaging and Empowering the Front Lines During the COVID-19 Outpatient Practice Reactivation

Engaging and Empowering the Front Lines During the COVID-19 Outpatient Practice Reactivation

Pediatric Modification of the Medically Necessary, Time-Sensitive Scoring System for Operating Room Procedure Prioritization During the COVID-19 Pandemic

BackgroundThe COVID-19 pandemic forced surgeons to reconsider concepts of “elective” operations. Perceptions about the time sensitivity and medical necessity of a procedure have taken on greater significance during the pandemic. The evolving ethical and clinical environment requires reappraisal of perioperative factors, such as personal protective equipment conservation; limiting the risk of exposure to COVID-19 for patients, families, and healthcare workers; preservation of hospital beds and ICU resources; and minimizing COVID-19-related perioperative risk to patients.Study DesignA scaffold for the complex decision-making required for prioritization of medically necessary, time-sensitive (MeNTS) operations was developed for adult patients by colleagues at the University of Chicago. Although adult MeNTS scoring can be applied across adult surgical specialties, some variables were irrelevant in a pediatric population. Pediatric manifestations of chronic diseases and congenital anomalies were not accounted for. To account for the unique challenges children face, we modified the adult MeNTS system for use across pediatric subspecialties.ResultsThis pediatric MeNTS scoring system was applied to 101 cases both performed and deferred between March 23 and April 19, 2020 at the University of Chicago Comer Children's Hospital. The pediatric MeNTS scores provide a safe, equitable, transparent, and ethical strategy to prioritize children's surgical procedures.ConclusionsThis process is adaptable to individual institutions and we project it will be useful during the acute phase of the pandemic (maximal limitations), as well as the anticipated recovery phase.

ASE Statement on the Reintroduction of Echocardiographic Services during the COVID-19 Pandemic

• Echocardiography services have been interrupted by the COVID pandemic. • Services are being gradually reintroduced as healthcare facilities reopen. • Operational, workflow and prioritization considerations are suggested.

Rapid Implementation of a SARS-CoV-2 Diagnostic Quantitative Real-Time PCR Test with Emergency Use Authorization at a Large Academic Safety Net Hospital

BackgroundSignificant delays in the rapid development and distribution of diagnostic testing for SARS-CoV-2 (COVID-19) infection have prevented adequate public health management of the disease, impacting the timely mapping of viral spread and the conservation of personal protective equipment. Furthermore, vulnerable populations, such as those served by the Boston Medical Center (BMC), the largest safety net hospital in New England, represent a high-risk group across multiple dimensions, including a higher prevalence of pre-existing conditions and substance use disorders, lower health maintenance, unstable housing, and a propensity for rapid community spread, highlighting the urgent need for expedient and reliable in-house testing.MethodsWe developed a SARS-CoV-2 diagnostic medium-throughput qRT-PCR assay with rapid turnaround time and utilized this Clinical Laboratory Improvement Amendments (CLIA)-certified assay for testing nasopharyngeal swab samples from BMC patients, with emergency authorization from the Food and Drug Administration (FDA) and the Massachusetts Department of Public Health.FindingsThe in-house testing platform displayed robust accuracy and reliability in validation studies and reduced institutional sample turnaround time from 5–7 days to less than 24 h. Of over 1,000 unique patient samples tested, 44.1% were positive for SARS-CoV-2 infection.ConclusionsThis work provides a blueprint for academic centers and community hospitals lacking automated laboratory machinery to implement rapid in-house testing.FundingThis study was supported by funding from the Boston University School of Medicine, the National Institutes of Health, Boston Medical Center, and the Massachusetts Consortium on Pathogen Readiness (MASS CPR).

Adapting a Comfort Care Order Set in a Large Health System during the COVID-19 Pandemic.

Adapting a Comfort Care Order Set in a Large Health System during the COVID-19 Pandemic.

Modifications of emergency dental clinic protocols to combat COVID-19 transmission.

During the COVID‐19 pandemic, incidence rates for dental diseases will continue unabated. However, the intent to prevent the spread of this lethal respiratory disease will likely lead to reduced treatment access due to restrictions on population movements. These changes have the potential to increase dental‐related emergency department visits and subsequently contribute to greater viral transmission. Moreover, dentists experience unique challenges with preventing transmission due to frequent aerosol‐producing procedures. This paper presents reviews and protocols implemented by directors and residents at the Dental College of Georgia to manage a dental emergency clinic during the COVID‐19 pandemic. The methods presented include committee‐based prioritization of dental patients, a multilayered screening process, team rotations with social and temporal spacing, and modified treatment room protocols. These efforts aid in the reduction of viral transmission, conservation of personal protective equipment, and expand provider availability. These protocols transcend a university and hospital‐based models and are applicable to private and corporate models.

Conservation of personal protective equipment for head and neck cancer surgery during COVID-19 pandemic.

BackgroundCOVID‐19 pandemic has led to a global shortage of personal protective equipment (PPE). This study aims to stratify face shield needs when performing head and neck cancer surgery.MethodsFifteen patients underwent surgery between March 1, 2020 and April 9, 2020. Operative diagnosis and procedure; droplet count and distribution on face shields were documented.ResultsForty‐five surgical procedures were performed for neck nodal metastatic carcinoma of unknown origin (n = 3); carcinoma of tonsil (n = 2), tongue (n = 2), nasopharynx (n = 3), maxilla (n = 1), and laryngopharynx (n = 4). Droplet contamination was 57.8%, 59.5%, 8.0%, and 0% for operating, first and second assistant surgeons, and scrub nurse respectively. Droplet count was highest and most widespread during osteotomies. No droplet splash was noted for transoral robotic surgery.ConclusionFace shield is not a mandatory adjunctive PPE for all head and neck surgical procedures and health care providers. Judicious use helps to conserve resources during such difficult times.

Rapid Implementation of a SARS-CoV-2 Diagnostic qRT-PCR Test with Emergency Use Authorization at a Large Academic Safety-Net Hospital

The coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is now a major global public health crisis. In the United States, significant delays in the rapid development and distribution of diagnostic testing for SARS-CoV-2 infection have prevented adequate COVID-19 patient care and public health management of the pandemic, impacting the timely mapping of the dynamics of viral spread in the general population, and more topically, the conservation of personal protective equipment. Furthermore, vulnerable populations such as those served by Boston Medical Center (BMC), the largest safety net hospital in New England, represent a high-risk group across multiple dimensions, including a higher prevalence of pre-existing conditions and substance use disorders, lower general health maintenance, unstable housing, and a propensity for rapid community spread, highlighting the urgent need for rapid and reliable in-house testing infrastructure. Here, we report the rapid implementation of a SARS-CoV-2 diagnostic RT-PCR assay with Emergency Use Authorization (EUA) from the Food and Drug Administration (FDA). Our test offers a more rapid turnaround time in comparison to currently available commercial or state laboratory facilities, and enables clinicians and patients to make more informed decisions with personal and public health ramifications. The template and protocol that we have generated and validated could be useful for other smaller community hospitals lacking capital intensive automated clinical laboratory machinery to run molecular biology assays.

Collaborative Multidisciplinary Incident Command at Seattle Children’s Hospital for Rapid Preparatory Pediatric Surgery Countermeasures to the COVID-19 Pandemic

Washington was the first US state to have a patient test positive for COVID-19. Before this, our children’s hospital proactively implemented an incident command structure that allowed for collaborative creation of safety measures, policies, and procedures for patients, families, staff, and providers. Although the treatment and protective standards are continuously evolving, this commentary shares our thoughts on how an institution, and specifically, surgical services, may develop collaborative process improvement to accommodate for rapid and ongoing change. Specific changes outlined include early establishment of incident command; personal protective equipment conservation; workforce safety; surgical and ambulatory patient triage; and optimization of trainee education. Please note that the contents of this manuscript are shared in the interest of providing collaborative information and are under continuous development as our regional situation changes. We recognize the limitations of this commentary and do not suggest that our approaches represent validated best practices.

Coronavirus Disease 2019 and the Pediatric Gastroenterologist.

Coronavirus Disease 2019 and the Pediatric Gastroenterologist.