Covid-19 PPE: Indications, Procurement & Conservation in ... · 1. Identify type of PPE and define...
Transcript of Covid-19 PPE: Indications, Procurement & Conservation in ... · 1. Identify type of PPE and define...
Covid-19 PPE: Indications, Procurement & Conservation inNorthern Ontario
Dr Bhanu Nalla MBBS, FRCA(UK), FRCPC
Staff in Critical Care & Anesthesia, HSN, Sudbury
12th June 2020
NOSM Weekly Covid-19 Clinical Rounds
Disclosures
• No expert knowledge on Personal Protective Equipment (PPE) prior to
the Covid-19 pandemic
• Evidence related to PPE use in the pandemic is constantly evolving
and may change following this talk
• No financial ties to any PPE manufacturer or dubious distributor!
Objectives
1. Identify type of PPE and define their role during the COVID-19
pandemic
2. Appraise levels of risk to healthcare personnel providing care to
suspected or confirmed COVID-19 patients and associated PPE
recommendations.
3. Describe rational for healthcare PPE working groups including
planning challenges for the procurement, conservation and reuse of
PPE.
Introduction
• PPE is a hot topic!
• Appropriate use related to minimizing transmission
of coronavirus between patient and health care
worker (HCW)
• Emotive subject globally
• Main issues
• Lack of supply
• Massive increase in demand
• Inappropriate use
Chain of hazard controls in healthcare setting
Elimination & Substitution
Engineering & Systems Controls
Administrative Controls
PPE
Types of PPE
1. Facemasks
• Non-fluid resistant vs non-fluid resistant
• Respirators
2. Eye/face protection
• Goggles, protective glasses, face-shields
3. Isolation Gowns
• Disposable, non-disposable, coveralls
4. Gloves
5. Head protection – bonnets, caps
Mask Terminology…confusing!
Procedure Mask Surgical Mask
Non-fluid resistant (paper) Fluid resistant (surgical)
Types of Respirators
Isolations Gowns –protection & risk exposure
• Ideal gown:
• AAMI 2-3
• Extends below knee
• Back covered
• Full cuffs on arm
• Covers neck
• Quick to don, Easy to doff
• Disposable?
AAMI = Assoc for the Advancement of Medical Instrumentation
Transmission of Covid-19
Factors affecting exposure risk of HCWs to Covid-19 patient
Proximity to patientDuration of
exposure to patient
PPE
Appropriate choice
Donning/doffing technique
Room ventilation
• Negative vs positive pressure
• Air changes per hr (ACH)
High risk Aerosol Generating Medical
Procedures (AGMPs)
List of AGMPs
Laryngoscopy, endotracheal intubation & extubation, bag mask ventilation
Bronchoscopy & BAL
Tracheostomy procedures
Non-invasive ventilation (BIPAP & CPAP)
High flow nasal cannula (HFNC)?
Sputum induction, open deep suctioning via ETT or tracheostomy
Surgical procedures – laparascopy, ENT, Thoracic procedures
Dental procedures – high speed drilling, ultrasonic scalers
CPR – chest compression & defibrillation?
PPE for different risk levels
Moderate High Highest
Name Droplet + Contact Enhanced Airborne Enhanced NRI or AGMP
Situations Generalized contact with Covid-19 presumed or positive patients
HCW in the room with AGMPs performed, chest compression, defibrillation, circulating OR staff during AGMPs.
Directly performing AGMP (Anesthesia/Surgery) or assisting (RT)
PPE required Goggles or face-shieldFluid-resistant mask Procedure or surgical maskAAMI level 2 gownGloves
Eye protection + face-shieldN95 or similar maskAAMI level 2 gownGlovesHead protection
Eye protection + face-shieldN95 or similar maskAAMI level 2 gown +Double glovesHead & neck protection
Lockhart, SL et al. Can J Anesth, April 2020: 1-11
Why is there a PPE shortage?
• Unprecedented demand
• Healthcare adopting a ”just in time” policy to ordering supplies
• Majority of supplies from China• own needs vs limited capacity to
supply
• Local, provincial and national expired stockpile
• Dependent on provincially approved supply sources
Preparing for PPE during the Pandemic
Planning
Procurement & Preservation
Education
- Dr Michael J Ryan, Chief Executive Director, WHO Emergencies Program
Mission: optimizing PPE availability for HCWs
Optimize PPE
availability
Co-ordinate PPE supply
chain
Minimize wastage
Use appropriately
Conservation & re-use
strategies
Planning at HSN: PPE Working Group
Players:• Operational & Clinical Lead
• Supplies staff & Processing
• Infection Prevention & Control (IPAC)
• Nursing Clinical Managers
• Physicians
• Occupational Health
• HSN Foundation representative
Responsibilities: • Purchasing
• Inventory / Burn Rate
• Storage – security
• Quality control
• Conservation and reprocessing planning
• Contigency algorithms
• Regular update to IC
Inventory
• Requirement by MOH to update
daily
• Existing, expired & donated
stock
• Changes in stock over 1 week
• Historic vs projected usage
• Days on hand – important to
ramp up operations
Procurement of PPE
• Exponential global demand has led to significant challenges for PPE
supply in the North
• Supplies from standard sources, donations, alternative sources
• Traditional supply chain:
• limited supply available to facilities based on historical usage
• healthcare facilities dependent on provincially approved sources
• questionable stability
• Federal attempts at bulk orders have not come to fruition
• Global competition and political hierarchy have strained regular supply
Industrial Suppliers & Donations
Northern region has access to
mining/industry suppliers
Most stocks critically low by mid March –
competition with mining companies and Toronto
customers buying up stock
Multiple donations:
• Industry
• Small businesses
• Physicians
Challenges to take stock and centralize receiving
process
Alternative sources of PPE
• Less strictly regulated private supply chain
• Multiple new suppliers, importers and distributors offering services
• Challenges:
• Most distributors want cash up front
• Numerous reports of counterfeit items or substandard quality
• Most products from China – timeline on delivery increasing from days to weeks
• Cost of products rising with time
How can we tell the good from the bad?
Conservation and Re-use Strategies
PPE can be used over an extended period of time and over the course of many patients (eg cohort or ward of suspected or confirmed COVID-19 patients)
Applies to N95, surgical/procedure masks, all isolation gowns, eye/face protection
Extended Use
Limited reuse refers to the practice of using the same PPE for multiple encounters with patients but carefully removing it (‘doffing’) after each encounter, storing it safely, and then putting it back on (‘donning’) without sterilization.
Applies to N95, masks, cloth isolation gowns, eye/face protection
Limited re-use
Sterilization Methods for Reprocessing of PPE
Methods approved by Health Ontario:
Vapourized Hydrogen Peroxide (VHP) Ultraviolet Germicidal Irradiation (UVGI)
Issues:
Ability to remove and/or inactivate viral particulate safely
Ability to preserve structural integrity of the mask
System required to collect used masks safely (brown paper bags)
Strategy to disinfect, clean, sanitize and decontaminate disposable PPE for future use – applies specifically to N95 respirators
Limited re-use between cases
Conservation of N95s for future reprocessing
Our N95 Planning Algorithm
Conventional
Existing medical grade N95s, disposable - fit tested <5yrs
Contingency
Medical grade N95s > 5yrs old, disposable
Limit fit testing to HCWs who perform AGMPs
Crisis
Limited re-use and extended use of medical grade N95s
Industrial grade respirators (NIOSH or CE approved)
Reprocessed medical grade N95s
Re-usable half and full-face respirators, PAPR units
No PPE
Non-NIOSH or CE approved masks (KN95)
Fluid-resistant surgical masks
Home-made masks
Education
Planning algorithms apply to all aspects of
PPE
Regular updates on current stock and
usage
Effective communication on
conservation strategies vital
Close co-ordination with IPAC and clinical
staff
Walkarounds addressing PPE
needs in different departments and offering solutions
Consistent messaging on best available
evidence and practice
Summary
• Despite our low Covid-19 cases, PPE usage remains high and is expected to do so for the foreseeable future
• Inadequate PPE for HCWs associated with increased rates of transmission
• Overuse or misuse of PPE has unintended consequences:
• Impending shortages
• Compromised quality of patient care
• Risk of HCW contamination from doffing
• Strategies to preserve PPE include:
• Optimizing supply from all sources
• Initiate and adopt conservation strategies
• Effective communication and education to staff
References
1. IPAC Recommendations for Use of Personal Protective Equipment for Care of Individuals
with Suspect or Confirmed COVID‐19 (https://www.publichealthontario.ca/-
/media/documents/ncov/updated-ipac-measures-covid-19.pdf?la=en)
2. CDC Strategies to Optimize the Supply of PPE and Equipment, 2020
(https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html)
3. Ontario Health Recommendations on the Use and Conservation of PPE
(https://www.ontariohealth.ca/sites/ontariohealth/files/2020-
05/Ontario%20Health%20Personal%20Protective%20Equipment%20Use%20During%20th
e%20COVID-19%20Pandemic_rev10May20%20PDF_v2.pdf)
4. Chu, D.K et al (2020). Physical distancing, face masks, and eye protection to prevent person-
to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-
analysis. The Lancet (online print); 1st June: 1-14.
Questions?