NOSM Weekly Covid-19 Clinical Rounds Covid-19 PPE: Indications, Procurement & Conservation in Northern Ontario Dr Bhanu Nalla MBBS, FRCA(UK), FRCPC Staff in Critical Care & Anesthesia, HSN, Sudbury 12 th June 2020
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 & PPE Systems Controls Administrative Controls
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 PPE Duration of Appropriate choice Proximity to patient exposure to patient Donning/doffing technique Room ventilation High risk Aerosol • Negative vs positive Generating Medical pressure Procedures • Air changes per hr (AGMPs) (ACH)
Laryngoscopy, endotracheal intubation & extubation, bag mask ventilation Bronchoscopy & BAL Tracheostomy procedures Non-invasive ventilation (BIPAP & CPAP) List of AGMPs 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 HCW in the room with Directly performing Covid-19 presumed or AGMPs performed, chest AGMP positive patients compression, (Anesthesia/Surgery) or defibrillation, circulating assisting (RT) OR staff during AGMPs. PPE required Goggles or face-shield Eye protection + face- Eye protection + face- Fluid-resistant mask shield shield Procedure or surgical N95 or similar mask N95 or similar mask mask AAMI level 2 gown AAMI level 2 gown + AAMI level 2 gown Gloves Double gloves Gloves Head protection Head & 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 Minimize Use wastage appropriately Co-ordinate Conservation PPE supply & re-use chain strategies Optimize PPE availability
Planning at HSN: PPE Working Group Players: Responsibilities: • Operational & Clinical Lead • Purchasing • Supplies staff & Processing • Inventory / Burn Rate • Infection Prevention & Control • Storage – security (IPAC) • Quality control • Nursing Clinical Managers • Conservation and reprocessing • Physicians planning • Occupational Health • Contigency algorithms • HSN Foundation representative • 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 Most stocks critically low Northern region has by mid March – access to competition with mining companies and Toronto mining/industry suppliers customers buying up stock Multiple donations: • Industry Challenges to take stock • Small businesses and centralize receiving • Physicians 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) Extended Use Applies to N95, surgical/procedure masks, all isolation gowns, eye/face protection Limited reuse refers to the practice of using the same PPE for multiple encounters with patients but carefully removing it (‘doffing’) after each Limited re- encounter, storing it safely, and then putting it back on (‘donning’) without use sterilization. Applies to N95, masks, cloth isolation gowns, eye/face protection
Strategy to disinfect, clean, sanitize and decontaminate disposable PPE for future use – applies specifically to N95 respirators Sterilization System required to collect used masks safely (brown paper bags) Methods for Reprocessing Issues: of PPE Ability to remove and/or inactivate viral Ability to preserve structural integrity of particulate safely the mask Methods approved by Health Ontario: Vapourized Hydrogen Peroxide (VHP) Ultraviolet Germicidal Irradiation (UVGI)
Conservation of N95s for future reprocessing Limited re-use between cases
Our N95 Planning Algorithm Conventional Contingency Crisis No PPE Existing medical Medical grade N95s Limited re-use and Non-NIOSH or CE grade N95s, > 5yrs old, extended use of approved masks disposable - fit tested disposable medical grade N95s (KN95) <5yrs Limit fit testing to Industrial grade Fluid-resistant HCWs who perform respirators (NIOSH or surgical masks AGMPs CE approved) Home-made masks Reprocessed medical grade N95s Re-usable half and full-face respirators, PAPR units
Education Effective Planning algorithms Regular updates on communication on apply to all aspects of current stock and conservation PPE usage strategies vital Walkarounds Close co-ordination addressing PPE Consistent messaging with IPAC and clinical needs in different on best available staff departments and evidence and practice offering solutions
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
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