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?